Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany.

BACKGROUND: Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma. METHODS: This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire. RESULTS: A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: "reminders of trauma" and "hopelessness" in relation to the traumatic experience; "immediate relief" and "healing through pharmaceutical treatment" in relation to provider interventions, and "support" and "cultural differences" in relation to interactions with providers. CONCLUSIONS: There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.

Association between distress and displacement settings: a cross-sectional survey among displaced Yazidis in northern Iraq.

BACKGROUND: Globally 70.8 million people have been forcibly displaced from their homes and are at disproportionally high risk for trauma. At the time of this study, there was an estimated 1.6 million internally displaced persons (IDP) in Iraq, more than two-thirds of whom reside in private, urban settings. This study aims to understand the impact of post-displacement accommodation on mental well-being of the Yazidi minority group displaced in Iraq. METHODS: Multi-stage stratified sampling was used to randomly select IDPs in camp and out of camp settlements in northern Iraq. Standardized questionnaires evaluated factors including exposure to violence and self-reported distress symptoms (measured by Impact of Event Scale-Revised). A multi-variate linear model assessed the relationship between settlement setting and distress symptoms. RESULTS: One thousand two hundred fifty-six displaced Yazidi participants were included in the study: 63% in camps and 37% out of camps. After controlling for exposure to violence, social cohesion, unemployment, and access to basic services, IDPs in camps were predicted to have a 19% higher mean distress symptom score compared to those out of camps. CONCLUSIONS: This study provides a framework to investigate post-displacement accommodation as a potential intervention to improve well-being for displaced populations. With a shift towards new models of emergency and long-term housing, it is important to understand the potential and limitations of more decentralized models, and identify effective methods to maintain access to basic services while improving living conditions for both displaced populations and their host communities.

Spatiotemporal Trends in Discarded Needle Reports in San Francisco Over a 10-year Period, 2010-2019.

BACKGROUND: To describe the geographic and spatiotemporal distribution of needle reports in San Francisco, and examine spatial relationships between needle reports and needle disposal boxes, needle disposal kiosks, and homeless shelters. METHODS: We conducted multiple geospatial analyses of a crowdsourced database of non-emergency service requests. We describe changes in discarded needle and bulky item reports across San Francisco between 2010 and 2019, and compared changes in the reporting patterns of these items, while 200-meter Euclidean buffers captured needle reports in close proximity to needle deposit boxes, needle deposit kiosks, and homeless shelters in 2019. RESULTS: 34,912 needle reports were included. Yearly needle reports increased by 3827.1%, with a markedly different geospatial distribution from bulky item reports. 45.6% of needle reports originated in the five downtown neighborhoods with the highest needle report density, and 33.8% were identified within 200 meters of boxes, kiosks, or homeless shelters. CONCLUSIONS: Reports of discarded needles in San Francisco increased dramatically over the last decade, and more than one third of 2019 reports were adjacent to harm reduction and homeless shelter locations. Needle reports provide an opportunity to understand changes in public injection drug use and target harm reduction services.

Frailty Is Associated With Increased Rates of Acute Cellular Rejection Within 3 Months After Liver Transplantation.

Frailty, a state of decreased physiological reserve, has been associated with dysregulation of the immune system. We hypothesized that frailty is associated with differential rates of acute cellular rejection (ACR) in liver transplantation (LT) recipients. Our study included LT recipients from 2014 to 2016 who had a pre-LT frailty assessment using the liver frailty index (LFI). Frailty was defined as an LFI ≥4.5. ACR at 3 months was ascertained from pathology reports, and immunosuppression regimens were collected from chart review. There were 241 LT recipients who were included: 46 (19%) were classified as frail before LT. Median tacrolimus trough levels, mycophenolate doses, and corticosteroid doses at discharge and 3 months were similar between frail and nonfrail patients. Within 3 months after LT, 7 (15%) frail patients versus 10 (5%) nonfrail patients experienced ACR (P = 0.02). In the univariate analysis, frailty was associated with a higher odds of ACR at 3 months (OR, 3.3; 95% confidence interval, 1.2-9.3; P = 0.02). Bivariate analyses were conducted with covariates that were associated with ACR in the univariate analysis or that were previously associated with either frailty (age and female sex) or ACR (Model for End-Stage Liver Disease score and ascites), as well as relevant immunosuppression variables. In the bivariate analyses, frailty remained significantly associated with ACR at 3 months with an odds ratio relatively similar to the unadjusted value. In conclusion, frailty is associated with an increased rate of ACR within 3 months, despite similar immunosuppression regimens, suggesting that frailty should be considered in immediate post-LT management.

Sex Differences in the Association Between Frailty and Sarcopenia in Patients With Cirrhosis.

OBJECTIVES: Frailty is prevalent in patients with cirrhosis and is hypothesized to result in part from sarcopenia, but the precise contribution of sarcopenia to frailty in this population is poorly understood. METHODS: Included were patients with cirrhosis from 2011 to 2014 who had an ambulatory frailty assessment and abdominal computed tomography scan within 3 months. Logistic regression assessed the associations between frailty (=Liver Frailty Index ≥4.5), and sarcopenia (=skeletal muscle index of <39 cm/m for women and <50 cm/m for men). RESULTS: Two hundred ninety-one participants were included: 33% were female. The median (interquartile range) Liver Frailty Index was 3.7 (3.3-4.2); 19% were frail. The median (interquartile range) skeletal muscle index was 49 cm/m (31-69); 36% had sarcopenia. Among the 54 frail participants, 48% had sarcopenia. In univariable logistic regression, sarcopenia was associated with a 1.86× increased odds of being frail (95% confidence interval [CI], 1.02-3.38). After adjusting for sex, etiology, hepatocellular carcinoma, MELDNa, ascites, encephalopathy, and hypertension, sarcopenia was associated with a 2.38× increased odds of being frail (95% CI, 1.17-4.85). After stratifying by sex and adjusting for MELDNa, sarcopenia among males was associated with a significantly increased odds of frailty (odds ratio 2.81, 95% CI, 1.19-6.67), whereas sarcopenia among females was not (odds ratio 1.38; 95% CI, 0.45-4.25). DISCUSSION: In patients with cirrhosis, sarcopenia was associated with a nearly 2-fold increased odds of being frail. Two-thirds of frail men displayed sarcopenia compared with only one-quarter of frail women. Contributors to the frail phenotype may differ by sex and support the need for sex-specific strategies to reduce frailty in this population.

Immunization coverage among refugee children in Berlin.

BACKGROUND: The Tempelhof refugee camp offers in-camp immunizations. Other camps, like Neukölln, rely on a centralized immunization system. We aimed to determine the impact of conflict on immunization rates of Syrian children and to measure the efficacy of in-camp immunization services. METHODS: Families with children aged 1-5 in Tempelhof and Neukölln camps were surveyed. Surveys included siblings under the age of 18. Differences were compared using χ2 test. RESULTS: Data on 179 children at Tempelhof and 40 children at Neukölln were collected. At Tempelhof, amongst Syrian children, 27.8% under the age of 5 were "fully immunized-memory," in contrast to 73.7% over the age of 5 (P = 0.005). This difference in immunization rates by memory between the age groups was not observed in Afghani children (P = 0.34) or in Iraqi children (P = 0.10). Furthermore, compared to the 27.8% of Syrian children, 75% of Afghani children under the age of 5 were "fully vaccinated-memory" (P = 0.0009). Compared to Tempelhof, more children at Neukölln were partially immunized (93%) or had no immunizations (5%) (P < 0.001).