A nurturing and caring environment to facilitate nursing students' professional development in Rwanda: a focused ethnographic study.

OBJECTIVES: To explore the values, practices, and behaviours that support nursing students' professional development in practice-based learning environments in Rwanda. METHODS: A focused ethnographic approach was used. Nursing students (n=12), nurses (n=11), clinical instructors (n=7) and nurse leaders (n=8) from three teaching hospitals and an educational program participated in the study. Data was collected trough individual interviews and participant observation. RESULTS: Participants embraced a culture of preparing nursing students for their professional roles as a professional responsibility, and a means of securing the nursing profession. Modeling the appropriate behaviours to students and respecting them as learners and humans constituted the caring attributes that sustain a positive learning environment for their professional growth. CONCLUSIONS: Nurturing and caring environments offer students opportunities to integrate caring attitudes into their interactions with patients and to develop professionally. IMPLICATIONS FOR INTERNATIONAL AUDIENCE: Findings underscore the need to enhance caring values within nursing curricula.

Antenatal depressive symptoms in rwanda: rates, risk factors, and social support.

BACKGROUND: Prevalence of perinatal depression is high in Rwanda and has been found to be associated with the quality of relationship with partner. This study extends this work to examine the relationship between antenatal depressive symptoms and social support across several relationships among women attending antenatal care services. METHODS: Structured survey interviews were conducted with 396 women attending antenatal care services in 4 health centres in the Southern Province of Rwanda. The Edinburgh Postnatal Depression Scale (EPDS) and Maternity Social Support Scale (MSSS) were used to assess antenatal depressive symptoms and the level of support respectively. Socio-demographic and gestational information, pregnancy intentions, perceived general health status, and experience of violence were also collected. Univariate, bivariate analyses and a multivariate logistic regression model were performed to determine the relationship between social support and risk factors for antenatal depressive symptoms. RESULTS: More than half of respondents were married (55.1%) or living with a partner in a common-law relationship (28.5%). About a third (35.9%) were in their 6th month of pregnancy; the rest were in their third term. The prevalence of antenatal depressive symptoms was 26.6% (EPDS ≥ 12). Bivariate analyses suggested that partner and friend support negatively predict depression level symptoms. Adjusting for confounding variables such as unwanted pregnancy (AOR: 0.415, CI: 0.221- 0.778), parity (AOR: 0.336, CI: 0.113-1.000) and exposure to extremely stressful life events (AOR: 2.300, CI: 1.263- 4.189), partner support (AOR: 4.458, CI: 1.833- 10.842) was strongly significantly associated with antenatal depressive symptoms; women reporting good support were less likely to report depressive symptoms than those reporting poor support or those with no partner. Friend support was no longer significant. CONCLUSION: The study revealed that social support may be a strong protector against antenatal depressive symptoms but only support from the partner. This suggests that strengthening support to pregnant women may be a successful strategy for reducing the incidence or severity of maternal mental health problems, but more work is required to assess whether support from the broader social network can compensate for absent or unsupportive partners.

Depression-level symptoms among Syrian refugees: findings from a Canadian longitudinal study.

BACKGROUND: Canada launched the Syrian Refugee Resettlement Initiative in 2015 and resettled over 40,000 refugees. AIM: To evaluate the prevalence of depression-level symptoms at baseline and one year post-resettlement and analyze its predictors. METHODS: Data come from the Syrian Refugee Integration and Long-term Health Outcomes in Canada study (SyRIA.lth) involving 1924 Syrian refugees recruited through a variety of community-based strategies. Data were collected using structured interviews in 2017 and 2018. Depression symptoms were measured using Patient Health Questionnaire 9 (PHQ-9). Analysis for associated factors was executed using multinomial logistic regression. RESULTS: Mean age was 38.5 years (SD 13.8). Sample included 49% males and 51% females settled in Ontario (48%), Quebec (36%) and British Columbia (16%). Over 74% always needed an interpreter, and only 23% were in employment. Prevalence of depression-level symptoms was 15% at baseline and 18% in year-2 (p < 0.001). Significant predictors of depression-level symptoms at year-2 were baseline depression, sponsorship program, province, poor language skills, lack of satisfaction with housing conditions and with health services, lower perceived control, lower perceived social support and longer stay in Canada. CONCLUSION: Increase in depression-level symptoms deserves attention through focusing on identified predictors particularly baseline depression scores, social support, perceived control and language ability.

A cross-sectional study of the prevalence and factors associated with symptoms of perinatal depression and anxiety in Rwanda.

BACKGROUND: Perinatal depression and anxiety are increasingly recognized as important public health issues in low and middle-income countries such as Rwanda and may have negative consequences for both mothers and their infants. Maternal mental health may be particularly challenged in Rwanda because of the prevalence of risk factors such as poverty, low education levels, negative life events and marital problems. However, there are limited data about perinatal depression and anxiety symptoms in Rwanda. This study thus aimed to explore the prevalence of symptoms of perinatal depression and anxiety in Rwanda, and factors associated with them. METHODS: A sample of 165 women in the perinatal period (second and third trimester of pregnancy, up to 1 year postnatal) were interviewed individually over 1 month in October 2013. Women were interviewed at 5 of 14 health centres in the Eastern Province or the affiliated district hospital. Participants answered socio-demographic questions and scales measuring symptoms of perinatal depression (EPDS: Edinburgh Postnatal Depression Scale) and anxiety (SAS: Zung Self-rating Anxiety Scale). RESULTS: Among women in the antenatal period (N = 85), 37.6% had symptoms indicating possible depression (EPDS ≥10) and 28.2% had symptoms associated with clinical levels of anxiety (SAS > 45). Among women within the postnatal period (N = 77), 63.6% had symptoms of possible depression, whereas 48,1% had symptoms of probable anxiety. Logistic regression showed that symptoms of postnatal depression were higher for respondents who had four or more living children relative to those having their first child (Odds Ratio: 0.07, C.I. = 0.01-0.42), and for those with a poor relationship with their partner (Odds Ratio: .09, C.I. =0.03-0.25). Any lifetime exposure to stressful events was the only predictor of symptoms of postnatal anxiety (Odds Ratio = 0.20, C.I. = 0.09-0.44). CONCLUSIONS: Symptoms of postnatal depression and anxiety were prevalent in this Rwandan sample and most strongly predicted by interpersonal and social factors, suggesting that social interventions may be a successful strategy to protect against maternal mental health problems in the Rwandan context.

The Social Determinants of Refugee Mental Health in the Post-Migration Context: A Critical Review.

With the global increase in the number of refugees and asylum seekers, mental health professionals have become more aware of the need to understand and respond to the mental health needs of forced migrants. This critical review summarizes the findings of recent systematic reviews and primary research on the impact of post-migration conditions on mental disorders and PTSD among refugees and asylum seekers. Historically, the focus of mental health research and interventions with these populations has been on the impact of pre-migration trauma. Pre-migration trauma does predict mental disorders and PTSD, but the post-migration context can be an equally powerful determinant of mental health. Moreover, post-migration factors may moderate the ability of refugees to recover from pre-migration trauma. The importance of post-migration stressors to refugee mental health suggests the need for therapeutic interventions with psychosocial elements that address the broader conditions of refugee and asylum seekers' lives. However, there are few studies of multimodal interventions with refugees, and even fewer with control conditions that allow for conclusions about their effectiveness. These findings are interpreted using a social determinants of health framework that connects the risk and protective factors in the material and social conditions of refugees' post-migration lives to broader social, economic and political factors.

South Asian youth mental health in Peel Region, Canada: Service provider perspectives.

The Peel Region of Toronto, Canada is home to over a third of the province's South Asian population. Youth are at a vulnerable time period in terms of their mental health. South Asian youth populations may face additional challenges to their mental health such as acculturative stress, intergenerational conflict, and racism and discrimination. This qualitative study set out to understand the mental health concerns and service access barriers experienced by South Asian youth populations in the Peel Region of Toronto, Canada from the perspective of mental health service providers. In-depth semi-structured interviews were carried out with mental health service providers (n = 22) who work with South Asian youth living in Peel Region. Thematic analysis was used to elucidate themes related to mental health stressors and service access barriers experienced by youth. According to mental health service providers, South Asian youth navigate a number of unique stressors related to the domains of culture, religion, and family dynamics, experiences of discrimination, the impact of migration, beliefs around mental illness and help-seeking, help-seeking trajectories and therapy recommendations, and lastly, sex differences. Mental health service providers outlined steps needed to effectively address the unique mental health challenges, best practice guidelines, and recommendations for working with South Asian youth, families, and communities to provide a practical and nuanced overview on how a multi-level strategy for mental health care can effectively meet the needs of South Asian youth populations.

Predicting postnatal depressive symptoms in a prospective cohort study in Rwanda: the impact of poor maternal social support.

Background: Postnatal depression is a significant public health issue that demands attention, and recent evidence indicates that rates are relatively high in low-income countries such as Rwanda. However, lack of social support is recognized as a potential risk factor for postnatal depressive symptoms. This study sought to explore the influence of poor maternal social support on postnatal depressive symptoms in a sample of women in Rwanda. Method: A prospective cohort research design was conducted with women recruited from four different health centers in Rwanda's Southern Province. A sample of 396 pregnant women accessing antenatal care services was recruited at the baseline from their late second term or later, then followed up after giving birth. The dropout rate was 21.46%; thus, the data of 311 women were analyzed. The outcome variable was the presence of depressive symptoms (Edinburgh Postnatal Depression Scale (EPDS) (≥12 cut-off score), while predictor variables included maternal social support measured using a modified Maternal Social Support Scale (MSSS), perceived health status, socio-demographic information (marital status, wealth class, age, education, occupation), negative life events, gestational and obstetric information (parity, pregnancy intention, age at birth, children given birth, and mode of delivery). Univariate and multivariate analyses were performed. Results: From a sample of 311 participants, over a quarter (20.9%) had elevated postnatal depressive symptoms (EPDS ≥ 12 scores). Elevated scores were predicted by poor perceived health status; respondents reporting neither poor nor good (AOR = 0.28, CI = 0.11; 0.72, p = 0.007) or good health (AOR = 0.14, CI = 0.05; 0.37, p = 0.001) were less likely to be affected. Poor maternal social support was also linked with postnatal depressive symptoms; poor partner support (AOR = 4.22; CI = 1.44; 12.34; p = 0.009) was associated with high risk, while good friend support (AOR = 0.47, CI = 0.23; 0.98, p = 0.04) was a significant protector. Additionally, violence or negative life events were also independent predictors of postnatal depressive symptoms (AOR: 2.94, CI: 1.37-6.29, p = 0.005). Conclusion: Postnatal depressive symptoms were found to affect one in five Rwandan women. However, good maternal social support can be a strong protector. Early interventions targeting mothers in the postnatal period and strengthened social support networks for women at risk should be developed.

Primary health care utilization in the first year after arrival by refugee sponsorship model in Ontario, Canada: A population-based cohort study.

BACKGROUND: Canada's approach to refugee resettlement includes government sponsorship, a pioneering private sponsorship model and a third blended approach. Refugees are selected and supported differently in each approach including healthcare navigation. Little is known about how well private sponsors facilitate primary care navigation and whether this changed during the large-scale 2015 Syrian resettlement initiative characterized by civic and healthcare systems engagement. METHODS AND FINDINGS: Population-based cohort study of resettled refugees arriving in Ontario between April 1, 2008 and March 31, 2017, with one-year follow-up, using linked health and demographic administrative databases. We evaluated associations of resettlement model (GARs, Privately Sponsored Refugees [PSRs], and Blended-Visa Office Referred [BVORs]) by era of arrival (pre-Syrian and Syrian era) and by country cohort, on measures of primary care (PC) navigation using adjusted Cox proportional hazards and logistic regression. There were 34,591 (pre-Syrian) and 24,757 (Syrian era) resettled refugees, approximately half of whom were GARs. Compared with the reference group pre-Syrian era PSRs, Syrian PSRs had slightly earlier PC visits (mean = 116 days [SD = 90]) (adjusted hazard ratios [aHR] = 1.19, 95% CI 1.14-1.23). Syrian GARs (mean = 72 days [SD = 65]) and BVORs (mean = 73 days [SD = 76]) had their first PC visit sooner than pre-Syrian era PSRs (mean = 149 days [SD = 86]), with respective aHRs 2.27, 95% CI 2.19-2.35 and 1.89, 95% CI 1.79-1.99. Compared to pre-Syrian PSRs, Syrian GARs and BVORs had much greater odds of a CHC visit (adjusted odds ratios 14.69, 95% CI 12.98-16.63 and 14.08, 95% 12.05-16.44 respectively) and Syrian PSRs had twice the odds of a CHC visit. CONCLUSIONS: Less timely primary care and lower odds of a CHC visit among PSRs in the first year may be attributed to selection factors and gaps in sponsors' knowledge of healthcare navigation. Improved primary care navigation outcomes in the Syrian era suggests successful health systems engagement.

Access to Virtual Mental Healthcare and Support for Refugee and Immigrant Groups: A Scoping Review.

Immigrant and refugee populations face multiple barriers to accessing mental health services. This scoping review applies the (Levesque et al. in Int J Equity Health 12:18, 2013) Patient-Centred Access to Healthcare model in exploring the potential of increased access through virtual mental healthcare services VMHS for these populations by examining the affordability, availability/accommodation, and appropriateness and acceptability of virtual mental health interventions and assessments. A search in CINAHL, MEDLINE, PSYCINFO, EMBASE, SOCINDEX and SCOPUS following (Arksey and O'Malley in Int J Soc Res Methodol 8:19-32, 2005) guidelines found 44 papers and 41 unique interventions/assessment tools. Accessibility depended on individual (e.g., literacy), program (e.g., computer required) and contextual/social factors (e.g., housing characteristics, internet bandwidth). Participation often required financial and technical support, raising important questions about the generalizability and sustainability of VMHS' accessibility for immigrant and refugee populations. Given limitations in current research (i.e., frequent exclusion of patients with severe mental health issues; limited examination of cultural dimensions; de facto exclusion of those without access to technology), further research appears warranted.

Assessing Virtual Mental Health Access for Refugees during the COVID-19 Pandemic Using the Levesque Client-Centered Framework: What Have We Learned and How Will We Plan for the Future?

During the COVID-19 pandemic, mental health services rapidly transitioned to virtual care. Although such services can improve access for underserved populations, they may also present unique challenges, especially for refugee newcomers. This study examined the multidimensional nature of access to virtual mental health (VMH) care for refugee newcomers during the COVID-19 pandemic, using Levesque et al.'s Client-Centered Framework for Assessing Access to Health Care. One hundred and eight structured and semi structured interviews were conducted in four Canadian provinces (8 community leaders, 37 newcomer clients, 63 mental health or service providers or managers). Deductive qualitative analysis, based on the Client-Centered Framework, identified several overarching themes: challenges due to the cost and complexity of using technology; comfort for VMH outside clinical settings; sustainability post-COVID-19; and communication and the therapeutic alliance. Mental health organizations, community organizations, and service providers can improve access to (virtual) mental health care for refugee newcomers by addressing cultural and structural barriers, tailoring services, and offering choice and flexibility to newcomers.

Immigrant and refugee social networks: determinants and consequences of social support among women newcomers to Canada.

Recent immigrants and refugees (newcomers) vary on many dimensions but do share similar challenges. Newcomers must rebuild social networks to obtain needed social support but often face social exclusion because of their race, language, religion, or immigrant status. In addition, most have limited access to personal, social, and community resources. Effects of situational and personal variables on the benefits and limitations associated with the social networks of female newcomers were explored through interviews and focus groups with 87 women from 7 communities. Using thematic analysis, the authors identify 5 sources of informal support across all 7 communities, which were almost exclusively limited to co-ethnic relationships, and the types of support, limitations, and reciprocity within each. Perceived support was strongest from family and close friends and, when support from close relationships was unavailable, from primary care providers. The results suggest that co-ethnic peer support networks may be overwhelmed in newcomer communities because of their limited size and resources.

The Impact of Education and Employment Quality on Self-rated Mental Health Among Syrian Refugees in Canada.

Finding appropriate employment is a common challenge faced by refugees when resettling in a new country. For refugees with higher education, finding work commensurate with their skills and qualifications may be even more difficult. Refugees with higher education may experience more distress around employment because their expectations for employment are more discrepant from the realities of resettlement. As part of the SyRIA.lth project, the present study looked at employment rates and job quality of Syrian refugees resettling in Canada (N = 1805). Moderately and highly educated participants were more likely to be employed than those with less than high school education. Among those currently employed 2 to 3 years after arrival (n = 627), moderately and highly educated participants reported lower job satisfaction, quality, and appropriateness compared to those with lower education. As expected, employed former refugees with high education reported poorer mental health which was explained by the job quality measures.

A "Co-CREATES" framework to foster a positive learning environment for nursing students' professional development in Rwanda.

AIM: The future of the nursing profession in Rwanda in large part depends on the students who join the workforce and the education they have received. Preparing students with the necessary knowledge, values and judgement requires practice settings to be learner-centered. This study aimed at exploring strategies that might improve the current practice-based learning environment. DESIGN: A focused ethnographic approach was used. METHODS: Nursing students, staff nurses, clinical instructors and nurse leaders from three hospitals and an educational program participated in individual interviews. RESULTS: Five key areas of improvement emanated from study data: 1) strengthening institutional support; 2) improving school-hospital collaboration; 3) building the capacity of nurses and clinical instructors; 4) restructuring clinical placement; and 5) reviewing the current supervision model. Based on these findings a "Co-CREATES" framework grounded in the actions of collaboration, care, recognizing, empowering, actively engaging, transforming, enhancement and support was developed. The framework offers a collaborative approach that engages every stakeholder in "cocreating" conditions that build positive practice environments which are conducive to preparing students as professional nurses. CONCLUSION: The positive outcomes stemming from such a collaborative approach can further enhance a positive culture of collaboration in nursing education and practice.

Examining Trends of Cigarette Smoking Amongst Syrian Refugees During Their First Two Years in Canada.

This brief report explored trends of cigarette smoking among Syrian newcomers in the first two years of resettlement in Canada. 1794 adult Syrian refugees were surveyed about their physical and mental health, and smoking behaviours. Results were analyzed using descriptive statistics, Wilcoxon signed-rank tests, and logistic regressions. Almost 27% of the sample reported cigarette smoking (50% light smokers and 50% moderate/heavy smokers). Light smokers increased and moderate/heavy smokers decreased in the number of cigarettes smoked from year 1 to year 2. Moderate/heavy smokers were more likely to be male and reported higher post-traumatic stress scores, while light smokers reported higher depression scores. Only 14.3% of smokers recalled receiving advice from health care providers in Canada regarding their smoking habits. Healthcare providers should provide tailored advice to everyone who is an active smoker with a specific emphasis on those who have concurrent health issues.

Differences in Self-Reported Health and Unmet Health Needs Between Government Assisted and Privately Sponsored Syrian Refugees: A Cross-Sectional Survey.

Between November 2015 and January 2017, the Government of Canada resettled over 40,000 Syrian refugees through different sponsorship programs (GAR and PSR). Timely access to healthcare is essential for good health and successful integration. However, refugee support differs depending on sponsorship program, which may lead to differences in healthcare service access and needs. A cross-sectional study with a sample of Syrian refugees was conducted to assess healthcare access, and perceived physical and mental health status. Results indicate demographic and healthcare access differences between GARs and PSRs. GARs reported significantly lower perceived physical and mental health, as well as, higher unmet healthcare needs than PSRs. GARs are among the most vulnerable refugees; they report higher needs, more complex medical conditions and tend to have more difficulty re-settling. These factors likely combine to help explain lower self-reported health and higher health needs in our sample compared to PSRs.

Unmet Health Care Needs for Syrian Refugees in Canada: A Follow-up Study.

Unmet health care needs are under explored among refugees. Previously we found unmet health care needs in Syrian refugees may be higher than in the general Canadian population (Oda et al. CMAJ Open 5(2):E354-E358, 2017; Oda et al. J Immigr Minor Health, 2018. https://doi.org/10.1007/s10903-018-0780-z). This follow-up study with Syrian refugees who entered Canada between July 2015 and July 2016 aimed to understand if there are changes in unmet health care needs 6 months to a year after baseline collection. The number reporting unmet needs was high (42.6%). Although some refugees had their needs met, unmet health needs persist, and it seems that they are linked with sponsorship pathway and post-migration socio-economic position. While caution should be used generalizing these results, they do suggest that greater coordination between services may be needed as many of the refugees report unmet needs within months of arriving and continue to report needs after being here for a period up to 2 years.

Similarly Torn, Differentially Shorn? The Experience and Management of Conflict between Multiple Roles, Relationships, and Social Categories.

In three studies we examined the experience and management of conflict between different types of multiple identities. Participants described a conflict between pairs of role, relational, or social identities before rating the experience (i.e., magnitude, stress, and growth) and management of conflict on a newly developed scale assessing four strategies: reconciliation, where identities are integrated, realignment, where one identity is chosen over another, retreat, where both identities are avoided, and reflection, where fit (with others, situation) determines identity selection. In general, the types of identities mattered for conflict management but not its experience: Magnitude and growth did not differ, however, stress was greater for role identity conflicts (Study 3 only) and participants endorsed the use of more realignment for role conflicts (Study 2) and more retreat for relational conflicts (Study 3) relative to other types of identity conflicts. Furthermore, findings suggested that the perceived flexibility of identities, not their importance or valence, were associated with realignment and retreat for roles and with retreat for relationships. Experiencing conflicts between multiple identities leaves people similarly torn, but multiple roles and relationships may be differentially shorn to manage conflict.

Health care needs and use of health care services among newly arrived Syrian refugees: a cross-sectional study.

BACKGROUND: Canada welcomed 33 723 Syrian refugees between November 2015 and November 2016. This paper reports the results of a rapid assessment of health care needs and use of health care services among newly arrived Syrian refugees in Toronto. METHODS: A cross-sectional study was conducted in Toronto among Syrian refugees aged 18 years or more who had been in Canada for 12 months or less. Participants were recruited initially through distribution of flyers in hotels and through direct referrals and communication with community and settlement agency partners, and then through snowball sampling. We collected sociodemographic information and data on self-perceived physical health and mental health, unmet health care needs and use of health care services. RESULTS: A total of 400 Syrian refugees (221 women [55.2%] and 179 men [44.8%]) were enrolled. Of the 400, 209 (52.2%) were privately sponsored refugees, 177 (44.2%) were government-assisted refugees, and 12 (3.0%) were refugees under the Blended Visa Office-Referred Program. They reported high levels of self-perceived physical and mental health. Over 90% of the sample saw a doctor in their first year in Canada, and 79.8% had a family doctor they saw regularly. However, almost half (49.0%) of the respondents reported unmet health care needs, with the 3 most common reasons reported being long wait times, costs associated with services and lack of time to seek health care services. INTERPRETATION: Many factors may explain our respondents' high levels of self-perceived physical and mental health during the first year of resettlement, including initial resettlement support and eligibility for health care under the Interim Federal Health Program. However, newly arrived Syrian refugees report unmet health care needs, which necessitates more comprehensive care and management beyond the initial resettlement support.