Social ecological determinants of the mental distress among Syrian refugees in Lebanon and Turkey: A transnational perspective.

OBJECTIVE: Refugees are frequently shown to have worse mental health outcomes than non-displaced populations. This fact is commonly attributed to traumatic pre-displacement experiences. While important, the focus on trauma risks overlooking the role socioeconomic living-conditions in different arrival and transit contexts can play in determining refugees' mental distress. Building on the ecological model of refugee distress, we investigate how social ecological conditions relate to the mental distress of Syrians in Lebanon and Turkey. Both countries present important spaces of arrival and transit for millions of displaced Syrians, each with a specific historical, political, social and economic context. METHODS: The empirical analysis is based on data gathered in early 2021 in face-to-face surveys among displaced Syrians in Lebanon (N = 1127) and Turkey (N = 1364). Individual mental distress is evaluated using the Patient Health Questionnaire (PHQ-8) score as the dependent variable in a multivariate regression analysis. RESULTS: Social ecological factors do not only differ in their extent of deprivation between Lebanon and Turkey. They also differ in their relationship with individual mental health outcomes. In Lebanon, limited access to the health care system and having family in the same city are major risk factors for elevated mental distress, whereas in Turkey, these are low education, poverty, unemployment as well as employment as day laborer. Discrimination and social isolation emerge as relevant predictors in both countries. CONCLUSION: Based on this analysis, we argue that a context-specific understanding of mental distress amidst the social ecology refugees face in countries of refuge and transit is necessary. This approach needs to be pursued to provide adequate support and alleviate refugees' mental distress both, in the country of first refuge and after possible onward migration. In addition to clinical implications, the study particularly highlights the important role anti-discrimination and social inclusion policies could play in promoting refugee mental health.

Good practice in reaching and treating refugees in addiction care in Germany - a Delphi study.

BACKGROUND: Health and adequate access to health care are human rights. Refugees are at risk for substance abuse. Despite the known structural and personal risk factors for abuse, refugees in Germany continue to face barriers to adequate addiction prevention and care, which is a violation of the fundamental human right to health care. The question arises as to how barriers for refugees in reaching addiction services and care can be overcome. In the presented study, strategies for good practices to deconstruct these barriers were identified. METHOD: A total of 21 experts participated in a three-round, consensus-oriented Delphi-Process. The experts represented five different fields: addiction care services, including specialized programs for women, refugee aid services, academia, policy-making and immigrants' self-help services. RESULTS: The Delphi-Process generated 39 strategies of good practice summarized in 9 major categories: Care System, Framework Conditions, Multilingualism, Information and Education, Access, Service-Level, Employee-Level, Employee-Attitudes and Networking. CONCLUSION: In order to guarantee human rights regarding health and adequate access to health care for refugees, institutional barriers limiting access to prevention and treatment programs for addictive disorders must be abolished. The identified good practice strategies for Germany, if widely implemented, could contribute to this aim. By opening up prevention and treatment facilities for refugees, other marginalized groups could also benefit. While some of the strategies need to be implemented at the institutional level, political steps are also required at the system level including, e.g. financing of adequate translation services.

Challenges in substance use treatment as perceived by professionals and Arabic-speaking refugees in Germany.

BACKGROUND: Substance use (SU) and substance use disorders (SUDs) have been recently documented among forcibly displaced populations as a coping mechanism to migration and postmigration stressors. Although the literature exploring substance use among refugees has grown recently, little is known about SU among Arabic-speaking refugees and, more specifically, on the challenges and experiences in regards to SU treatment. This study investigates this topic from the perspectives of Arabic-speaking refugees and professionals in Germany. METHODS: Design and participants To expand our knowledge on this topic, a qualitative approach was employed by conducting in-depth and semi-structured interviews among 26 participants (13 refugees and 13 professionals) in Germany during 2020-2021. Purposive sampling was used to recruit Arabic-speaking refugees in two rehabilitation centers in Berlin. Data and analysis Interviews were conducted with 26 participants of which 13 were refugees and 13 professionals. Refugees were interviewed individually in the rehabilitation centers, they ranged from 21 to 52 years of age, and their average time in Germany was 6.3 years. An open-ended survey was conducted among the professionals via the SoSci-survey platform, and they ranged from 22 to 66 years of age, with an average of 5 to 9 years of work experience. Data were analyzed using thematic analysis. RESULTS: Three themes resulted from the thematic analysis: (1) The treatment is facilitated by institutional and emotional support; (2) The affected refugees struggle with complex contextual barriers to access SUD treatment; and (3) Individual and community preventive strategies are needed. CONCLUSIONS: This study provides insight into the support and challenges of accessing effective SU treatment and prevention among Arabic-speaking refugees in Germany. Collaborative efforts by the community, professionals, and policymakers are needed to facilitate access to effective treatment and implement culturally and linguistically sensitive approaches for the treatment and prevention of SU among refugees.

An ecosystemic view on refugee mental health care: on caring environments and their interaction.

Despite the burden of mental health problems among refugees, knowledge about mental health care for this group is limited. In this context, the comprehensive discussion is important because care is more than professional care, but takes place in everyday situations and between different groups of people. In this study, we look at expert views (based on profession and lived experience) on caring environments concerning refugees' mental health on different system levels. These levels include the individual level, family level, community level and the society. Additionally, we aimed to understand how these system levels interact. We conducted interviews with 11 psychotherapists from Germany and 12 participants who fled from Arabic-speaking countries to Germany. We analyzed transcripts following Braun and Clarke's reflexive thematic analysis. Interviewees shared ideas on how society in general (e.g. increase acceptance), professional actors (e.g. be sensitive about cultural differences), other refugees (e.g. exchange information), family/friends (e.g. provide emotional help) and refugees with mental health problems themselves (e.g. be open to involve others) could provide care. Participants provided examples of how system levels interacted, for example when legal norms made care among family members harder. The interactions between different system levels point to a multidisciplinary approach towards mental health care for refugees and call for building expert networks instead of viewing refugee mental health as a medical, psychiatric issue alone. To improve the mental health of refugees, different societal actors should keep in mind the interactions across different system levels and exchange their respective expert knowledge.

Germans' awareness of refugees' information barriers regarding health care access: a cross-sectional study.

BACKGROUND: In light of their experiences on the refuge and upon their arrival in the receiving society, refugees may have differentiated needs regarding health care. However, negative attitudes of the members of the receiving society and a lack of information pose as barriers for refugees when trying to access health care services. In that sense, it is largely unknown, which antecedents positively affect Germans' perception of information barriers that refugees face. Based on an extended version of the Empathy-Attitude-Action model, this study examined selected predictors of problem awareness in the form of perceived information barriers that refugees face, emphasizing the role of positive intercultural contact experiences. METHODS: A sample of members of the receiving society, here: Germans (N = 910) completed a cross-sectional online survey with validated self-report measures. From the perspective of Germans, assessments covered positive intercultural contact, attitudes on refugees' rights, the recognition of refugees' socio-emotional support needs as a form of cognitive empathy, and the perception of refugees' information barriers when accessing health care. We conducted structural equation modeling to examine hypothesized latent associations and specified three different models with unidirectional paths between the study variables, each allowing another direct path from intercultural contact to the variables. We determined the best model using the chi-square-difference test and tested for indirect effects along the paths through bias-corrected bootstrapping. RESULTS: Our results show consistency with the Empathy-Attitude-Action model. We found Germans' cognitive empathy toward refugees to be associated with more positive attitudes and a greater awareness of refugees' information barriers. We further found more positive intercultural contact to be associated with greater cognitive empathy toward refugees and with more positive attitudes. While these contact experiences showed a slightly direct negative effect on Germans' perception of refugees' information barriers to accessing health care, the indirect effects via cognitive empathy and positive attitudes were positive. CONCLUSION: Previous positive intercultural contact may be directly and indirectly linked to greater awareness for refugees, helping Germans as the receiving community (1) to become more empathetic toward refugees, (2) to improve their attitudes toward refugees' rights and to (3) raise consciousness for information barriers that refugees face when trying to access health care services.

Rethinking mental health care provided to migrants and refugees; a randomized controlled trial on the effectiveness of Value Based Counseling, a culturally sensitive, strength-based psychological intervention.

BACKGROUND: Despite traumatic experiences and persistent psychosocial stressors, many refugees and migrants display resilience and strength in the midst and aftermath of hardships. 'Value Based Counseling' (VBC), a low-threshold, short-term and culturally sensitive psychological intervention avoids the stigmatization and pathologization of mental health problems, and, in line with latest research calling for a rethink of mental health care for migrants and refugees, focusses on the resilience and resources of clients. METHOD: This pragmatic, assessor-blinded randomized controlled trial employed a pre-post control group design to assess the effectiveness of VBC in the development of psychological assets. Refugees and migrants aged 18 or above were randomly assigned to either VBC sessions delivered by counselors matched with their clients according to gender and native language, or to a waiting list. RESULTS: Per protocol and intention-to-treat (ITT) analyses revealed that compared with participants in the waiting-list group (n = 50), the VBC group (n = 53) experienced a greater improvement in resilience (adjusted difference 11.59, 95% CI 8.35 to 14.84, effect size .49, p < .001) and perspective taking (adjusted difference 3.98, 95% CI 2.12 to 5.84, effect size .39, p < .001) after four sessions on average. These positive results remained consistent until a 3-month follow-up assessment within the VBC group. CONCLUSION: VBC with a focus on personal resources in the Here and Now, and with a culturally sensitive approach, helps clients exposed to persistent psychosocial stressors to develop strength and to increase agency over their lives.

Substance (mis)use among refugees as a matter of social ecology: insights into a multi-site rapid assessment in Germany.

BACKGROUND: Previous research concluded that substance (mis)use is increasing among forcibly displaced populations. Nevertheless, little research has been conducted within a social ecological framework aimed at identifying and understanding the factors affecting substance (mis)use embedded in the post-migration context in high-income countries. The present study aims to develop an understanding of the links and underlying mechanisms between refugees' social ecological determinants and substance (mis)using behavior. METHODS: Rapid assessments (RAs), including 108 semi-structured interviews and 10 focus group discussions with key persons from various professional, and personal backgrounds, were carried out in German urban and rural areas. The RA approach of interviewing key persons and not solely refugees that (mis)use substances allowed us to gather multi-perspective knowledge on this sensitive topic. Qualitative content analysis was applied, aiming at identifying determinants of substance (mis)use embedded in the post-migration context of refugees and understanding the underlying mechanisms. RESULTS: One main result of the data suggests that the link between refugees' countries of origin and their post-migration substance (mis)use is not as direct as often assumed. It is observed that refugees' prospects and opportunities in receiving countries (e.g., work permits) undermine this commonly reproduced link. Further determinants are related to living conditions in German refugee shelters and social relations with peers and families. The influence of refugees' living conditions can be summarized as potentially increasing substance availability and distress, whereas family separation produces a loss of control and responsibility, increasing the risk for substance (mis)use. Peers' influence on substance (mis)use was reported to reflect a search for a sense of belonging. CONCLUSIONS: Given that refugees who (mis)use substances have limited to no control over the factors identified in our study to be associated with substance (mis)use, common treatment and prevention approaches are challenged. Furthermore, we recommend aiming for a holistic comprehension of refugees' substance (mis)use by expanding the focus beyond individuals to the social ecological context in any attempt, including prevention, treatment, research, and policy.

Environmental stress, minority status, and local poverty: risk factors for mental health in Berlin's inner city.

This study examines whether climate change-associated environmental stressors, including air and noise pollution, local heat levels, as well as a lack of surrounding greenspace, mediate the effects of local poverty on mental health, using the 28-item General Health Questionnaire. We recruited 478 adults who were representative of eleven of Berlin's inner-city neighborhoods. The relationship of individual-level variables, neighborhood-level sociodemographic and environmental data from the Berlin Senate (Department for Urban Development, Building and Housing) to mental health was assessed in a multilevel model using SPSS. We found that neither local exposure to environmental stressors, nor available greenspace as a protective factor, mediated the effects of local poverty on variance in mental health (all p values > 0.2). However, surrounding greenspace (r = -0.24, p < 0.001), nitrogen dioxide levels (r = 0.10, p < 0.05), noise pollution (rho = 0.15, p < 0.01), and particle pollution (r = 0.12, p < 0.001) were associated with local poverty, which, more strongly than individual factors, accounted for variance in mental health (ß = 0.47, p < 0.001). Our analysis indicates that the effects of local poverty on mental health are not mediated by environmental factors. Instead, local poverty was associated with both an increased mental health burden and the exposure to climate-related environmental stressors.

Racism and psychosis: an umbrella review and qualitative analysis of the mental health consequences of racism.

Black people and People of Color are disproportionately affected by racism and show increased rates of psychosis. To examine whether racialized migrant groups are particularly exposed to racism and therefore have higher risks for psychosis, this paper (1) systematically assesses rates of psychosis among racialized migrant groups concerning the country of origin, and (2) analyzes interviews regarding the association of racism experiences with psychosis-related symptoms in racialized Black people and People of Color populations in Germany. We present an umbrella review of meta-analyses that report the incidence of positive symptoms (e.g., hallucinations and delusions) and negative symptoms (e.g., apathy and incoherent speech) of diagnosed schizophrenia, other non-affective psychotic disorders (e.g., schizoaffective disorder) or first-episode psychosis among migrants by country of origin. We also report 20 interviews with first- and second-generation migrants racialized as Black and of Color in Germany to capture and classify their experiences of racism as well as racism-associated mental health challenges. In the umbrella review, psychosis risk was greatest when migration occurred from developing countries. Effect size estimates were even larger among Caribbean and African migrants. In the qualitative study, the application of the constant comparative method yielded four subordinate themes that form a subclinical psychosis symptomatology profile related to experiences of racism: (1) a sense of differentness, (2) negative self-awareness, (3) paranoid ideation regarding general persecution, and (4) self-questioning and self-esteem instability. We here provide converging evidence from a quantitative and qualitative analysis that the risk of poor mental health and psychotic experiences is related to racism associated with minority status and migration.

A systematic review of qualitative research on substance use among refugees.

AIMS: To evaluate qualitative research on substance use and substance use disorders (SUDs) among refugees in terms of practitioners' and substance users' attitudes, beliefs and experiences. METHODS: Six medical, allied health and social sciences databases (EBSCO, PubMed, ScienceDirect, Web of Science, Scholar and the Cochrane Library) were systematically searched in a time frame between January and April 2021 to identify original peer-reviewed articles describing qualitative findings related to substance use among refugees (alcohol, illicit drugs, tobacco and prescription drugs). Study selection, critical appraisal and detailed extraction were performed via the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Systematic Reviews (PRISMA) (2018). Three independent reviewers selected the relevant abstracts and articles. Synthesis of the evidence identified prominent themes relating to the context and consequences of substance use. RESULTS: Twenty-six studies were included in this review. Twenty-three studies applied qualitative methods and three applied mixed methods. Synthesis of the evidence from the included studies resulted in four main findings: there is a considerable susceptibility of refugees to substance use and SUDs; the harmful consequences of substance use are complicated by the social insecurities of refugees; there are rather high barriers to treatment and health facilities for refugees in many host countries; and there is a strong need to improve effective access to treatment, interventions and prevention approaches. CONCLUSIONS: Refugees are at high risk for substance use and substance use disorders and often face high barriers to treatment and interventions in host countries.

[Structural discrimination and racism in hospital care: the role of the economic conditions in intercultural openness]. / Strukturelle Diskriminierung und Rassismus in der Krankenhausversorgung: die Rolle ökonomischer Rahmenbedingungen in der interkulturellen Öffnung.

BACKGROUND: Racism and structural discrimination in German healthcare have been little studied to date, although intercultural openness has been demanded for many years. At the same time, the processes of economization are progressing, especially in hospital care. This study examines current challenges of intercultural openness, including the influence of the economic framework. METHODS: One hundred twelve guided interviews were conducted with hospital employees in Berlin from various professional groups and departments. They were asked about challenges, how they were coping, and ideas for solutions. RESULTS: The consequences of economization are particularly visible in the care of patients with a history of flight or migration. A lack of resources combined with a lack of funding for language mediation leads to overburdening of healthcare workers and the tendency toward culturalization, in which the "culture" of the patients is used to explain their actions, and open racism. The breeding ground for this is the multiple insecurities experienced by staff due to the additional needs of these patients. Culturalization is described as an attempt to cope with their emotional distress in the face of lack of time and staff shortages. First and foremost, the wish for more time and additional staff was voiced. This being granted, further measures to reduce racism and structural discrimination were defined. DISCUSSION: In order to counteract racism and culturalization, measures that focus on the economic framework conditions and institutional change processes are central.

New directions in the mental health care of migrants, including refugees-A randomized controlled trial investigating the efficacy of value-based counselling.

OBJECTIVE: Specialized literature has identified a need for evidence-based, low-threshold, short-term, and intracultural psychological interventions that can be made available to migrants, including refugees, who suffer from psychological symptoms in host countries. The objective of the present study is to measure the efficacy of value-based counselling (VBC) as such an intervention. METHOD: We conducted a pragmatic, rater-blinded randomized controlled trial employing a pre-post control group design to assess the efficacy of VBC based on a study sample of 103 migrants, including refugees, who resided in Germany at the time. A set of instruments was used to evaluate primary outcome measures of depression, posttraumatic stress disorder (PTSD) symptoms, perceived stress, generalized anxiety, and somatic complaints. RESULTS: Per protocol analysis included 42 participants in the VBC group, and 43 in the waiting list. Compared with participants in the waiting-list group, the VBC group, following an average of four counselling sessions, experienced a clinically meaningful reduction of depression (adjusted difference 7.06, 95% CI [4.86, 9.26], effect size 0.68, p < .001), PTSD (adjusted difference 17.15, 95% CI [10.49, 23.81], effect size 0.76, p < .001), perceived stress (adjusted difference 9.25, 95% CI [6.23, 12.27], effect size 0.75, p < .001), anxiety (adjusted difference 5.34, 95% CI [3.47, 7.20], effect size 0.70, p < .001), and somatic complaints (adjusted difference 5.52, 95% CI [3.30, 7.74], effect size 0.72, p < .001). The positive outcomes were maintained at 3-month follow-up. Utilization of mental health services was significantly reduced at the 3-month follow-up conducted with participants of the VBC group. CONCLUSIONS: VBC, a culturally sensitive and strength-based mental health service, is an effective short-term intervention which meets the specific mental health needs of migrants, including refugees.

A Central Clearing Clinic to Provide Mental Health Services for Refugees in Germany.

Objective: To determine migration related distress pattern in refugees and feasibility of a de novo established, central low-threshold outpatient clinic serving more than 80,000 newly arrived refugees in the metropole of Berlin. Methods: In an observational cohort study the relative prevalence of major psychiatric disorders by age, place of living within berlin, language and region of origin were assessed in a refugee cohort from 63 nationalities speaking 36 languages. Findings: Within 18 months, a total of 3,096 cases with a mean age of 29.7 years (11.7) have been referred from all 12 districts and 165 of 182 subdistricts of Berlin to the CCC. 33.7% of the patients were female. The three most frequent diagnoses were unipolar depression (40.4%), posttraumatic stress disorder (24.3%), and adjustment disorder (19.6%). Conclusion: The present data gives insight into the distribution of mental disorders in a large sample of refugees and provides evidence that a CCC is an effective service to quickly and broadly provide psychiatric consultations and thus to overcome classical barriers refugees usually experience in the host communities. In Berlin, Germany, and Europe treatment resources for this population should focus on stress and trauma related disorders.

Tanzanian women´s knowledge about Cervical Cancer and HPV and their prevalence of positive VIA cervical screening results. Data from a Prevention and Awareness Campaign in Northern Tanzania, 2017 - 2019.

Background: 14.9 million women (≥15 years) in Tanzania are at risk of developing cervical cancer. Limited cancer care facilities, prevention programs and sparse knowledge among community members and healthcare workers contribute to late-stage presentation leading to a high mortality rate. Objective: This study aims to scientifically accompany prevention and awareness campaigns (PrevACamp) in northern Tanzania in its real-world settings to obtain (1) a better understanding about cervical cancer and HPV knowledge amongst female PrevACamp participants and (2) to determine the prevalence of pre-cancerous lesions among women undergoing cervical cancer VIA screening. Method: Cross-sectional survey among PrevACamp attendees in two regions in Northern Tanzania. Two data collections tools were used: Questionnaires and clinical data from VIA screening. Data were collected from October 2017 to March 2019. Results: 2,192 PrevACamp attendees were interviewed and 2,224 received VIA screening. There was significant nescience on cervical cancer regardless of education level, resident status, or number of children as well as nescience on HPV in all age groups, especially in urban areas and misconceptions about cancer. Screening revealed VIA positivity rate of 3.1%. Conclusion: There is an alarming lack of knowledge about cervical cancer and, to a lesser Extent, about HPV among the study participants. Having health insurance influenced the level of knowledge significantly. Outreach programs in rural areas appear to target the population in need of health education. Low positive VIA screening results are paralleled with lower HIV rates among the women. We assume that the high density of primary health care coverage in northern Tanzania contributes to these findings..

[Exploring the relationship between refugee women and female volunteers]. / Zur Beziehungsgestaltung zwischen geflüchteten Frauen und weiblichen Freiwilligen.

The growing number of refugees arriving in Germany in 2015 increased the need for support and care in psychosocial matters, on the part of both, refugees and volunteers. The research project ReWoven investigated the relationship between refugee women and female volunteers, who were not necessarily familiar with each other, through 32 guided interviews (16 with Arab & Farsi speaking women, 16 women with female volunteers). The results reveal a relevant uncertainty surrounding the definition of "volunteering" on both sides as well as misunderstandings and imbalances in their interaction. Both constitute obstacles in building close, reciprocal relationships between members of the two groups. When exploring the relationship between refugee women and female volunteers, the influence of the organization that provides the context of their encounters should be considered.

[Peer-to-Peer Self-help Interventions for Refugees: A Pilot Study]. / Peer-to-Peer-Selbsthilfe-Interventionen für Geflüchtete ­ eine Pilotstudie.

The arrival of a large number of forcibly displaced people in Germany since 2015 has led to increased challenges in the mental health care system. To build up knowledge and raise awareness of refugees regarding mental health services and to provide practical support, a manual for peer-to-peer (P2P) counseling was developed at Charité-University Medical Center Berlin and refugees were trained as peer counsellors. In a pilot study, we qualitatively evaluated four P2P groups with Farsi / Dari or Arabic speaking male and female refugees. Individual interviews were conducted, which assessed perceived benefits and pitfalls of the P2P group as well as preferences and expectations of the participants. Data were coded and analyzed with the software package MAXQDA. All P2P participants expressed their satistfaction with the intervention. The P2P group helped them to find friends and to strengthen social support. Participants suggested to modify group sessions according to individual needs. The results of our study suggest that integrating P2P approaches in the mental health services for refugees may increase access to the health care system on the one hand and reduce access barriers on the other hand.

[Poverty, migration and mental health]. / Armut, Migration und psychische Gesundheit.

Poverty and social exclusion are closely related to an increased risk for the deterioration of mental health. In 2018 approximately 19% of the German population were threatened by poverty and the associated social ostracization. Migrant groups in particular often show an increased risk for poverty and are often exposed to multiple socioeconomic stress factors depending on the context of migration, pre-migration and post-migration social factors. Numerous studies have shown that societal exclusion, precarious living conditions and the residential environment negatively affect mental health beyond the effects of pre-migration risk factors. This article provides a review and discussion on the relationship between mental health, poverty and related constructs, such as social cohesion, social capital and social exclusion in general as well as in specific risk groups, such as migrant and refugee populations.

[The (Refugee) Crisis in the Psychotherapeutic Treatment Room]. / Die (Flüchtlings-) Krise im psychotherapeutischen Behandlungszimmer.

OBJECTIVE: Aim of the study was to examine how discourses of refugees in the media influence the perspective of independent psychotherapists working with refugees. METHODS: 20 problem-centered interviews were carried out across Germany with independent psychotherapists, and were analyzed using the principles of Grounded Theory. RESULTS: 4 portrayals of refugees were identified: 'The problematic Other' (1), 'No Other' (2), 'The advantageous Other' (3) and 'The excluded subject' (4). CONCLUSION: The impact of discourses about refugees in the media can contribute to understand the findings in this study. Further explanations for the findings could be the differing access to knowledge about the situation of refugees, difficult living conditions of refugees in Germany and a psychotherapeutic approach focusing mainly on mental disorders.