A survey of refugee health assessments in the United States

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

"We Are from Nowhere": A Qualitative Assessment of the Impact of Collective Trauma from the Perspective of Resettled Bhutanese Refugees

Background: Limited research has explored mental health concerns and collective trauma experienced by Bhutanese refugees due to their displacement from Bhutan, refugee camp life in Nepal, and resettlement to U.S. society.

Purpose: To understand how collective trauma experienced by Bhutanese refugees influences the process of resettlement and integration into U.S. society to better address mental health concerns from the community.

Methods: Qualitative data were collected through four focus groups (N=40) with Bhutanese refugee women in central Massachusetts from June to November of 2016 to discuss refugee resettlement experiences and mental health concerns.

Findings: Bhutanese refugees shared insights on their resettlement experiences where several broader themes emerged, including historical collective trauma, closed-door culture, and processing mental health stigma. The displacement from Bhutan, hardships in Nepal refugee camps, and isolation in U.S. society led to a collective trauma among the community. Participants described America as having a closed-door culture that limits their integration into society, causing unique challenges based on their context of integration. The collective trauma also poses challenges toward processing mental health stigma, yet community building offers insights on how Bhutanese refugees can address these issues in collective spaces.

Conclusions: The historical collective trauma must be considered when working with Bhutanese refugees to understand the context of their resettlement to address mental health concerns.

Navigating healthcare systems before and after resettlement: Exploring experiences and recommendations for improvement from the perspectives of a Bhutanese refugee community

Background

Though refugees often survive in refugee camps for many years, little is known about the impact of their interactions within the healthcare system during that time and how it may affect current concerns with the healthcare system after resettlement. Guiding our analysis was the Community Health Development model, which emphasizes the importance of understanding the impact of historical experiences on a community's health to identify specific current health needs, and plan solutions alongside the community to address and improve health concerns.

Objective

To better understand the healthcare system related experiences of Bhutanese refugees before and after resettlement, and describe potential solutions based on their perspectives to improve their health status.

Methods

This study used an explorative qualitative research design. Four focus group discussions were conducted with 40 female participants to examine their experiences within the healthcare system in Nepal (e.g. before resettlement) and the US (after resettlement). Focus group data were audio-recorded, translated, coded, and reported based on qualitative thematic analysis.

Results

Findings revealed that Bhutanese refugees were mistreated in the Nepalese healthcare system, often neglected from healthcare access and services because of their refugee status. Upon arrival to the United States after resettlement, study participants also reported experiencing challenges within the US health care system including cultural and linguistic barriers when interacting with medical interpreters during visits with their providers, as well as having inadequate time during the visit to fully express their concerns. Respondents’ recommendations to improve their overall health centered on their experiences with the US health care system including initiatives developing leadership skills for building community capacity towards advocating for the refuges, while increasing access to external resources.

Conclusion

The result of this study outlines an account of Bhutanese refugees’ experiences and recommendations for improving their community's health based on such past experiences and their current needs. These findings provide a starting point for future research with underserved refugee migrant groups and indicate a need for health programs to be historically and culturally sensitive in order to be more effective. Further, the understanding of refugees’ collective history should inform the development of collaborative interventions with community members in order to be effective.

Defining effective care coordination for mental health referrals of refugee populations in the United States

Objectives: Refugee populations arriving to the United States report high rates of exposure to trauma and associated psychiatric distress that may necessitate referrals to mental health services. Although refugee arrivals receive a voluntary health screening, mental health screening is not routine. Public health providers report that one barrier to mental health screening concerns uncertainty about how to connect refugee patients to mental health services. This article reports essential components of successful and unsuccessful care coordination related to mental health referrals of refugees.Design: A community based participatory research study explored the characteristics of successful and unsuccessful mental health referrals of refugee patients through an online survey of refugee providers. Ten coders sorted provider stories of mental health referrals into critical incidents that were analyzed using principle components analysis (PCA). Care coordination emerged as an important characteristic of referral success. This category of care coordination was analyzed further into components of successful and unsuccessful care coordination using a higher order PCA. A similar process was followed examining providers' perceptions of why care coordination was successful or unsuccessful.Results: Components describing successful care coordination include ongoing communication between providers, scheduling initial appointments directly, access to emergency mental health services, and case management provided by health plan staff. Components related to unsuccessful care coordination describe the failure to communicate about care or establish appointments in a timely manner and the failure to resolve access barriers. Trust in relationships among providers and between refugee patients and providers was an important reason why care coordination was successful.Conclusion: Ongoing communication between providers is essential to successful mental health referrals of patients with refugee backgrounds. Multidisciplinary systems of care may benefit from education about the importance of building relationships among providers and the essential components of successful care coordination.

Impact of Length of Residence in the United States on Risk of Diabetes and Hypertension in Resettled Refugees

The relationship between resettlement and development of chronic disease has yet to be elucidated in refugees. We aimed to assess the relationship between length of residence in the US and development of diabetes and hypertension utilizing multivariable logistic regression models in a sample of former refugee patients seeking primary care services. Multivariable logistic regression models adjusting for age, gender, and country of origin showed significantly increasing odds of type 2 diabetes (OR 1.12, 95% CI 1.03-1.22, p < 0.01) and hypertension (OR 1.07, 95% CI 1.00-1.14) with increasing length of stay in the US for resettled refugee adults. A significant proportion of diabetes (26.7%) and hypertension (36.9%) diagnoses were made within one year of arrival, highlighting the critical role of focusing diagnosis and prevention of chronic disease in newly resettled refugees, and continuing this focus throughout follow-up as these patients acculturate to their new homeland.

Barriers to healthcare access among refugees with disabilities and chronic health conditions resettled in the US Midwest

Chronic conditions and related functional disabilities are highly prevalent among resettled refugees in the United States. There is a need to explore this population's access to appropriate healthcare services in order to identify service disparities and improve interventions. Using a community-based participatory research approach, semi-structured interviews were conducted with key informants to identify healthcare access barriers affecting disabled and chronically ill refugees. Eighteen participants were interviewed, revealing three main barriers: (1) inadequate health insurance, (2) language and communication barriers, and (3) a complex maze of service systems. These barriers were found to operate at systems, provider, and individual levels. Broad-based policy and practice interventions are required to address barriers including: an expanded pool of medical interpreters, peer navigators, innovative health information technologies, and greater collaboration and information-sharing between service systems. Further research is needed to monitor the impact the Affordable Care Act on service access of refugees with disabilities and chronic conditions.

A cost-benefit analysis of a proposed overseas refugee latent tuberculosis infection screening and treatment program

BACKGROUND

This study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). The purpose of this study was to estimate the costs and benefits of LTBI screening and treatment in United States bound refugees prior to arrival.

METHODS

Costs were included for foreign and domestic LTBI screening and treatment and the domestic treatment of active TB. A decision tree with multiple Markov nodes was developed to determine the total costs and number of active TB cases that occurred in refugee populations that tested 55, 35, and 20 % tuberculin skin test positive under two models: no overseas LTBI screening and overseas LTBI screening and treatment. For this analysis, refugees that tested 55, 35, and 20 % tuberculin skin test positive were divided into high, moderate, and low LTBI prevalence categories to denote their prevalence of LTBI relative to other refugee populations.

RESULTS

For a hypothetical 1-year cohort of 100,000 refugees arriving in the United States from regions with high, moderate, and low LTBI prevalence, implementation of overseas screening would be expected to prevent 440, 220, and 57 active TB cases in the United States during the first 20 years after arrival. The cost savings associated with treatment of these averted cases would offset the cost of LTBI screening and treatment for refugees from countries with high (net cost-saving: $4.9 million) and moderate (net cost-saving: $1.6 million) LTBI prevalence. For low LTBI prevalence populations, LTBI screening and treatment exceed expected future TB treatment cost savings (net cost of $780,000).

CONCLUSIONS

Implementing LTBI screening and treatment for United States bound refugees from countries with high or moderate LTBI prevalence would potentially save millions of dollars and contribute to United States TB elimination goals. These estimates are conservative since secondary transmission from tuberculosis cases in the United States was not considered in the model.

Premigration harm and depression: findings from the new immigrant survey, 2003

Studies examining refugees from conflict areas have found that persecution in the place of origin is a risk factor for depression. No studies have looked at this association between mental health and the experience of premigration harm due to race, gender or religion in the general population of United States immigrants. The New Immigrant Survey baseline questionnaire was administered to a random sample of adults receiving legal permanent residency in the U.S. in 2003 (n = 8,573), including refugees, asylees and other immigrants. In multivariate analysis controlling for visa type, premigration harm was a predictor of general depression of borderline statistical significance [odds ratio (OR), 1.33; 95 % CI 0.98-1.80, p = 0.068] and a significant predictor of major depression with dysphoria (OR, 2.24; 95 % CI 1.48-3.38, p = 0.0001). These findings suggest that premigration harm is a risk factor for depression in the general immigrant population and not just among refugees.

War trauma and torture experiences reported during public health screening of newly resettled Karen refugees: a qualitative study

Background

Karen refugees have suffered traumatic experiences that affect their physical and mental health in resettlement. The United States Centers for Disease Control and Prevention recommends assessing traumatic histories and mental health symptoms during initial public health screening. This article reports the traumatic experiences that Karen refugees were able to describe during a short screening and contributes knowledge to existing human rights documentation systems.

Methods

Four semi-structured and open-ended items asked about lifetime experiences of war trauma and torture. Interviews were completed with adult, Karen refugees during their initial public health screening. Experiences of war trauma and torture were coded using the extensive Human Rights Information and Documentation (HURIDOCS) Micro-thesauri coding system. Additional codes were created to describe experiences not captured by existing codes.

Results

Over 85% of 179 Karen people interviewed experienced life-threatening war trauma. All participants who reported war trauma or torture stories were able to describe at least one event. New war trauma codes proposed include: widespread community fear, systematic destruction/burning of house or village, exposure to dead bodies, orphaned in the context of war, injury caused by a landmine, fear of Thai police or deportation from Thailand, and harm or killings in the context of war. New torture codes include: forced portering; forced to be a human landmine sweep; forced to be a soldier, including child soldier; forced contact with a dead body; and removal of the eyes.

Conclusion

Karen refugees were able to report traumatic experiences in the context of a brief health screening. The findings confirm existing reports of human rights violations against Karen people and suggest that additional codes be added to the HURIDOCS Micro-thesauri system that is used by torture treatment centers. Understanding the nature of traumatic experiences of this group is important for health providers working with resettled Karen refugees in their countries of resettlement. Health providers may need specialized training to understand the traumatic histories of this new refugee group, learn how to initiate conversations about trauma and its impact on health, and make appropriate mental health referrals in the context of a brief public health screening.

High prevalence of chronic non-communicable conditions among adult refugees: implications for practice and policy

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

Under- and over-nutrition among refugees in San Diego County, California

Resettled refugees often arrive in their host country with little knowledge of nutrition or available food choices. We explored nutrition-related issues of recent refugee arrivals to San Diego County-the second largest California resettlement site. In-depth interviews (n = 40) were conducted with refugees, health care practitioners, and refugee service organizations. Content analysis identified nutrition-related themes. Unhealthy weight gain after arrival was the most common concern and was attributed to social pressures among adolescents, food choices and a more sedentary lifestyle. Conversely, undernutrition remained a concern due to poor diets. Factors influencing nutritional problems included continuation of past habits, acculturation, unfamiliarity with available foods and socio-economic influences. The nutritional concerns encountered by resettled refugees in San Diego are not unique to this group but are aggravated by their past experiences, and abrupt changes to food choices and behavior. Addressing contextual factors of poor food choices may prevent some of the long term health consequences of poor nutrition.

Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: A qualitative study

Migration is known to be associated with poor health outcomes for certain marginalised and socially disadvantaged populations. This paper reviews a number of reasons why residential mobility in the 'host' country may be associated with poor mental health for refugee populations and reports on a qualitative study of Somalis living in London, UK, and their beliefs about the relationship between residential mobility, poor health and health service use. Two discussion groups were undertaken with 13 Somali professionals and four groups with 21 lay Somalis in East and South London, UK. Lay Somalis did not wish to move accommodation but felt they were forced to move. Some Somali professionals believed that the nomadic history of Somalis made them more likely to elect to move in order to escape problems of living, but this was not supported by the lay group. Frequent geographical movements were seen as stressful and undesirable, disrupted family life and child development and were detrimental to well being. Residential mobility was also perceived to interfere with health care receipt and therefore should be more comprehensively assessed in larger quantitative studies.

A private-sector preferred provider network model for public health screening of newly resettled refugees

US law and regulations stipulate a process for the health screening of refugees. The responsibility of caring for refugees resettled in the United States rests, in part, with public health or welfare departments. Massachusetts has met its screening responsibilities through the innovative creation of a network of private preferred providers. We explore the Massachusetts model of public-private collaboration within the context of federal refugee health priorities and current state fiscal restraints affecting public health programs, and demonstrate the model's accomplishments.