Health of war-affected Karen adults 5 years post-resettlement.

BACKGROUND: An estimated 140 000 refugees from Burma have resettled to the USA since 2009, comprising 21% of total resettlement in the USA over the last decade. Our objective was to describe patterns of longitudinal health outcomes in a cohort of Karen refugees resettled in the USA for 5 years, and to translate these findings to a primary healthcare context. METHODS: The study was a retrospective cohort study focused on the analysis of the first 5 years of electronic health records of a sample of 143 Karen refugees who were initially resettled between May 2011 and May 2013. RESULTS: Through descriptive, inferential and survival statistics, we described patterns of retention in primary care, biometric trends, condition prevalence and survival probabilities. Highest prevalence health conditions documented at any point in the 5-year period included diagnoses or symptoms associated with pain (52%); gastrointestinal disturbance (41%); metabolic disorder (41%); infectious process (34%); mental health condition (31%) and central nervous system disorder (24%). CONCLUSIONS: This study is the first retrospective longitudinal analysis of patterns of health in Karen refugees originating from Burma and resettled to the USA. Findings identified in the 5-year, the post-resettlement period provided important clinical insights into the health trajectories of war-affected populations. Burden of illness was high although results did not demonstrate the extent of trauma-associated physical health conditions reported in the literature. Indicators such as significant increases in body mass index (BMI), the overall prevalence of dyslipidaemia and others suggested that the cohort may be exhibiting an early trajectory towards the development of these conditions. Authors summarize potential protective factors experienced by the cohort that promoted aspects of health frequently challenged in forced migration.

Defining effective care coordination for mental health referrals of refugee populations in the United States.

Objectives: Refugee populations arriving to the United States report high rates of exposure to trauma and associated psychiatric distress that may necessitate referrals to mental health services. Although refugee arrivals receive a voluntary health screening, mental health screening is not routine. Public health providers report that one barrier to mental health screening concerns uncertainty about how to connect refugee patients to mental health services. This article reports essential components of successful and unsuccessful care coordination related to mental health referrals of refugees.Design: A community based participatory research study explored the characteristics of successful and unsuccessful mental health referrals of refugee patients through an online survey of refugee providers. Ten coders sorted provider stories of mental health referrals into critical incidents that were analyzed using principle components analysis (PCA). Care coordination emerged as an important characteristic of referral success. This category of care coordination was analyzed further into components of successful and unsuccessful care coordination using a higher order PCA. A similar process was followed examining providers' perceptions of why care coordination was successful or unsuccessful.Results: Components describing successful care coordination include ongoing communication between providers, scheduling initial appointments directly, access to emergency mental health services, and case management provided by health plan staff. Components related to unsuccessful care coordination describe the failure to communicate about care or establish appointments in a timely manner and the failure to resolve access barriers. Trust in relationships among providers and between refugee patients and providers was an important reason why care coordination was successful.Conclusion: Ongoing communication between providers is essential to successful mental health referrals of patients with refugee backgrounds. Multidisciplinary systems of care may benefit from education about the importance of building relationships among providers and the essential components of successful care coordination.

Validation of a brief mental health screener for Karen refugees in primary care.

BACKGROUND: Karen refugees from Burma are one of the largest refugee groups currently resettling in the USA. Karen people have endured decades of civil war and human rights violations, leaving them more likely to develop serious mental health disorders. There is a noted lack of brief, culturally validated tools present in primary care settings for detecting posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) in Karen refugees. OBJECTIVE: To create the Karen Mental Health Screener, a five-question screening tool used to identify depression and PTSD and to validate it against a clinical reference standard. METHODS: This validation study was conducted during a primary care visit. Participants completed a 20-item questionnaire using a 4-point visual aid and the PTSD and MDD portions of the Structured Clinical Interview for DSM Disorders (SCID-CV for DSM-IV) as the reference standard. Both the questionnaire and the relevant sections of the SCID-IV were rigorously translated and administered by trained researchers along with a trained Karen interpreter. RESULTS: Logistic regression models and receiver operating characteristic curve analyses were used to determine a subset of items that could be used to construct a screener to identify Karen patients who were most likely to have PTSD and/or MDD. A final five-question screener was created with very strong performance characteristics. With a clinical cut score of 4, these items displayed very strong performance characteristics with sensitivity = 0.96, specificity = 0.97, positive predicted value = 0.83 and negative predicted value = 0.99. CONCLUSION: The Karen Mental Health Screener is a valid measure for detecting PTSD and major depression in Karen people from refugee backgrounds presenting in a primary care setting.

Characteristics of Successful and Unsuccessful Mental Health Referrals of Refugees.

In this community based participatory research study, we explored key characteristics of mental health referrals of refugees using stories of providers collected through an on-line survey. Ten coders sorted 60 stories of successful referrals and 34 stories of unsuccessful referrals into domains using the critical incident technique. Principal components analysis yielded categories of successful referrals that included: active care coordination, establishing trust, proactive resolution of barriers, and culturally responsive care. Unsuccessful referrals were characterized by cultural barriers, lack of care coordination, refusal to see refugees, and system and language barriers. Recommendations for training and policy are discussed.

War trauma and torture experiences reported during public health screening of newly resettled Karen refugees: a qualitative study.

BACKGROUND: Karen refugees have suffered traumatic experiences that affect their physical and mental health in resettlement. The United States Centers for Disease Control and Prevention recommends assessing traumatic histories and mental health symptoms during initial public health screening. This article reports the traumatic experiences that Karen refugees were able to describe during a short screening and contributes knowledge to existing human rights documentation systems. METHODS: Four semi-structured and open-ended items asked about lifetime experiences of war trauma and torture. Interviews were completed with adult, Karen refugees during their initial public health screening. Experiences of war trauma and torture were coded using the extensive Human Rights Information and Documentation (HURIDOCS) Micro-thesauri coding system. Additional codes were created to describe experiences not captured by existing codes. RESULTS: Over 85% of 179 Karen people interviewed experienced life-threatening war trauma. All participants who reported war trauma or torture stories were able to describe at least one event. New war trauma codes proposed include: widespread community fear, systematic destruction/burning of house or village, exposure to dead bodies, orphaned in the context of war, injury caused by a landmine, fear of Thai police or deportation from Thailand, and harm or killings in the context of war. New torture codes include: forced portering; forced to be a human landmine sweep; forced to be a soldier, including child soldier; forced contact with a dead body; and removal of the eyes. CONCLUSION: Karen refugees were able to report traumatic experiences in the context of a brief health screening. The findings confirm existing reports of human rights violations against Karen people and suggest that additional codes be added to the HURIDOCS Micro-thesauri system that is used by torture treatment centers. Understanding the nature of traumatic experiences of this group is important for health providers working with resettled Karen refugees in their countries of resettlement. Health providers may need specialized training to understand the traumatic histories of this new refugee group, learn how to initiate conversations about trauma and its impact on health, and make appropriate mental health referrals in the context of a brief public health screening.

Exploring the mental health effects of political trauma with newly arrived refugees.

We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culture-bound disorders and idioms of distress.

Refugees' advice to physicians: how to ask about mental health.

BACKGROUND: About 45.2 million people were displaced from their homes in 2012 due to persecution, political conflict, generalized violence and human rights violations. Refugees who endure violence are at increased risk of developing chronic psychiatric disorders such as posttraumatic stress disorder and major depression. The primary care visit may be the first opportunity to detect the devastating psychological effects of trauma. Physicians and refugees have identified communication barriers that inhibit discussions about mental health. OBJECTIVES: In this study, refugees offer advice to physicians about how to assess the mental health effects of trauma. METHODS: Ethnocultural methodology informed 13 focus groups with 111 refugees from Burma, Bhutan, Somali and Ethiopia. Refugees responded to questions concerning how physicians should ask about mental health in acceptable ways. Focus groups were recorded, transcribed and analyzed using thematic categorization informed by Spradley's Developmental Research Sequence. RESULTS: Refugees recommended that physicians should take the time to make refugees comfortable, initiate direct conversations about mental health, inquire about the historical context of symptoms and provide psychoeducation about mental health and healing. CONCLUSIONS: Physicians may require specialized training to learn how to initiate conversations about mental health and provide direct education and appropriate mental health referrals in a brief medical appointment. To assist with making appropriate referrals, physicians may also benefit from education about evidence-based practices for treating symptoms of refugee trauma.

Welcoming new neighbors: Minnesota's rapid response model to address the urgent health needs of Afghan newcomers, 2021-2022.

As a result of the United States withdrawal from Afghanistan in fall 2021, 1,260 Afghan evacuees arrived in Minnesota between October 2021 and February 2022. Several contextual factors including an overtaxed health system under duress from COVID-19 and uncertain benefit eligibility prompted a coordinated public health response to appropriately address the acute and pressing medical concerns of our new neighbors. This community case study describes the State of Minnesota's cross-sectoral response that created a welcoming environment, identified public health concerns, and addressed acute medical needs. Medical volunteers provided an initial health and safety check for Afghan families upon arrival. Volunteers also offered onsite culturally and linguistically appropriate mental health assessments, group therapy, women's clinics, vaccine clinics, medication refills, and ongoing walk-in primary care. Care coordinators facilitated primary care and specialty care referrals. The majority (96%) of eligible arrivals were screened as part of this response and the median time between arrival to Minnesota and initial health screening was 2 days. Half of all arrivals screened reported at least one health concern and 56% were referred to a specialty for further evaluation. Almost one in four adults (24%) reported mental health concerns. Existing partnerships across local sectors can be leveraged to provide comprehensive physical and mental health services to newcomers in an emergency response.

Associations between gender, torture, and health: A 5-year retrospective cohort analysis.

Our purpose was to identify longitudinal associations between torture exposure, physical and mental health outcomes, and gender in a cohort of 143 war-affected Karen adults five years post resettlement. Results showed that participants who self-reported primary torture experiences had higher rates of certain mental and physical health diagnoses. We observed gender differences in health over time in the cohort. Findings have implications for how primary care and public health providers implement war trauma screening tools and timelines, targeted healthcare services, and community resources to promote health and prevent disease in populations that have trauma from torture or war.

Connecting Refugees to Substance Use Treatment: A Qualitative Study.

An emerging body of literature identifies substance use as a growing concern among refugees resettling in the United States. Like immigrants, refugees may face cultural, linguistic, or systems barriers to connecting with mainstream substance use treatment programs, which may be compounded by refugees' unique experiences with exposure to trauma, displacement in refugee camps, and resettlement. This qualitative study explores factors that support and prevent refugees from connecting with chemical health treatment. Fifteen participants who identified as social service or public health professionals who work with refugees responded to an online, semistructured survey about their experiences referring refugees to substance use treatment. Resulting data was analyzed using thematic analysis. Themes emerged identifying a lack of culturally informed treatment models, policy issues, and client characteristics such as motivation and past trauma as barriers to engaging with treatment. Ongoing case management and coordination were identified as important to successful linkage. Findings from this study contribute to a better understanding of how to support refugees seeking substance use treatment and suggest that developing trauma informed, culturally relevant models of treatment that are integrated with primary health care and geographically accessible may enhance treatment linkage.