Trend of Disease Burden of North Korean Defectors in South Korea Using Disability-adjusted Life Years from 2010 to 2018.

BACKGROUND: This study aimed to examine the disease burden of North Korean defectors in South Korea by sex, age, and disease from 2000 to 2018 and to study the changes in the disease burden over time. METHODS: Based on the incidence-based disability-adjusted life year (DALY) developed in a Korean National Burden of Disease (KNBD) study, we calculated the years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY) for approximately 22,753 North Korean defectors in South Korea whose claims data were available from the National Health Insurance Service (NHIS). RESULTS: In 2018, the rates of YLL, YLD, and DALY for North Korean defectors per 100,000 population was 3,763 (male 8,491; female 2,404), 37,683 (male 27,742; female 40,539), and 41,446 (male 36,233; female 42,943), respectively. Major depressive disorders constituted the highest DALY, followed by cirrhosis of the liver and low back pain. The disease burden of North Korean defectors consistently decreased from 2010 to 2018. The decrease in YLD contributed to the overall decline in DALY per 100,000 population in 2018, which decreased by 25.2% compared to that in 2010. CONCLUSION: This is the first study to measure the disease burden of North Korean defectors in South Korea. Given the decreasing or substantially increasing trends in disease burden, it is necessary to establish appropriate public health policies in a timely manner, and the results of this study provide a basis for the development of customized public health and healthcare policies for North Korean defectors in South Korea.

Association of Refugees' Knowledge of Mental Illness and Their Attitudes Toward Mental Illness.

The purpose of this study is to identify the level of mental health knowledge of defectors and to investigate the effect of sociodemographic characteristics and mental health knowledge level on mental health attitudes. We conducted a questionnaire survey of 150 people and analyzed the data of 138 people. The t test and one-way analysis of variance were used to analyze differences according to demographic characteristics. Hierarchical regression analysis was performed to measure the effect of mental illness knowledge on attitudes toward mental illness. The positive correlations between the mental health attitudes of North Korean defectors and the knowledge level were significant, and the knowledge level between final academic achievement in South Korea and the entry year into South Korea was also significant. The higher the knowledge of mental health, the more generous the minds of those with mental illness because they know better about it, and they have negative thoughts about regulating their lives.

The association between oral health literacy and oral health behaviors in North Korean defectors: a cross-sectional study.

BACKGROUND: The present study aimed to investigate the association between oral health literacy and oral health behaviors among North Korean defectors. METHODS: This study involved the collection of self-reported questionnaires from 123 North Korean defectors visited a dental clinic that offered complimentary services, to receive dental treatment in a metropolitan area of South Korea from December 2017 to April 2018. Oral health literacy was measured with the Test of Korean Functional Health Literacy in Dentistry (TOKFHLiD), which consists of 30 items concerning verbal oral health literacy and 42 items concerning functional oral health literacy (28 items for reading comprehension and 14 items for numeracy). In addition, the questionnaire contains 15 and 14 items related to demographic characteristics and oral health behaviors (interest, lifestyle, diet, prevention), respectively, for a total of 101 items. RESULTS: The mean oral health literacy score was 44 (out of a maximum possible score of 72). Oral health literacy and oral health behaviors were positively correlated (r = 0.526, P < 0.001), and oral health literacy also had a significant effect on oral health behaviors (Beta = 0.26, 95% CI: 0.04-0.33). However, although functional oral health literacy had a significant effect on oral health behaviors (Beta = 0.20, 95% CI: 0.01-0.43), verbal oral health literacy did not (Beta = 0.13, 95% CI: - 0.06-037). CONCLUSIONS: Educational interventions are needed to improve oral health literacy, and thus oral health behaviors, as a part of the health promotion measures undertaken to facilitate the stable adjustment of North Korean defectors in South Korean society.

Migration-Related Stressors and Suicidal Ideation in North Korean Refugee Women: The Moderating Effects of Network Composition.

Alarmingly high rates of suicidal ideation have been reported in North Korean (NK) refugee women living in South Korea. This population often endures traumatic experiences and violence in North Korea as well as human trafficking and sexual exploitation in intermediary countries. Following resettlement in South Korea, NK refugee women continue facing multiple hardships, such as discrimination, that can negatively affect their mental health and contribute to suicidality. Support from social networks can buffer the harmful impacts of pre- and postmigration stressors on mental health in NK refugee women. Using the stress-buffering hypothesis, the present study examined the moderating effects of network composition (i.e., network diversity and church-based ties) on the associations among premigration trauma, postmigration discrimination, and suicidal ideation in NK refugee women living in South Korea. Participants (N = 273) were NK refugee women living in South Korea who were 19 years of age or older; 34.4% of the participants reported past-year suicidal ideation. The study results indicated that network diversity significantly moderated the association between postmigration discrimination and suicidal ideation, p = .031, whereas networks with church-based ties significantly moderated the association between premigration trauma and suicidal ideation, p = .026. The present findings support the hypothesis that social ties can buffer the appraisal of migration-related stressors on suicidality. These findings have implications for practitioners serving vulnerable populations that experience multiple traumatic events.

Effects of Narrative Exposure Therapy on Posttraumatic Stress Disorder, Depression, and Insomnia in Traumatized North Korean Refugee Youth.

Refugees affected by multiple traumatic stressors are at high risk for developing trauma-related mental disorders, including posttraumatic stress disorder (PTSD), depression, and insomnia, which is sometimes overlooked. The present study examined the effectiveness of narrative exposure therapy (NET) on trauma-related symptoms in a sample of North Korean refugee youth. We focused on sleep patterns in addition to changes in symptom severity for PTSD, depression, and internalizing and externalizing symptoms. North Korean refugee youth (N = 20) with PTSD were assigned to either an NET-based treatment group or a control group, which consisted of treatment as usual (TAU). There were clinically significant reductions in PTSD, depression, and internalizing and externalizing symptoms for the NET group, Hedges' g = 3.6, but not the TAU group. The change in diagnostic status for PTSD was more notable for participants in the NET group compared to the TAU group. Of note, NET also produced a significant improvement in insomnia symptoms and sleep quality, Hedges' g = 2.1. The substantial recovery regarding overall posttraumatic symptoms in the NET group was observed 2 weeks after the end of treatment and remained stable at 6-month follow-up. The results of the present study suggest that NET may be a treatment option for traumatized North Korean refugee youth and may also be effective for the treatment of sleep problems that arise from traumatic experiences.

The effect of early trauma on North Korean refugee youths' mental health: Moderating effect of emotional regulation strategies.

Research shows that North Korean refugee youths are exposed to early traumatic events and are, therefore, vulnerable to mental health problems. We investigated the relationship between early trauma and emotion regulation strategies with symptoms of depression and attention-deficit hyperactivity disorder (ADHD) among North Korean refugee youths. In 2017-2018, we surveyed youths attending alternative schools for North Korean refugees in Seoul. One hundred and fifty-seven students (54 boys, 103 girls; 18.66 ± 2.82 years) completed questionnaires assessing early trauma experiences, emotion regulation strategies, depressive symptoms, and ADHD symptoms. Descriptive, correlation, and moderation analyses were conducted. Early trauma experience directly and negatively affected both the depressive and ADHD symptoms of North Korean refugee youths. The use of expressive suppression strategy significantly aggravated these effects of early trauma on both depressive and ADHD symptoms, indicating that it might be a risk factor for mental health problems among them. Contrarily, cognitive reappraisal seemed to buffer the effect of the expressive suppression strategy on depressive symptoms. A tailored intervention promoting emotion regulation strategies to prevent depressive and ADHD symptoms among this group is necessary.

Health Literacy, Drug Knowledge, and Drug Misuse Behaviors Among North Korean Refugees.

PURPOSE: This study measured levels of health literacy, drug knowledge, and drug misuse behavior and analyzed the relationship among major variables related to 137 North Korean refugees who could only receive limited medical benefits owing to cultural and linguistic barriers. METHOD: The data were analyzed using descriptive statistics, t test, and the Pearson correlation coefficient using SPSS. RESULTS: The subjects' health literacy and drug knowledge levels were low; however, drug misuse behavior was not high. The drug dosage was significant considering the health literacy of the subjects; notably, the functional health literacy of women was high. However, many drug misuse cases were identified among women in their 40s. Health literacy and drug knowledge levels showed a significant relationship. CONCLUSION: It is necessary to provide community-based information to vulnerable groups to ensure safe use of medications and to develop a level-based and tailored educational program considering North Korean refugees' literacy levels and cultural characteristics.

Alexithymia and frontal-amygdala functional connectivity in North Korean refugees.

BACKGROUND: Refugees commonly experience difficulties with emotional processing, such as alexithymia, due to stressful or traumatic experiences. However, the functional connectivity of the amygdala, which is central to emotional processing, has yet to be assessed in refugees. Thus, the present study investigated the resting-state functional connectivity of the amygdala and its association with emotional processing in North Korean (NK) refugees. METHODS: This study included 45 NK refugees and 40 native South Koreans (SK). All participants were administered the Toronto Alexithymia Scale (TAS), Beck Depression Inventory (BDI), and Clinician-administered PTSD Scale (CAPS), and differences between NK refugees and native SK in terms of resting-state functional connectivity of the amygdala were assessed. Additionally, the association between the strength of amygdala connectivity and the TAS score was examined. RESULTS: Resting-state connectivity values from the left amygdala to the bilateral dorsolateral prefrontal cortex (dlPFC) and dorsal anterior cingulate cortex (dACC) were higher in NK refugees than in native SK. Additionally, the strength of connectivity between the left amygdala and right dlPFC was positively associated with TAS score after controlling for the number of traumatic experiences and BDI and CAPS scores. CONCLUSIONS: The present study found that NK refugees exhibited heightened frontal-amygdala connectivity, and that this connectivity was correlated with alexithymia. The present results suggest that increased frontal-amygdala connectivity in refugees may represent frontal down-regulation of the amygdala, which in turn may produce alexithymia.

Perceived Trajectories of Past, Present, and Future Life Satisfaction of North Korean Defectors.

This study compared perceived trajectories of life satisfaction (LS) between North Korean defectors' (NKDs') and the general South Korean population and examined psychosocial factors associated with future LS. Data were obtained from 300 NKDs residing in South Korea and 5089 South Koreans using self-questionnaires and face-to-face interviews. LS values from 5 years ago (3.46 vs. 6.18) and at present (5.30 vs. 5.91) were lower in NKDs than the control group, but the inverse was true for expected LS score in 5 years (7.82 vs. 6.87). NKDs' LS trajectory showed a more statistically positive trend than that of the control group. Among NKDs, subjective sense of loneliness and satisfaction with one's sense of autonomy were associated with expected future LS. NKDs experience higher life satisfaction and expect an optimistic future relative to the control group. Social policies and therapeutic approaches to loneliness and improving a sense of autonomy may be beneficial.

Intimate Partner Violence Against Women Among North Korean Refugees: A Comparison With South Koreans.

North Korean refugees in South Korea have been reported as at higher risk of intimate partner violence (IPV). However, few studies have examined risk factors of IPV among North Korean refugees. This study aimed to report the prevalence of IPV against women among North Korean refugees, and compared the risk factors of IPV against women between South Koreans and North Korean refugees in South Korea. Data from a nationwide survey about domestic violence in South Korea were used. The rate of IPV against women by North Korean refugees was 57.1%, which is considerably higher than that of South Koreans (9.9%). The regression analysis indicated that North Korean refugees perpetrated partner violence against women more frequently than South Koreans, even after controlling for socioeconomic factors. Child abuse victimization and witnessing IPV between parents were the main factors of IPV against women among South Koreans. On the other hand, stress and a tolerant attitude toward using violence were significantly associated with IPV against women among North Korean refugees. The findings suggested that stress management and education on reducing tolerance to violence should be provided to prevent IPV against women among North Korean refugees.

Factors Related to Change in Depression among North Korean Refugee Youths in South Korea.

This study investigated change in depression and revealed factors related to change using one-year follow-up data. A sample of 108 North Korean Refugee Youths (NKRYs) aged 13 to 26 years (66 females) was recruited from two alternative schools for NKRYs in South Korea. Based on the Center for Epidemiologic Studies Depression Scale cut-off score of 16, respondents were grouped based on change in depression score after one year as stable low, alleviated, deteriorated, or prolonged. Multinomial logistic regression assessed the influence of baseline psychological scores (resilience, emotional regulation strategy, and self-esteem), and reported social support (psychological/practical) on the odds of group classification. With the stable low group as the reference category, those with alleviated depression at Time 2 had significantly higher odds of expressive suppression and tended to have lower self-esteem at Time 1. The deteriorated depression group was more likely than the stable low group to have lower resilience and cognitive appraisal scores. Those with prolonged high depression were more likely than the stable low group to have lower resilience, less practical social support, and lower self-esteem. Psychological interventions, particularly those focused on increasing self-esteem and resilience, could be helpful for NKRYs with potential risk of depression. In addition, practical support should be provided on an as-needed basis to prevent chronic depression among NKRYs.

A model of identity development: Life-course narratives of North Korean youth resettling in South Korea.

INTRODUCTION: Identity development is a convoluted process for youth experiencing traumatic interruptions in their lives. This study aimed to build a model of identity development in an understudied cultural group of trauma-exposed youth who fled North Korea and resettled in South Korea. METHODS: Sixteen participants (75% female, Mage = 26.63 years, Mdefection age = 16.29 years, Mdefection duration = 5.72 years) produced life-course narratives, as guided by the life-lines they drew to depict their high and low points and future trajectories. The cross-sectional qualitative data were analyzed using thematic content analysis. Themes of identity, trauma, and turning points were derived and coded, and then organized sequentially to classify stages of identity development. RESULTS: The Vulnerable stage defined a sense of helplessness during an early life of deprivation in North Korea. Their identity entered the Invisible stage during their hiding in China. Upon reaching South Korea, they traversed four stages: The Renewal stage signaling a fresh outset; the Turmoil stage characterized by acculturative stress, rejection, and family disruption; the Achieved stage of relative stability; and the Self-Transcendence stage in which youth extended beyond their immediate views of self and focused on meaning and purpose across the themes of social change, reconciliation, and spirituality. DISCUSSION: The six-stage model of identity development demonstrates that North Korean youth who defect to South Korea undergo a multifaceted identity development process as they navigate adversities, interruptions, and turning points. Results suggest that traumatic experiences can spur positive identity development and provide implications for professionals working with youth affected by intense and prolonged social conflict.

The perceptions and experiences of North Korean refugee doctors concerning the burden of non-communicable diseases in North Korea.

BACKGROUND: Non-communicable diseases (NCDs) are a major challenge to health and social development in the 21st century, and North Korea is no exception. However, there is a lack of information concerning NCDs in North Korea, and a different approach is needed to understand the NCDs burden there. This study examines the perceptions and experiences of refugee doctors from North Korea concerning the NCDs burden in North Korea. METHODS: Focus group discussions were conducted with 10 refugee doctors from North Korea who had been recruited through snowball sampling. RESULTS: North Korean refugee doctors participating in this study indicated that NCDs are the highest priority diseases, that North Koreans did not appear to have a high level of understanding and knowledge of NCDs, that economic breakdown was the primary cause of the NCDs burden, and that a high priority should be assigned to targeting NCDs in North Korea. DISCUSSION: Although the North Korean refugee doctors were medical professionals, they faced serious challenges accessing and managing patients with NCDs. South Korea needs to prepare for a potentially large number of people with NCDs should a freer movement of peoples occur between the two countries.

Challenges Experienced By North Korean Refugee Doctors in Acquiring a Medical License in South Korea: A Qualitative Analysis.

INTRODUCTION: In general, refugee doctors encounter difficulties in regularly practicing medicine in their host countries. In particular, many barriers impede the efforts of North Korean refugee doctors (NKRDs) who have settled in South Korea to acquire a medical license in the country. This study examines the experiences and opinions of NKRDs in their attempts to acquire permission to legally practice medicine in South Korea and the opinions of South Korean experts regarding this matter. METHODS: In-depth interviews were conducted among 23 participants divided into 2 groups. The first group comprised 16 NKRDs recruited through snowball sampling, whereas the second group included 7 South Korean doctors experienced in operating programs assisting NKRDs in license acquisition. RESULTS: All participating NKRDs perceived that they face grave difficulties at every stage of acquiring a South Korean medical license and, particularly, in gaining recognition for their educational credentials. Furthermore, South Korean experts expressed the necessity of supporting, establishing, and expanding a system in the country whereby NKRDs can acquire a medical license. DISCUSSION: Strengthening and changing their clinical competency to meet South Korean standards is the best option for NKRDs to acquire a medical license. Furthermore, the study reveals that the government should eliminate the obstacles in medical license acquisition by NKRDs and support the latter in their efforts to improve and demonstrate their competency.

Epidemiology survey of infectious diseases in North Korean travelers, 2015-2017.

BACKGROUND: Up until now, there are limited studies available on the epidemiology of infectious diseases in Democratic People's Republic of Korea (DPRK, North Korea). However, different types of infectious diseases have been found in North Korean travelers at Dandong port. Entry surveillance data of those North Korean travelers may provide some insight into the probable epidemiology of some infectious diseases in DPRK. METHODS: We actively analyzed the medical test result of North Korean travelers entering China through Dandong port. Detection of hepatitis B virus (HBV), tuberculosis (TB), syphilis and malaria was made by specific laboratory tests according to the national technical guidelines. Infectious diseases surveillance data for 2015-17 was analyzed and compared among subgroups. RESULTS: Between Jan 1, 2014, and Dec 31, 2016, 557 cases of infectious diseases were identified among 18,494 North Korean travelers, HBV active infection (466 cases), active TB infection (33 cases), current active syphilis infection (57) cases, Plasmodium falciparum (P.falciparum) malaria infection (1 case). The incidence of HBV, TB and syphilis in North Korean travelers was high. Incidence of TB increased from 11.7256 (1/10,000) in 2015 to 28.2738 (1/10,000) in 2017. HBV immunization rate in in North Korean travelers was relatively high in 0-10 age group. CONCLUSION: This report is the first to characterize the profile of infectious diseases among arriving North Korean travelers in mainland China. Our findings suggest high incidence of HBV, TB and syphilis among North Korean travelers. The screening for TB in North Korean workers should be strengthened in order to prevent infections imported into China.

Pre-migration Trauma, Repatriation Experiences, and PTSD Among North Korean Refugees.

Many studies on refugees suggested that refugees' traumatic events associated with post-traumatic stress disorder (PTSD). However, it is unknown whether refugees' PTSD was caused by their negative experience before or after the entry of their destination country. Thus, a separation of refugees' pre-migration from their post-migration experience is particularly important in understanding the causal impact of trauma. Using a sample from North Korean refugees, this study investigates the prevalence of PTSD symptoms, the impact of tortured trauma, repatriation experiences, on PTSD among North Korean refugees (n = 698). We found that North Korean refugees in our sample (a) demonstrated a high rate of current probable PTSD; (b) were demonstrated a higher frequency of repatriation experiences with a greater risk for PTSD symptoms. The findings suggest that particular types of trauma for populations with particular socio-demographic characteristics may be at a greater risk of PTSD.

Understanding Educational Barriers and Needs of North Korean Defector Nursing Students: A Qualitative Descriptive Study.

INTRODUCTION: A growing number of North Korean defector students enter nursing schools in South Korea. Many of them, however, quit nursing school and fail to obtain a nurse license. The purpose of this study was to describe the educational barriers and needs of North Korean defector nursing students. METHOD: A qualitative descriptive approach was employed. Convenience sampling was used, and 14 students participated. Qualitative content analysis was employed. RESULTS: Five themes emerged: lack of preparation for higher education, multiple language barriers, differences in education and culture, lack of support and resources, and lack of information and understanding. DISCUSSION: South Korean government needs to provide North Korean defector students with more practical supportive programs. South Korean nursing schools need to provide more transcultural education for South Korean students and supportive adaptation programs for North Korean defector students to produce culturally competent nurses who provide culturally congruent health care.

Health risk behaviors and psychological problems among South Korean, North Korean, and other multicultural family adolescents (2011-2016).

This study was aimed to investigate the health risk behaviors and psychological problems among North Korean, other multicultural, and South Korean family adolescents. The data were collected from the Korea Youth Risk Behavior web-based survey (2011-2016) data set. A total of 17,195 adolescents (mean age 14.65 ±â€¯0.01 years) were analyzed to compare health risk behaviors and psychological problems among the three groups. Concerning risk behaviors, multicultural family adolescents showed a higher rate of alcohol use, smoking, drug use and sexual relations compared to South Korean family adolescents. Moreover, North Korean family adolescents were more likely to experience those risk behaviors than other multicultural family adolescents. Concerning psychological problems, multicultural family youth displayed more depressed mood, and more suicidal ideation, planning, and attempts when compared with South Korean family youth. Among multicultural families, North Korean family adolescents were more depressed and showed higher suicidality. School-based education and preventive interventions are necessary to manage risk behaviors and psychological difficulties of adolescents in North Korean and other multicultural families.

Infections of Soil-Transmitted Helminth in Refugees from North Korea.

Soil-transmitted helminthiases (STH) are now no longer public health problems in the Republic of Korea (South Korea), but their status are unavailable in the residents of North Korea (NK) despite the expectation of large scale traffic and future reunification of the Korean Peninsula. A total of 20 female refugees from NK who had been admitted to the Division of Gastroenterology, Dankook University Hospital, were subjected in this study. Among them, 15 refugees were examined by the colonoscopy and 10 ones were examined with the stool examination (formalin-ether sedimentation). Both diagnostic methods were commonly adopted in 5 patients. Eggs of Trichuris trichiura were detected in 7 out of 10 refugees in the stool examination. In the colonoscopy, T. trichiura worms were found in 6 (40.0%) out of 15 refugees. Total 9 (45.0%) peoples were confirmed to be infected with human whipworms. Additionally, 1 case of clonorchiasis was diagnosed in the stool examination and a worm of Ascaris lumbricoides was discovered from a trichuriasis case. These findings suggested that STH is highly prevalent in NO, in which living conditions are not so good in the aspect of general hygiene and medical care.

Health-seeking experience of North Korean women defectors in South Korea.

OBJECTIVE(S): The objective of the study was to explore and describe the health-seeking experience of North Korean women defectors settled in South Korea. DESIGN AND SAMPLE: A qualitative study was conducted using Colaizzi's phenomenological method. Participants were 10 North Korean women defectors. MEASURES: Data were collected through in-depth, unstructured interviews with individual participants. RESULTS: A total of 24 themes, eight theme clusters, and four categories emerged. The structure of the health-seeking experience for them was identified as 'having new opportunities to better understand my own body and protecting my own health while adapting to the health care system of the South'. The four categories were: finding out about my own body, confusion regarding the medical treatment, enjoying the health care benefits, and protecting my own health. CONCLUSIONS: The findings of this study will help improve the understanding of the health-seeking experience of North Korean women defectors and provide valuable resources to assist in caring for their health needs. This will contribute to preparing the groundwork to enhance the quality of their remaining life in South Korea.