The Association of Post-traumatic and Postmigration Stress with Pain and Other Somatic Symptoms: An Explorative Analysis in Traumatized Refugees and Asylum Seekers

Co-designing a Physical Activity Service for Refugees and Asylum Seekers Using an Experience-Based Co-design Framework

People from refugee and asylum seeker backgrounds resettling in Australia often experience intersecting risks for poor mental and physical health. Physical activity can promote better health outcomes, however there are limited programs tailored for this population. Therefore, understanding how to support refugees and asylum seekers to engage in physical activity is crucial. This paper aims to describe how the experience-based co-design (EBCD) process was used to identify priorities for a new physical activity service for refugees and asylum seekers. Using an EBCD framework we conducted qualitative interviews and co-design workshops with service users (refugees and asylum seekers living in the community) and service providers at a community Centre in Sydney, Australia. Sixteen participants, including eight service users and eight service providers engaged in the EBCD process over 12-months. The interviews revealed common themes or 'touchpoints' including barriers and enablers to physical activity participation such as access, safety and competing stressors. Subsequent co-design focus groups resulted in the establishment of five fundamental priorities and actionable strategies; ensuring cultural and psychological safety, promoting accessibility, facilitating support to access basic needs, enhancing physical activity literacy and fostering social connection. Using EBCD methodology, this study used the insights and lived experiences of both service users and providers to co-design a physical activity service for refugees and asylum seekers which is safe, supportive, social and accessible. The results of the implementation and evaluation of the program are ongoing.

Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review

OBJECTIVE

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

METHODS

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

RESULTS

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

CONCLUSIONS

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

Perceived discrimination and its association with self-rated health, chronic pain, mental health, and utilization of health services among Syrian refugees in Norway: a cross-sectional study

Background

There is a scarcity of research on discriminatory experiences and their association with health outcomes among Syrian Refugees in Norway. Thus, this study aims to examine the relationship between perceived discrimination, self-rated health (SRH), chronic pain, poor mental health, and healthcare utilization among Syrian refugees resettled in Norway.

Methods

Cross-sectional data from the Integration for Health project were analyzed, including 154 Syrian refugees who resettled in Norway in 2018-19. Perceived discrimination, SRH, chronic pain, psychological distress, post-traumatic stress symptoms, and healthcare visits were assessed. Statistical analyses, including Poisson regression and multinomial logistic regression, were conducted. The significant statistical level was set at 0.05.

Results

Approximately 30% of participants reported experiencing discrimination, with no significant associations between sociodemographic factors and perceived discrimination. Perceived discrimination was significantly associated with psychological distress (adjusted PR: 2.07, 95%CI: 1.21-3.55), post-traumatic stress symptoms (adjusted PR: 11.54, 95%CI: 1.25-106.16), and 4 or more psychologist visits (adjusted OR: 12.60, 95%CI: 1.72-92.16). However, no significant associations were found between perceived discrimination and SRH; pain symptoms, or general healthcare utilization.

Conclusion

Experienced discrimination is highly prevalent and seems to be associated with mental health outcomes, but not clearly with SRH, pain, or general healthcare visits among Syrian refugees living in Norway. Efforts should focus on reducing discrimination, promoting social inclusion, and improving access to mental health services for refugees. Public awareness campaigns, anti-discrimination policies, and cultural training for healthcare professionals are recommended to address these issues and improve the well-being of Syrian refugees in Norway.

Self-perceived problems of Afghan asylum seekers and refugees and their experiences with a short psychological intervention

BACKGROUND

The present study examined Afghan asylum seekers' and refugees' self-perceived problems, and their experiences of treatment with an adapted version of the brief transdiagnostic psychological intervention "Problem Management Plus" (aPM+). Specifically, the study explored which problems trouble them most and how these problems influence their daily functioning. Further, it examined how various standardized outcome measures correlate with these subjectively perceived problems.

METHOD

This study is part of a larger RCT study (PIAAS study) in which 88 Afghan asylum seekers and refugees were randomly allocated either to aPM + in addition to treatment as usual (aPM+/TAU) or TAU alone. The presented study uses a multi-method approach consisting of two parts: First, we investigated participants' self-identified problems and subjective functional impairment using quantitative and qualitative assessment in both the aPM+/TAU and TAU group (n = 88). Second, we conducted in-depth qualitative interviews with a subsample of the aPM+/TAU group (n = 24) to gain a deeper understanding of participants' personal experiences with aPM + and to obtain suggestions for improvement. Spearman correlations were applied for quantitative data, and deductive and inductive approaches of thematic analysis were used for qualitative data.

RESULTS

We identified six main themes of self-perceived problems (primary post-migration living difficulties, general mental health problems, interpersonal stressors, secondary post-migration living difficulties, mental health problems specifically associated with stress, and somatic problems) and their consequences, as well as subjective functional impairment. Standardized measures of general mental health, posttraumatic psychopathology, and quality of life did not correlate with the intensity of self-perceived problems. aPM + was mostly perceived positively, and few participants had recommendations for its improvement.

CONCLUSION

The study aimed at giving a voice to Afghan trauma survivors to inform service providers and policy makers about their needs. Based on their expertise, future interventions can be tailored to their actual needs and optimized in terms of practical use. aPM + proved to be a positively perceived intervention that reduces subjective symptom burden and facilitates daily functioning. Culture-sensitive treatments within (mental) health services should increase service utilization and improve (mental) health in the long term.

Poverty, Somatisation Tendency and Potency in Low-Income Adolescent Groups of India and Israel: Explorations from the Field

Poverty increases vulnerability towards somatisation and influences the sense of mastery and well-being. The present study on adolescents living in relative poverty in a high-income group country (Israel) and a low-middle-income group country (India) explored the nature of somatisation tendency (ST) and its relationship with potency and perception of poverty (PP). Potency, a buffer against stress-induced negative health effects, was hypothesized to be negatively related to ST and mediate the link between PP and ST. Purposive sampling was used to collect questionnaire-based data from community youth (12-16 years) of two metropolitan cities-Kolkata (India, N = 200) and Tel-Aviv (Israel, N = 208). The nature of ST, PP and potency was analysed using descriptive and inferential statistics and correlation-regression statistics and mediation analysis were used to understand the relationship among them. A clinically significant level of ST was reported by both Indian and Israeli youth experiencing 5-7 somatic symptoms on average. Potency was found to be a significant predictor of ST in both countries (p < 0.05) and emerged as a significant mediator (p < 0.001) in the PP and ST relationship among Indian adolescents. The present study highlights potency as a protective buffer in economically vulnerable community adolescents and re-establishes a high prevalence of ST among them, irrespective of their country's global economic position.

Migrant women's engagement in health-promotive activities through a women's health collaboration

Introduction

Social determinants of health impact health, and migrants are exposed to an inequitable distribution of resources that may impact their health negatively, leading to health inequality and social injustice. Migrant women are difficult to engage in health-promotional activities because of language barriers, socioeconomic circumstances, and other social determinants. Based on the framework of Paulo Freire, a community health promotion program was established in a community-academic partnership with a community-based participatory research approach.

Aim

The aim of this study was to describe how a collaborative women's health initiative contributed to migrant women's engagement in health promotion activities.

Materials and methods

This study was part of a larger program, carried out in a disadvantaged city area in Sweden. It had a qualitative design with a participatory approach, following up on actions taken to promote health. Health-promotional activities were developed in collaboration with a women's health group, facilitated by a lay health promoter. The study population was formed by 17 mainly Middle Eastern migrant women. Data was collected using the story-dialog method and the material was analyzed using thematic analysis.

Result

Three important contributors to engagement in health promotion were identified at an early stage of the analysis process, namely, the group forming a social network, the local facilitator from the community, and the use of social places close to home. Later in the analysis process, a connection was made between these contributors and the rationale behind their importance, that is, how they motivated and supported the women and how the dialog was conducted. This therefore became the designated themes and were connected to all contributors, forming three main themes and nine sub-themes.

Conclusion

The key implication was that the women made use of their health knowledge and put it into practice. Thus, a progression from functional health literacy to a level of critical health literacy may be said to have occurred.

Knowledge of legal rights as a factor of refugee and asylum seekers' health status: a qualitative study

OBJECTIVES

To examine health behaviours of refugees and asylum seekers, in relation to their knowledge of public benefits and legal rights.

DESIGN

Qualitative study, utilising an open-ended, semi-structured interview guide to ensure information-rich data collection. Thematic content was analysed using qualitative research software.

SETTING

Participants were drawn from the Weill Cornell Center for Human Rights (WCCHR) in New York City, a single-center, human rights clinic with a globally representative patient population. All interviews were conducted at the Weill Cornell Medicine Clinical and Translational Science Center, a multidisciplinary space within an urban academic medical center.

PARTICIPANTS

Twenty-four refugees and asylum seekers currently living in the greater New York City area. Eligible participants were 18 years of age or older and had previously sought services from the WCCHR. The recruitment rate was 55%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Themes and concepts in participants' health, knowledge, perceptions of and experiences with accessing healthcare and public benefits programmes.

RESULTS

Twenty-four participants represented 18 countries of origin and 11 primary languages. Several impediments to accessing healthcare and public benefits were identified, including pragmatic barriers (such as prohibitive costs or lack of insurance), knowledge gaps and mistrust of healthcare systems.

CONCLUSIONS

There is low health engagement by refugees and asylum seekers, as a result of multiple, complex factors impeding the ability of refugee and asylum seekers to access healthcare and other public benefits for which they are eligible-with resultant detrimental health effects. However, there is an opportunity to utilise novel approaches, such as digital technologies, to communicate relevant information regarding legal rights and public benefits to advance the health of vulnerable individuals such as refugees and asylum seekers.

Weathering within war: Somatic health complaints among Vietnamese older adults exposed to bombing and violence as adolescents in the American war

OBJECTIVE

People living in war may experience deteriorating health via weathering (wear and tear) from long-term exposures to psychosocial and environmental stressors. Weathering embodied in somatic health complaints may illuminate the effects of war on health.

METHODS

We investigate whether wartime stress exposures occurring during adolescence and early adulthood affect weathering in late adulthood via linear regression with data from the Vietnamese Health and Aging Study (VHAS). VHAS is a cross-sectional study wherein investigators surveyed 2447 adults aged 60+ in four districts of northern and central Vietnam in 2018. These same individuals ranged in age from seven to 52 in 1965, with most having been in adolescence or early adulthood at the peak of the American war in Vietnam (1965-1975). The sample used for this study (n = 2254) were participants in the first VHAS wave in 2018.

RESULTS

We find older Vietnamese adults exposed to higher-intensity provincial bombing suffer more numerous somatic health complaints (unstandardized β = 0.005, SE = 0.001, p = 0.001). Additionally, greater health complaints emerge among older adults whose most intense bombing exposures were at younger ages of adolescence (< age 15) as compared to those whose peak exposures were in older ages (19-25) (unstandardized β = 0.62 95%, SE = 0.19, p = 0.01).

CONCLUSION

Our findings suggest that age of exposure to armed conflict is a critical determinant of weathering across the life course.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Associations between gender, torture, and health: A 5-year retrospective cohort analysis

Our purpose was to identify longitudinal associations between torture exposure, physical and mental health outcomes, and gender in a cohort of 143 war-affected Karen adults five years post resettlement. Results showed that participants who self-reported primary torture experiences had higher rates of certain mental and physical health diagnoses. We observed gender differences in health over time in the cohort. Findings have implications for how primary care and public health providers implement war trauma screening tools and timelines, targeted healthcare services, and community resources to promote health and prevent disease in populations that have trauma from torture or war.

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.

Psychological Distress, Post-Traumatic Stress, and Suicidal Ideation Among Resettled Nepali-Speaking Bhutanese Refugees in the United States: Rates and Predictors

INTRODUCTION

Bhutanese refugees may exhibit psychological distress (PD), post-traumatic stress (PTS), and suicidal ideation (SI), but little is known about predictors of these mental health problems.

PURPOSE

To examine rates and predictors of PD, PTS, and SI among Bhutanese refugees.

METHODS

Cross-sectional correlational study of 209 Bhutanese refugees in Midwestern United States. Data were collected using the Hopkins Symptom Checklist/Nepali version and Refugee Health Screener-15/PTS subscale and then analyzed using simultaneous multiple regression.

RESULTS

Rates of PD, PTS, and SI were 18.7%, 8.1%, and 7.7%, respectively. Significant predictors of PD were a history of mental health treatment (p<.001) and fewer years of schooling (p = .032). Predictors of PTS were history of mental health treatment (p<.001), female gender (p = .016), fewer years of schooling (p = .012), and being single/previously married (p = .004). PTS predicted SI (ρ<.001).

DISCUSSION

Health providers should routinely assess Bhutanese refugees' mental health status for timely further assessment and treatment.

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study

OBJECTIVES

This study aims to examine associations, predictors and pharmacological treatment of chronic pain and mental health problems among Syrian refugees in a longitudinal perspective.

DESIGN

Prospective cohort study.

SETTING

We collected survey data among Syrian refugees in Lebanon granted resettlement to Norway (self-administered questionnaires) and at follow-up 1 year after arrival in Norway (structured telephone interviews).

PARTICIPANTS

Adult Syrian refugees attending mandatory pretravel courses in Lebanon in 2017-2018 were invited to participate. In total, 353 individuals participated at both time points.

PRIMARY AND SECONDARY OUTCOMES

We examined the cross-sectional associations between pain, mental health and migration-related exposures at baseline and follow-up and assessed whether associations changed significantly with time. Furthermore, we investigated the longitudinal association between mental health at baseline and pain at follow-up. We also evaluated temporal changes in use of analgesics and psychotropic drugs.

RESULTS

While most refugees reported improved health from the transit phase in Lebanon to the early resettlement phase in Norway, a few had persisting and intertwined health problems. Most migration-related stressors were more closely associated with chronic pain and mental health problems after resettlement as compared with the transit phase. In parallel, poor mental health was associated with chronic pain in the follow-up (adjusted risk ratio (ARR) 1.5 (1.0, 2.2)), but not at baseline (ARR 1.1 (0.8, 1.5)). Poor mental health at baseline was a statistically significant predictor of chronic pain at follow-up among those not reporting chronic pain at baseline. At both timepoints, one in four of those with chronic pain used analgesics regularly. None with mental health problems used antidepressants daily.

CONCLUSIONS

Providers of healthcare services to refugees should be attentive to the adverse effect of postmigration stressors and acknowledge the interrelations between pain and mental health. Possible gaps in pharmacological treatment of pain and mental health problems need further clarification.

Gender Differences in Traumatic Experiences, PTSD, and Relevant Symptoms among the Iraqi Internally Displaced Persons

Conflict in Iraq has led to a large number of internally displaced Iraqis, with a great impact on their mental health. A few previous studies investigated the gender differences of mental disorders in Iraqi internally displaced persons (IDPs). The aim of this study was to assess gender differences among Iraqi IDPs after the 2014 terrorist attacks in terms of types of traumatic experiences, prevalence of post-traumatic stress disorder (PTSD), and other symptoms of common mental disorders (depression, anxiety, and somatization symptoms). A cross-sectional survey was conducted in April-June 2015 among 358 female and 464 male adult IDPs living in IDP camps in Duhok, Iraq. The Harvard Trauma Questionnaire (HTQ), General Health Questionnaire (GHQ-28), and Self-Reporting Questionnaire (SRQ-20) were applied by local interviewers. Comparison of scores of these measures between the two genders was performed using independent sample t-tests. Logistic regression analysis was carried out to identify predictors for PTSD. Although the types of traumatic events experienced by female and male IDPs were nearly similar, males reported higher exposure to combat situation, torture, oppressions, and destruction of personal properties (t = 3.718 and 4.758, respectively, p < 0.001). Overall, males experienced more events than females (p < 0.001). The probable PTSD prevalence rates (29.1% among females and 31.9% among males) did not differ significantly (p = 0.212). Female IDPs reported more somatic (p < 0.001) and depressive/anxious (p < 0.001) symptoms than males. The demographic factors and duration of camp stay were not associated significantly with PTSD diagnosis. Probable PTSD rates among male and female IDPs in Iraq are substantial. Although no gender differences were found in probable PTSD rates between female and male Iraqi IDPs, the mean score of common mental disorders cases was higher among females and they presented with higher levels of somatic and depressive/anxious symptoms. Further studies are needed to clarify the underlying mechanisms contributing to gender differences in PTSD.

Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study

BACKGROUND

Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden.

METHODS

A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture.

RESULTS

About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F(2, 316) = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001).

CONCLUSIONS

Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study

BACKGROUND

Previous studies have already proven high rates of common mental disorders in Syrian refugees. Nevertheless, little is known about the patterns of somatic distress among this refugee population. For this reason, we aimed to examine the prevalence, co-occurrence, and risk factors of somatic distress among Syrian refugees in Germany.

METHODS

This study analyzes the second measurement point (N = 116) of a prospective register-based survey among 200 adult Syrian refugees with residence permission in Germany. The survey consisted of information on sociodemographic and migration-specific characteristics, health care utilization, traumatic life events, acculturative stress (Barcelona Immigration Stress Scale (BISS); subscales: perceived discrimination, intercultural contact stress, homesickness, and general psychosocial stress), and self-reported outcomes of somatic distress (Patient Health Questionnaire (PHQ-15)), depression (PHQ-9), generalized anxiety disorder (GAD-7), and post-traumatic symptoms (Essen Trauma Inventory (ETI)).

RESULTS

Almost half of the respondents (49.1%) were identified as being at risk of somatic distress (PHQ-15 score ≥ 6), and even 24.1% being bothered by moderate-to-severe levels of somatic distress (PHQ-15 score ≥ 10). The most robust associations with somatic distress were found for female gender, the amount of health care utilization, multiple trauma exposures, general psychosocial stress, and self-reported depression and anxiety symptoms. High comorbidities with somatic distress were shown for all of the common mental disorders studied.

CONCLUSIONS

The presented study reveals a significant risk of somatic distress among this displaced population and highlights implications for policy and health care providers.

An embodied distress: African asylum seekers' experiences of mental health difficulties while awaiting an asylum outcome in Ireland

The mental health of asylum seekers has attracted significant interest and examination. Quantitative studies have consistently indicated that asylum seekers experience mental distress at a higher rate than both host populations and their refugee counterparts. Qualitative insight into asylum seekers' embodied experience of mental distress is limited. This qualitative narrative study aimed to explore African asylum seekers' everyday embodied experiences of mental distress. Sixteen semi-structured one-to-one interviews were conducted with African asylum seekers who had experienced mental distress and were receiving mental health care services in Ireland. Narrative data were analysed using a holistic analysis framework of narrative form and content. Participants described their everyday endurance of relentless rumination, shame, self-loathing, anger, and mistrust, and of becoming demoralised and hopeless. Study findings indicate that asylum seekers' mental distress interweaves the physical, psychological, emotional, and social realms, thus impacting on the whole of their being. Consequences for asylum seekers include feeling anaesthetised, having a severely diminished capacity to connect and interact with their external surroundings and other people, and, for some, efforts to end their life.Examinations of, and responses to, asylum seekers' mental distress must delve beyond the confines of diagnostic categorisations and codifications of symptomology. To achieve heightened understanding and efficacious interventions, we must empathetically listen and engage with asylum seekers' narratives of distress and the socio-cultural and socio-political context they inhabit.

Sudden and persistent dysphonia within the framework of COVID-19: The case report of a nurse

In December 2019, clusters of atypical pneumonia with unknown etiology emerged in the city of Wuhan in China. In early January 2020, the Center for Disease Control in China announced that it was identified a new coronavirus, first tentatively named 2019-nCoV and officially named SARS-CoV-2 by the International Committee on Taxonomy of Viruses. On February 11, 2020 the WHO identified the disease caused by SARS-CoV-2 as COVID-19 (COronaVIrus Disease-19 based on the year of appearance). Although only a few months have passed since the beginning of this pandemic, numerous studies, case reports, reviews by leading international scientific and medical journals have been published. However, given the unpredictability of virus behaviour and the still limited knowledge about it, many aspects of the infection are still little known. A recent epidemiological study has shown the presence of dysphonia in some patients with COVID-19, with a minority reporting aphonia during the clinical course of the disease. This case study draws attention on a 50-year-old female nurse presented with a history of fatigue resulting from minor exertion and persistent dysphonia at the Occupational Health Department of a major University Hospital in central Italy. The patient had a history of COVID-19 infection, which lasted about two months with pulmonary and extrapulmonary symptoms. After two RT-PCR negativities for SARS-CoV-2, dysphonia and fatigue due to minor exertionpersisted. The patient, following the persistence of the symptomatology, was subject to numerous specialist examinations, which showed no organic alterations. Based on her clinical and instrumental history, we hypothesized a psychogenetic dysphonia related to COVID-19. This case report highlights the importance of personalized medicine with long-term follow-up and rubustpsychological support in patients who tested positive for COVID-19 and in particular in the categories at greatest risk of both contagion and adverse physical and mental outcomes like health care workers.

•

Despite world updates produced daily, general knowledge of COVID-19 remains unclear.

•

Update answers to clinical questions can be difficult particularly regarding clinical presentations and treatment strategies.

•

Importance of personalized medicine with long-term follow-up and good psychological support in patients who tested positive for COVID-19.

•

Health care workers are at greatest risk of both contagion and adverse physical and mental outcomes.

Supporting migrants and refugees with posttraumatic stress disorder: development, pilot implementation, and pilot evaluation of a continuing interprofessional education for healthcare providers

BACKGROUND

Refugees and migrants face an increased risk of developing posttraumatic stress disorder (PTSD). Adequate care can be insufficient due to language barriers, cultural differences, and knowledge deficits of health service providers. Therefore, professional associations requested that healthcare providers to be educated to provide culturally sensitive care. An evidence-based educational intervention in the form of a continuing interprofessional education (CIPE) for healthcare providers on the topic of PTSD in migrants and refugees was developed, pilot-implemented, and evaluated according to the first two levels of the Kirkpatrick evaluation model (reaction and learning).

METHODS

The development of a curriculum for the CIPE intervention was based on a narrative literature review. Its content was validated by experts (N = 17) in an online survey and analyzed using both the Content Validity Index and a thematic analysis. The evaluation of the CIPE intervention was performed by conducting a pilot study with a quasi-experimental single group, using a pre-posttest design. In total, there were 39 participants distributed among three pilot courses. We collected and analyzed data on satisfaction, knowledge, and feasibility.

RESULTS

The curriculum for a half-day course, consisting of 8 modules, showed almost excellent content validity (S-CVI = 0.92). In the pilot-implementation phase, participants were "very satisfied" with the pilot courses and a positive effect on their knowledge was detected. No correlation between satisfaction and knowledge gain was found.

CONCLUSIONS

The CIPE intervention can be considered feasible and seems promising in its effects on satisfaction and knowledge. The insights gained in this study can be used to adapt and optimize the educational intervention, whereby the feedback from course attendees is particularly useful. Future studies need to further examine the effects in larger samples and more robust study designs.

"Having a Normal Life": A Qualitative Study on Client Goal-Setting Within a Health Care and Social Needs Navigation Program

Client goals within healthcare and social needs navigation programs are neither well understood nor incorporated into ambulatory care practices. This study provides a qualitative analysis of client-established goals within the Interprofessional Care Access Network (I-CAN), a community-based health care and social needs navigation program. One hundred eleven client goal lists were analyzed using conventional content analysis. Twenty-two codes were developed and grouped into 4 main categories including Physical/Mental Health, Social/Social Services, Health Care System, and Daily Living. The results of this study offer insight into client goals within health care and social needs navigation programs and provide suggestions for future research.

Barriers to access to outpatient mental health care for refugees and asylum seekers in Switzerland: the therapist's view

BACKGROUND

More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care.

METHODS

An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data.

RESULTS

Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers.

CONCLUSIONS

Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study

Background

The health of forcibly displaced individuals changes along their migration path and estimates of disease burden are essential to develop health care policies and practices adequately corresponding to their health care needs. This study aims to describe the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. Further, we aim to investigate the associations between migration related exposures and both chronic pain and mental health among Syrian refugees.

Methods

This is a cross-sectional study based on survey data collected among 827 adult Syrian refugees in Lebanon and Norway during 2017–2018. The survey instrument included items measuring somatic status (including chronic pain), mental health (using the HSCL-10 and HTQ items), use of medication and migration related exposures. We used descriptive statistics to calculate standardised prevalence proportions and regression analyses to study associations between migration related exposures and health outcomes.

Results

The response rate was 85%. The mean age in the sample was 33 years and 41% were women. Half of the participants reported that they had never had any health problems. The prevalence of non-communicable diseases was 12%. Headache and musculoskeletal complaints were the most prevalent conditions reported, with 30% reporting chronic pain lasting for more than six months. Symptoms indicating anxiety and/or depression were presented by 35%, while 7% revealed symptoms compatible with post-traumatic stress disorder. Among those reporting non-communicable diseases a substantial share did not seem to receive adequate treatment. Trauma experiences were associated with both chronic pain and anxiety/depression symptoms, and the latter were also associated with migrating without family members.

Conclusions

Migrant-friendly public health policies and practises should acknowledge migration related risks, address discontinuity in care of chronic conditions and target common complaints such as chronic pain and mental health problems among forcibly displaced individuals.

A Point in the Heart: Concepts of Emotional Distress Among Albanian-Speaking Immigrants in Switzerland

Cultural variability regarding concepts of distress for common mental disorders (CMD) has been reported extensively in cultural clinical psychology across the globe. However, little is known about illness narratives in social communities from Southeast Europe. The purpose of this paper is to identify cultural concepts of distress (CCDs) among Albanian-speaking immigrants in Switzerland and to integrate the findings into literature from other parts of the world. Twenty semi-structured qualitative interviews were conducted using the Barts Explanatory Model Inventory (BEMI). A set of concepts was described through content analysis and semantic network analysis. The results show complex expressions of distress, which are mainly associated with post-migration living difficulties. Social problems and life-changing events mark the onset of the most common symptoms. Self-management and social support were described as the most important coping behaviors. Participants expressed trust in physical health care but little belief in psychotherapy. There is indication that mental illnesses are stigmatized in this population. It is therefore important to use non-stigmatizing terms in health communication. Moreover, individuals from this community consider suffering to be part of life, and they assume that this suffering must be endured with patience. It is vital to address these beliefs in psychological interventions.

Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the "Islamic State" (IS)

BACKGROUND

Refugees with a history of war or sexual violence often experience somatic symptoms along with mental disorders. After being held in captivity by the so-called "Islamic State" (IS), 1100 especially vulnerable Yazidi women and children (around 400 women) received special medical and psychological support. We report on their (psycho-) somatic complaints and concepts of illness.

METHODS

Female refugees (N = 116) were surveyed regarding their somatic complaints and concepts of illness. The Impact of Event Scale-Revised (IES-R) and self-developed questionnaire items with ratings on a five-point Likert scale from 0 ("not at all") to 4 ("extremely") were used. Subgroup analyses and a multiple linear regression model were computed.

RESULTS

Pain (M = 2.43, SD = 1.70) is the main somatic complaint with a moderate rated severity, followed by feelings of suffocation (M = 2.37, SD = 1.53), and movement disorders (M = 1.62, SD = 1.70). In a linear regression model, pain explains variance (R² = 0.325) in the refugees' self-reported health-related wellbeing. Somatic symptoms are mainly attributed to psychological causes, followed by physical (e.g., physical origin of symptoms), religious, and supernatural causes. Women with pain symptoms attributed their symptoms more to physical causes (M = 1.90, SD = 1.78) than did women without pain symptoms (M = 1.07, SD = 1.59).

CONCLUSION

Female Yazidi refugees being kept in IS captivity mainly suffer from pain, which is attributed to an explanatory psychological model. The study results show the specific psychosomatic and psychotherapeutic needs and demands for specifically tailored psychotherapy.

Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland

Background: Due to their experiences of major stressful life events, including post-displacement stressors, refugees and asylum seekers are vulnerable to developing mental health problems. Yet, despite the availability of specialized mental health services in Western European host countries, refugees and asylum seekers display low mental healthcare utilization. Objective: The aim of this study was to explore structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. Method: In this qualitative study, key-informant (KI) interviews with Syrian refugees and asylum seekers, Swiss healthcare providers and other stakeholders (e.g. refugee coordinators or leaders) were conducted in the German-speaking part of Switzerland. Participants were recruited using snowball sampling. Interviews were audiotaped and transcribed, and then analysed using thematic analysis, combining deductive and inductive coding. Results: Findings show that Syrian refugees and asylum seekers face multiple structural and socio-cultural barriers, with socio-cultural barriers being perceived as more pronounced. Syrian key informants, healthcare providers, and other stakeholders identified language, gatekeeper-associated problems, lack of resources, lack of awareness, fear of stigma and a mismatch between the local health system and perceived needs of Syrian refugees and asylum seekers as key barriers to accessing care. Conclusions: The results show that for Syrian refugees and asylum seekers in Switzerland several barriers exist. This is in line with previous findings. A possible solution for the current situation might be to increase the agility of the service system in general and to improve the willingness to embrace innovative paths, rather than adapting mental healthcare services regarding single barriers and needs of a new target population.

Exploring the Representation of Depressive Symptoms and the Influence of Stigma in Arabic-Speaking Refugee Outpatients

The number of distressed refugees from the Arab world is relatively high in Germany and other host countries worldwide. For this specific population, substantial challenges and barriers have already been identified that hamper access to Germany's health care system. This study aims to contribute to this line of research by exploring the representation of depressive symptoms, both somatic and psychological, in order to inform clinicians about the most prevalent symptoms reported by Arabic-speaking refugee outpatients. Furthermore, this paper investigates the longstanding claim that mental health stigma fosters the expression of bodily distress. For these purposes, a total of 100 Arabic-speaking refugee outpatients, mostly Syrians, were recruited in Berlin, Germany. Somatic and psychological symptoms were assessed with the Patient Health Questionnaire (PHQ) 15 and 9, while stigma was assessed with the Brief Version of the Internalized Stigma of Mental Illness Scale (ISMI-10). Study results show that both somatic and psychological symptom severity was moderate while sleeping problems and energy loss were the most reported symptoms across both scales. Stigma was low and showed no association with somatic complaints in a multiple regression analysis, but was associated with more psychological symptoms. A principal factor extraction on the PHQ-15 items revealed five independent, somatic symptom clusters that were interpreted considering the rich poetic resources of the Arabic language. In conclusion, both somatic and psychological symptoms were commonly reported by Arabic-speaking refugees with symptoms of depression. Whereas, stigma does not seem to influence the expression of somatic symptoms, the present results provide first empirical indications for the relationship of symptom expression with the use of explanatory models and conceptualizations of mental illness within the Arabic culture and language. Future research efforts should be dedicated to enhancing our understanding of mental health care needs in this population as well as to exploring other mediators that might help explain the varying degree of somatic symptoms in depression across cultures.

Two interventions to treat pain disorders and post-traumatic symptoms among Syrian refugees: protocol for a randomized controlled trial

Background

There is a high prevalence of pain and post-traumatic symptoms among refugees and feasible interventions to manage these are needed. However, knowledge about the effect of physiotherapy and psychological group interventions among refugees is scarce. Our aim is to determine whether two different interventions, the Physiotherapy Activity and Awareness Intervention (PAAI) and Teaching Recovery Techniques (TRT), reduce pain and post-traumatic symptoms among refugees from Syria living in Norway.

Methods/design

Syrian adults with either pain disorders or post-traumatic symptoms, or both, will be recruited to this randomized control trial. The trial will include two separate interventions: participants with dominating pain symptoms will be assigned to the PAAI; and those with a predominance of post-traumatic symptoms will be assigned to the TRT intervention. Participants will be randomized to either the immediate intervention group or the delayed intervention group, for each of the interventions (PAAI and TRT). A minimum of 68 participants will be recruited for the PAAI and 78 participants for TRT, in order to detect clinically and statistically significant symptom improvement, assuming 25–30% attrition after recruitment. The main outcomes for the analyses will be pain intensity measured by the Brief Pain Inventory questionnaire and the scores of the Impact of Events Scale — Revised. The effect will be evaluated at the end of interventions lasting 8 weeks (PAAI) and 6 weeks (TRT) using the same instruments after the end of the intervention, and again 4–6 weeks later. Additionally, a qualitative evaluation will be conducted through an embedded process evaluation and personal interviews with participants after each of the interventions is finished.

Discussion

Our study will determine the feasibility of the implementation of two different interventions and the effect of these interventions among refugees from Syria with pain disorders and/or post-traumatic symptoms.

Trial registration

Clinical Trials.gov, NCT03951909. Retrospectively registered on 19 February 2019.

Pain from torture: assessment and management

Introduction:

Survivors of torture are for many reasons at particularly high risk for inadequate assessment and management of pain. Among the many health problems associated with torture, persistent pain is frequent, particularly pain in the musculoskeletal system. The pathophysiology underlying post-torture pain is largely unknown, but pain inflicted in torture may have profound effects on neurophysiology and pain processing.

Methods:

A narrative review of assessment and treatment studies, informed by clinical experience, was undertaken.

Results:

The clinical presentation in survivors of torture shares characteristics with other chronic primary pain syndromes, including chronic widespread pain. Unfortunately, such pain is often misunderstood and dismissed as a manifestation of psychological distress, both in specialist psychosocially oriented torture services and in mainstream health care. This means that pain is at risk of not being recognized, assessed, or managed as a problem in its own right.

Conclusions:

The available research literature on rehabilitation for torture survivors is predominantly targeted at mental health problems, and studies of effectiveness of pain management in torture survivors are lacking. Rehabilitation is identified as a right in the UN Convention on Torture, aiming to restore as far as possible torture survivors' health and capacity for full participation in society. It is therefore important that pain and its consequences are adequately addressed in rehabilitative efforts. This article summarizes the current status on assessment and management of pain problems in the torture survivor.

The management of post-traumatic stress disorder and associated pain and sleep disturbance in refugees

More than 68 million people worldwide have been forcibly displaced and one-third of these are refugees. This article offers an overview of the current literature and reviews the epidemiology and evidence-based psychological and pharmacological management of post-traumatic stress disorder (PTSD), sleep disturbance and pain in refugees and asylum seekers. It also considers the relationship between sleep disturbance and PTSD and explores concepts of pain in relation to physical and psychological trauma and distress. During diagnosis, clinicians must be aware of ethnic variation in the somatic expression of distress. Treatments for PTSD, pain and sleep disturbance among refugees and asylum seekers are essentially the same as those used in the general population, but treatment strategies must allow for cultural and contextual factors, including language barriers, loss of freedom and threat of repatriation.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

The Socioeconomic Burden of Pain From War

War's burden on the health and well-being of combatants, civilians, and societies is well documented. Although the examination of soldiers' injuries in modern combat is both detailed and comprehensive, less is known about war-related injuries to civilians and refugees, including victims of torture. The societal burden of war-related disabilities persists for decades in war's aftermath. The complex injuries of combat survivors, including multiple pain conditions and neuropsychiatric comorbidities, challenge health care systems to reorganize care to meet these survivors' special needs.We use the case study method to illustrate the change in pain management strategies for injured combat survivors in one national health system, the US Department of Veterans Affairs (VA). The care of veterans' disabling injuries suffered in Vietnam contrasts with the care resulting from the VA's congressional mandate to design and implement a pain management policy that provides effective pain management to veterans injured in the recent Middle East conflicts.The outcomes-driven, patient-centric Stepped Care Model of biopsychosocial pain management requires system-wide patient education, clinician training, social networking, and administrative monitoring. Societies are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare, including combatants and refugees.