Future orientation of youth with a history of war trauma: a qualitative study in the African context.

Adolescence is an important developmental period for social relationships, identity formation and future planning. Traumatic experiences, such as war and persecution, may interfere with optimal development, including the future orientation of adolescents. The present study examines how young adult war survivors construct, make sense of, and narrate their future goals, plans, and expectations. The participants were 13 Liberian 25-35-year old male and female refugees living in Ghana. This qualitative study is based on semi-structured interviews with prompting questions. By applying a phenomenological approach the interview transcripts were categorized into themes and subthemes about future orientations. Results revealed three main themes, two of them desired a positive future orientation, indicating optimism and determination to improve one's own life and to contribute to a flourishing nation and to peacebuilding. The third theme illustrated a failure to reconstruct war-shattered lives and involved pessimistic views of the future. The results are discussed in relation to peacebuilding and the developmental challenges of young adults as war survivors.

Narratives of Agency and Capability from Two Adolescent Girls in Post-conflict Liberia.

Between 1989 and 2003, Liberia experienced a brutal civil war characterized by ethnic killings, sexual violence and the use of child soldiers. Five years after the war ended, half the population of Liberia was under 18 years old. Understanding the needs of these youth is thus essential to the recovery of the nation. This study focuses on the narratives of two female adolescents, selected from 75 in-depth individual interviews with post-conflict Liberian youth conducted in 2012. A narrative analysis approach was employed to examine each interview for multiple layers of meaning. The aim of the study was to elucidate factors that may enable post-conflict youth to reclaim a sense of agency and return to normal developmental tasks. The study explores the ways in which these youth navigate complicated power dynamics in the post-conflict setting and how gender impacts their experiences of their own agency and capability. The dynamics between the participants and the interviewer are explored to further illustrate how power dynamics manifest. These narratives support the involvement of youth in projects that help others as an avenue for promoting agency and resilience for themselves.

"My Heart Die in Me": Idioms of Distress and the Development of a Screening Tool for Mental Suffering in Southeast Liberia.

The integration of culturally salient idioms of distress into mental healthcare delivery is essential for effective screening, diagnosis, and treatment. This study systematically explored idioms, explanatory models, and conceptualizations in Maryland County, Liberia to develop a culturally-resonant screening tool for mental distress. We employed a sequential mixed-methods process of: (1) free-lists and semi-structured interviews (n = 20); patient chart reviews (n = 315); (2) pile-sort exercises, (n = 31); and (3) confirmatory focus group discussions (FGDs); (n = 3) from June to December 2017. Free-lists identified 64 idioms of distress, 36 of which were eliminated because they were poorly understood, stigmatizing, irrelevant, or redundant. The remaining 28 terms were used in pile-sort exercises to visualize the interrelatedness of idioms. Confirmatory FDGs occurred before and after the pile-sort exercise to explain findings. Four categories of idioms resulted, the most substantial of which included terms related to the heart and to the brain/mind. The final screening tool took into account 11 idioms and 6 physical symptoms extracted from patient chart reviews. This study provides the framework for culturally resonant mental healthcare by cataloguing language around mental distress and designing an emic screening tool for validation in a clinical setting.

Dietary patterns in Liberian refugees in Buduburam, Ghana.

Previous research suggests that acculturation (i.e., exposure and assimilation to local culture) is associated with changes in dietary patterns among immigrants. This study investigates this association in a refugee population using time in refugee settlement as a proxy for acculturation. A cross-sectional survey was conducted among a systematic sample to (a) identify dietary patterns in Liberian refugees and Ghanaians living in or near a refugee settlement, (b) compare adherence to these dietary patterns between groups, and (c) investigate the association between acculturation and dietary patterns in Liberian refugees. Participants were Liberian and Ghanaian women with young children living in the Buduburam refugee settlement or Awutu in Ghana (n = 480; 50% Liberian; mean age 28, SD 6.3, range 16-48 years). Time in settlement was assessed by self-report; food consumption was assessed by food frequency questionnaire. Principal component analysis was used to identify dietary patterns; a generalized linear model was used to test the association of interest. Three distinct dietary patterns emerged: Healthy, Sweets, and Fats. Ghanaians were more adherent to the Healthy pattern than Liberians (p < 0.05). Liberians were more adherent to the Sweets and Fats patterns than Ghanaians (p < 0.05). There were no significant differences in dietary pattern adherence among the Liberians based on time in settlement. Ghanaians living in Awutu were more adherent to the Healthy pattern than Ghanaians who lived in settlement (p < 0.05). Differences in dietary patterns were observed between Liberian refugees and Ghanaians. These differences were not associated with acculturation and may be related to the food environment in the settlement.

Secondary migration and relocation among African refugee families in the United States.

The purpose of this study was to understand the secondary migration and relocation of African refugees resettled in the United States. Secondary migration refers to moves out of state, while relocation refers to moves within state. Of 73 recently resettled refugee families from Burundi and Liberia followed for 1 year through ethnographic interviews and observations, 13 instances of secondary migration and 9 instances of relocation were identified. A family ecodevelopmental framework was applied to address: Who moved again, why, and with what consequences? How did moving again impact family risk and protective factors? How might policies, researchers, and practitioners better manage refugees moving again? Findings indicated that families undertook secondary migration principally for employment, affordable housing, family reunification, and to feel more at home. Families relocated primarily for affordable housing. Parents reported that secondary migration and relocation enhanced family stability. Youth reported disruption to both schooling and attachments with peers and community. In conclusion, secondary migration and relocation were family efforts to enhance family and community protective resources and to mitigate shortcomings in resettlement conditions. Policymakers could provide newly resettled refugees jobs, better housing and family reunification. Practitioners could devise ways to better engage and support those families who consider moving.

Cerebral and Plasmodium ovale Malaria in Rhode Island.

We report two cases of malaria diagnosed in Rhode Island. First, a 21-year-old female who presented with 5 days of fevers, chills, headache, and myalgias after returning from a trip to Liberia, found to have uncomplicated malaria due to P. ovale which was treated successfully with atovaquone/proguanil and primaquine. Second, a chronically ill 55-year-old male presented with 3 days of headache followed by altered mental status, fever, and new-onset seizures after a recent visit to Sierra Leone, found to have P. falciparum malaria requiring ICU admission and IV artesunate treatment. The diagnosis and management of malaria in the United States (US), as well as its rare association with subdural hemorrhage are subsequently reviewed.

Pregnancy among HIV-infected refugees in Rhode Island.

In 1999, immigration laws lifted previous barriers, allowing more HIV-infected refugees entrance to the US. Many of these refugees are women of reproductive age. At our center in Providence, RI, a significant number of HIV-infected refugees have become pregnant since resettling in the US. We describe the pregnancies seen among these predominantly West African HIV-infected refugees. A retrospective chart review was conducted on all HIV-infected female refugees who established care from 2000-2006. Descriptive statistics were used to describe the population at this site. We found that between 2000 and 2006, 28 HIV-infected female refugees established care. Liberia was the country of origin of 79% (22) of the women. There were 20 pregnancies among 14 women between 2000-2006. The median time from resettlement in the US to first pregnancy was 16 (<1-69) months. The median age at time of first pregnancy was 29 years (19-39). At time of pregnancy, the median CD4 count was 506 cells/mL and the median plasma viral load (PVL) was 3.36 log10 copies/ml. There were nine deliveries, one current pregnancy and one loss to follow-up. Other pregnancy outcomes included five terminations and three spontaneous abortions. All women received antiretroviral therapy during their pregnancy. At the time of delivery the median PVL was <1.88 log. There was one HIV transmission from mother to child. Two women became pregnant while on efavirenz, which was subsequently discontinued. One of the women delivered a normal term infant; the other relocated and transferred her care. Among this cohort of HIV-infected refugees, there is a high rate of pregnancy, highlighting the need for timely initiation of medical care, including comprehensive preconception counseling, upon resettlement in the US. It is important to gain a better understanding of this unique and growing population in order to provide the best possible care for these women.

Factors Influencing Dietary Practices Among Ghanaian Residents and Liberians Living in a Protracted Refugee Situation in Ghana.

OBJECTIVE: Examine dietary practices among Liberian refugees living in a protracted refugee situation and Ghanaians living among them. DESIGN: Qualitative data were collected via audio-taped in-depth interviews as part of a larger mixed-methods cross-sectional study. SETTING: Buduburam Refugee Settlement and neighboring villages, Ghana. PARTICIPANTS: Twenty-seven Liberian and Ghanaian women aged ≥16 years, who lived with ≥1 other female generation. PHENOMENON OF INTEREST: Similarities and differences in factors influencing dietary practices among Liberian refugees living in Buduburam Refugee Settlement and Ghanaians living in and around this settlement. ANALYSIS: Domains, themes, and subthemes were confirmed through a highly iterative coding and consensus process. ATLAS.ti (version 7.5.10) was used to finalize coding and extract quotations. RESULTS: Seven domains emerged forming direct and indirect pathways influencing dietary patterns among Liberian refugees and Ghanaians: social support, food availability, nutrition knowledge, cultural food beliefs, food access, food preparation, and national identity. CONCLUSIONS AND IMPLICATIONS: Findings provide important insights into crucial factors driving dietary practices among refugees and local communities in and around a former protracted refugee settlement. Results strongly suggest that nutrition education, food availability, and access issues should be addressed with culturally sensitive programs targeting both the refugee and host communities.

Risk factors for elevated blood lead levels among African refugee children in New Hampshire, 2004.

OBJECTIVES: Surveillance blood lead screening of refugee children resettled in Manchester, NH, in 2004 revealed that 39 (42%) of 92 children had elevated levels (>or=10 microg/dL) after resettlement. Furthermore, 27/92 children (29%) had nonelevated screening blood lead levels on arrival (BLL1) but had elevated follow-up blood lead levels 3-6 months after settlement (BLL2). The main objective was to identify risk factors for increasing lead levels among refugee children after resettlement in Manchester in 2004. PATIENTS AND METHODS: We conducted a cohort study, with completion of household interviews and home assessments for refugee families who had resettled in 2004 in Manchester, NH. Blood lead level (BLL) data were abstracted from the New Hampshire (NH) Childhood Lead Poisoning Prevention Program. To assess acute and chronic malnutrition among refugees, we used anthropometric data from International Organization of Migration documents to calculate nutritional indices. RESULTS AND DISCUSSION: Of the 93 African refugee children in 42 families who participated, 60 (65%) had been born in a refugee camp. Median age was 5.5 years at the time of BLL2 measurement. Thirty-six (39%) of the refugee children had BLL2 >or= 10 microg/dL. Liberians and those born in refugee camps had higher geometric mean BLL2 than those not Liberian or not born in camps. Younger children and children with nutritional wasting before immigrating to the United States had a greater increase in geometric mean from BLL1 to BLL2, compared to older children and those without nutritional wasting. Follow-up blood lead testing of refugee children, particularly those resettled in areas with older housing stock, as in Manchester, is important for identifying lead exposure occurring after resettlement. Increased attention to improve nutritional status of children in refugee camps and after arrival in the United States and awareness of children who were born in refugee camps should be incorporated into lead-poisoning prevention strategies.

Congenital rubella syndrome in a child born to Liberian refugees: clinical and public health perspectives.

We describe a case of congenital rubella syndrome with typical stigmata in an infant born in New Hampshire to Liberian refugees. The infant's clinical specimens were tested for rubella. Rubella immunity status was sought for contacts. The infant's specimen cultures grew wild-type rubella virus; serum immunoglobulin M and G were positive. Eighteen of 20 contacts were rubella-immune. Family's transit history, mother's vaccination history, and infant's estimated gestational age supported congenital infection acquired overseas. Clinicians should maintain vigilance for congenital rubella syndrome in infants with relevant stigmata, particularly those whose mothers are from countries with nonexistent or recently implemented rubella vaccination programs.

[Difficulty in diagnosing pediatric tuberculosis]. / Tubercolosi pediatrica una diagnosi difficile.

Tuberculosis (TB) in children is an important warning sign in a community, as it could signal recent infection of a cavitary form in an adult. Thus, while early diagnosis is crucial for effective treatment in children, it is also imperative for the control of tuberculosis at the public health level since it allows rapid identification of contagious adult cases. Here we report four cases of difficult and delayed diagnosis of TB in children. From this experience we highlight the need for an extensive medical history of the patient during diagnostic work-up. This includes: the positive history for contact with infected adults, especially for immigrant children; exclusion of TB diagnosis for persistent respiratory symptoms (2-3 weeks) after antibiotic therapy; and the need for high-definition CT scan when the radiological picture is not specific, especially for children under 5 years of age.

Health-Needs Assessment for West African Immigrants in Greater Providence, RI.

African immigrants in the United States may experience barriers to health-care access and effectiveness. This mixed-methods study used paper-based surveys of people (N=101) in the target population from Nigeria, Ghana, and Liberia, recruited through convenience and snowball sampling. Semi-structured interviews were conducted with 3 clergy members who pastor churches with large Nigerian, Ghanaian, and Liberian populations, respectively; and five physicians and a clinical pharmacist who serve African immigrants. RESULTS: Length of stay in the United States was associated with the health status of refugee children. Undocumented immigration status was associated with lack of health insurance. Cardiovascular diseases, uterine fibroids and stress-related disorders were the most prevalent reported conditions. Regardless of English fluency, many immigrants are unfamiliar with medical terminology. CONCLUSION: African immigrants in the state of Rhode Island need more health education and resources to navigate the US health-care system. [Full article available at http://rimed.org/rimedicaljournal-2017-01.asp].

Trauma healing in refugee camps in Guinea: a psychosocial program for Liberian and Sierra Leonean survivors of torture and war.

From 1999 to 2005, the Minneapolis-based Center for Victims of Torture (CVT) served Liberian and Sierra Leonean survivors of torture and war living in the refugee camps of Guinea. A psychosocial program was developed with 3 main goals: (a) to provide mental health care, (b) to train local refugee counselors, and (c) to raise community awareness about war trauma and mental health. Utilizing paraprofessional counselors under the close, on-site supervision of expatriate clinicians, the treatment model blended elements of Western and indigenous healing. The core component consisted of relationship-based supportive group counseling. Clinical interventions were guided by a 3-stage model of trauma recovery (safety, mourning, reconnection), which was adapted to the realities of the refugee camp setting. Over 4,000 clients were provided with counseling, and an additional 15,000 were provided with other supportive services. Results from follow-up assessments indicated significant reductions in trauma symptoms and increases in measures of daily functioning and social support during and after participation in groups. The treatment model developed in Guinea served as the basis for CVT's ongoing work with survivors in Sierra Leone and Liberia. ((c) 2006 APA, all rights reserved).

Brief report: Imported case of congenital rubella syndrome--New Hampshire, 2005.

In 2004, an independent panel convened by CDC declared rubella no longer endemic in the United States. Nine cases of rubella were reported in 2004, and four cases of congenital rubella syndrome (CRS) were reported during 2001-2004. However, worldwide, an estimated 100,000 infants are born with CRS annually. This report describes a case of imported CRS diagnosed in an infant girl aged 10 weeks born in New Hampshire to Liberian refugee parents. To prevent transmission of rubella, clinicians should consider a diagnosis of CRS in infants with compatible clinical signs, particularly those born to mothers who recently immigrated from countries without rubella control programs, and rubella vaccine should be administered to susceptible persons.

Food insecurity and budgeting among Liberians in the US: how are they related to socio-demographic and pre-resettlement characteristics.

Objectives of this study: (1) Examine food insecurity (FI) prevalence and its relationship with sociodemographic and pre-resettlement characteristics; (2) Investigate differences in amount of money spent on food/month by food security status and socio-demographic characteristics. A pilot study with semi-structured in-home interviews was conducted with Liberian caregivers (n = 33). FI was indicated in 61% of households. FI was higher among women >40, had ≤ high school education and those making ≤$1,000/month. Women arriving in US >15 years of age were more likely to be food insecure. Participants spent an average $109/month on groceries/member. Food insecure women, and those without a car spent more money on food (P < .10). Liberian women in this sample experience high levels of FI upon resettlement. Besides poor economic conditions, pre-resettlement characteristics were associated with food security status. These findings call for future research to understand how preresettlement conditions affect food choices, budgeting and thereby food security status.

Health and nutritional status of Liberian refugee children--Guinea, 1990.

Since December 1989, civil strife in Liberia has caused mass displacement of persons to neighboring Guinea and Ivory Coast (Figure 1). Liberian refugees initially settled in the Forest Region of Guinea and shared food and shelter with members of the same ethnic groups (mainly Gio and Mano) already residing in the area. The number of refugees overwhelmed the capacity of affected villages to provide basic needs, and camp-like settlements were established that received substantial external relief. In May 1990, to determine appropriate priorities for relief assistance, the health and nutritional status of Liberian refugees in the Forest Region of Guinea was assessed by CDC for the U.S. Department of State's Bureau for Refugee Programs. In May, an estimated 80,000 refugees were in the area; by December the number had increased to an estimated 400,000. This report summarizes findings of the health and nutritional assessment of Liberian refugee children.

Oral health among Liberian refugees in Ghana.

OBJECTIVE: To promote community involvement in the provision of oral health services. DESIGN: The project consisted of a four-week training course in oral health for selected refugees, an oral health survey based on WHO guidelines and conducted by the refugees themselves and the provision of oral health care services to the community by the trained refugees. SETTING: Liberian refugee camp, Gomoa Buduburam in Ghana. SUBJECTS: Liberian refugees of all ages. INTERVENTIONS: Twelve refugees were given short term training in oral health. In the oral health survey, 196 refugees were clinically examined for dental caries, periodontal disease and malocclusion. MAIN OUTCOME MEASURES: DMFT (for dental caries), CPITN (for periodontal disease), and malocclusion scores for selected subjects. Also clinical services rendered. RESULTS: Oral health survey revealed a mean age (+/- SD) of 25.7 (+/- 9.5) years. Only thirty nine (19.9%) of the subjects were caries-free, and total DMFT was 2.5 +/- 2.2. Based on the CPITN, 107 (54.6%) required oral hygiene instructions (OHI), and 41 (20.9%) required prophylactic scaling with OHI. Forty four (22.5%) of the subjects had normal occlusion and 152 (77.5%) mild to severe malocclusion. Periodontal (75.5%), prosthetic (52.5%) interventions and extractions (34.2%) constituted the bulk of the treatment needs required. Clinical treatment was rendered by the trained refugees to 846 patients over a twelve month period. CONCLUSION: Relief programmes for refugees should emphasise a primary health care approach, focusing on prevention, based on appropriate technology, and promoting involvement by the refugee community in the provision of services.

[Natural vector capacity level of Simulium damnosum s.l. (Diptera: Simuliidae) at the ecology station of Tai (Côte d'Ivoire)]. / Capacités vectrices naturelles du complexe Simulium damnosum s.l. (Diptera:Simuliidae) au niveau de la station écologique de Taï (Côte d'Ivoire).

Several studies have been carried out on the transmission of Onchocerciasis by Simulium damnosum s.l. in the forest zone of Côte d'Ivoire. This study, carried out in 1979-1980 was devoted to determine the risk of onchocerciasis transmission inside and outside the rain forest of Taï (5 degrees 50' N-7 degrees 25' W). We present the vectorial capacity of S. sanctipauli in the region of Taï before massive flow of refugees from areas of Liberia without any control Programme. The results of micromorphological technics for determination of S. damnosum adults, showed that mainly females of S. sanctipauli were present. The studied populations had low parturity rates: 39.2% outside and 30.9% of parous flies inside the rain forest. The parasitic rates (0.4% of infectious females outside and 0.1% inside) and their parasitic loads (15 and 3 infective larvae per 1000 parous female respectively outside and inside the rain forest) were low, consequently their vectorial capacity with Onchocerca volvulus was almost non-existent in natural conditions. Before massive flow of refugees including persons carrying microfilariae, there were no problem of onchocerciasis within and outside the rain forest of Taï. However, the massive flow of refugees and the deforestation for growing crops can create situations favourable to the installation of more efficient vectors, increase man/vector contact and contribute to more intense onchocerciasis transmission. The monitoring of onchocerciasis transmission is necessary.