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The prevalence of mental health problems in Rwandan and Burundese refugee camps

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Abstract

We examined the prevalence of mental health problems in refugees living in camps that emerged in Tanzania during the Rwanda crisis that started in 1994. Using the 28-item version of the General Health Questionnaire (GHQ-28), we examined two samples: a random sample (n = 854) and a sample of clients of a psychosocial support programme in these camps (n = 23). Sensitivity, specificity and positive- and negative predictive values were estimated for several cut-off scores of the GHQ-28. The prevalence of serious mental health problems was estimated at 50% (SE 12%). When using the GHQ-28 as a screener, a cut-off score of 14 is recommended. Given the high prevalence of mental health problems, psychosocial programmes for large refugee populations should aim at strengthening community structures and supporting groups instead of focusing at individuals. The screening capacity of the GHQ-28 could be used to identify mentally vulnerable groups.

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... The World Health Organization (2014) described refugees as a population exposed to extreme stressors and therefore at risk of mental health and social problems. Some of these stressors include stigma, public humiliation, intimidation, hunger, rape, torture, death of relatives ,and other forms of hardship (De Jong et al. 2000;Hauff and Vaglum 1995;Lavik et al. 1996). Other issues refugees have to cope with the loss of their country, culture, language, profession, family, friends, and future plans (Tribe 2002). ...
... In a study done among Rwandan and Burundese refugees in Tanzania, De Jong and colleagues (2000) stated that about half reported serious mental health problems. Many studies have shown that the prevalence of mental ill health among refugees is high due to a number of pre-and post-migration stressors as well as the refugees' cultural background and the host environment (De Jong et al. 2000;Hauff and Vaglum 1995;Lavik et al. 1996;Lustig et al. 2004). Miller et al (2002) in a study done among Bosnian refugees revealed that exposure to war (pre-migration) and social isolation in the refugee camp (post-migration) were significant stressors associated with posttraumatic stress disorder (PTSD) and depression among the participants. ...
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Refugees are exposed to extreme stressors and are therefore at risk of mental health and social problems. Other issues refugees have to cope with include the loss of their country, culture, language, profession, family, friends, and future plans. Much of the studies that have been done on refugee mental health have not attempted to explain what these experiences mean to these individuals. Thus, this study provides explorative data on the mental health and quality of life of West African refugees living in Nigeria in order to understand their views and perspectives. This study carried out in 2010 employed qualitative methods; a total of four focus group discussions (FGDs) were conducted among adult male and female refugees purposively selected at the Oru Refugee Camp, Ogun State, Nigeria. Respondents described quality of life as a major determinant of mental health status. Most of the participants believed that women were more predisposed to mental ill health due to their sensitive emotional make-up. Factors identified by respondents as affecting mental health and quality of life among refugees included poverty, unemployment, physical health, housing and environment, discrimination, stigmatization, and insecurity. Refugees rated their mental health and quality of life as poor due to the aforementioned factors. Recommendations were made to the international community, national and local governments to invest more on education, provision of vocational and entrepreneurial skills as well as adequate housing in order to improve the mental health and quality of life of refugees.
... This chapter reviews some of the current literature with respect to the phenomenon of depression and its prevalence among people living with HIV/AIDS. (Dyregtov, Gupta, Gjestad & Mukanoheri, 2000;Schaal & Elbert, 2006) and the mental health needs of refugees (De Jong, Scholte, Koeter & Hart, 2000). Dyregtov et al. (2000) assessed the trauma exposure and psychological reactions to genocide among Rwandan children approximately a year after the genocide and concluded that 79% of the interviewed children presented moderate to severe post traumatic stress reactions. ...
... A study of trauma and post traumatic stress symptoms among adults Rwandan found that of the 2091 participants, 518 (24.8%) met symptoms criteria for PTSD (Pham, Weinstein & Longman, 2004). In a survey conducted by de Jong et al. (2000) to assess the prevalence of mental health problems in Rwandan and Burundese refugee camps, it was estimated that 50% (n=854) of adults who were living in these refugee camps suffered severe mental disorders. ...
... Although the prevalence of HIV has fallen in the past several years, many families continue to live with the illness in poverty and without strong access to services (13). The country's past history of genocide and war has been linked with widespread PTSD (14)(15)(16)(17) and depression (18,19) in adults nationwide, problems which are thought to have important intergenerational effects on parenting and child development (20)(21)(22)(23)(24)(25)(26)(27). ...
... Participants in free listing exercises were drawn from hospital waiting areas at Rwinkwavu District Hospital. Focus groups were composed of HIV-affected family members and were separated by gender and by age (caregivers; children ages 10-13; children ages [14][15][16][17]. Additional focus groups were held with community health workers, accompagnateurs, social workers, mental health staff, and pediatric doctors who interact regularly with HIV-affected families. ...
... The prevalence of psychiatric disorders Studies of the mental status of refugees from various regions of the world demonstrate very high rates of prevalence of mental disorders, especially posttraumatic stress disorder (PTSD), depression, and other anxiety disorder. De Jong et al. have found that the rate of the prevalence of "serious mental health problems" in Rwandan and Burundese refugee camps was 50% (de Jong et al. 2000), but the measured rate of psychiatric disorders could go up to 90% (Kinzie et al. 1990). In fact, the rates of the prevalence of psychiatric disorders in refugees varied in various studies, depending on the applied assessment method. ...
... A considerable number of refugees suffer from PTSD-related symptoms, which is related to the destructive influences that traumatic events and the conditions of life in exile had on their mental health (de Jong et al. 2000;Lavik et al. 1996). These persons can be especially sensitive to negative events in exile such as existential and housing problems, not only because of their individual characteristics but also because of their situation. ...
... ica iz razlicitih podrucja ukazuju na veoma visoke stope prevalencije mentalnih poremecaja, posebno posttraumatskog stresnog poremecaja (PTSP) i depresije, ali i drugih anksioznih poremecaja. De Jong i saradnici su u izbeglickim kampovima u Ruandi i Burundiju našli da je stopa prevalencije " ozbiljnih problema mentalnog zdravlja " iznosila 50% (de Jong i sar. 2000) , ali izmerena stopa psihijatrijskih poremecaja može da bude i do 90% (Kinzie i sar. 1990). Zapravo, stope prevalencije psihijatrijskih poremecaja medu izbeglicama variraju u razlicitim istraživanjima, zavisno od primenjenog metoda procene. Najcešci nacin procene je preko kratkih instrumenata za samoprocenu, ali nacelno prevalence osta ...
... Veliki broj osoba u izbeglištvu pati od simptoma povezanih sa PTSP -om, što je povezano sa destruktivnim uticajem koje na njihovo mentalno zdravlje imaju traumatski dogadaji i okolnosti života u izbeglištvu (de Jong i sar. 2000; Lavik i sar. 1996). Osobe mogu biti posebno osetljive na negativne dogadaje u izbeglištvu, kao što su egzistencijalni problemi i pitanje stanovanja, i to ne zbog svojih individualnih karakteristika nego zbog situacije u kojoj se nalaze. Izmedu posttraumatske patologije, koja dovodi do slabije sposobnosti za prilagodavanje, i loših soci ...
... Studies with adult refugees living in camps indicate prevalence rates between 30% and 55% for PTSD (Neuner et al., 2004;Riley, Varner, Ventevogel, Taimur Hasan, & Welton-Mitchell, 2017;Tekin et al., 2016) and between 10% and 89% for other mental health problems (de Jong, Scholte, Koeter, & Hart, 2000;Riley et al., 2017;Tekin et al., 2016). ...
... Onemonth prevalence of PTSD of parents is in the range of prevalence rates found in other studies in refugee camps (Neuner et al., 2004). However, we found higher levels of psychological distress in the parents in our sample than other studies (de Jong et al., 2000). Four distinct classes in the LCA supported our hypothesis to find a pattern of coexistence of morbidity within families. ...
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Background: Although the family constitutes the prime source of risk and resilience for thewell-being of children growing up in adverse conditions, the mental health of children livingin refugee camps has rarely been investigated in conjunction with their parents’mentalhealth. Objectives: To examine the prevalence of posttraumatic stress disorder (PTSD) and othermental health problems among Burundian refugee children and their parents living inTanzanian refugee camps and to identify patterns of comorbidity among children andtheir parents based on PTSD symptom levels and functional impairment. Methods: We recruited a representative sample of 230 children aged 7–15 years and both oftheir parents (n = 690) and conducted separate structured clinical interviews. Latent ClassAnalysis was applied to identify patterns of comorbidity. Results: Children and parents were exposed to multiple traumatic event types. In total, 5.7% of children fulfilled DSM-5 criteria for PTSD in the past month and 10.9% reported enhancedlevels of other mental health problems. 42.6% indicated clinically significant functionalimpairment due to PTSD symptoms. PTSD prevalence was higher among mothers (32.6%)and fathers (29.1%). Latent Class Analysis (LCA) revealed a familial accumulation of PTSDsymptoms as children with high symptom levels and impairment were likely to live infamilies with two traumatized parents. Conclusions: Although the number of children who need support for trauma-related mentalhealth problems was relatively low, taking into account parental trauma could aid to identifyat-risk children with elevated PTSD symptom levels and impairment even in the face ofexisting barriers to mental health care access for children in refugee camp settings (e.g. lackof targeted services, prioritization of managing daily stressors).
... When defining refugees, Canada uses the "Refugee Convention" definition (1951): " A refugee is a person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country..." According to a vast number of research studies, many refugees have experienced multiple traumatic events, significant associated posttraumatic symptoms, shaken identity, cultural loss, and mental health problems (i.e.Mollica, 2011;Flaherty, Gaviria, & Pathak, 1988;Carey, Stein, ZZungu-Dirwayi, & Seedat, 2003;Sareen, Coz, Stein, Afifi, Fleet, & Asmundson, 2007;Sledjeski, Speisman, & Dierker, 2008;Halvorsen & Stenmark, 2010;Kruse, Joksimovic, Cavka, Wöller, & Schmitz, 2009;Baþoðlu, 2006;Englund, 1998;Harris, 2009;Mollica, Cui, McInnes, & Massagli, 2002;Cardozo, Vergara, Agani, & Gotway, 2000Hollifield et al., 2002De Jong, Scholte, Koeter, & Hart, 2000;Porter & Haslam, 2001;Burnett & Peel, 2001;Kleijn, Hovens, & Rodenburg, 2001;Terheggen, Stroebe, & Kleber, 2001;Friedrich,1999). In the searching the literature for this research, social factors and rituals, cultural stories, and myths/legends and their effect on recovery from trauma were the focus of the review. ...
Article
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There has been some evidence of the benefits of participating in group analytic music therapy with traumatized people. This pilot clinical project investigates the impact of a combination of narrative therapy and group analytic music therapy on refugee/newcomer women in Canada. An ongoing therapy group met for a period of 8 sessions, to share stories and feelings of past experiences and of resettlement. The focus of this group was emotional expression (verbal and musical). Musical listening, improvisation, art, writing, clay-work, and relaxation techniques were used. Several consistent themes re-emerged, including feelings around loneliness, fear guilt, and loss. The analysis of the therapy process showed many commonalities among these women and the process they were going through to deal with their feelings.
... When repeated and prolonged traumatization, as well as difficulties with living in exile, are combined with worries about the future, the risk for mental health problems such as depression, anxiety disorders, and posttraumatic stress disorder (PTSD) increases. De Jong, Scholte, Koeter, and Hart (2000) reported that 50% of the refugees in Rwandan and Burundese camps had serious mental health problems. A study of Cambodian refugees living in the ThailandÁ Cambodia border camp indicated that 55% had depression and 15% had PTSD (Mollica et al., 1993). ...
Article
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The most common mental health problems among refugees are depression and posttraumatic stress disorder (PTSD). Eye movement desensitization and reprocessing (EMDR) is an effective treatment for PTSD. However, no previous randomized controlled trial (RCT) has been published on treating PTSD symptoms in a refugee camp population. Examining the effect of EMDR to reduce the PTSD and depression symptoms compared to a wait-list condition among Syrian refugees. Twenty-nine adult participants with PTSD symptoms were randomly allocated to either EMDR sessions (n=15) or wait-list control (n=14). The main outcome measures were Impact of Event Scale-Revised (IES-R) and Beck Depression Inventory (BDI-II) at posttreatment and 4-week follow-up. Analysis of covariance showed that the EMDR group had significantly lower trauma scores at posttreatment as compared with the wait-list group (d=1.78, 95% CI: 0.92-2.64). The EMDR group also had a lower depression score after treatment as compared with the wait-list group (d=1.14, 95% CI: 0.35-1.92). The pilot RCT indicated that EMDR may be effective in reducing PTSD and depression symptoms among Syrian refugees located in a camp. Larger RCTs to verify the (cost-) effectiveness of EMDR in similar populations are needed.
... In a large household-based survey (N = 3323) in the West Nile, some of us estimated the population prevalence of PTSD to be 48% in Southern Sudan, 46% for Sudanese refugees, and 18% for West Nile Ugandan nationals. De Jong, Scholte, and colleagues (De Jong et al., 2001;De Jong, Scholte, Koeter, & Hart, 2000;Scholte et al., 2004) found that 37% of the civilian respondents fulfilled the diagnosis for PTSD in Algeria, 28% in Cambodia, 18% in the Gaza, and 20% in Eastern Afghanistan. ...
Chapter
Disarmament, demobilization, and reintegration (DDR) programs are part of most international peace-building efforts and post-conflict interventions in developing countries. Well over a million former combatants have participated in DDR programs in more than 20 countries, the vast majority of them in sub-Saharan Africa. The impact, however, has remained disappointing. A significant portion of ex-combatants suffer from mental-health issues, caused by repeated exposure to severe psychological distress. Individuals with PTSD, depression, substance dependence, or psychotic conditions are heavily impaired in their daily functioning. It is often difficult for them to reintegrate into civilian society, and they are less able to support the process of reconciliation and peace-building within their communities and postwar areas at large. Others, who as child combatants adapted to a culture of violence and aggression, have never been taught the moral attitudes and the behavioral repertoire that are required in peaceful settings. These failures to adjust fuel cycles of violence that might reach across generations. Psychological components of DDR programs are frequently neither sufficiently specific nor professional enough to address reintegration failure and the threat of continuing domestic or armed violence. This chapter presents examples from post-conflict settings, in which specific and targeted mental-health interventions and dissemination methods have been successfully evaluated, including Narrative Exposure Therapy and Interpersonal Therapy. It suggests a comprehensive, community-based, DDR program, which offers mental-health treatment for affected individuals, as well as community interventions to facilitate reintegration and lasting peace.
... 6. Other studies on PTSD in Rwanda have already been carried out focusing mainly on reconciliation (Pham, Weinstein, and Longman 2004), on refugees (de Jong et al. 2000) or on children (Dyregrov et al. 2000), taking for granted the identities of the interviewees (Munyandamutsa et al. 2012). Furthermore, most studies have been conducted over a short period of time (Pham, Weinstein, and Longman 2004), with support from local institutions as gatekeepers (Bolton 2001) or de-contextualizing diagnosis completely (Hagengimana and Hinton 2009). ...
Article
In this work, I argue that among the mental illnesses recognized in Rwanda, post-traumatic stress disorder (or trauma) is uniquely exempted from social stigma due to its inextricable link with the 1994 genocide. As it afflicts only genocide survivors, trauma symptoms validate the recognition of violence and victimhood. Individuals do not occupy a space of moral uncertainty, as they embody the memory of the genocide and the innocence of its victims, and so participate in the creation of a historical past shared by all Rwandans. I investigate the legitimacy of trauma as a lens for understanding the relationship between morality and power. With that purpose in mind, I analyse the context in which trauma becomes a performative aspect of victimhood, disambiguating identities and mapping social relationships. Drawing on ethnographic data, I argue that the moral legitimacy associated with this psychiatric disorder is deeply rooted in its corporeal nature, as the translation of signs into symptoms is linked to, but also prescinds from, any immediate experience of violence. Data suggest that diagnoses of trauma often take into account individuals’ ethnic backgrounds, discerning between legitimate and illegitimate forms of memory, and appropriating the former within official historical discourses of the genocide. The production of moral entitlement through the body thus endorses a dichotomous logic that is crucial to the construction of an ideal status of nationhood which is built upon a very exclusivist recognition of suffering.
... Kinzie provided a report on one case based on psychological and psychopharmacological intervention. Recommendations for treatment include: Group counseling for refugees who have had similar traumatic experiences (Yule, 2000 ); psychosocial interventions for strengthening the community and providing support to large groups, using psychoeducational approaches, and management of therapeutic activity centers (De Jong, Scholte, Koeter, & Hart, 2000 ); and targeting psychosocial risk factors for enhancing treatments (Mollica, Cui, McInnes, & Massagli, 2002 ). ...
Chapter
Refugees are a special migration group and their counseling needs tend to be different from immigrants. The chapter identifies the primary task for therapists is to focus on resolving trauma, and posttraumatic effects of relocation, and providing coping strategies, along with attending to basic needs such as housing, acquisition of language and job skills. Once trauma resolution has been addressed identity development of refugees in host culture, and acculturation is explored. Further, this chapter explores culturally responsive healing approaches from trauma, and discusses counseling implications.
... Research on the mental health of refugees from the Great Lakes Region of Africa is limited but suggests high rates of distress. Among a random sample of Burundian and Rwandan refugees in camps, 50% met criteria for serious mental health problems (de Jong, Scholte, Koeter, & Hart, 2000). Among a sample of individuals in the Democratic Republic of Congo, approximately 42% met criteria for PTSD and 27% met criteria for depression (Pham, Vinck, Kinkodi, & Weinstein, 2010). ...
Article
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Refugees resettled in the United States have disproportionately high rates of psychological distress. Research has demonstrated the roles of postmigration stressors, including lack of meaningful social roles, poverty, unemployment, lack of environmental mastery, discrimination, limited English proficiency, and social isolation. We report a multimethod, within-group longitudinal pilot study involving the adaptation for African refugees of a community-based advocacy and learning intervention to address postmigration stressors. We found the intervention to be feasible, acceptable, and appropriate for African refugees. Growth trajectory analysis revealed significant decreases in participants' psychological distress and increases in quality of life, and also provided preliminary evidence of intervention mechanisms of change through the detection of mediating relationships whereby increased quality of life was mediated by increases in enculturation, English proficiency, and social support. Qualitative data helped to support and explain the quantitative data. Results demonstrate the importance of addressing the sociopolitical context of resettlement to promote the mental health of refugees and suggest a culturally appropriate, and replicable model for doing so. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
... That refugees have high rates of mental health problems has been well established (e.g. De Jong et al, 2000) -causes include migration, often with painful transit experiences, difficult camp life and the experience of major trauma, including multiple losses of family members as well as the loss of property and tradi tional lifestyle. However, the Afghan refugees in Pakistan have been poorly studied. ...
Article
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There was a large influx of Afghan refugees into Pakistan during the 1980s and in particular after the US invasion of Afghanistan in 2001. That refugees have high rates of mental health problems has been well established (e.g. De Jong et al , 2000) — causes include migration, often with painful transit experiences, difficult camp life and the experience of major trauma, including multiple losses of family members as well as the loss of property and traditional lifestyle. However, the Afghan refugees in Pakistan have been poorly studied. Although the mental health problems of Afghan refugees have been studied in the West, the numbers of participants in such research have been relatively small.
... Hanlon et al. (2014), working in five diverse countries (including Uganda, South Africa, and Ethiopia) present a strong case for the potential application of existing models of primary health care (with their estab- lished mechanisms of engaging and keeping people in treatment, outreach, and adherence support) to mental health care. Further, group-based treatments, espe- cially those focused on psychoeducation and mutual support, may be a viable, more cost-effective mode of treatment, and consistent with cultural values of social support (de Jong, Scholte, Koeter, & Hart, 2000). ...
Article
Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In individual interviews or written surveys in French or Kirundi with patients (N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each (“Would it work?” “Why or why not?”). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people’s beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.
... Refugees in camps seem to be particularly at risk. In a study of refugees residing in Rwandan and Burundese camps, 50% of them were found to have serious mental health problems (de Jong et al., 2000). A study of Cambodian refugees living in the Thailand-Cambodia border camp indicated that 15% had posttraumatic stress disorder (PTSD) and 55% depression (Mollica et al., 1993). ...
Article
Turkey is hosting the majority of Syrian refugees. The current study investigates the prevalence of probable posttraumatic stress disorder (PTSD) and depression among adult Syrians residing in a camp (N = 781) and potential predictors. The Impact of Event Scale-Revised was used to measure PTSD and the Beck Depression Inventory depression. Probable PTSD prevalence was 83.4%, with predictors being female sex (odds ratio [OR], 4.1), previous mental health problems (OR, 4.5), life threat (OR, 3.0), and injury of a loved one (OR, 1.8). Probable depression prevalence was 37.4%, with predictors being female sex (OR, 5.1), previous mental health problems (OR, 2.9), having a loved one who was tortured (OR, 1.7), and not being satisfied at the camp (OR, 1.7). The current study reveals high rates of probable PTSD and depression among Syrian refugees and highlights vulnerabilities such as great risk for women of having psychopathology.
... This resulted in 45 per cent of children showing symptoms of post-traumatic stress disorder and 44 per cent exhibiting indicators of depression (Sirin and Rogers-Sirin, 2015, p. 1). A similar pattern was also observed in adult refugee populations: in Tanzanian camps, a prevalence of mental health problems was found in around 50 per cent of Rwandan refugees (de Jong et al., 2000). ...
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This report analyses how mobile learning projects and practices are addressing: individual challenges that can negatively impact refugees’ learning opportunities as well as their lives beyond the learning environment; Education system challenges that transcend individual education levels and domains and stem from issues in the education system more broadly; and challenges related to educational levels that pertain to the different levels and types of education.
... inconsistent access to nutrition, interruption to education, poor sanitation, limited access to health care and child protection risks including sexual assault and violence (Reed et al., 2012, De Jong et al., 2000. ...
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Background: There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised non-specialist providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania. Methods: A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention. Results: Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of non-specialist facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE. Conclusions: The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.
... So far, it is unclear to what extent selection factors or the difference between regional conditions cause these differences. Researchers have suggested that factors such as poor quality of living within the refugee camp [50], experiences of racism in the host country, joblessness, administration difficulties in the camp [51], and insecurity in refugees' status and longer stay in the host country [52] contribute to the maintenance of mental health disorders and may be responsible for differences between countries. ...
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Abstract Background: Since the Syrian civil war began in March 2011, more than half of the Syrian population was forced to escape from their homes, and more than 5 million of them fled their country. The aim of the present study is to estimate the psychological consequences of this conflict among the refugee population who fled to Iraq. Method: In 2017, a team of locally trained psychologists and social workers interviewed 494 married couples (988 individuals) who were Syrian Kurdish refugees in the Kurdistan Region of Iraq. Validated Kurdish Kurmanji and Arabic versions of post-traumatic stress disorder (PTSD) Checklist for DSM-5 and depression section of Hopkins Symptom Checklist-25 were used for assessing PTSD and depression symptoms. Results: Almost all of the participants (98.5%) had experienced at least one traumatic event and 86.3% of them experienced three or more traumatic event types. The prevalence of probable PTSD was about 60%. Gender, length of time in the camp, area in which participants were grown up, and the number of traumatic event types were significant predictors for the presence of PTSD symptoms. Approximately the same rate of participants (59.4%) experienced probable depression, which was associated with gender, age, time spent in the camp, and the number of traumatic event types. Conclusion: PTSD and depression are prevalent among refugees exposed to traumatic events, and various variables play important roles. The pattern of risk factors in this population is consistent with findings from war-affected populations in other regions and should be considered for intervention within this population and more broadly. Keywords: Refugees, Syria, War, PTSD, Depression
... The majority (85%) of the world's 26 million refugees are hosted in low-and middle-income countries (LMIC) and 40% of the global refugee population are children under the age of 18 years [33]. The multiple risks to development and mental health faced by young people and their families during conflict are further compounded through displacement in LMIC contexts [30], particularly camp settings, where risks include inconsistent access to nutrition, interruption to education, poor sanitation, limited access to health care and child protection risks including sexual assault and violence [11,24]. ...
Article
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Background There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania. Methods A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention. Results Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE. Conclusions The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.
... The prevalence of psychopathology in refugees in camp settings is likely to be high owing to past traumatization and ongoing exposure to the chronic stressors of life in the camp; for example, high levels of violence, lack of food and basic necessities, and crowded housing (Reed, Fazel, Jones, Panter-Brick, & Stein, 2012). For instance, prevalence rates of 50% for serious mental health problems, for example, anxiety, depression, somatic symptoms, (de Jong, Scholte, Koeter, & Hart, 2000), and of up to 50.5% for PTSD (Neuner et al., 2004), have been found among adults living in refugee camps. Among youth living in refugee camps, rates for depressive symptoms ranged between 35% and 90% and for PTSD between 0% and 87% depending on the specific setting (Vossoughi, Jackson, Gusler, & Stone, 2018). ...
Article
Maltreatment by parents can be conceptualized as pathogenic escalations of a disturbed parent-child relationship that have devastating consequences for children's development and mental health. Although parental psychopathology has been shown to be a risk factor both for maltreatment and insecure attachment representations, these factors`joint contribution to child psychopathology has not been investigated. In a sample of Burundian refugee families living in refugee camps in Western Tanzania, the associations between attachment representations , maltreatment, and psychopathology were examined by conducting structured interviews with 226 children aged 7 to 15 and both their parents. Structural equation modeling revealed that children's insecure attachment representations and maltreatment by mothers fully mediated the relation between maternal and child psychopathology [model fit: comparative fit index (CFI) = 0.96; root mean square error of approximation (RMSEA) = 0.05]. A direct association between paternal and child psychopathology was observed (model fit: CFI = 0.96; RMSEA = 0.05). The findings suggest a vicious cycle, wherein an insecure attachment to a mother suffering from psychopathology may be linked to children's risk to be maltreated, which may reinforce insecure representations and perpetuate the pathogenic relational experience. Interventions targeting the attachment relationship and parental mental health may prevent negative child outcomes.
... When the refugees exposed to repeated and prolonged traumatization, with the difficulties of living situations, and fears from the unpredictable future, the probable rates of depression, anxiety, and PTSD increase. 3,4 A research showed that half of the studied refugees in Rwandan and Burundese camps had sever psychiatric disorders. Prevalence of PTSD ranges between (14%) and (37%) in community populations affected by war and (6-8%) in those non-affected by war as in the United States. ...
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Objectives: The present study aimed to determine the prevalence of posttraumatic stress disorder (PTSD); to identify the relationship between PTSD symptom severity with the experienced traumatic events; and, to assess whether quantity or quality of trauma exposure is associated more with PTSD symptom severity. Method: PTSD and its relation to traumatic experiences in a random sample of 820 Syrian refugees at Domiz 2 camp of the Northern Iraq in April- June 2015 were assessed. Face to face interviews were conducted to collect socio-demographic data, and level of trauma exposure and PTSD by Harvard Trauma Questionnaire (HTQ). Results: of the 820 Syrian refugees, 134 (16.3%) had PTSD symptomatology. The rate of PTSD among mildly traumatized refugees was (12%), among moderately traumatized refugees was (13.6%), and among severely traumatized respondents was (50%). PTSD rates were high among respondents experienced separation, physical and emotional violence. All trauma types, except sexual violence, were significantly associated with PTSD severity and a significant association was found between cumulative trauma effect and the severity of PTSD. Conclusion: PTSD symptom severity was related to cumulative traumatic events and was significantly associated with different trauma types. Important steps are needed to provide humanitarian protection to those who fled their countries and cross international borders. Mental health treatment programs are needed for Syrian refugees suffering from PTSD and other psychological problems.
... That being said, our study reports a lower rate of tobacco use when compared to other studies conducted in similar limited-resource settings [31]. Furthermore, though little information is available regarding the health conditions of individuals living in IDP camps, self-reported pre-existing conditions from our sample appear to be considerably low, particularly for chronic and mental health conditions, when compared to values expected from the literature [32][33][34][35]. Health staff administering surveys reported that many participants did not know what the surveyed conditions were, had little recollection of previous diagnoses, and had rarely visited a health professional in the past, which would be consistent with the significant lack of formal education (88.7%) among participants and lack of access to a nearby healthcare facility (48.2%) and may explain the lower reported prevalence of chronic, pre-existing conditions found in this study. ...
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Background: Three million internally displaced Somalis live in overcrowded settlements with weakened infrastructure, insufficient access to WASH facilities, and inaccessible health services. This vulnerable population is especially susceptible to COVID-19, which is expected to have worsened health outcomes and exacerbate existing structural challenges in the implementation of public health measures. This study examines knowledge of COVID-19, self-reported prevalence of preexisting conditions, and access to essential health services among residents of internally displaced persons (IDP) camps in Somalia. Methods: A descriptive, cross-sectional survey design assessing demographics, current health profiles, knowledge and perceptions of COVID-19, and access to resources was used. 401 Somali IDP camp residents completed the survey. Results: Though 77% of respondents reported taking at least one COVID-19 preventative public health measure, respondents reported a severe lack of access to adequate sanitation, an inability to practice social distancing, and nearly universal inability to receive a COVID-19 screening exam. Questions assessing knowledge surrounding COVID-19 prevention and treatment yielded answers of "I don't know" for roughly 50% of responses. The majority were not familiar with basic information about the virus or confident that they could receive medical services if infected. Those who perceived their health status to be "fair," as opposed to "good," showed 5.69 times higher odds of being concerned about contracting COVID-19. Respondents who felt more anxious or nervous and those who introduced one behavioral change to protect against COVID-19 transmission showed 10.16 and 5.20 times increased odds of being concerned about disease contraction, respectively. Conclusion: This study highlights immense gaps in the knowledge and perceptions of COVID-19 and access to treatment and preventative services among individuals living in Somali IDP camps. A massive influx of additional resources is required to adequately address COVID-19 in Somalia, starting with educating those individuals most vulnerable to infection.
... 30 31 Furthermore, although little information is available regarding the health conditions of individuals living in IDP camps globally, self-reported pre-existing conditions from our sample appear to be considerably low, particularly for chronic and mental health conditions, when compared with values expected from the literature. [32][33][34][35] Health staff administering surveys reported that many participants did not know what the surveyed conditions were, had little recollection of previous diagnoses and had rarely visited a health professional in the past. This is consistent with the significant lack of formal education among participants and lack of access to health facilities and may explain the lower reported prevalence of chronic, pre-existing conditions found in this study. ...
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Objectives This study examined knowledge and perceptions of COVID-19, prevalence of pre-existing conditions and access to essential resources among residents of internally displaced person (IDP) camps in Somalia, where overcrowded settlements with weakened infrastructure, inadequate water, sanitation, and hygiene facilities, and limited access to health services make this vulnerable population particularly susceptible to a COVID-19 outbreak. Design A descriptive, cross-sectional survey. Setting Twelve IDP camps across six areas of the Lower Shabelle region in Somalia. Participants 401 adult Somali IDP camp residents. Results The majority of participants were female (86%) and had received no formal education (89%). While 58% reported being in ‘good’ health, half of the participants reported having one or more pre-existing conditions. Though 77% of respondents reported taking at least one COVID-19 preventative public health measure, respondents reported a lack of access to adequate sanitation, an inability to practice social distancing and nearly universal inability to receive a COVID-19 screening exam. Questions assessing knowledge surrounding COVID-19 prevention and treatment yielded answers of ‘I don’t know’ for roughly 50% of responses. The majority of participants were not familiar with basic information about the virus or confident that they could receive medical services if infected. 185 (47%) respondents indicated that camp living conditions needed to change to prevent the spread of COVID-19. Conclusion This study highlights low levels of COVID-19 knowledge and limited access to essential prevention and treatment resources among individuals living in Somali IDP camps. A massive influx of additional resources is required to adequately address COVID-19 in Somalia, starting with codesigning interventions to educate those individuals most vulnerable to infection.
... Moreover, these traumatic events have consequences for refugees' mental health (Fazel, Wheeler, & Danesh, 2005). Their symptoms range from posttraumatic stress disorder, to anxiety and depression (de Jong, Scholte, Koeter, & Hart, 2000;Lopes Cardozo, Talley, Burton, & Crawford, 2004;Pavlish, 2007;Perera et al., 2013;. ...
Article
This study explores the daily life and its psychological meaning in a young refugee camp in Molé, in the North of the Democratic Republic of Congo (DRC). This is an original case study that aims to understand aspects from daily life in the camp, like health, education, food, shelters, hobbies, jobs, psychological needs, and its main psychological consequences. This research was exploratory and qualitative, based on open-ended questions, participant observation, and recording of photos, with eight Central-African refugee camp inhabitants. The main results point to a permanent focus on the bad living conditions in the camp, associated with sadness, hopelessness, deep psychological suffering, and uncertainty about the future. The discussion of these results is necessary to understand life in camps and to improve life conditions with other types of protection, since camps are an immediate solution. It is also important to address refugees’ psychological needs and to draw community and individual interventions as early as possible in order to mitigate their suffering.
... Many studies have found high rates of psychiatric disorder among refugees. Post-traumatic stress disorder (PTSD) and depression are the most common (de Jong et al, 2000). Wide variation in the rates of disorder can be attributed to differing cultures and experiences in the groups sampled. ...
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What follows is an attempt to describe the provision of mental health care for refugees (including asylum seekers). Our views are based on our work with refugees in inner-London and on consultation with service providers. There are some 50 million refugees and displaced persons in the world ([
... For example, refugees from Cambodia, Laos, Vietnam, Sierra Leone, Bhutan, and Bosnia have had high rates of exposure to trauma and torture and symptoms correlating with anxiety, depression, and posttraumatic stress disorder (PTSD). [4][5][6][7][8][9][10] Very few studies describe mental illness in African refugees 9,[11][12][13] ; published work on this topic pertaining to Somali refugees is not readily available. ...
Article
Objective: To study how mental illness is understood, expressed, and treated among Somali refugees and how these factors influence use of health services for mental problems. Method: Seventeen adult Somali refugees (9 women, 8 men) were recruited by mail or by word-of-mouth to participate in the study. The study setting was an urban community health center in Rochester, N.Y., that provides family practice patient care to local Somali refugees. A qualitative design was used that incorporated a combination of methods, chiefly semistructured interviews. Interviews focused on the ways in which sadness, depression, and anxiety are expressed and on the participants' understanding of the origins of and treatment strategies for these problems. Interview transcripts were analyzed to identify recurrent themes. Results: Nearly all participants felt that mental illness was a new problem for their community that did not exist to the same extent in prewar Somalia. Themes that emerged to explain the causes of mental illness included the shock and devastation of war; dead, missing, or separated family members; and spirit possession or a curse. Three major types of mental problems were identified that were associated with specific behaviors and treatment strategies: murug (sadness or suffering), gini (craziness due to spirit possession), and waali (craziness due to severe trauma). Rather than seek help from a clinician, participants preferred to first use family support, prayer, or traditional therapies for most situations. Conclusion: Somali refugees have distinct ways of conceptualizing, expressing, and treating commonly understood mental problems. Participants differed in their opinions about whether they would consult a doctor to discuss feelings of sadness or craziness. Effective mental health care of refugees should address culture-specific belief systems in diagnosis and treatment.
... On the other hand, the challenges required to earn the refugee status at the arrived country, acculturation problems experienced while trying to adjust to the culture and language or waiting for acceptance by the country of final arrival may be listed among other major stressors experienced by refugees and asylum seekers [5] Studies conducted up to now, reported that 35.0-50.0% of forcibly displaced children may experience mental problems and that the most frequent diagnoses were Post-traumatic Stress Disorder (PTSD), depression and anxiety disorders [6][7][8]. Problems such as experiencing traumatic stressors in the country of origin like open conflict/assault, loss of parents, negative socioeconomic conditions prior to migration, lack of access to adequate habitation, nutrition, health and education at the target country and problems of acculturation lead to negative physical, social and emotional consequences for refugee and migrant children, thereby increasing the risk of psychiatric disorders [9,10]. ...
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Aim: We aimed to determine traumatic events, mental health problems and predictors of PTSD in a sample of conditional refugee children. Methods: The sociodemographic features, chief complaints, traumatic experiences and psychiatric diagnoses according to DSM-5 were evaluated retrospectively. Results: 20.7% (n = 70) of children experienced the armed conflict or exposed to firefights at their country of origin. Most common diagnoses were anxiety disorders (n = 82, 24.3%), major depressive disorder (n = 52, 15.4%) and PTSD (n = 43, 12.7%). Age, number of traumatic experiences, explosion and sexual violence are the most important predictors for PTSD. Conclusions: Our results suggest that the number of traumas exposed as well as their nature predicted PTSD diagnosis. Refugee children have increased risk for psychiatric problems after migration and resettlement underlining the importance of an adequate follow-up for mental health and ensuring social support networks.
Article
The purpose of this article is to review the available literature on the intersections of religion and migration with reference to African refugees and migrants. I draw primarily on works that have emerged in the last decade to address both the under-explored role of religion in the lives of African refugees and migrants and the active role they play in shaping the religious landscape in their migratory contexts and in their countries of origin. Published research on religion and African migration varies in scope, ranging from rich descriptions of the religious beliefs and practices of refugees in rural camps in Africa to analyzes of the impact of religion on the realities of settlement faced by African migrants in urban cities in Europe. Other works investigate processes of societal change resulting from the intersection of religion and African migration, while others examine how religious institutions that have come into being to deal with the spiritual and socio-economic and political needs of African refugees and migrants and their efforts to maintain contact with people in their homeland. I argue that future research could benefit from moving beyond individual case studies that reflect particular disciplinary perspectives to more comparative and intra-disciplinary analyzes of migrant identities and experiences. Such studies have the potential to inform about conceptual and experiential differences of being an African migrant and alternately, what it entails to be European or American in the age of globalization.
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Introduction: Research in several international settings indicates that children and adolescents affected by HIV and other compounded adversities are at increased risk for a range of mental health problems including depression, anxiety, and social withdrawal. More intervention research is needed to develop valid measurement and intervention tools to address child mental health in such settings. Objective: This article presents a collaborative mixed-methods approach to designing and evaluating a mental health intervention to assist families facing multiple adversities in Rwanda. Methods: Qualitative methods were used to gain knowledge of culturally-relevant mental health problems in children and adolescents, individual, family and community resources, and contextual dynamics among HIV-affected families. This data was used to guide the selection and adaptation of mental health measures to assess intervention outcomes. Measures were subjected to a quantitative validation exercise. Qualitative data and community advisory board input also informed the selection and adaptation of a family-based preventive intervention to reduce the risk for mental health problems among children in families affected by HIV.. Community-based participatory methods were used to ensure that the intervention targeted relevant problems manifest in Rwandan children and families and built on local strengths. Results: Qualitative data on culturally-appropriate practices for building resilience in vulnerable families has enriched the development of a Family-Strengthening Intervention (FSI). Input from community partners has also contributed to creating a feasible and culturally-relevant intervention. Mental health measures demonstrate strong performance in this population. Conclusion: The mixed-methods model discussed represents a refined, multi-phase protocol for incorporating qualitative data and community input in the development and evaluation of feasible, culturally-sound quantitative assessments and intervention models. The mixed-methods approach may be applied to research in other parts of sub-Saharan Africa and beyond.
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This article addresses the ways in which years of war and periods of serious drought have affected the cultural representations of the populations in Gorongosa District, Mozambique. In the wake of these events different cultural and historical representations have been disrupted, leaving the members of these communities with fragmented protective and resilience factors to cope effectively. Emphasis is placed on the disruption of madzawde, a mechanism that regulates the relationship between the child (one to two years of life) and the mother, and the family in general. The war, aggravated by famine, prevented the populations from performing this child-rearing practice. Nearly a decade after the war ended, the posttraumatic effects of this disruption are still being observed both by traditional healers and health-care workers at the district hospital. The results suggest that this disruption is affecting and compromising the development of the child and the physical and psychological health of the mother. An in-depth understanding of this level of trauma and posttraumatic effects is instrumental in making a culturally sensitive diagnosis and in developing effective intervention strategies based on local knowledge that has not been entirely lost but is nonetheless being questioned. ©2003 Michigan Association for Infant Mental Health.
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There is scant documentation of the mental health characteristics of low-income communities recovering from armed conflict. To prepare for quantitative health surveys and health service planning in Burundi, we implemented a qualitative study to explore concepts related to mental distress and coping among adults. Mental distress was defined as problems related to feelings, thinking, behaviour and physical stress. Using free listing and key informant interviews with a range of community members, we triangulated data to identify salient issues. Thirty-eight free list respondents and 23 key informants were interviewed in 5 rural communities in Burundi using 2 interview guides from the WHO Toolkit for Mental Health Assessment in Humanitarian Settings. Based on these interviews, we identified four locally defined idioms/terms relating to mental distress: ihahamuka (anxiety spectrum illnesses), ukutiyemera (a mix of depression and anxiety-like syndrome), akabonge (depression/grief-like syndrome) and kwamana ubwoba burengeje (anxiety-like syndrome). Mental distress terms were perceived as important problems impacting community development. Affected individuals sought help from several sources within the community, including community leaders and traditional healers. We discuss how local expressions of distress can be used to tailor health research and service integration from the bottom up.
Article
Constructivist, hands-on, inquiry-based, science activities may have a curative potential that could be valuable in a psychological assistance programme for child victims of violence and war. To investigate this idea, pilot sessions were performed in an orphanage located in Ruhengeri, Rwanda, with seven young adults and two groups of 11 children aged from 9 to 16 years. Despite a number of imperfections in this attempt, significant observations have been made. First, a sound communication was established with all, even with the young adults who at the beginning were not as enthusiastic as the children. Furthermore, some children, originally isolated, silent and sad, displayed a high degree of happiness during the activities, and an overall increasing positive change of attitude. In addition, they appropriated well some principles of experimental science. This suggests that a joint development of science literacy and joy may be an interesting approach, both in education and therapy.
Article
In order to create an economic measure of the direct and indirect effects of crime, it is necessary to consider the effects of crime on victims. The article reviews the state of research into the effects of crime on individuals, in respect of personal and household victimisation, and the effects of crime on businesses. General population surveys have concentrated upon the common property offences and minor violence and have tended to ignore the dimension of the course of victimisation over time. Longitudinal studies are rare and have concentrated upon serious violent crime. Because of the element of clinical judgment, much work on PTSD is unsuitable for creating an economic measure of effects over all types of crime. There needs to be a marriage of survey methodology with time measures, possibly using a panel design.
Article
Genocide, defined as 'the deliberate and systematic extermination of a national, racial, political, or cultural group has stained human history. For example, in relatively recent times several episodes of genocide took place. In 1915, over one and a half million Armenians lost their lives at the hands of the Ottoman Empire. Later, in 1933-1945, about six million Jews lost their lives in Nazi-occupied Europe and North African. More recently, in 1994, an estimated 700,000 to one million Tutsis lost their lives at the hand of the Hutus in Rwanda. There were others that have dotted the map of Asia, Central America and the Balkans. This chapter reviews the research evidence on the psychopathological aftermath of two of those episodes, the Jewish Holocaust and the Tutsi genocide in Africa.
Article
Refugees and internally displaced persons remain high on the international priority agenda as a result of war, inter-ethnic conflict and other forms of violent conflict. 1.5 billion people live in countries affected by violent conflict with an estimated 40 % of post-conflict societies returning to conflict within 10 years. This chapter focuses on the health and mental health impact on the refugee experience. A new model of refugee care called the H 5Model of Refugee Trauma and Recovery is presented. The centerpiece of this model is the appreciation of the traumatic life history of refugees and their communities including past, present and threatening future traumatic life events. The five elements of the H 5 Model taken up in detail include: (1) Human Rights; (2) Humiliation; (3) Healing (self-care); (4) Health Promotion; (5) Habitat and Housing. The cultural and scientific evidence behind this model is presented. This chapter lays out a roadmap for the implementation of a new approach to the recovery of refugee communities worldwide.
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Introduction Despite high levels of mental distress, accessing psychological treatment is difficult for asylum seekers in Western host countries due to a lack of knowledge about mental disorders, and the health system, as well as due to cultural and language barriers. This study aims to investigate whether brief culturally sensitive and transdiagnostic psychoeducation is effective in increasing mental health literacy. Methods and analysis The study is a parallel two-group randomised controlled trial with 1:1 individual allocation to either culturally sensitive, low-threshold psychoeducation (‘Tea Garden’ (TG)) or a waitlist (WL) control group. It takes place at four study sites in Germany. A total of 166 adult asylum seekers who report at least mild mental distress will be randomly assigned. The TG consists of two 90 min group sessions and provides information about mental distress, resources and mental health services in a culturally sensitive manner. The primary outcome is the percentage of participants in the TG, as compared with the WL, achieving an increase in knowledge concerning symptoms of mental disorders, individual resources and mental healthcare from preintervention to postintervention. The further trajectory will be assessed 2 and 6 months after the end of the intervention. Secondary outcomes include changes in mental distress, openness towards psychotherapy and resilience. Furthermore, healthcare utilisation and economics will be assessed at all assessment points. Ethics and dissemination The study has been approved by the Ethics Commission of the German Psychological Society (ref: WeiseCornelia2019-10-18VA). Results will be disseminated via presentations, publication in international journals and national outlets for clinicians. Furthermore, intervention materials will be available, and the existing network will be used to disseminate and implement the interventions into routine healthcare. Trial registration number DRKS00020564; Pre-results. Protocol version 2020-10-06, version number: VO2F.
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Article
A pilot study and two intensive studies were conducted to document the local vocabularies used by Burundians to describe mental health problems and their understandings about the causes. The pilot study-in which 14 different large groups of community members awaiting appointments at a village health clinic were engaged in open-ended discussions of the local terminology and causal beliefs about mental health problems-suggested three key syndromes: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In Study 1 ( N = 542), individual interviews or surveys presented participants with the names of these syndromes and asked what they considered to be the symptoms and causes of them. Study 2 ( N = 143) cross-validated these terms with a different sample (also in individual interviews/surveys), by presenting the symptom clusters and asking what each would be called and about their causes. Findings of both studies validated this set of terms and yielded a rich body of data about causal beliefs. The influence of education level and gender on familiarity with these terms was also assessed. Implications for the development of mental health services and directions for future research are discussed.
Article
Aims: The Syrian conflict has generated a large flow of refugees, more than one million of them located in Lebanon. Very few studies were conducted on mental health of Syrian refugees. The objective of this study was to examine post-traumatic stress disorder (PTSD) symptoms and to determine the associated risk factors in a sample of Syrian refugees living in North Lebanon. Methods: An observational cross-sectional study was conducted, during February and March 2016, on a random sample of 450 (84.67% women and 15.33% men) Syrian refugees, aged between 14 and 45 years, living in North Lebanon. Each participant was interviewed individually using the Primary Care-PTSD (PC-PTSD) screening tool, translated into Arabic, with a back-translation to the original language to verify its accuracy. Reporting three or more PTSD symptoms was defined as a positive screen. Descriptive statistics and multiple regression analyses were used to examine the prevalence of a positive PTSD screen and associations with socio-demographic and health-related characteristics. Results: The prevalence of positive PTSD screen in our sample of Syrian refugees was 47.3%. There were statistically significant associations between a positive PTSD screen and being a woman (P=0.011), married (P<0.001), older than 18 years (P=0.006), having chronic medical conditions (P<0.001) and reporting more than 2 stressful life events (P<0.001). Conclusion: The results of this survey are alarming, with high proportions of refugees at risk for PTSD. Early screening may help identify individuals who would benefit from interventions to improve mental health.
Chapter
The global increase in refugees has led to a number of critical challenges, which should be addressed by an interdisciplinary approach to permit identification and understanding of the complex needs and vulnerabilities of the diverse refugee groups, and guide both emergency aid and long-term planning.
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Background Over 240 million children live in countries affected by conflict or fragility, and such settings are known to be linked to increased psychological distress and risk of mental disorders. While guidelines are in place, high-quality evidence to inform mental health and psychosocial support (MHPSS) interventions in conflict settings is lacking. This systematic review aimed to synthesise existing information on the delivery, coverage and effectiveness of MHPSS for conflict-affected women and children in low-income and middle-income countries (LMICs). Methods We searched Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Psychological Information Database (PsycINFO)databases for indexed literature published from January 1990 to March 2018. Grey literature was searched on the websites of 10 major humanitarian organisations. Eligible publications reported on an MHPSS intervention delivered to conflict-affected women or children in LMICs. We extracted and synthesised information on intervention delivery characteristics, including delivery site and personnel involved, as well as delivery barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data. Results The search yielded 37 854 unique records, of which 157 were included in the review. Most publications were situated in Sub-Saharan Africa (n=65) and Middle East and North Africa (n=36), and many reported on observational research studies (n=57) or were non-research reports (n=53). Almost half described MHPSS interventions targeted at children and adolescents (n=68). Psychosocial support was the most frequently reported intervention delivered, followed by training interventions and screening for referral or treatment. Only 19 publications reported on MHPSS intervention coverage or effectiveness. Discussion Despite the growing literature, more efforts are needed to further establish and better document MHPSS intervention research and practice in conflict settings. Multisectoral collaboration and better use of existing social support networks are encouraged to increase reach and sustainability of MHPSS interventions. PROSPERO registration number CRD42019125221.
Article
Improving food security status through socio-economic ‎determinants is always important at the household level. In this study, ‎after assessing the food security level of households in urban and rural ‎areas of Khuzestan province, associated factors including economic, social, and racial with food security were identified in 1397. To achieve the goals, 1876 and ‎‎1495 questionnaires were collected in urban and rural areas ‎respectively. The logistic regression model was used to identify effective ‎factors. The results showed that 63 % and ‎‎68 % of households in urban and rural areas face food insecurity respectively. Hamidiyeh county with 18 %, Omidieh 25 % ‎, and Dezful 28 % had the least percent of food secured households in the urban areas of Khuzestan province, respectively. Also, ‎the cities of Shadegan with 13 %, Izeh with 15 %, and Mahshahr port with ‎‎18 % had the least percent of food security households in ‎rural areas, respectively. The results of the quantitative estimated model in the present study showed that employment of the head of the household, income, number of rooms and personal car ownership were significantly and directly associated with food security in urban and rural areas of Khuzestan province. Therefore, due to the weakness of income policies which are applying as the only ways to ameliorate food security status in Iran, paying close attention to socio-economic factors related to improving the level of household food security before any intervention is necessary.
Article
According to 2019 data, there are 26 million refugees and 3.5 million asylum seekers around the globe, representing a major humanitarian crisis. This Major Contribution provides information on the experiences of refugees resettled in the United States via the presentation of five manuscripts. In this introductory article, we address the current refugee crisis, refugee policies, and resettlement processes in the United States, as well as the American Psychological Association’s response to the crisis and the role of counseling psychology in serving refugees. Next follows three empirical articles, addressing aspects of the resettlement experiences of three groups of refugees: Somali, Burmese, and Syrian. The final article provides an overview of a culturally responsive intervention model to use when working with refugees.
Article
This article follows recent publications regarding the conceptualization of refugees’ trauma (Transcultural Psychiatry, 2000, Vol. 37, No. 3), and describes the neglected and misunderstood perspective of child and adolescent psychiatry. The first issues concern the validity, social impairment and multiaxial understanding of psychiatric disorders such as post-traumatic stress disorder and depression that occur in young refugees. Second, aspects of the variability in risk and resilience of young refugees are discussed. Third, it is suggested that the psychiatric perspective is compatible with the tiering of mental health services, with accessible community-based services for many children, and specialist clinic-based services for those whose problems are more complex and associated with greater impairment. These issues are illustrated by a brief account of a school-based refugee mental health service.
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More than 700,000 refugees from Southeast Asia have settled in the United States since 1975. Although many have suffered serious trauma, including torture, few clinical reports have described their trauma-related symptoms and psychosocial problems. The authors conducted a treatment study of 52 patients in a clinic for Indochinese. They found that these patients were a highly traumatized group; each had experienced a mean of 10 traumatic events and two torture experiences. Many of the patients had concurrent diagnoses of major affective disorder and posttraumatic stress disorder as well as medical and social disabilities associated with their history of trauma. The authors also found that Cambodian women without spouses demonstrated more serious psychiatric and social impairments than all other Indochinese patient groups.
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The prevalence and course of mental disorders among Vietnamese refugees were studied, using a model including variables from different research traditions. A consecutive community cohort of 145 Vietnamese boat refugees aged 15 and above were personally interviewed on their arrival in Norway and three years later. Three years later, there was, unexpectedly, no decline in self-rated psychological distress (SCL-90-R), almost one in four suffered from psychiatric disorder and the prevalence of depression was 17.7% (Present State Examination). Female gender, extreme traumatic stress in Vietnam, negative life events in Norway, lack of a close confidant and chronic family separation were identified as predictors of psychopathology. The effects of war and persecution were long-lasting, and compounded by adversity factors in exile. A uniform course of improvement in mental health after resettlement cannot be expected in all contexts. The affected refugees need systematic rehabilitation.
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Refugees have long been considered at risk for mental disorder. We sought to characterise this risk in an out-patient refugee sample by analysing the relationship between psychiatric symptoms and dysfunction, and between symptoms and the socio-demographic background and stressors specific to this refugee sample. A consecutive sample of 231 refugee patients referred to the psychiatric out-patient unit at the Psychosocial Centre for Refugees, University of Oslo, was examined with a semi-structured interview guide, Brief Psychiatric Rating Scale (BPRS), Hopkins Symptom Check-List (HSCL-25) and a check-list for post-traumatic symptoms (PTSS-10). Global Assessment of Function (GAF) scores were obtained; and the data were analysed using nine predictor variables. It was found that 46.6% of the patients had a post-traumatic stress disorder according to the criteria for DSM-III-R as the main diagnosis, while the mean GAF score for the patients was 57.3. Analysis of the GAF and BPRS data did not reveal any predictor of psychotic behaviour. However, torture emerged as an important predictor of emotional withdrawal/retardation. Also, age, gender and no employment or education predicted for anxiety/depression, while refugee status and no employment or school predicted for hostility/aggression. The results confirm earlier findings that refugees constitute a population at risk for mental disorder. Past traumatic stressors and current existence in exile constitute independent risk factors. However, stressors other than those discussed here appear to be important also, particularly with regard to psychotic symptoms.
Article
Objective. —To assess the long-term impact of trauma and confinement on the functional health and mental health status of Cambodian displaced persons living on the Thailand-Cambodia border.Design. —Household survey of 993 adults randomly selected from household rosters. Household sample selection by multistage area probability sample.Setting. —Site 2, the largest Cambodian displaced-persons camp on the Thailand-Cambodia border.Participants. —Adults 18 years of age and older selected at random within households; 98% of eligible persons selected agreed to participate.Results. —From 1975 through 1979 (Khmer Rouge regime), more than 85% reported lack of food, water, shelter, and medical care, brainwashing, and forced labor; 54% reported murder of a family member or friend; 36% reported torture; 18% reported head injury; and 17% reported rape or sexual abuse. During the refugee period between 1980 and 1990, 56% reported lack of food or water, 44% reported lack of shelter, 28% reported lack of medical care, 24% reported brainwashing, and 8% reported torture. Since 1980, reports of murder of a family member, head injury, and rape/sexual abuse have decreased to 5%. Reports of experiencing combat situations and shelling attacks have remained consistent between the two time periods, approximately 44% and 30%, respectively. From 1989 to 1990, 25% reported experiencing lack of food or water, and 5% to 10% reported serious injury, combat, and shelling conditions. More than 80% said they were in fair or poor health, felt depressed, and had a number of somatic complaints despite good access to medical services. Fifty-five percent and 15% had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Fifteen percent to 20% reported health impairments limiting activity, and moderate or severe bodily pain. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents.Conclusions. —Reports of extensive trauma, poor health status, and depressive symptoms of this population are of concern in predicting future morbidity and mortality. The health and mental health needs of Cambodian displaced persons and their impact on social and economic behavior should be addressed now that the Cambodians have been repatriated.(JAMA. 1993;270:581-586)
Article
The term ‘somatization' carries a wide range of meanings and its use in transcultural psychiatry needs to be placed in context. Somatic presentations of psychiatric disorders are common in all ethnic groups; particularly high rates are reported in non-Western cultures and among ethnic minority groups in the West. An analysis of the language of emotion in different cultures indicates three basic modes of expression: somatic sensations, somatic metaphor, and abstract psychological language. Examples of all three modes can also be found in ancient literature, such as the Hebrew Bible and the epics of Homer. The absence of specific words for depression or anxiety is not associated with any lack of psychological-mindedness. Transcultural research in psychiatry needs to pay close attention to methodological issues to avoid ethnocentric bias. Currently-available instruments for cross-cultural research on somatic symptoms are reviewed. These have been used to examine the extent of cultural differences in the experience and expression of somatic symptoms. In the light of these findings, the validity of the concept of ‘somatization' is questioned, particularly because of its inherent dualism. Finally, a new model of somatic symptom formation is proposed which takes account of language, cultural beliefs and cultural norms of illness behaviour.
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Treating the consequences of violence in refugees, immigrants, and other minority groups is complicated by several factors. One of these factors involves the treatment of such problems, which are often related to both past violence as well as to current adverse conditions or precipitants. Another factor relates to cross-cultural assessment and treatment, which requires special education, experience, and supervision. Thirdly, there is usually the matter of concurrent acculturation, which may be undermined by biopsychosocial maladjustment due to past violence and which may in turn precipitate psychiatric syndromes that are related to previous violence. The future implications of these factors for research, training, and service needs are reviewed in this paper.
Article
A method is described for the use of a two-phase design in a prevalence survey of non-psychotic psychiatric morbidity. The method consists of screening a population sample, then giving a standardised psychiatric interview to varying proportions of those screened, stratified according to the probability of each respondent's being a case. Prevalence rates can then be calculated by weighting back to the original population. By harnessing together two well-proven instruments, the General Health Questionnaire and the Present State Examination, one can obtain a rigorous and internationally comparable description of morbidity while at the same time efficiently deploying scientific staff in the field.
Article
Synopsis A two-phase study of psychiatric prevalence has been carried out among the inhabitants (aged 18–64) of a Dutch health area (Nijmegen). In phase 1, a random sample of 3232 persons answered the GHQ–30 (response rate:75%). In phase 2,486 of the respondents were interviewed withthe full PSE within two weeks. The relationship of PSE-‘caseness’ (ID ≥ 5) and GHQ score was expressed in a logistic regression model, the parameters of which showed strong agreement with the Canberra results, for all socio-demographic variables examined, except for urbanization. means of the logistic model the point-prevalence of PSE cases was calculated at 7·3% (range5·5%-9·2%). Prevalence did not differ significantly in men and women. Higher case rates were found in age category of 55–59 years, among divorced and widowed persons, the lower educational and occupational levels, the unemployed, chronically ill and unable to work, and with city people. This study adds further evidence to a growing body of epidemiological data suggesting similar rates and patterns of psychiatric disorder in populations in industrialized countries.
Article
There are pitfalls in the singular application of western categories in diagnosing psychiatric disorders and distress among refugees. Based on my research with Cambodian refugees I argue that cultural bereavement, by mapping the subjective experience of refugees, gives meaning to the refugee's distress, clarifies the 'structure' of the person's reactions to loss, frames psychiatric disorder in some refugees, and complements the psychiatric diagnostic categories. Cultural bereavement includes the refugees' picture--what the trauma meant to them; their cultural recipes for signalling their distress; and their cultural strategies for overcoming it--and the cultural interpretation of symptoms commonly found among refugees that resemble post-traumatic stress disorder. Cultural bereavement may identify those people who have post-traumatic stress disorder on the Diagnostic and Statistical Manual (DSM) criteria but whose 'condition' is a sign of normal, even constructive, rehabilitation from devastatingly traumatic experiences. Cultural bereavement should be given appropriate status in the nosology.
Article
All 322 patients at a psychiatric clinic for Indochinese refugees were surveyed to determine the presence of posttraumatic stress disorder (PTSD). If PTSD was not diagnosed at the time of initial evaluation, a structured reinterview was performed. Seventy percent of the patients (N = 226) met the criteria for a current diagnosis of PTSD, and an additional 5% (N = 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93%) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1988, 46% (N = 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make.
Article
It is made abundantly clear by a number of recent epidemiological studies that chronic Post-Traumatic Stress Disorder (PTSD) exacts a heavy toll in psychosocial disability. Of particular interest is the unusual epidemiological analysis of mortality rates among young men chosen by the draft for military service during the Vietnam war era compared with those who were not chosen
Article
The authors describe the psychiatric assessments and trauma testimonies of 20 Bosnian refugees of "ethnic cleansing" who have recently resettled in the United States. Refugees referred from agencies managing refugee resettlement underwent systematic, trauma-focused, clinical interviews that included standardized assessment scales. The traumatic experiences of ethnic cleansing in these Bosnian refugees were genocidal in nature. The number of types of traumatic experiences correlated positively with age. Posttraumatic stress disorder (PTSD) was diagnosed in 65% of the refugees, and depressive disorders in 35%. PTSD severity scores were correlated with the number of types of traumatic events experienced. Ethnic cleansing has caused high rates of PTSD and depression, as well as other forms of psychological morbidity, in this group of resettled Bosnian refugees. The longitudinal sequelae of ethnic cleansing as a form of massive psychic trauma remain to be studied.
Article
Synopsis In this study we assessed the accuracy of the General Health Questionnaire in detecting psychiatric disorders in general medical out-patients. A total of 290 newly referred patients were interviewed with the Present State Examination. Prior to the interview, 112 patients completed the full GHQ-60, 100 completed the GHQ-30 and 78 completed the GHQ-12. Data from the first group were used to study the full GHQ-60, together with the GHQ-30 and and GHQ-12, when disembedded from the full questionnaire. In a comparison between the disembedded and the separate versions of the GHQ-30 and GHQ-12 we observed considerable variation in the cut-off scores where a certain sensitivity and specificity was attained. In ROC-analysis, the versions were not materially different in their discriminatory capacity (area under the curve). The use of different criteria to define a ‘case’ demonstrated that case severity was another source of increasing cut-off scores. Our data demonstrate that the use of disembedded or separate versions of the questionnaire, together with variation in the case criteria can be a major explanation for variation in cut-off scores that was observed in previous studies.
Article
A community cohort of 145 Vietnamese boat refugees in Norway was prospectively studied for presence of chronic posttraumatic stress disorder (PTSD) after resettlement. Ten percent had PTSD on arrival and/or after 3 years. This group had been exposed to significantly more traumatic stress before their escape (e.g., reeducation camps, combat, and other war incidents) and had more psychopathology (SCL-90-R Global Assessment Scale) after resettlement. A logistic regression analysis indicated that different types of traumatic stress had an independent relationship with chronic PTSD. Nine SCL-90-R items discriminated between the PTSD group and the rest both on arrival and follow-up. These were not anxiety items, but related to interpersonal sensitivity, somatization, and aggression. The inclusion of additional diagnostic features in the criteria for chronic PTSD is indicated.
Article
This study's purpose was a) to determine the prevalence of DSM-III-R disorders in newly arrived ethnic Vietnamese and ethnic Chinese refugees from Vietnam and b) to determine the correlates of DSM-III-R disorders. A Vietnamese-speaking psychiatrist administered translated sections of the Structured Clinical Interview for DSM-III-R to 201 Vietnamese new arrivals undergoing mandatory health screening. Overall, 18.4% had one or more current disorders: 8.5% had adjustment disorder and 5.5% had major depression. Ethnic Vietnamese, compared with ethnic Chinese, had significantly (p < .05) higher rates of current posttraumatic stress disorder and generalized anxiety disorder. Ethnic differences in psychopathology were largely explained by the fact that ethnic Vietnamese refugees had experienced more traumatic events and separation from family. After adjusting for ethnicity, refugees who reported traumatic events, refugees who were married, and veterans were significantly (p < .05) more likely to have one or more psychiatric disorders.
Article
Sixty-nine Cambodian adolescents and young adults were interviewed to determine their experience as children surviving the Pol Pot regime (1975-1979); their first-year experience of resettlement in this country; and their experience of stressful events during the past year. Current DSM-III-R diagnostic status was also determined. A strong relationship between earlier war trauma, resettlement strain, and symptoms of posttraumatic stress disorder (PTSD) was found. In contrast, the strongest relationship with depressive symptoms was found for recent stressful events. These results are discussed in light of current findings from stress and PTSD research.
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