Health of adolescent refugees resettling in high-income countries

Person-centred integrated primary care for refugees: a mixed-methods, stepped wedge design study to assess the impact

AIM

To assess the impact of a person-centred culturally sensitive approach in primary care on the recognition and discussion of mental distress in refugee youth.

BACKGROUND

Refugee minors are at risk for mental health problems. Timely recognition and treatment prevent deterioration. Primary care is the first point of contact where these problems could be discussed. However, primary care staff struggle to discuss mental health with refugees.Guided by the needs of refugees and professionals we developed and implemented the Empowerment intervention, consisting of a training, guidance and interprofessional collaboration in four general practices in the Netherlands.

METHODS

This mixed-method study consisted of a quantitative cohort study and semi-structured interviews. The intervention was implemented in a stepped wedge design. Patient records of refugee youth and controls were analysed descriptively regarding number of contacts, mental health conversations, and diagnosis, before and after the start of the intervention.Semi-structured interviews on experiences were held with refugee parents, general practitioners, primary care mental health nurses, and other participants in the local collaboration groups.Findings:A total of 152 refugees were included. Discussions about mental health were significantly less often held with refugees than with controls (16 versus 38 discussions/1000 patient-years) but increased substantially, and relatively more than in the control group, to 47 discussions/1000 patient-years (compared to 71 in the controls) after the implementation of the programme.The intervention was much appreciated by all involved, and professionals in GP felt more able to provide person-centred culturally sensitive care.

CONCLUSION

Person-centred culturally sensitive care in general practice, including an introductory meeting with refugees, in combination with interprofessional collaboration, indeed results in more discussions of mental health problems with refugee minors in general practice. Such an approach is assessed positively by all involved and is therefore recommended for broader implementation and assessment.

Changing landscape of paediatric refugee health in South Western Sydney, Australia: a retrospective observational study

OBJECTIVES

To examine the changing health needs of refugee children and young people (CYP) entering Australia, in relation to key government policy changes.

STUDY DESIGN

Retrospective analysis of health service use data over 11 years.

SETTING

Paediatric refugee clinics in South Western Sydney (SWS), the Australian region with the largest annual resettlement of refugees.

PARTICIPANTS

Refugee CYP (≤25 years) attending the SWS paediatric refugee clinics for their first visit between 2009 and 2019.

MEASURES

Clinician defined health conditions categorised as communicable and non-communicable disease (NCD).

RESULTS

Data were analysed for 359 CYP, mean age 9.3 years; 212 male (59.1%). Most CYP (n=331, 92.2%) had health problems identified; 292 (81.3%) had ≥1 NCD and 24 (6.7%) had ≥1 communicable disease. The most frequent individual NCDs were dental disease (n=128, 35.7%) and vitamin D deficiency (n=72, 20.1%). Trend analysis showed increased odds of identifying an NCD from 2013 onwards (crude OR 1.77, 95% CI 1.06 to 2.96). Neurodevelopmental problems, especially Global Developmental Delay (n=31, 8.6%), emerged as more prevalent issues in the latter half of the decade. There were significantly increased odds of identifying a neurodevelopmental problem in 2016-2019, especially in 2016-2017 (adjusted OR 2.93, 95% CI 1.34 to 6.40). Key policy changes during this period included acceptance of refugees with disabilities from 2012, additional Australian Humanitarian Programme intake from the Eastern Mediterranean region and mandatory offshore processing for those seeking asylum by boat from 2013. In response to the changing needs, local health services adopted nurse-led primary healthcare screening, early childhood services, youth and disability clinics.

CONCLUSIONS

Refugee CYP in Australia are presenting with a growing burden of NCDs, with neurodevelopmental problems contributing. Government policy changes affect the sociodemographics of resettled populations, influencing health profiles. Paediatric refugee health services need to be responsive to the changing needs of these populations to optimise well-being.

Emergency paediatric medicine consultation-a practical guide to a consultation with refugee and asylum-seeking children within the paediatric emergency department

There are increasing numbers of refugee and asylum-seeking children entering the UK annually who face significant barriers to accessing healthcare services. Clinicians working in the emergency department should have an awareness of the journeys children may have taken and the barriers they face in accessing care and have a holistic approach to care provision. We conducted a narrative literature review and used experiential knowledge of paediatricians working in the Paediatric Emergency Department to formulate a step-by-step screening tool. We have formulated a step-by-step screening tool, CCHILDS (Communication, Communicable diseases, Health-physical and mental, Immunisation, Look after (safeguarding), Deficiencies, Sexual health) which can be used by healthcare professionals in the emergency department.

CONCLUSION

Due to increasing numbers of refugee and asylum-seeking children, it is important that every point of contact with healthcare professionals is an impactful one on their health, well-being and development. Future work would include validation of our tool.

WHAT IS KNOWN

•The number of refugees globally are rapidly increasing, leading to an increase in the number of presentations to the PED. These patients are often medically complex and may have unique and sometimes unexpected presentations that could be attributed to by their past. There are a multitude of resources available outlining guidance on the assessment and management of refugee children.

WHAT IS NEW

•This review aims to succinctly summarise the guidance surrounding the assessment of refugee children presenting to the PED and ensure that healthcare professionals are aware of the pertinent information regarding this cohort. It introduces the CCHILDS assessment tool which has been formulated through a narrative review of the literature and acts as a mnemonic to aid professionals in their assessment of refugee children in the PED.

Health and wellbeing in refugee families from Syria resettled in Denmark

Aims

The aim was to evaluate self-reported health status and wellbeing in a well-defined group of refugee families from Syria 2-4 years after resettlement in Denmark, and, where possible, compare it with a Danish reference population. The purpose was to determine the need for specialized health care to resettled refugees.

Methods

This cross-sectional study involved 90 individuals from Syria aged 13-56 years. We used questionnaire survey to assess the general health and wellbeing in the study population in relation to a Danish reference population. Objective measurements of selected health indicators like overweight, hypertension and levels of cholesterol and blood glucose (HbA1c) were also determined for the study population.

Results

Mean wellbeing scores and the proportion of study participants rating their health as good were lower among the study participants compared with the Danish population for all age groups. The proportion of participants who reported often being alone against their will was significantly higher than among Danes, as was the proportion who had nobody to talk to when having problems. A significantly higher proportion of participants experienced various forms of pain or discomfort than in the Danish population. Overall, 23.6% and 3.4% of participants had elevated cholesterol and HbA1c levels, respectively, and the prevalence of overweight (BMI ≥ 25) was 70%. Hypertension was more frequent (16.2%) than in another refugee population in Denmark (9%).

Conclusions

The study demonstrated various mental and physical health challenges among the Syrian refugee families, and their health and wellbeing appeared to be substantially poorer as compared to the Danish reference population. The findings emphasize the need for systematic and specialized health care services at a municipality level to resettling refugees as a prerequisite for the refugees to become contributing citizens.

MMR vaccine coverage and associated factors among overseas-born refugee children resettled in Aotearoa New Zealand: a national retrospective cohort study

Background

Refugee children may be under-immunised against common vaccine-preventable diseases due to a myriad of factors related to their migration journey.

Methods

This retrospective cohort study explored the rates and determinants of enrolment on the National Immunisation Register (NIR) and measles, mumps and rubella (MMR) coverage among refugee children up to 18 years old who resettled in Aotearoa New Zealand (NZ) from 2006 to 2013. Univariate and multivariable logistic regression were conducted to determine associations.

Findings

Of the cohort (N = 2796), two thirds of the children (69%) were enrolled on the NIR. Among this sub-cohort (n = 1926), less than one third (30%) were age-appropriately vaccinated with MMR. MMR coverage was highest among younger children and improved over time. Logistic modelling revealed that visa category, year of arrival, and age group were significant factors that influenced NIR enrolment and MMR vaccine uptake. Those arriving via asylum seeking, family reunification and humanitarian pathways were less likely to be enrolled and vaccinated compared to refugees who entered under the national quota programme. More recent arrivals and younger children were more likely to be enrolled and vaccinated compared to children who arrived in NZ longer ago and were older.

Interpretation

Resettled refugee children have suboptimal NIR enrolment and MMR coverage rates which varied significantly by visa category, highlighting the need for immunisation services to better engage with all refugee families. These findings suggest that broad structural factors related to policy and immunisation service delivery may influence the differentials seen.

Funding

Health Research Council of New Zealand (18/586).

Preoperative Evaluation of Refugee Children With Heart Disease

The objective of this report is to identify nutritional deficiencies and health concerns in Canadian paediatric refugee patients with heart disease before cardiac surgery. A retrospective case study was conducted with 4 refugee children, aged 0-18 years, with heart disease referred to Cardiac Surgery. A total of 75% of patients had low vitamin D levels, 50% had selenium deficiency, 50% had iron deficiency anaemia, 75% were below the third percentile for height and weight for age, and 75% had dental caries. Early laboratory, nutritional, and dental screening of paediatric refugee patients at the time of heart disease diagnosis can optimize general and cardiovascular health before surgical intervention.

The role of sport in coping and resilience amongst resettled South Sudanese youth in Australia

In this article, the use of sport as a coping strategy by South Sudanese youth who have suffered the trauma of forced migration is examined. This article explores the relationship that has emerged between the young people and sport, in particular basketball, and how they use their participation in basketball and sports to cope with the stressors of their lives. The research intended to explore to what degree sport can play in improving mental health and what mental health interventions, in general, were being sought by this marginalized demographic. This qualitative study was underpinned by the psychosocial conceptual framework. We undertook semi-structured interviews with 23 South Sudanese youth aged 14-21 years, we also conducted focus groups of 11 South Sudanese elders and parents. The results of this research were feed back to the wider South Sudanese community through two forums. The data collected were analyzed using thematic analysis. The results of the study identified sport as an important coping strategy for the participants, both as a diversion from drug and alcohol misuse, potential criminal activity and as a way to self-manage the symptoms of anxiety and depression they were experiencing, and a mechanism to enhance self-worth. The study also indicated there was a lack of mental health interventions for these young people and that they had shown a great deal of resilience to develop their own ways to deal with the trauma they had experienced. The research reported positive associations of wellbeing and participation in sport, however more research needs to be conducted to ascertain the extent to which sport impacts mental health and how this can be incorporated into interventions for Sudanese youth and young people from similar forced migration and resettlement backgrounds. This study suggested that sport can be a driving force of good for many of the young people's lives, worthy of further research.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

Assessment of the World Food Programme summer camps in Lebanon: a model of effective interventions for vulnerable adolescents

The World Food Programme (WFP) offers yearly health and nutrition summer camps hosting vulnerable Syrian and Lebanese children and aiming at improving physical, mental and social well-being while contributing to better social cohesion. The present study aimed to assess the 2019 WFP summer camps' effectiveness in reaching the intended outcomes and to provide recommendations for improvement. A multi-method approach using (1) quantitative student pre-/post-surveys (n 443), (2) focus group discussions and (3) key informant interviews and surveys (n 42) was adopted. Mean test results showed improvements in nutrition (4·79 (sd 1·9) v. 5·34 (sd 2·7); t(269) = 4·51, P = 0·000) and life skills knowledge (4·97 (sd 1·9) v. 5·55 (sd 2); t(294) = 4·52, P = 0·000) but no improvement in health knowledge and social cohesion scores. Qualitative data revealed positive changes in social cohesion and an increase in health knowledge. In addition, there was a positive attitude towards the summer camps from students, instructors and administrators specifically regarding the integrated content, snacks and atmosphere of fun and learning. The main weaknesses identified were the short time to prepare for the camps, shortage in instructor training and short camp duration. There were also points of debate regarding sexual and reproductive health-related topics and how they should be delivered. All in all, the camps were shown to be a commendable initiative for incorporating an integrated and holistic approach in the support of education and development among vulnerable children and adolescents.

Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

Background

Asylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital.

Methods

We performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups.

Results

A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1–2) in the asylum-seeking and 2 (IQR 1–4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (> 15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients.

Conclusions

Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

Acute infection as cause of hospitalization of asylum-seeking children and adolescents in Stockholm, Sweden 2015-2016

We aimed to identify hospitalizations due to infectious diseases among asylum seekers and compare them to those of the resident population 1.6.2015-31.10.2016. Administrative numbers assigned to hospitalized non-resident children made them identifiable in the discharge register. The examined populations, expressed as person-years, were 334,573 residents and 7565 asylum seekers. There were 2500 episodes of infectious disease in 2240 resident children and 139 episodes in 121 asylum seekers. Among prevalent infections contracted before or during migration, there were 33 cases of tuberculosis, four of malaria, and one of louse-borne relapsing fever, all of which occurred in 13-17-year-old unaccompanied minors. Among younger asylum seekers, there were no significant differences in the spectrum of infectious discharge diagnoses compared to residents, but across all incident infections, 0-6-year-old asylum seekers had 3.2-fold and 7-12-year-old a 4.7-fold greater risk of being admitted. Screening for multidrug-resistant bacteria showed that 45/160 (28%) of the asylum seekers were colonized, but clinical infections caused by these species were rare.Conclusion: There was a high rate of hospitalizations for acute infectious diseases in asylum-seeking children, but the spectrum and severity of infections were similar to that in resident children. What is known: • Mental and physical health problems are common in immigrant children and adolescents. What is new: • Hospitalizations due to acute infections in asylum-seeking children and adolescents are common. In the context of this study, the severity and spectrum of infectious diseases seemed to be the same in the two groups; the increased hospitalization rate in asylum seekers may be due to social factors and perceived need for more support.

Paediatric asylum seekers in Western Australia: Identification of adversity and complex needs through comprehensive refugee health assessment

AIM

Asylum seekers (ASs) report high rates of trauma and difficulty accessing health and educational services. This study aims to ascertain the needs of paediatric ASs managed by the tertiary Western Australian paediatric Refugee Health Service (RHS), including demographic features, the range of health and psychosocial issues and ongoing management challenges.

METHODS

An audit of multidisciplinary RHS assessments, health records and hospital admissions for new AS patients (<16 years) between July 2012 and June 2016 was undertaken.

RESULTS

Records for 110 ASs were reviewed (mean age 6 years, standard deviation 4.72 years). Multiple issues (medical, psychological, developmental, educational) were identified after the first tertiary assessment (median 4, interquartile range (IQR) 3-6) compared to referral sources (median 1, IQR 0-2, P < 0.001). The median number of issues per child at audit completion was 6 (IQR 4-7, P < 0.001). Multiple refugee adverse childhood experiences were identified, with all experiencing >3 (median 4, IQR 4-5). Most had detention experience (107/110, 97.2%), family separation (91/108, 84%) and interrupted education (41/46, 89.2%). The median duration of detention was 7 months (IQR 3-12.5 months) at time of initial review across multiple sites (median 2, IQR 1-3 locations). High rates of hospital interaction were evident, with 45.4% requiring hospital admission and 36% presenting to the emergency department. The median number of outpatient appointments attended per child was 5 (IQR 2-8). Parental and child mental health concerns were identified in 53.6 and 46.3%, respectively.

CONCLUSIONS

Paediatric ASs have complex trauma backgrounds with exposure to multiple adverse events within disrupted family units. The majority of Western Australian ASs assessed demonstrated negative health or education sequelae compounded by detention not previously identified prior to comprehensive paediatric review. Our data support the urgent removal of ASs from held detention. Ongoing holistic assessment and management engaging multidisciplinary trauma-informed paediatric refugee services to optimise health and well-being is recommended.

Do health reception policies in the Nordic region recognize the rights of asylum-seeking and resettled refugee children?

According to the United Nations Committee on the Rights of the Child, it is critical that refugee children's rights are upheld in all national policies covering vulnerable children. This article examines how health policies in the Nordic region recognize the health needs of newly arrived refugee children, and whether these policies respect their individual rights. The article maps out, compares and contrasts health reception policies in Denmark, Finland, Norway and Sweden, paying particular attention to how each addresses the rights and needs of refugee children. The policy documents were obtained through desk-research conducted from January 2017-January 2018. We analysed 34 national laws and guidelines that support the health reception of refugee children. We find that only a few health reception policies across the Nordic region have been written specifically for refugee children. The policies identified predominantly recognize refugee children's right of access to somatic healthcare services, and to emergency services. Their rights to mental health services or broader health-enabling contexts were addressed to a lesser extent. We conclude that there is a need for further recognition of refugee children as rights-holders, and for the intentions of health reception policies to be expanded to include mental health services and health-promoting initiatives. Further research is needed on whether and how the current policies play out in actual health reception practices.

Medical needs of adolescent refugees resettling in Western Australia

OBJECTIVE

To investigate the medical needs and socioeconomic determinants of health among adolescent refugees resettling in Western Australia.

DESIGN

Comprehensive medical and socioeconomic health data of resettling adolescent refugees aged 12 years and above attending a Refugee Health Service over a 1-year period were analysed.

RESULTS

Medical records of 122 adolescents, median (range) age of 14 (12-17) years, were reviewed. Socioeconomic vulnerabilities included dependence on government financial support (50%), housing issues (27%) and child protection service involvement (11%). Medical concerns included non-communicable disorders (85%), infectious diseases (81%), nutrition/growth (71%) and physical symptoms of non-organic origin (43%). One quarter (27%) of female adolescents had sexual/reproductive health issues. A median (range) of 5 (2-12) health concerns were identified for each adolescent with 49% requiring referral to subspecialty services.

CONCLUSION

Resettling adolescent refugees are socioeconomically vulnerable with a range of medical issues that frequently require additional subspecialty health referrals.

Complexities of conducting research in adolescent refugees resettling in Australia

Adolescent refugees resettling in Australia are a vulnerable and marginalised population. Dedicated research to help better understand their health-care needs remains scarce. There are multiple complexities which may deter health professionals from conducting research with this population. Health-care system barriers, such as lack of adolescent- and refugee-specific health-care services, complicate comprehensive data collection. Limited investigator knowledge pertaining to culturally appropriate research in a population with limited English proficiency or a history of trauma can have an impact on adolescent participation and retention in research studies. Additional ethical and legal issues relating to adolescent consent and confidentiality, which include suicidality and physical or sexual abuse, can arise during research and cause potential harm to adolescents if not managed appropriately. This article highlights current knowledge and understanding relating to these issues along with recommendations to address barriers and safeguard adolescents, with the aim of promoting high-quality research that will benefit resettling adolescent refugees.

Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes

Background

In order to provide effective primary care for refugees and to develop interventions tailored to them, we must know their needs. Little is known of the health needs and experiences of recently arrived refugees and other migrants throughout their journey through Europe. We aimed to gain insight into their health needs, barriers in access and wishes regarding primary health care.

Methods

In the spring of 2016, we conducted a qualitative, comparative case study in seven EU countries in a centre of first arrival, two transit centres, two intermediate-stay centres and two longer-stay centres using a Participatory Learning and Action research methodology. A total of 98 refugees and 25 healthcare workers participated in 43 sessions. Transcripts and sessions reports were coded and thematically analyzed by local researchers using the same format at all sites; data were synthesized and further analyzed by two other researchers independently.

Results

The main health problems of the participants related to war and to their harsh journey like common infections and psychological distress. They encountered important barriers in accessing healthcare: time pressure, linguistic and cultural differences and lack of continuity of care. They wish for compassionate, culturally sensitive healthcare workers and for more information on procedures and health promotion.

Conclusion

Health of refugees on the move in Europe is jeopardized by their bad living circumstances and barriers in access to healthcare. To address their needs, healthcare workers have to be trained in providing integrated, compassionate and cultural competent healthcare.

Common Diagnoses among Refugee Populations: Linked Results with Statewide Hospital Discharge Database

BACKGROUND

According to the U.S. State Department's Refugee Processing Center and the U.S. Census Bureau, in the fiscal year 2016, among all states in the United States, Nebraska resettled the highest number of refugees per capita.

OBJECTIVES

The objectives of this study were to determine the most common reasons for refugees utilizing hospital services in Nebraska between January 2011 and September 2015, and to examine whether refugee patients had increased risks for adverse health conditions compared to non-refugee patients.

METHODS

Statewide linkage was performed between Nebraska Medicaid Program's immigration data, and 2011-2015 Nebraska hospital discharge data inpatient and outpatient files. The linkage produced 3017, 5460, and 775 cases for emergency department visits, outpatient clinic visits, and inpatient care for the refugee sample, respectively.

FINDINGS

Refugee patients were at increased risk for a number of diagnoses or medical conditions, including pregnancy complications, abdominal pain, upper respiratory infections, viral infections, mood disorders, disorders of teeth and jaw, deficiency and anemia, urinary system disorders, headache, nausea and vomiting, limb fractures, spondylosis, essential hypertension, and uncomplicated diabetes mellitus.

CONCLUSIONS

The findings suggest a greater emphasis on preventive healthcare, especially in areas of maternal health and perinatal outcomes, psychological counseling, screening for infectious diseases, nutrition and healthy eating, and oral health. Additionally, culturally appropriate measures to address prevention, health screening, and treatments should be adopted by health providers who care for refugees.

Constructing health capital in ecological systems: A qualitative evaluation of community-based health workshops in the refugee community

Refugee communities face numerous health and mental health concerns both during and after resettlement. Health issues, already deteriorated by chronic poverty, malnutrition and poor living conditions, are exacerbated by acculturative challenges, such as cultural and language barriers, stigma, and lack of resources and information. Since such needs in refugee communities affect both individual and collective capacity, it is important to consider policy environment and socioecological contexts for cultural adjustment and community resources for navigating systems, rather than individual health behaviours and communication skills only. To expand our understanding of health promotion capacity and resources, a broad and context-dependent concept will be necessary. Adopting a concept of health capital, this study aims to explore the impact of community-based health workshops, while expanding and redefining the framework in the context of health promotion efforts for the refugee community in resettlement. As part of community-based participatory research, this qualitative study conducted seven focus group discussions (FGDs) with 22 Bhutanese refugees in 2014. Using a hybrid thematic analysis, themes emerged from the FGD data were organised and categorised into health capitals in ecological systems. The participants reported enhanced confidence and capacity for health promotion at individual, family and community levels. Given the interdependent coping and lifestyles of refugee communities, impacts on the participants' interactions and relations with family and community were significant, which emphasises the importance of assessment of interventions beyond an individualistic approach. The findings of this study underscore the vital role of varied forms of health capital in promoting health in the refugee community and connecting members to needed health resources and information. Health capital is an old and yet still new concept with a great potential to broaden our understanding of health resources by elaborating the impacts and interactions in individuals, family and community for health promotion.

Identification of health risk behaviours among adolescent refugees resettling in Western Australia

OBJECTIVE

Adolescent refugees encounter traumatic stressors and are at risk of developing psychosocial health problems; limited research data exist internationally. This study aims to identify health risk behaviours among adolescent refugees resettling in Western Australia and assess the feasibility of using a standardised adolescent health questionnaire for this purpose.

DESIGN

Refugees aged 12 years and above attending a tertiary Refugee Health Service (RHS) were recruited over 12 months. Sociodemographic data were collected. Psychosocial assessments based on the 'Home, Education/Eating, Activities, Drugs, Sexuality, Suicide/mental health' (HEADSS) framework were undertaken utilising interpreters where required. Health concerns identified were managed through the RHS.

RESULTS

A total of 122 adolescents (20 ethnicities) participated; 65% required interpreters. Median age (range) was 14 (12-17) years. Most (80%) had nuclear family separation. Almost half (49%) had a deceased/missing family member. A third (37%) had lived in refugee camps and 20% had experienced closed detention. The median time (range) since arrival in Australia was 11 (2-86) months. Every adolescent had at least one health concern identified during the psychosocial assessment. Frequency of health concerns identified in each domain were 87% for home, 66% for education, 23% for eating, 93% for activities, 5% for drugs, 88% for sexuality and 61% for suicide/mental health. Most adolescents (75%) required intervention, consisting of counselling for health risk behaviours and/or referral to health or community services.

CONCLUSION

It is feasible to use a standardised adolescent health questionnaire to identify health risk behaviours among a cohort of ethnically diverse adolescent refugees. Use of the questionnaire identified a large burden of psychosocial health issues requiring multidisciplinary intervention.

Migrant children's health problems, care needs, and inequalities: European primary care paediatricians' perspective

BACKGROUND

Primary care paediatricians' perception of migrant children's health in Europe has not been explored before. Our aim was to examine European paediatricians' knowledge on migrant children's health problems, needs, inequalities, and barriers to access health care.

METHODS

European primary care paediatricians were invited by the European Academy of Paediatrics Research in Ambulatory Setting Network country coordinators to complete a web-based survey concerning health care of migrant children. A descriptive analysis of all variables was performed.

RESULTS

The survey was completed by 492 paediatricians. Sixty-three per cent of the respondents reported that the general health of migrant children is worse than that of nonmigrants, chronic diseases cited by 66% of the respondents as the most frequent health problem. Sixty-six per cent of the paediatricians reported that migrant children have different health needs compared to nonmigrant children, proper oral health care mentioned by 86% of the respondents. Cultural/linguistic factors have been reported as the most frequent barrier (90%).to access health care. However, only 37% of providers have access to professional interpreters and cultural mediators. Fifty-two per cent and 32% do not know whether one or more of the family members are undocumented and whether they are refugees/asylum seekers, respectively. Updated guidelines for care of migrant children are available for only 35% of respondents, and 80% of them have not received specific training on migrant children's care.

CONCLUSIONS

European primary care paediatricians recognize migrant children as a population at risk with more frequent and specific health problems and needs, but they are often unaware of their legal state. Lack of interpreters augments the existing language barriers to access proper care and should be solved. Widespread lack of guidelines and specific providers' training should be addressed to optimize health care delivery to migrant children.

The Neuropsychological Consequences of Armed Conflicts and Torture

PURPOSE OF REVIEW

At any point in time, there are hundreds of armed conflicts throughout the world. Neuropsychological disorders are a major cause of morbidity during and after armed conflicts. Conditions such as closed and open head injuries, acute stress disorder, post-traumatic stress disorder, depression, anxiety, and psychosis are prevalent among survivors. Herein, we summarize information on the various forms of torture, the resultant neuropsychological pathology, and treatment strategies to help survivors.

RECENT FINDINGS

Strategies to address the needs of individuals who experienced neuropsychological trauma due to armed conflicts and torture include pharmacological and psychological interventions. The former includes antidepressant, antianxiety, and antipsychotic medications. The latter includes narrative exposure therapy and trauma-focused cognitive-behavioral therapy. Neuropsychological disorders are major causes of morbidity among survivors of armed conflicts and torture. Treatment strategies must be affordable, applicable across cultures, and deliverable by individuals who understand the victims' psychosocial and ethnic background.

Adversity and resilience amongst resettling Western Australian paediatric refugees

AIM

Cumulative adverse childhood experiences have long-term consequences and may manifest within and influence health, educational and psychosocial domains. The Princess Margaret Hospital Refugee Health Service (RHS) undertakes multidisciplinary screening of refugee children <16 years, allowing standardised identification of negative childhood experiences. Addition of the extended Strengths and Difficulties Questionnaire (SDQ) in 2014 aimed to augment psychological assessment of this cohort.

METHODS

An audit of prospectively collected standardised RHS proformas, health records and initial and 6-month follow-up SDQs for new patients aged 2-16 years between August 2014 and January 2016 was undertaken. Wider refugee adverse childhood experiences (R-ACE) were also captured.

RESULTS

Initial SDQ data were obtained from 204 patients (mean age 9.2 ± SD 4.4 years) with 143 follow-up SDQs available. One third (37.3%) had at least one psychological symptom identified based on initial screening proforma. Multiple R-ACE were disclosed with 126 of 201 (62.7%) experiencing ≥3. African ethnicity, age >10 years, separation anxiety on initial proforma and no formal parental education were associated with higher R-ACE. Initial SDQ results varied with age/ethnicity; however, peer problem scores were consistently elevated. Total difficulty SDQ scores did not capture psychopathology at expected frequencies. Improvement in follow-up SDQ results were appreciated for children aged 4-10 years. Most patients (80.2%) disclosed improvement in health status following RHS involvement.

CONCLUSIONS

Refugee children have complex backgrounds with exposure to multiple traumatic events. Comprehensive standardised health and psychological screening is recommended to target intervention. Further validation of culturally age-appropriate mental health screening tools in this diverse population is required.

International Emergency Psychiatry Challenges: Disaster Medicine, War, Human Trafficking, Displaced Persons

Mental health disorders are a major cause of morbidity and a growing burden in low-income and middle-income countries; but there is little existing literature on the detailed epidemiology, diagnosis, and treatment in low-resource settings. Special situations with vulnerable populations, such as those created by international humanitarian emergencies, refugees or internally displaced people, and victims of human trafficking, are increasing in prevalence. These victims are often resettled in developed countries and come to the emergency department seeking care. To better care for these populations, knowledge of specialized psychosocial and cultural considerations should inform the comprehensive psychiatric assessment and treatment plan.