The Impact of Parent Torture and Family Functioning on Youth Adjustment in War-Affected Families: A Path Analysis Describing Intergenerational Trauma and the Family System.

The direct exposure to physical or psychological trauma from torture or war leads to well-documented individual health consequences. Less understood are the inclusive and intergenerational effects of war trauma on family systems and youth adjustment. The purpose was to examine mechanisms in war-affected families that explained the significant emotional and behavioral consequences of intergenerational trauma in youth through the use of multiple methods. Quantitative assessments of maternal and paternal caregivers and youth characterized associations between parent torture, parent mental health distress, parent physical health problems, family functioning, and youth adjustment. Narrative statements further contextualized processes through which the trauma of a parent impacted youth and family systems. The research was conducted in partnership with local, refugee-serving community-based organizations. The study sample included parents and youth in 96 Karen families, originating from Burma in Southeast Asia, who had been resettled to the United States through the U.S. Refugee Admissions Program. Path analysis results indicated that parent torture (ß = -0.173) had statistically significant negative direct effects on youth adjustment. Parent torture had a negative indirect effect on youth adjustment through the mental health (ß = -0.345) and physical health problems of parents (ß = -0.305), and youth gender (ß = 0.126) and trauma exposure of youth (ß = -0.048). Family functioning type demonstrated a positive direct effect on youth adjustment (ß = 0.449). Family type had an indirect effect on youth adjustment through youth gender (ß = 0.142), youth trauma exposure (ß = -0.165), parent physical health problems (ß = -0.202), and parent mental health (ß = 0.509). The current study developed and tested the first model of intergenerational trauma's effects on the adjustment of Karen refugee youth. Results emphasize that individual recovery from torture must be accompanied by adjunct interventions focused on family systems and youth adjustment, to holistically address intergenerational sequala of trauma.

School Nurse Cultural Competency Development Using the National CLAS Standards: A Quality Improvement Project.

As numbers of culturally diverse students rise, struggles with language, cultural differences, and health care create challenges for school nurses. The focus of this quality improvement project was to utilize the National Standards for Culturally and Linguistically Appropriate Services (CLAS) as a framework to initiate cultural competency development among school nurses. Eighteen public school nurses attended programming that began with the webinar "CLAS is in Session," an introduction to the standards as applicable to school nursing practice. Outcome measures included self-report of cultural awareness and sensitivity (CAS) and culturally competent behaviors (CCB). A greater percentage of nurses reported feeling "somewhat competent" after program completion, though CAS and CCB scores did not significantly change. Despite lack of measurable improvement in CCB, implementation of the CLAS Standards created an important starting point for CC programming.

"Sleeping in a boundary" constructing the meaning of health in a refugee camp.

Sociopolitical discourses surrounding refugee migration and resettlement are characterized by divisiveness, assumptions, and fear. When these discussions are grounded in the narratives of women refugees a deeper understanding of issues impacting health, family, and resilience emerges. We examine how 26 Karen women living in camps along the Thai-Burma border construct meaning around health, in relation to livelihoods. Through directed content analysis, themes emerged: precursors to achieving health, health and livelihoods, and position and agency. Women identified barriers and facilitators to health, identified a dynamic relationship between health and livelihoods, and described their position and agency in the systems they navigate.

Religious Coping, Symptoms of Depression and Anxiety, and Well-Being Among Somali College Students.

This study examined the associations between positive and negative religious coping, symptoms of depression and anxiety, physical and emotional well-being among Somali college students in Minnesota. In this online cross-sectional survey study, 156 participants (ages 18-21, M = 21, SD = 2.3) were recruited. Participants reported using more positive religious coping methods. Negative religious coping was associated with an increase in symptoms of both depression (b = .06, p = .003) and anxiety (b = .04, p = .05), and positive religious coping was associated with a decrease in symptoms of depression (b = -.04, p = .05).

Modeling Psychological Functioning in Refugees.

BACKGROUND: Refugee trauma survivors often experience posttraumatic stress disorder, other anxiety disorders, depression, and somatization. As a result, many suffer a disproportionate vulnerability to a variety of interpersonal, health, and social problems. OBJECTIVE: The study purpose was to develop a preliminary predictive model identifying high-risk refugee trauma survivors based on levels of trauma and psychological functioning. METHOD: A subset of 449 Somali and Oromo refugee trauma survivors was randomly selected from a larger study for secondary data analysis. Data from the PTSD Checklist-Civilian version, the Revised Hopkins Symptom Checklist, and the Sheehan Disability Inventory contributed to a psychological functioning score. A researcher-developed survey contributed to a composite trauma score. RESULTS: Predictors associated with functioning level differed by gender. Of interest, caring for children and increasing coping strategies were related to lower functioning in women. The regression relationship between trauma and functioning was linear in men but quadratic in women. CONCLUSION: Understanding the mechanisms linking trauma and function is implicated in the assessment of risk among trauma survivors. Predictive models inform the effective psychosocial interventions targeting those at greatest risk.

"There are many fevers": Communities' perception and management of Febrile illness and its relationship with human animal interactions in South-Western Uganda.

Diagnosing the causative agent of febrile illness in resource-limited countries is a challenge in part due to lack of adequate diagnostic infrastructure to confirm cause of infection. Most febrile illnesses (>60%) are non-malarial, with a significant proportion being zoonotic and likely from animal origins. To better characterize the pathways for zoonotic disease transmission and control in vulnerable communities, adequate information on the communities' experiences and lexicon describing fever, and their understanding and perceptions of risk pathways is required. We undertook an ethnographic study to understand behaviors, exposures, and attitudes toward fever at the community level. Our hope is to better elucidate areas of priority surveillance and diagnostic investment. A focused ethnography consisting of participant observation, informal conversations, 4 barazas (community meetings), and formal ethnographic interviews (13 Focus group discussions and 17 Key informant interviews) was conducted between April and November 2015 in Kasese and Hoima Districts in Uganda. Perception of illness and associated risk factors was heavily influenced by the predominant livelihood activity of the community. The term "fever" referred to multiple temperature elevating disease processes, recognized as distinct pathological occurrences. However, malaria was the illness often cited, treated, or diagnosed both at the health facilities and through self-diagnosis and treatment. As expected, fever is as an important health challenge affecting all ages. Recognition of malarial fever was consistent with a biomedical model of disease while non-malarial fevers were interpreted mainly through ethno etiological models of explanation. These models are currently being used to inform education and prevention strategies and treatment regimens toward the goal of improving patients' outcomes and confidence in the health system. Development of treatment algorithms that consider social, cultural, and economic contexts, especially where human-animal interaction is prevalent, should factor animal exposure and zoonotic illnesses as important differentials.

A descriptive study of zoonotic disease risk at the human-wildlife interface in a biodiversity hot spot in South Western Uganda.

Zoonotic diseases pose a significant health challenge at the human-wildlife interface, especially in Sub-Saharan Africa where ecosystem services contribute significantly to local livelihoods and individual well-being. In Uganda, the fragmented forests of Hoima district, form part of a "biodiversity and emerging infectious disease hotspot" composed of communities with high dependency on these wildlife protected areas, unaware of the associated health risks. We conducted a cross-sectional mixed methods study from March to May 2017 and interviewed 370 respondents, using a semi-structured questionnaire from eight villages neighbouring forest fragments in Hoima District, Uganda. Additionally, a total of ten (10) focus group discussions (FGDs) consisting of 6-10 men or women were conducted to further explore the drivers of hunting and perception of zoonotic disease risks at community level. Qualitative and quantitative data were analysed using content analysis and STATA version 12 respectively. We found twenty-nine percent (29.0%, CI: 24.4-33.9) of respondents were engaged in hunting of wildlife such as chimpanzee (Pan troglodytes) and 45.8% (CI: 40.6-51.0), cane rats (Thryonomyidae spp). Acquisition of animal protein was among the main reasons why communities hunt (55.3%, CI: 50.1-60.4), followed by "cultural" and "medicinal" uses of wildlife and or its parts (22.7%, CI: 18.6-27.4). Results further revealed that hunting and bushmeat consumption is persistent for other perceived reasons like; bushmeat strengthens the body, helps mothers recover faster after delivery, boosts one's immunity and hunting is exercise for the body. However, respondents reported falling sick after consumption of bushmeat at least once (7.9%, CI: 5.3-11.1), with 5.3% (CI: 2.60-9.60) reporting similar symptoms among some family members. Generally, few respondents (37.0%, CI: 32.1-42.2) were aware of diseases transmissible from wildlife to humans, although 88.7% (CI: 85.0-92.0) had heard of Ebola or Marburg without context. Hunting non-human primate poses a health risk compared to edible rats (cane rats) and wild ruminants (cOR = 0.4, 95% CI = 0.1-0.9) and (cOR = 0.7, 95% CI = 0.2-2.1) respectively. Study suggests some of the pathways for zoonotic disease spillover to humans exist at interface areas driven by livelihoods, nutrition and cultural needs. This study offers opportunities for a comprehensive risk communication and health education strategy for communities living at the interface of wildlife and human interactions.

Narratives as Borders: Using an Adapted Narrative Approach to Understand the Retelling of the Physical Narratives of Trauma by Karen Women With Refugee Status Resettled in the United States.

The refugee narrative spans time, geography, and generations, enfolding the complexity of constructing identities through displacement and migration. Through adapted narrative analysis, we examined the physical narratives of war trauma which a sample of Karen refugee women constructed, as they claimed their experiences of war trauma and torture in interview discussions. We employed an adapted narrative method relevant to the analysis of field texts to interpret the remembering and retelling of trauma narratives. This method helped to elicit positional identities and physical/sensory memories that were prominent in women's experiences and to contextualized concurrently collected quantitative data. Accounts revealed key constructs relevant to the narrative function and orientation of the narratives: remembering childhood, being a mother, embodiment of trauma.

Mechanisms Explaining the Relationship Between Maternal Torture Exposure and Youth Adjustment In Resettled Refugees: A Pilot Examination of Generational Trauma Through Moderated Mediation.

The intergenerational effects of trauma resulting from torture and war are complex and multi-faceted and have important implications for the family system. The current study aimed to identify key relationships between refugee maternal caregiver exposure to torture, mental health, and physical health with maternal-reported youth adjustment. Ninety-six Karen maternal caregivers originating from Burma and resettled in the United States participated in a cross-sectional, explanatory mixed methods study. Maternal mental health distress was found to mediate the relationship betweenmaternal torture experiences and youth adjustment, R2 = .357. Physical health problems was found to moderate the degree to which mental health distress mediated the relationship between torture and war trauma experiences and youth adjustment, R2 = .409. The current study is significant in that it enhances our mechanistic understanding of factors relevant to the intergenerational effects of trauma within families where maternal caregivers experienced trauma from torture and/or war.

Too late smart: farmers' adoption of self-protective behaviors in response to exposure to hazardous noise.

Farmers are exposed to hazardous noise from equipment and livestock and experience high rates of noise-induced hearing loss (NIHL); however, their use of hearing protection devices (HPDs) is low. The purpose of this study was to describe farmers' personal experiences using HPDs, influencing others' use of HPDs, and overcoming barriers to the use of HPDs. A purposive sample of farmers who reported a high frequency of HPD use was selected for face-to-face interviews. Findings indicated that farmers have frequent exposure to hazardous noise. They described their motivation to adopt protective behaviors to avoid hearing loss, noise annoyance, or tinnitus. Many tried to influence others' use of HPD, particularly family members. These farmers have developed a variety of methods to ensure convenient access to HPDs when needed, and have developed effective techniques for overcoming common barriers to protection. Findings from this study will be used to form the foundation for future studies aimed at developing and testing an intervention to increase HPD use and decrease rates of NIHL among farmers.

Health Realization Community Coping Intervention for Somali Refugee Women.

Health Realization (HR) is a strengths-based stress and coping intervention used to promote the use of internal and external coping resources. Our three-arm comparison group trial examined the effects of a culturally adapted Somali HR intervention on coping and mental health outcomes in 65 Somali refugee women post-resettlement. Subjects participated one of three conditions: HR intervention, nutrition attention-control, and evaluation-control. The HR intervention significantly affected multiple dimensions of coping: WAYS-distancing (p = 0.038), seeking social support (p = 0.042), positive reappraisal (p = 0.001); and Refugee Appraisal and Coping Experience Scale-Internal subscale (p = 0.045). The HR intervention also demonstrated improvement in depression symptom ratings (p = 0.079). We discuss findings from the pilot, challenges encountered conducting a three-arm comparison group trial, and implications for further research involving the HR intervention with culturally diverse refugee communities.

A theoretical framework for using health realization to reduce stress and improve coping in refugee communities.

Refugees have faced extraordinarily stressful situations in their past, and many continue to experience stress daily as they cope with the refugee adjustment experience. A strengths-based, community-focused intervention known as Health Realization (HR) is a promising strategy for nurses to promote positive psychological outcomes in these populations. Although similar in some ways to cognitive therapy, the HR intervention emphasizes the role of thought versus the content of thought. It does not promote actively changing intrusive or negative thoughts but rather promotes an understanding that allows a degree of detachment from thoughts--a shift in consciousness that can provide relief and facilitate healing. An adapted stress and coping model provides a theoretical framework to test the effectiveness of using HR with refugees, which in turn provides a solid foundation for research that can support or refute the existing substantial anecdotal evidence for the use of this intervention in holistic nursing practice.

Noise and hearing protection: Latino construction workers' experiences.

This study explored Latino construction workers' experiences with occupational noise and hearing protection to provide qualitative data to be used in designing an intervention to prevent noise-induced hearing loss. An ecological framework provided the theoretical foundation for this study. Fifteen Latino construction workers participated in one of four focus groups exploring perceptions of exposure to noise on the job and barriers to and supports for wearing hearing protection. Support for an ecological framework was apparent in the environmental and personal factors revealed in the data: how it feels, personal responsibility, they make us wear it, we don't care about ears, it won't happen to me, being Latino, keeping our jobs, hearing protection is uncomfortable, and we can handle it. Researchers are applying results of this study in the development of a hearing conservation intervention for Latino construction workers to be evaluated in a randomized, controlled trial.

"What About the Next Generation That's Coming?": The Recontextualization of Mothering Post-Refugee Resettlement.

The purpose of this analysis was to explore the recontextualization of mothering in Karen refugees from Burma. We collected ethnographic data over an 11-month period with a cohort of 12 Karen women postresettlement. Using Spradley's and tools of critical discourse analysis, we interpreted the migration narratives of women, in particular, experiences they shared as mothers. These narratives were grounded in the space of cultural difference; thus, we engaged hybridity as a theoretical frame. Findings reflect the negotiation of mothering practices within the norms, structures, and policies of the country of resettlement. We identified the spaces of transformation a woman constructed to usher change while sustaining a connection between herself, her culture, and her children.

Nurses' beliefs about public health emergencies: fear of abandonment.

BACKGROUND: Since the events of September 11, 2001, subsequent anthrax mailings, world political events, and natural disasters such as Hurricane Katrina and the recent tsunami, public health emergencies including bioterrorism events are viewed as realistic possibilities. Public health emergencies would stress the current health care system. OBJECTIVE: The objective was to identify beliefs and concerns of nurses who work in hospitals designated as receiving sites during public health emergencies. METHODS: A qualitative study using focus groups with a total of 33 hospital nurses in 2003 was used. Audiotapes were analyzed, and codes, categories, and a theme were identified. RESULTS: Fear of abandonment was the overarching theme. Nurses believed that clinical settings would be chaotic, without a clear chain of command, and with some colleagues refusing to work. Limited access to personal protective equipment, risk of infection, unmanageable numbers of patients, and possibly being assaulted for their personal protective equipment resulted in the sense that they would be in unsafe clinical environments. Loss of freedom to leave the hospital and fears that hospitals would not provide treatment to nurses who become ill as a result of caring for patients contributed to the sense of abandonment. CONCLUSION: Although these nurses worked in hospitals with comprehensive public health emergency plans, they believed that they would not have readily accessible material and human resources to cope with a bioterrorism event. Readiness plans should include a systematic assessment of nurses' concerns. Health care readiness plans should incorporate focused interventions to improve safety, a sense of control, and facilitate coping in public health emergencies.

Public health emergencies: nurses' recommendations for effective actions.

During a public health emergency such as an influenza pandemic or a bioterrorism attack, nurses may be at risk for exposure to lethal infectious diseases when caring for victims. The aim of this study was to identify interventions nurses believe will support their ability to cope during public health emergencies. A qualitative research design was used with 33 nurses from designated bioterrorism-receiving hospitals. Nurses recommended adequate protective equipment, education, drills, accessible information and available content experts, and available administrators. Other recommendations included increased security to protect nurses, emotional and physical support, communication with nurses' families, and commitment from institutions to care for ill or injured nurses. Preparations for emergencies should include assessments of nurses' and other stakeholders' concerns. These nurses proposed specific measures to improve safety, reduce anxiety, increase trust in hospitals, and provide physical and emotional support.

Trauma and coping in Somali and Oromo refugee youth.

PURPOSE: To describe war-related trauma history, immigration factors, problems, and coping of Somali and Oromo refugee youth. METHODS: Analysis of a subset of participants (N = 338) aged 18-25 years from a population-based survey of Somali and Oromo refugees conducted in 2000-2002. Data included trauma history, life situation, and scales for physical (Cronbach alpha =.69), psychological (alpha =.56), and social problems (alpha =.69). Data were analyzed using Chi-square and Mann-Whitney U tests. RESULTS: Average emigration age was 14.8 years, with 4.2 years in transit and 2.0 years in the United States; 60% reported plans to return home to live. Two-thirds (66%) had less than a high school education, 49% had English language problems, 49% were employed (38% female vs. 57% male); 70% were single, with Somali females more likely than Oromo to be partnered and mothers (39% vs. 19%). There were significant ethnicity/gender differences for all problem scales. More females reported feeling alone (24% vs. 61%, p <.001). Youth with symptoms of posttraumatic stress syndrome reported more traumatic events (mean number of events: 28 vs.16). Trauma history was strongly associated with physical, psychological, and social problems. Most frequent strategies to combat sadness were praying (55.3%), sleeping (39.9%), reading (32.3%), and talking to friends (27.8%). CONCLUSIONS: Many young Somali and Oromo immigrants to the United States experience life problems associated with war trauma and torture, but many others are coping well. The findings suggest a need to develop age-appropriate strategies to promote the health of refugee youth to facilitate their successful adaptation to adult life in the United States.