Hypertension and Its Associated Mental Health Challenges Among Female African Refugees in Durban, South Africa.

ABSTRACT: Hypertension is a serious medical condition that leads to various adverse health complications when left untreated. In addition to psychological challenge that female migrant refugees are exposed to premigration, they encounter barriers to care postmigration from xenophobia that affects their hypertension. We investigated the extent and mental health drivers of hypertension in refugees in Durban, South Africa. We interviewed 178 adult female African help-seeking refugees/migrants for hypertension (blood pressure ≥130/90 mm Hg) and mental health challenges (e.g., adverse childhood experience [ACE] and depression using the Center for Epidemiologic Studies-Depression scale). Eighty-six percent (n = 153) of participants were hypertensive, and based on the adjusted regression models, exposure to at least one ACE (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.11-7.26) and depression (aOR, 3.54; 95% CI, 1.10-11.37) were associated with hypertension, independent of smoking, alcohol, obesity, and physical exercise status. Hypertension and its associated mental health challenges are overlooked conditions in this population, with further efforts for screening being needed.

"A woman's honor tumbles down on all of us in the family, but a man's honor is only his": young women's experiences of patriarchal chastity norms.

Purpose: In this qualitative study we explored how young women living in Sweden with ethnic and cultural roots in the Middle East and East Africa comply with or resist so-called honour norms and how they perceive that these norms affect their living conditions. Method: In depth interviews were performed with 14 young women. The majority were between 21 and 32 years of age with a mean age of 24. All interviews were transcribed verbatim and a grounded theory approach was used. To reflect the diversity in women's experiences, the grounded theory approach was conducted from a feminist perspective to transform women's personal narratives to a larger social context. Results: We analysed the core category "Honorable women in becoming" as the central emerging phenomenon related to categories about structural and individual control of women, the women's adjustment and resistance, and the continuum of severe consequences and violence that they experienced in their struggle for autonomy. Conclusion: Simone de Beauvoir's feminist theory about women as "the other" was an inspiration and gave us valuable input to highlight women's experiences and situations from a perspective of gender, power, and oppression.

"We Are Like Any Other People, but We Don't Cry Much Because Nobody Listens": The Need to Strengthen Aging Policies and Service Provision for Minorities in Canada.

BACKGROUND AND OBJECTIVES: This study explores the aging experiences and needs of immigrant Muslim communities in an urban center in Alberta, Canada. Over one million Muslims live in Canada, with the majority being immigrants and visible minorities. Aging-focused policies and services have yet to address the needs of this population as larger cohorts begin to enter older age. RESEARCH DESIGN AND METHODS: A community-based participatory research approach was adopted with a community advisory committee co-leading all aspects of the research process. Sixty-seven older adults and stakeholders from diverse ethnocultural immigrant Muslim communities participated in either individual interviews or one of the seven focus groups (2017-2018). Data were transcribed verbatim and thematically analyzed with a focus on factors that support or hinder positive aging experiences in this population. RESULTS: Participants not only described the benefits of growing old in Canada but also identified unique challenges stemming from their social positioning as religious minorities, immigrants, and older adults. We highlight these experiences in three themes: (a) aging while living across places, (b) negotiating access to aging-supportive resources in a time of scarcity, and (c) re-envisioning Islamic approaches to eldercare. DISCUSSION AND IMPLICATIONS: Immigrant Muslim communities report inequities experienced by older community members. There is a need for an in-depth analysis of the ways aging and migration policies intersect to influence the resources that immigrant minorities have access to as they grow old in Canada.

Chronic schistosomiasis in African immigrants in Israel: Lessons for the non-endemic setting.

To study the clinical presentation of Chronic Schistosomiasis (CS) in immigrants from East Africa to Israel and the tests that were useful in confirming the diagnosis.A retrospective study of all medical notes pertaining to hospitalized patients who were immigrants from East Africa with a pathological or microscopic confirmation of CS. Literature review was also conducted focusing on diagnosis of schistosomiasis among immigrants from endemic countries.We identified 32 suspected and 11 confirmed cases of CS. Most of the patients (82%) presented with gastrointestinal symptoms. Sensitivity of stool smear, serology and tissue diagnosis (by histopathology or microscopy) were 14%, 100%, 89%, respectively. Patients have undergone extensive diagnostic evaluation with long hospitalization stays (median 10 days, range 4 to 33 days).CS has multiple presentations and is seen in Israel among refugees from Eritrea and Sudan. Most of the manifestations are gastrointestinal, suggestive of infection with Schistosoma mansoni (S. mansoni). Standard diagnostic techniques used in endemic countries, such as microscopy for ova and parasites were unhelpful, necessitating more advanced procedures like colonoscopic or liver biopsy. We propose a diagnostic algorithm for CS in this patient population in order to make an accurate diagnosis and avoid unnecessary invasive procedures.

Preconception Folic Acid Supplement Use in Immigrant Women (1999-2016).

This study examines how preconception folic acid supplement use varied in immigrant women compared with non-immigrant women. We analyzed national population-based data from Norway from 1999-2016, including 1,055,886 pregnancies, of which 202,234 and 7,965 were to 1st and 2nd generation immigrant women, respectively. Folic acid supplement use was examined in relation to generational immigrant category, maternal country of birth, and length of residence. Folic acid supplement use was lower overall in 1st and 2nd generation immigrant women (21% and 26%, respectively) compared with Norwegian-born women (29%). The lowest use among 1st generation immigrant women was seen in those from Eritrea, Ethiopia, Morocco, and Somalia (around 10%). The highest use was seen in immigrant women from the United States, the Netherlands, Denmark, and Iceland (>30%). Folic acid supplement use increased with increasing length of residence in immigrant women from most countries, but the overall prevalence was lower compared with Norwegian-born women even after 20 years of residence (adjusted odds ratio: 0.63; 95% confidence interval: 0.60-0.67). This study suggests that immigrant women from a number of countries are less likely to use preconception folic acid supplements than non-immigrant women, even many years after settlement.

Cardiovascular Disease and hospital admissions in African immigrants and former Soviet Union immigrants: A retrospective cohort study.

BACKGROUND: Previous studies reported low prevalence of cardiovascular disease (CVD) despite an increasing prevalence of metabolic abnormalities in immigrants who moved from low CVD-risk regions to Western countries. Nevertheless, little is known about hospital admissions due to CVD in immigrants. METHODS: A retrospective cohort study of East Africa immigrants (EAI), Former Soviet Union immigrants (FSUI) and native-born Israelis (NBI) over 11-year period. Associations between ethnicity, age, sex, CVD, and hospital admission were assessed using logistic and Poisson regression models. Incidence density rates per person-years were calculated. RESULTS: The age-adjusted prevalence rates of ischemic heart disease in EAI, FSUI and NBI, respectively, were 1.8%, 8.2%, and 5.8%, respectively (p < 0.001). The corresponding rates for stroke were 2.6%, 3.5%, and 2.5%, respectively. Multivariate odds ratios for all CVD were found to be significantly lower in EAI for both sexes. Hospitalizations rate due to CVD were 9, 17, and 6 per 1000 person-years in EAI, FSUI and NBI, respectively (p < 0.001). EAI were more likely to be hospitalized due to hypertensive disease, cerebral vascular diseases and heart disease, in comparison to NBI and FSUI. However, when controlling for CVD risk factors profile, EAI had similar admission rates to NBI. EAI were more likely to be hospitalized in internal medicine, geriatrics, and neurology departments, and less likely to be admitted to intensive care units or surgical department. CONCLUSIONS: EAI had low rates of all types of CVD, and low risk of hospitalization after controlling for CVD risk factors profile.

Tuberculosis among asylum seekers in Milan, Italy: epidemiological analysis and evaluation of interventions.

In countries of the European Union, tuberculosis (TB) mainly affects marginalised people, including asylum seekers. Migratory flows from high-incidence countries to Italy have increased up to 2017, posing challenges to the national health system. This study sought to assess TB and latent TB infection (LTBI) prevalence among asylum seekers in Milan during the biennium 2016-2017 and to evaluate interventions in place.A two-level active surveillance and screening system was developed for both TB and LTBI. Asylum seekers underwent an initial screening with a tuberculin skin test (TST) and a questionnaire at the receiving sites. At the Regional TB Reference Centre, those with a positive result underwent chest radiography. People aged <35 years with negative chest radiography results underwent further testing by interferon-γ release assay. If results of the assay were positive, LTBI treatment was offered. TB and LTBI prevalence were compared with literature data.A total of 5324 asylum seekers, mostly young (10-39 years; 98%), male (84%) and from sub-Saharan Africa (69%), were enrolled in the study. 69 active TB cases were diagnosed and 863 LTBI-positive individuals were detected. TB prevalence was high (1236 per 100 000 population) and LTBI prevalence was 28%. Despite losses (41%) during the transition from initial screening sites and the diagnostic centre, a good TB cure rate (84%) and optimal LTBI treatment completion (94%) were achieved.Our study shows that TB incidence is high among asylum seekers in Milan and that well-coordinated screening measures are critical for early diagnosis and treatment. It also proves that rolling out successful at-scale interventions for both prophylaxis and disease management is feasible.

After crisis: health, politics and reflections on the European refugee crisis.

The years 2014 and 2015 saw a dramatic rise in the number of migrants entering Europe via the Mediterranean. This rise was mostly accounted for by refugees fleeing the civil war in the Syrian Arab Republic. Since that time Europe has been gripped in a political and humanitarian crisis as the incoming numbers overwhelmed individual state and collective European Union ability to respond effectively. In this article, I explore the European Migrant Crisis in geographical, political and humanitarian perspectives, describing and explaining the key events of the crisis. I then go on to a study of the major health issues arising from the crisis in terms of communicable and non-communicable disease, mental health, gender-related health and access to healthcare. Finally, I discuss the global dimensions of the refugee crisis and enter into a discussion of the roles and effectiveness of the UNHCR and the European Union's response as a whole.

The prevention of female genital mutilation in England: what can be done?

BACKGROUND: Female genital mutilation (FGM) is a global public health issue. Women in the UK are at risk of FGM and its adverse health consequences but little is known about its practice. Since 1985 it has been a criminal offence to perform FGM in the UK and further legislation has tightened the law but FGM continues. METHODS: Four community researchers from the Kenyan, Nigerian, Somalian and Sudanese communities in Oxford conducted focus groups and interviews with 53 people to understand the communities' beliefs about how best to prevent FGM. RESULTS: Participants believed that the current UK legislation alone was not sufficient to tackle FGM and might in fact be counterproductive by alienating communities through its perceived imposition. They felt that there had been insufficient consultation with affected communities, awareness raising and education about the legislation. Community-led solutions were the most effective way to tackle FGM. CONCLUSIONS: FGM adversely affects communities globally. In the UK, researchers from affected communities gathered data demonstrating the feasibility and importance of involving communities in FGM prevention work. Further research is needed to understand how best to prevent FGM in affected communities and, very importantly, to examine the impact of the UK legislation relating to FGM.

Direct-Acting Antiviral Therapy for Hepatitis C Infection in a Large Immigrant Community.

Hepatitis C treatment has rapidly evolved with the arrival of direct-acting antiviral therapy. Sustained virologic response (SVR) rates in clinical trials are high but it is unknown how this translates to the immigrant community. Data from December 2013 to September 2015 was collected from a Midwest academic and community practice with a large immigrant population. There were 802 patients with an overall SVR rate of 88%. Ledipasvir/sofosbuvir was associated with favorable response among genotype 1 and 4 patients compared to other regimens (p < 0.001 and p = 0.05). Factors associated with treatment failure included advanced liver disease, male gender, East African/Middle Eastern ethnicity, and non-compliance. Patients with genotype 4 had lower SVR rates than other genotypes (58% vs. 89%, p < 0.001), particularly among East Africans (40% vs. 82% for other ethnicities). Our SVR rate for genotype 4 infection is lower than clinical trials and may be related to cultural, biologic and socioeconomic factors.

Understanding the Experiences of East African Immigrant Women With Gestational Diabetes Mellitus.

OBJECTIVES: East African (EA) women are a subpopulation who are at very high risk for gestational diabetes (GDM) and poor obstetric outcomes, but little is known about the care experiences of this understudied group. The objective of this study was to document the impact of a diagnosis of GDM and the perceptions of diabetes care among EA immigrant women. METHODS: Semistructured in-depth interviews were conducted with 10 EA immigrant women diagnosed with GDM in Calgary; they were recruited from community and tertiary care settings. Interviews were transcribed verbatim and analyzed using inductive thematic content analysis to explore participants' experiences when accessing and receiving care. RESULTS: EA immigrant women had varied experiences related to GDM. Thematic analysis revealed the negative impact of GDM diagnoses on women, including the burdens of self-care, fear, community influences and cultural and financial barriers. The positive impacts of the experience of diagnosis noted were primarily in the empowerment to make healthful behaviour changes. CONCLUSIONS: Study findings point to the need for more context-specific and culturally appropriate support and care. Diagnoses of GDM extended beyond the individuals affected and impacted their families culturally, psychologically and financially. Addressing the emergent themes during pregnancy is imperative to improving care providers' engagement with EA immigrant women in postpartum diabetes screening activities and beyond. The findings of this study contain elements transferable to other immigrant groups in similar socioecologic contexts.

Vitamin D intake, serum 25-hydroxyvitamin D status and response to moderate vitamin D3 supplementation: a randomised controlled trial in East African and Finnish women.

Insufficient vitamin D status (serum 25-hydroxyvitamin D (S-25(OH)D)0·05 for differences between ethnic groups). In conclusion, high prevalence of vitamin D insufficiency existed among East African women living in Finland, despite higher vitamin D intake than their Finnish peers. Moderate vitamin D3 supplementation was effective in increasing S-25(OH)D in both groups of women, and no ethnic differences existed in the response to supplementation.

Patterns and predictors of posttraumatic stress disorder in refugees: A latent class analysis.

BACKGROUND: Although elevated rates of posttraumatic stress disorder (PTSD) have been well-documented in refugees, no study has investigated the heterogeneity of DSM-5 PTSD symptomatology in such populations. This study aimed to determine whether there are unique patterns of DSM-5 defined PTSD symptomatology in refugees, and investigate whether factors characteristic of the refugee experience, including trauma exposure and post-migration stress, predict symptom profiles. METHODS: Participants were 246 refugees and asylum-seekers from an Arabic-, English-, Farsi-, or Tamil-speaking background who had been resettled in Australia. Participants completed measures of post-migration living difficulties, trauma exposure, PTSD symptoms and functional disability. Latent class analysis was used to identify PTSD symptom profiles, and predictors of class membership were elucidated via multinomial logistic regression. RESULTS: Four classes were identified: a high-PTSD class (21.3%), a high-re-experiencing/avoidance class (15.3%), a moderate-PTSD class (23%), and a no PTSD class (40.3%). Trauma exposure and post-migration stress significantly predicted class membership and classes differed in degree of functional disability. LIMITATIONS: The current study employed a cross-sectional design, which precluded inferences regarding the stability of classes of PTSD symptomatology. CONCLUSIONS: This study provides evidence for distinct patterns of PTSD symptomatology in refugees. We identified a novel class, characterized by high-re-experiencing and avoidance symptoms, as well as classes characterized by pervasive, moderate, and no symptomatology. Trauma exposure and post-migration stress differentially contributed to the emergence of these profiles. Individuals with high and moderate probability of PTSD symptoms evidenced substantial disability. These results support conceptualizations of PTSD as a heterogeneous construct, and highlight the importance of considering sub-clinical symptom presentations, as well as the post-migration environment, in clinical contexts.

Spirituality for Mental Health and Well-Being of Adult Refugees in Europe.

This article reports on a pre- and post-test experimental study with 4504 refugees in 38 camps across nine destination countries. The aim was to examine the role of spirituality and a specially designed spiritual education programme in promoting mental health of refugees. A pre- and post-test experimental design has been used with three scales to examine the outcome measures: (1) the trauma screening questionnaire (2) life orientation test-revised and (3) mental health inventory-38. Results showed that compared with pre-test scores, the average post-test scores of the refugees on the trauma questionnaire were lower, and higher on optimism measure, and mental health inventory. Voluntary participation, full attendance and self-practice willingness were favourable predictors of refugee mental health. Hierarchical regression model showed that self-practice willingness was the most important predictor of positive mental health of refugees. Findings make a case for interventions for refugees grounded in cultural competency and spirituality.

Scaling a waterfall: a meta-ethnography of adolescent progression through the stages of HIV care in sub-Saharan Africa.

INTRODUCTION: Observational studies have shown considerable attrition among adolescents living with HIV across the "cascade" of HIV care in sub-Saharan Africa, leading to higher mortality rates compared to HIV-infected adults or children. We synthesized evidence from qualitative studies on factors that promote or undermine engagement with HIV services among adolescents living with HIV in sub-Saharan Africa. METHODS: We systematically searched five databases for studies published between 2005 and 2016 that met pre-defined inclusion criteria. We used a meta-ethnographic approach to identify first, second and third order constructs from eligible studies, and applied a socio-ecological framework to situate our results across different levels of influence, and in relation to each stage of the HIV cascade. RESULTS AND DISCUSSION: We identified 3089 citations, of which 24 articles were eligible for inclusion. Of these, 17 were from Southern Africa while 11 were from Eastern Africa. 6 explored issues related to HIV testing, 11 explored treatment adherence, and 7 covered multiple stages of the cascade. Twelve third-order constructs emerged to explain adolescents' engagement in HIV care. Stigma was the most salient factor impeding adolescents' interactions with HIV care over the past decade. Self-efficacy to adapt to life with HIV and support from family or social networks were critical enablers supporting uptake and retention in HIV care and treatment programmes. Provision of adolescent-friendly services and health systems issues, such as the availability of efficient, confidential and comfortable services, were also reported to drive sustained care engagement. Individual-level factors, including past illness experiences, identifying mechanisms to manage pill-taking in social situations, financial (in)stability and the presence/absence of future aspirations also shaped adolescents HIV care engagement. CONCLUSIONS: Adolescents' initial and ongoing use of HIV care was frequently undermined by individual-level issues; although family, community and health systems factors played important roles. Interventions should prioritise addressing psychosocial issues among adolescents to promote individual-level engagement with HIV care, and ultimately reduce mortality. Further research should explore issues relating to care linkage and ART initiation in different settings, particularly as "test and treat" policies are scaled up.

Khat Use is Associated with Tobacco, Alcohol, and Illicit Drug Use: A Cross-Sectional Examination in the United States.

No study has systematically examined khat (Catha edulis) use and its linkages with other substance use in the United States. This study provides novel findings related to the associations of khat with other substance use among immigrants in metropolitan areas of Minnesota where large East African communities reside. Using a convenience sampling, a total of 261 individuals completed a brief face-to-face interview during which demographic information and substance use were assessed. The proportion of lifetime and current use were 30% and 6.6% for khat, 35% and 18% for tobacco, 35% and 21% for alcohol, and 13% and 10% for other illicit drugs. Self-report history of khat use was associated with tobacco, alcohol, and other drug use. Tobacco use was related to alcohol and use of other drugs. The results suggest that a history of khat use is useful in identifying individuals who are vulnerable to substance-use-related problems. The findings indicate the need for more research on khat in the U.S.

Characteristics of US-Born Versus Foreign-Born Americans of African Descent With Chronic Hepatitis B.

Hepatitis B virus (HBV) infection is more common in African Americans than in white Americans. We compared the epidemiologic, clinical, and virological characteristics of US-born African Americans (USAAs) to those of foreign-born African Americans (FBAAs) with chronic hepatitis B. The adult cohort study of the Hepatitis B Research Network enrolls patients with HBV infection from 21 clinical sites in the United States and Canada. A total of 237 (15%) of the adult participants with chronic HBV infection that were enrolled from January 20, 2011, to October 2, 2013, were of African descent, including 57 USAAs and 180 FBAAs (76%). Compared with FBAAs, USAAs were older and more likely to have acquired HBV through sexual exposure, to be HBeAg-positive, to have higher HBV DNA levels, and to be infected with HBV genotype A2. FBAAs from West Africa were more likely to have elevated serum alanine aminotransferase (72% vs. 50%; P < 0.01) and higher HBV DNA levels (median, 3.2 log10 IU/mL vs. 2.8 log10 IU/mL; P = 0.03) compared with East African FBAAs. The predominant HBV genotype among West African FBAAs was E (67%), whereas genotypes A (78%) and D (16%) were common in East African FBAAs. Significant differences were found between USAAs and FBAAs, highlighting the need for tailored strategies for prevention and management of chronic HBV infection for African Americans.

Cancer incidence profile in sub-Saharan African-born blacks in the United States: Similarities and differences with US-born non-Hispanic blacks.

BACKGROUND: Sub-Saharan African-born blacks (ABs) are one of the fastest-growing populations in the United States. However, to the authors' knowledge, data regarding the cancer burden in this group are lacking, which would inform targeted cancer prevention and control. METHODS: The authors calculated age-standardized proportional incidence ratios (PIRs) comparing the frequency of the top 15 cancers in ABs with that of US-born non-Hispanic blacks (USBs) by sex and region of birth using incidence data for 2000 through 2012 from the Surveillance, Epidemiology, and End Results (SEER 17) program. RESULTS: Compared with USBs, ABs had significantly higher PIRs of infection-related cancers (liver, stomach, and Kaposi sarcoma), blood cancers (leukemia and non-Hodgkin lymphoma), prostate cancer, and thyroid cancers (females only). For example, the PIR for Kaposi sarcoma in AB versus USB women was 12.06 (95% confidence interval [95% CI], 5.23-18.90). In contrast, ABs had lower PIRs for smoking-related and colorectal cancers (eg, for lung cancer among men, the PIR was 0.30 [95% CI, 0.27-0.34]). Furthermore, cancer occurrence in ABs versus USBs varied by region of birth. For example, the higher PIRs for liver cancer noted among male ABs (PIR, 3.57; 95% CI, 1.79-5.35) and for thyroid cancer in female ABs (PIR, 3.03; 95% CI, 2.03-4.02) were confined to Eastern African-born blacks, whereas the higher PIR for prostate cancer (PIR, 1.90; 95% CI, 1.78, 2.02) was confined to Western African-born blacks. CONCLUSIONS: The cancer incidence profile of ABs is different from that of USBs and varies by region of birth, suggesting differences in environmental, cultural, social, and genetic factors. The findings of the current study could stimulate etiologic research and help to inform targeted interventions. Cancer 2017;123:3116-24. © 2017 American Cancer Society.

Health Disparities and Triple-Negative Breast Cancer in African American Women: A Review.

Importance: Variation in cancer incidence and outcome has well-documented correlations with racial/ethnic identity. In the United States, the possible genetic and ancestral hereditary explanations for these associations are confounded by socioeconomic, cultural, and lifestyle patterns. Differences in the breast cancer burden of African American compared with European/white American women represent one of the most notable examples of disparities in oncology related to racial/ethnic identity. Elucidating the source of these associations is imperative in achieving the promise of the national Precision Medicine Initiative. Observations: Population-based breast cancer mortality rates have been higher for African American compared with white American women since the early 1980s, largely reflecting declines in mortality that have been disproportionately experienced among white American patients and at least partly explained by the advent of endocrine therapy that is less effective in African American women because of the higher prevalence of estrogen receptor-negative disease. The increased risk of triple-negative breast cancer in African American women as well as western, sub-Saharan African women compared with white American, European, and east African women furthermore suggests that selected genetic components of geographically defined African ancestry are associated with hereditary susceptibility for specific patterns of mammary carcinogenesis. Disentangling health care access barriers, as well as reproductive, lifestyle, and dietary factors from genetic contributions to breast cancer disparities remains challenging. Epigenetics and experiences of societal inequality (allostatic load) increase the complexity of studying breast cancer risk related to racial/ethnic identity. Conclusions and Relevance: Oncologic anthropology represents a transdisciplinary field of research that can combine the expertise of population geneticists, multispecialty oncologists, molecular epidemiologists, and behavioral scientists to eliminate breast cancer disparities related to racial/ethnic identity and advance knowledge related to the pathogenesis of triple-negative breast cancer.