Effect of a Wearable Device-Based Physical Activity Intervention in North Korean Refugees: Pilot Randomized Controlled Trial.

BACKGROUND: Effective health interventions for North Korean refugees vulnerable to metabolic disorders are currently unelucidated. OBJECTIVE: This study aimed to evaluate the effects of digital health interventions in North Korean refugees using a wearable activity tracker (Fitbit device). METHODS: We conducted a prospective, randomized, open-label study on North Korean refugees aged 19-59 years between June 2020 and October 2021 with a 12-week follow-up period. The participants were randomly assigned to either an intervention group or a control group in a 1:1 ratio. The intervention group received individualized health counseling based on Fitbit data every 4 weeks, whereas the control group wore the Fitbit device but did not receive individualized counseling. The primary and secondary outcomes were the change in the mean daily step count and changes in the metabolic parameters, respectively. RESULTS: The trial was completed by 52 North Korean refugees, of whom 27 and 25 were in the intervention and control groups, respectively. The mean age was 43 (SD 10) years, and 41 (78.8%) participants were women. Most participants (44/52, 95.7%) had a low socioeconomic status. After the intervention, the daily step count in the intervention group increased, whereas that in the control group decreased. However, there were no significant differences between the 2 groups (+83 and -521 steps in the intervention and control groups, respectively; P=.500). The effects of the intervention were more prominent in the participants with a lower-than-average daily step count at baseline (<11,667 steps/day). After the 12-week study period, 85.7% (12/14) and 46.7% (7/15) of the participants in the intervention and control groups, respectively, had an increased daily step count (P=.05). The intervention prevented the worsening of the metabolic parameters, including BMI, waist circumference, fasting blood glucose level, and glycated hemoglobin level, during the study period. CONCLUSIONS: The wearable device-based physical activity intervention did not significantly increase the average daily step count in the North Korean refugees in this study. However, the intervention was effective among the North Korean refugees with a lower-than-average daily step count; therefore, a large-scale, long-term study of this intervention type in an underserved population is warranted. TRIAL REGISTRATION: Clinical Research Information Service KCT0007999; https://cris.nih.go.kr/cris/search/detailSearch.do/23622.

The rocky road to freedom: number of countries transited during defection and risk of metabolic syndrome among North Korean Refugees in South Korea.

OBJECTIVES: North Korean Refugees (NKRs) undergo defection, and this has been shown to impact their current health status in South Korea. However, little is understood about how the defection process is related to metabolic syndrome (MetS). This study regarded the defection process to be a quasi-measurement of traumatic experience and investigated whether defection was a risk factor for MetS among NKRs living in South Korea. STUDY DESIGN: This cross-sectional study obtained data from the Korea University Anam Hospital in Seoul. NKRs (N = 847) voluntarily completed questionnaires and underwent at least one medical examination between October 2008 and July 2021. METHODS: Multivariable logistic regression models were used to evaluate whether the number of countries transited by NKRs was associated with MetS by controlling for covariates. RESULTS: The prevalence of MetS among male and female NKRs in South Korea was 12.3% and 13.3%, respectively. The highest prevalence of MetS (33.4%) was among NKRs who had transited two countries. The number of months in transit countries (mean: 49.9 ± 51.7) and period of residence in South Korea (mean: 40.9 ± 40.9 months) were also considered. NKRs who transited three countries had a higher probability of MetS (odds ratio [OR] 2.660, 95% confidence interval [CI] 1.161-6.097) than those who travelled directly to South Korea. NKRs who transited three countries and had only resided in South Korea for a short period had a higher probability of MetS (OR 3.424, 95% CI 1.149-10.208) than those who have lived in South Korea for a longer period. CONCLUSIONS: Considering the social vulnerability of NKRs and consequential health problems, there is an urgent need for appropriate support from the government and society.

Depression in North Korean refugees: a mixed methods study.

OBJECTIVE: The objective of this study is to investigate beliefs and experiences about depression in North Korean refugees (NKRs) using both quantitative and qualitative methods. STUDY DESIGN: We used an exploratory sequential mixed methods study design with a quantitative survey followed by an in-depth individual interview. METHODS: We surveyed 329 NKRs who had been in South Korea for at least a year. Eleven participants were selected from the survey sample to complete an additional individual in-depth interview to obtain further understanding about depression among NKRs in their own words and context. RESULTS: About 44% of the sample had mild to severe depression; only 16% indicated that they were being treated for mood disorder. Individual in-depth interviews yielded key themes related to NKRs' depression beliefs and experiences: recognizing depression, factors contributing to depression, overcoming depression, and barriers to seeking help and treatment. Integration of quantitative and qualitative data revealed that although loneliness was one of the prominent subthemes contributing to depression, strong self-determination was noted as being critical to overcoming depression among those who had moderate to moderately severe depression but had no social support. CONCLUSIONS: Future efforts should be directed toward an enhanced support network and targeted education about the South Korean healthcare system, particularly in relation to mental health treatment.

Social networks and health-promoting behaviors among North Korean refugees in South Korea.

Poor health behaviors among North Korean refugees (NKRs) in South Korea are serious risk factors hindering their overall well-being. Despite their significance, little is known about the roles of social networks in promoting health behaviors of NKRs. Thus, we examined how social network characteristics were associated with health-promoting behaviors among 202 NKRs. We found that social networks featuring members of religious organizations were positively associated with overall health-promoting behaviors, health responsibility, exercise, and nutrition, whereas networks with South Korean friends were negatively associated with nutrition. Findings suggest that health interventions facilitating religion-based network ties may promote health behaviors among NKRs.

Childhood immunizations in China: disparities in health care access in children born to North Korean refugees.

BACKGROUND: Childhood immunization rates are at an all-time high globally, and national data for China suggests close to universal coverage. Refugees from North Korea and their children may have more limited health care access in China due to their legal status. However, there is no data on immunization rates or barriers to coverage in this population. METHODS: This study was conducted to determine the rates and correlates of immunizations in children (≥1 year) born to North Korean refugees in Yanbien, China. Child immunization data was obtained from vaccination cards and caregiver self-report for 7 vaccines and 1:3:3:3:1 series. Age-appropriate vaccination rates of refugee children were compared to Chinese and migrant children using a goodness-of-fit test. Logistic regression was used to determine correlates of immunization coverage for each vaccine and the 1:3:3:3:1 series. RESULTS: Age-appropriate immunization coverage rates were significantly lower in children born to North Korean refugees (12.1-97.8 %), compared to Chinese (99 %) and migrant (95 %) children. Increased father's age and having a sibling predicted significantly lower vaccination rates. CONCLUSIONS: Children born to North Korean refugees had significantly lower immunization rates, compared to Chinese or migrant children. Further research is needed to examine barriers of health care access in this high-risk population.

Changes in the concept of time among North Korean refugees: A socio-cultural perspective.

Refugees from diverse socio-cultural backgrounds and geopolitical locations face temporal challenges during their transition, yet more research needs to be conducted to understand their time conception in the host society. This study explores how North Korean refugees from remote rural areas in North Korea and China adjusted their time conception in a metropolitan city in South Korea. Data were collected through a pilot study (January-March 2017) and ethnographic fieldwork (February-July 2018), entailing semi-structured interviews, informal conversations, and field notes. Vygotsky's psychological tool and Ricoeur's interpretive approach were employed to solicit the mediation of time conception through organizational activities and narrative meanings. The analysis reveals themes that challenge refugees' time conception reflecting North Korean values and daily activities-Kimilsungism, collectivism, and task-oriented attitude-and the changes in time conception on the sense of the self. Refugees' learning in time conception is a holistic spiritual, social, and personal process.

Modeling the relationship between mentoring and depression symptoms among adolescent North Korean refugees.

This study examined the conditions for, and mechanisms of, mentoring efficacy against depression symptoms in a random sample of 202 adolescent North Korean refugees living in South Korea. Rhodes (2005) argued that mentoring may benefit adolescents with high parental attachment because social engagement comes easily to them, and that it also may benefit adolescents with weak attachment because of greater need. The present study drew on Rhodes' (2005) theory to postulate curvilinear moderation of the mentoring-depression relationship by parental attachment. Teacher and peer attachment were posited as mediators of the relationship between mentoring and depression. Using fixed effects regression models, Sobel tests, and non-parametric bootstraps to test the hypotheses, a negative association was identified between mentoring and depression symptoms. Results suggested mediation by social withdrawal, and models also found a significant curvilinear moderating effect of parental attachment on the mentoring-depression relationship. These findings suggest that adolescent North Korean refugees with strong parental attachment and adolescent North Korean refugees with weak parental attachment may disproportionately benefit from mentoring as compared with adolescent North Korean refugees who scored in the middle in parental attachment. These results are also consistent with the idea that mentoring may reduce social withdrawal which, in turn, reduces depression.

Suicidal ideation among North Korean refugees in South Korea: Exploring the influence of social network characteristics by gender.

Rates of death by suicide among North Korean refugees are three times higher than those among their host-country counterparts in South Korea. However, social and cultural factors predicting suicidality among North Korean refugees are not well known. Thus, we explored how social networks affect suicidal ideation in a sample of 405 North Korean refugees in South Korea using egocentric network data. Network diversity (number of different types of ties) was a protective factor for suicidal ideation among women. Having a help-providing and trustworthy church-based tie was a protective factor for women, whereas it was a risk factor for men. It is likely that women connected to people in diverse social contexts received more support to effectively deal with adversities. Because South Korean churches provide tailored worship services and financial aid to North Korean refugees, women might receive emotional comfort from church-based ties whom they can trust and receive help from, whereas men might become distressed about being financially dependent on others, which contradicts cultural expectations of a man's traditional role. Our findings have implications for mental health practitioners serving vulnerable populations, and highlight the importance of understanding the cultural context of social networks and gender in suicide research.

Violence Against North Korean Refugee Women: Doubly Victimized By Repatriation and Premigration Traumatic Experiences.

This study investigates the influence of traumatic events on the mental health of North Korean refugee women by examining the prevalence and severity of posttraumatic stress disorder (PTSD), depression, and anxiety in comparison with their male counterparts (women = 496; men = 131). Our results suggest that women are at greater risk of developing mental health problems than men. In particular, symptoms of PTSD and anxiety were higher among women who experienced forced repatriation to North Korea, which is operationalized as a constellation of gendered traumatic incidents such as sexual abuse, rape, witnessing infanticides, and forced abortion. The policy implications of our results and suggestions for future studies are discussed.

Shape analysis of the subcortical structures in North Korean refugees with post-traumatic stress disorder and major depressive disorder.

BACKGROUND: Despite the growing number of refugees and their mental health issues, neurobiological mechanisms to explain clinical symptoms resulting from traumatic events, such as post-traumatic stress disorder (PTSD) or major depressive disorder (MDD), have not been extensively investigated. Research on the mental health of North Korean refugees (NKRs) who defected to South Korea for resettlement is still at an early stage but commonly reports structural and functional abnormalities in brain regions related to reward and motivational processing. The nucleus accumbens (NAc) and ventral pallidum (VP) are the major sites in subcortical structures that play key roles in reward and motivation. METHODS: The present study examined subcortical structural abnormalities of 28 NKRs and age-, sex- matched South Korean Controls (SKCs) using shape analysis at the vertex level. RESULTS: Among the 28 NKRs, 18 had psychiatric disorders, including PTSD and MDD. The NKRs showed significantly reduced volumes in the right NAc and bilateral VP compared to the SKRs. The volume of the right VP showed a significant negative correlation with current PTSD severity in the NKR group. CONCLUSIONS: Our findings demonstrated that structural alterations of the NAc and VP may explain PTSD and MDD observed in the refugees and further suggest that the aftereffect of trauma, manifested as anhedonia and anxiety, may show chronically.

Polyvictimization Risk Among North Korean Refugee Women in South Korea.

North Korean (NK) refugee women living in South Korea are known to be vulnerable to interpersonal violence, but little is known about the possible link between or co-occurrence of acts of sexual violence (SV) and intimate partner violence (IPV) perpetrated against NK refugee women. This study examined the prevalence of polyvictimization and explored the association between SV in different settings (i.e., North Korea, intermediate countries, and South Korea) and various types of IPV. A convenience sample of 140 adult NK refugee women was analyzed, and logistic regression analyses were conducted to examine the link between SV and polyvictimization in IPV. NK refugee women with a history of SV reported a significantly higher rate of IPV over the previous 12 months (51.2%) compared to those without a history of SV (20.4%). NK refugee women with a history of SV are significantly more likely to become victims of most forms of IPV. SV victimization in intermediate countries significantly increased the odds of being physically victimized by their male partners in South Korea (OR = 3.31, p =.05). An SV victimization history in North Korea (OR = 4.50, p =.04) and SV victimization experienced outside their intimate relationship in South Korea significantly increased the odds of sexual IPV from their current intimate partner (OR = 4.74, p =.03). This study showed that victims of human trafficking and sexual assault during their journey to South Korea were at a greater risk of IPV in South Korea. Male partners of NK refugee women with a history of SV may shame and physically sanction NK refugee women for "breaching honor." Therefore, screening for potential risk of physical and sexual IPV among NK refugee women with a prior exposure to SV is needed to develop programs in safety planning for NK refugee women experiencing SV and IPV.

The Effects of Inhumane Treatment in North Korean Detention Facilities on the Posttraumatic-Stress Disorder Symptoms of North Korean Refugees.

OBJECTIVE: The study investigated the effects of severe human rights abuses in North Korean on Posttraumatic-stress disorder (PTSD) in North Korean Refugees (NKRs). METHODS: The study included 300 NKRs (245 females and 55 males) who completed self-report questionnaires that assessed PTSD, experiences of imprisonment, and exposure to inhumane treatment, by authorities in North Korea. A moderation analysis was conducted using a hierarchical multiple regression model to determine whether a moderation effect existed. In the next step, a post-hoc probing procedure of the moderation effect was performed using multiple regression models that included conditional moderator variables. RESULTS: The influence of the frequency of being imprisoned on PTSD varied as a function of recurrent exposure to inhumane treatment or punishment by authorities. Experiences of imprisonment were associated with PTSD only among those who were exposed to recurrent violence, such as beating or torture, by North Korean authorities. CONCLUSION: The present findings highlight the significant effects of human rights violations, such as the inhumane treatment of prisoners in North Korea, on the PTSD of NKRs.

Polysomnographic Sleep and Attentional Deficits in Traumatized North Korean Refugees.

INTRODUCTION: Attentional deficits and sleep problems are common in refugees who have experienced trauma. In the present study, we used polysomnography (PSG) to investigate the relationship between attentional deficits and objective measures of sleep structure in traumatized North Korean refugees. METHODS: We recruited 32 North Korean refugees (mean age = 33.78 ± 14.33 years) and 39 South Korean participants (mean age = 35.03 ± 11.08 years). Sustained attention and divided attention were assessed using the Computerized Attention Test. We conducted an overnight PSG to objectively assess sleep structure. The participants also completed the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Impact of Event Scale-Revised (IES-R), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). RESULTS: The North Korean refugees showed more commission errors (CEs, p < 0.05) and a larger standard deviation (SD) of the reaction time (RT) (p < 0.05) in the sustained attention task compared to the South Korean participants. Furthermore, the North Korean refugees showed a shorter period of wake after sleep onset (WASO, p < 0.01), less time spent in N1 (p < 0.05), and more time spent in N2 (p < 0.05). The larger SD of RT in the sustained attention task in the North Korean refugees was positively correlated with WASO (r = 0.62, p < 0.01) and N1 stage (r = 0.47, p < 0.05) after controlling for age, sex, BDI, BAI, and IES-R. CONCLUSION: The North Korean refugees showed poorer performance on the sustained attention task. Nocturnal PSG revealed shorter WASO and time spent in N1 in this population, which are independently associated with the preservation of attentional capacity. These data suggest that traumatized refugees may compensate for attentional deficits induced by their traumatic experiences via increased sleep continuity.

Perceived social stigma, self-concealment, and suicide risk among North Korean refugee women exposed to traumatic events.

INTRODUCTION: Suicide among North Korean (NK) refugee women is one of the most concerning public health problems in South Korea. Pre-resettlement trauma exposure and post-resettlement factors can contribute to suicide risk among NK refugee women; however, few studies have explored these associations. METHODS: This study aimed to assess suicidal ideation and suicide attempts among NK refugee women in South Korea (N = 212) and to examine the impact of pre-resettlement trauma exposure on suicide risk. Perceived social stigma and self-concealment in the post-resettlement phases were investigated as moderating factors for suicide risk related to trauma exposure using multiple regression analyses. RESULTS: Trauma exposure significantly increased suicidal ideation severity and the risk of suicide attempt. Furthermore, perceived social stigma significantly moderated this relationship such that the impact of trauma exposure in the pre-resettlement phases was amplified as perceived social stigma increased. CONCLUSION: Based on our study findings, professionals working with refugee populations should assess for perceived social stigma and exposure to traumatic events to reduce and prevent suicidal ideation and attempts.

Seroprevalence of scrub typhus, murine typhus and spotted fever groups in North Korean refugees.

OBJECTIVES: The aim of this study was to investigate the seroprevalence of antibodies against scrub typhus, murine typhus and spotted fever groups among North Korean refugees within 1 year of their arrival in South Korea. METHODS: We recruited North Korean refugees who had settled in South Korea after a short stay in a third country and did not have any health problems. The antibody titer was measured using a commercial indirect fluorescence assay immunoglobulin G antibody kit. RESULTS: The seroprevalence of antibodies against scrub typhus, murine typhus, and spotted fever groups among the 99 participants was 22.2%, 17.2%, and 10.1%, respectively, with 8.1% of participants testing positive for both spotted fever and murine typhus. CONCLUSIONS: Refugees may be exposed to rickettsial infections in North Korea and their journey from North Korea. This study is the first to report the seroprevalence of antibodies against the 3 common rickettsial diseases among North Korean refugees. The findings suggest that rickettsial infections should be added to the list of differential diagnoses for North Koreans with fever after entering South Korea.

A Qualitative Case Study on Influencing Factors of Parents' Child Abuse of North Korean Refugees in South Korea.

The purpose of this study is to investigate the influencing factors of parental child abuse by North Korean refugees who are living in South Korea. In-depth interviews were conducted with five parents who escaped from North Korea. The study identified three categories of factors impacting child abuse: the weakening of family functions from past experiences before and after defection, the stress of adapting to the culture of an unfamiliar society, and low parenting self-efficacy. North Korean parents suffered from emotional and functional crises from past traumatic events and, at the same time, experienced additional acculturative stress as a "minority" after entering South Korea, even as they continued to deal with Maternal Parenting Stress. These complex factors have been shown to lead to child abuse in migrant societies. This study contemplated the context of child abuse through specific examples. The results could provide thoughtful insights into child abuse among migrants and refugee parents, and provide evidence-based intervention plans for its prevention.

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.

Prevalence of General and Central Obesity and Associated Factors among North Korean Refugees in South Korea by Duration after Defection from North Korea: A Cross-Sectional Study.

Previous studies on obesity status among North Korean refugees (NKRs) have been limited. We investigated mean body mass index (BMI), waist circumference (WC), and general and central obesity prevalence among NKRs in South Korea (SK) by duration after defection from North Korea (NK), using cross-sectional data of the North Korean Refugee Health in South Korea (NORNS) study and compared these data with a sample from the general South Korean population (the fifth Korea National Health and Nutrition Examination Survey). The prevalence of general and central obesity among NKRs with duration after defection from NK of less than five years were lower than among South Koreans, except for central obesity among NKR females (obesity prevalence, 19% (12⁻27%) vs. 39% (34⁻44%) for NK vs. SK males (p < 0.001) and 19% (14⁻24%) vs. 27% (24⁻29%) for NK vs. SK females (p = 0.076); central obesity prevalence, 13% (6⁻19%) vs. 24% (20⁻29%) for NK vs. SK males (p = 0.011) and 22% (17⁻28%) vs. 20% (18⁻22%) for NK vs. SK females (p = 0.382)). The prevalence of general and central obesity among NKRs with duration after defection from NK (≥10 years) were comparable to those of South Koreans in both genders (obesity prevalence, 34% (18⁻50%) vs. 39% (34⁻44%) for NK vs. SK males (p = 0.690) and 23% (18⁻29%) vs. 27% (24⁻29%) for NK vs. SK females (0.794); central obesity prevalence, 21% (7⁻34%) vs. 24% (20⁻29%) for NK vs. SK males (p = 0.642); 22% (17⁻28%) vs. 20% (18⁻22%) for NK vs. SK females (p = 0.382)). Male sex, age and longer duration after defection from NK (≥10 years) were positively associated with obesity. As for central obesity, age was the only independently associated factor. NKR females with duration after defection from NK of less than five years had comparable central obesity prevalence to South Korean females in spite of a lower BMI, which suggests that we need further monitoring for their metabolic health among NKRs in SK.

Low Estimated Glomerular Filtration Rate Is Prevalent among North Korean Refugees in South Korea.

BACKGROUND: The number of North Korean refugees entering South Korea is rising. Few studies have investigated the risk of non-communicable disease in North Korean refugees. Moreover, kidney insufficiency, a risk factor for cardiovascular disease, has not been studied in this population. We compared the prevalence of non-communicable disease and kidney function in North Korean refugees and South Koreans. METHODS: Our study was conducted using a case-control design. We enrolled 118 North Korean refugees from the Hana Center and selected 472 randomly sampled South Korean individuals as controls, who were age- and sex-matched with the North Korean refugees in a ratio of 1:4, from the 2014 Korea National Health and Nutrition Examination Survey database. RESULTS: The prevalence of non-communicable disease did not differ significantly between the groups; however, a low estimated glomerular filtration rate (eGFR; <90 mL/min per 1.73 m2) was more prevalent in the North Korean refugees than in the South Korean population (52.1% vs. 29.9%, P<0.001). After adjusting for covariates and weight gain after escape, the prevalence of a low eGFR was associated with the length of residence in South Korea (odds ratio, 2.84; 95% confidence interval, 1.02-7.89). CONCLUSION: The prevalence of non-communicable disease did not differ between North Korean refugees and the South Korean population, while a low eGFR was more prevalent in North Korean refugees than in South Koreans. Moreover, after adjusting for other covariates, the prevalence of a low eGFR in North Korean refugees was associated with the length of residence in South Korea.

Trauma and Depression among North Korean Refugees: The Mediating Effect of Negative Cognition.

North Korean refugees experience adaptation difficulties, along with a wide range of psychological problems. Accordingly, this study examined the associations between early traumatic experiences, negative automatic thoughts, and depression among young North Korean refugees living in South Korea. Specifically, we examined how different factors of negative automatic thoughts would mediate the relationship between early trauma and depressive symptoms. A total of 109 North Korean refugees aged 13-29 years were recruited from two alternative schools. Our path analysis indicated that early trauma was positively linked with thoughts of personal failure, physical threat, and hostility, but not with thoughts of social threat. The link with depressive symptoms was only significant for thoughts of personal failure. After removing all non-significant pathways, the model revealed that early traumatic experiences were positively associated with depressive symptoms (ß = 0.61, 95% CI = 0.48-0.73) via thoughts of personal failure (ß = 0.17, 95% CI = 0.08-0.28), as well as directly (ß = 0.44, 95% CI = 0.27-0.59). Interventions that target negative cognitions of personal failure may be helpful for North Korean refugees at risk of depression.