• Perceptions and Health-Seeking Behaviour for Mental Illness Among Syrian Refugees and Lebanese Community Members in Wadi Khaled, North Lebanon: A Qualitative Study

      Al Laham, D; Ali, E; Mousally, K; Nahas, N; Alameddine, A; Venables, E (Springer, 2020-01-21)
      This is a qualitative exploration of the perceptions of mental health (MH) and their influence on health-seeking behaviour among Syrian refugees and the Lebanese population in Wadi Khaled, a rural area of Lebanon bordering Syria. Eight focus group discussions and eight key informant interviews were conducted with male and female Syrian refugees and Lebanese community members from March to April 2018. MH illness was associated with stigma, shame and fear among both populations. Beliefs surrounding mental illness were strongly linked to religious beliefs, including Jinn. Religious healers were considered the first line of help for people with mental illnesses, and were perceived as culturally acceptable and less stigmatizing than MH professionals. It is essential for MH professionals to build trust with the communities in which they work. Collaboration with religious healers is key to identifying MH symptoms and creating referral pathways to MH professionals in this context.
    • Physical and Sexual Violence, Mental Health indicators, and treatment seeking among street-based population groups in Tegucigalpa, Honduras

      Rio Navarro, J; Cohen, J; Rocillo Arechaga, E; Zuniga, E; Médecins Sans Frontières, México DF, México. javier.rio.navarro@geneva.msf.org (2012-05-01)
      To establish the prevalence of exposure to physical and sexual violence, mental health symptoms, and medical treatment-seeking behavior among three street-based subpopulation groups in Tegucigalpa, Honduras, and to assess the association between sociodemographic group, mental health indicators, and exposure to violence.
    • Positive Outcomes of HAART at 24 Months in HIV-Infected Patients in Cambodia.

      Ferradini, L; Laureillard, D; Prak, N; Ngeth, C; Fernandez, M; Pinoges, L; Puertas, G; Taburet, A; Ly, N; Rouzioux, C; et al. (2007-11-12)
      OBJECTIVES: African and Asian cohort studies have demonstrated the feasibility and efficacy of HAART in resource-poor settings. The long-term virological outcome and clinico-immunological criteria of success remain important questions. We report the outcomes at 24 months of antiretroviral therapy (ART) in patients treated in a Médecins Sans Frontières/Ministry of Health programme in Cambodia. METHODS: Adults who started HAART 24 +/- 2 months ago were included. Plasma HIV-RNA levels were assessed by real-time polymerase chain reaction. Factors associated with virological failure were analysed using logistic regression. RESULTS: Of 416 patients, 59.2% were men; the median age was 33.6 years. At baseline, 95.2% were ART naive, 48.9% were at WHO stage IV, and 41.6% had a body mass index less than 18 kg/m. The median CD4 cell count was 11 cells/microl. A stavudine-lamivudine-efavirenz-containing regimen was initiated predominantly (81.0%). At follow-up (median 23.8 months), 350 (84.1%) were still on HAART, 53 (12.7%) had died, six (1.4%) were transferred, and seven (1.7%) were lost to follow-up. Estimates of survival were 85.5% at 24 months. Of 346 tested patients, 259 (74.1%) had CD4 cell counts greater than 200 cells/microl and 306 (88.4%) had viral loads of less than 400 copies/ml. Factors associated with virological failure at 24 months were non-antiretroviral naive, an insufficient CD4 cell gain of less than 350 cells/microl or a low trough plasma ART concentration. In an intention-to-treat analysis, 73.6% of patients were successfully treated. CONCLUSION: Positive results after 2 years of advanced HIV further demonstrate the efficacy of HAART in the medium term in resource-limited settings.
    • The Prevalence of Mental Health Problems in Rwandan and Burundese Refugee Camps

      de Jong, J; Scholte, W F; Koeter, M W; Hart, A A; Médecins Sans Frontières, Holland, Amsterdam, The Netherlands. (2000-09)
      OBJECTIVE: We examined the prevalence of mental health problems in refugees living in camps that emerged in Tanzania during the Rwanda crisis that started in 1994. METHOD: Using the 28-item version of the General Health Questionnaire (GHQ-28), we examined two samples: a random sample (n = 854) and a sample of clients of a psychosocial support programme in these camps (n = 23). Sensitivity, specificity and positive- and negative predictive values were estimated for several cut-off scores of the GHQ-28. RESULTS: The prevalence of serious mental health problems was estimated at 50% (SE 12%). When using the GHQ-28 as a screener, a cut-off score of 14 is recommended. CONCLUSION: Given the high prevalence of mental health problems, psychosocial programmes for large refugee populations should aim at strengthening community structures and supporting groups instead of focusing at individuals. The screening capacity of the GHQ-28 could be used to identify mentally vulnerable groups.
    • Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees.

      Neuner, F; Schauer, M; Karunakara, U; Klaschik, C; Robert, C; Elbert, T; Department of Psychology, University of Konstanz and Center for Psychiatry Reichenau, D-78457 Konstanz, Germany. Frank.Neuner@Uni-Konstanz.de (2004)
      BACKGROUND: Political instability and the civil war in Southern Sudan have resulted in numerous atrocities, mass violence, and forced migration for vast parts of the civilian population in the West Nile region. High exposure to traumatic experiences has been particularly prominent in the Ugandan and Sudanese of the West Nile Region, representing an indication of the psychological strain posed by years of armed conflict. METHODS: In this study the impact of traumatic events on the prevalence and severity of posttraumatic stress disorder (PTSD) in a random sample of 3.339 Ugandan nationals, Sudanese nationals, and Sudanese refugees (1.831 households) of the West Nile region is assessed. RESULTS: Results show a positive correlation between the number of traumatic events and the number of endorsed PTSD symptoms. Of the 58 respondents who experienced the greatest number of traumatizing experiences, all reported symptoms which met the DSM-IV criteria for PTSD. CONCLUSIONS: There is a clear dose-effect relationship between traumatic exposure and PTSD in the studied populations with high levels of traumatic events. In this context, it is probable that any individual could develop PTSD regardless of other risk-factors once the trauma load reaches a certain threshold.
    • Psychological trauma of the civil war in Sri Lanka.

      de Jong, K; Mulhern, M; Ford, N; Simpson, I; Swan, A; van der Kam, S; Médecins Sans Frontières, Amsterdam, Netherlands. (Elsevier, 2002-04-27)
    • Roles and responsibilities of cultural mediators

      Venables, E; Whitehouse, K; Spissu, C; Pizzi, L; Al Rousan, A; di Carlo, S (Oxford University Press, 2021-03-01)
    • Self-perceived workplace discrimination and mental health among immigrant workers in Italy: a cross-sectional study.

      Di Napoli, A; Rossi, A; Baralla, F; Ventura, M; Gatta, R; Perez, M; Sarchiapone, M; Mirisola, C; Petrelli, A (BMC, 2021-02-09)
      Background: The process of immigration is associated with poor mental and physical health. While the workplace represents an important context of social integration, previous studies evaluating the effect of discrimination experienced in the workplace found worse mental health status among immigrants. The aim of this study was to investigate whether self-perceived workplace discrimination has any role in the mental health status of immigrants living and working in Italy, evaluating the contribution of other personal experiences, such as loneliness and life satisfaction. Methods: A cross-sectional study was conducted on a sample of 12,408 immigrants (aged 15-64) living and working in Italy. Data were derived from the first national survey on immigrants carried out by the Italian National Institute of Statistics (Istat). Mental health status was measured through the Mental Component Summary (MCS) of the SF-12 questionnaire. A linear multivariate linear regression was carried out to evaluate the association between mental health status, self-perceived workplace discrimination, and sociodemographic factors; path analysis was used to quantify the mediation effect of self-perceived loneliness, level of life satisfaction, and the Physical Component Summary (PCS). Results: Mental health status was inversely associated (p < 0.001) with self-perceived workplace discrimination (β:-1.737), self-perceived loneliness (β:-2.653), and physical health status (β:-0.089); it was directly associated with level of life satisfaction (β:1.122). As confirmed by the path analysis, the effect of self-perceived workplace discrimination on MCS was mediated by the other factors considered: self-perceived loneliness (11.9%), level of life satisfaction (20.7%), and physical health status (3.9%). Conclusions: Our study suggests that self-perceived workplace discrimination is associated with worse mental health status in immigrant workers through personal experiences in the workplace and explains the effect of the exposure to workplace discrimination on immigrants' psychological well-being. Our findings suggest that an overall public health response is needed to facilitate the social integration of immigrants and their access to health services, particularly those services that address mental health issues.
    • Short and Longer-term Psychological Consequences of Operation Cast Lead: documentation from a Mental Health program in the Gaza Strip

      Llosa, A E; Casas, G; Thomas, H; Mairal, A; Grais, RF; Moro, M-R; Epicentre, 8 rue Saint Sabin, Paris, 75011, France. Augusto.Llosa@epicentre.msf.org. (2012-10-23)
    • Suicidal ideation and attempt among school going adolescents in Bhutan – a secondary analysis of a global school-based student health survey in Bhutan 2016

      Dema, T; Thinley, S; Lhazeen, K; Penjore, T; Tenzin, K; Subba, D; Rani, M; Tripathy, J; Dhendup, T; Gurung, M; et al. (Springer Science and Business Media LLC, 2019-12-02)
      Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13–17 years).
    • Syrian refugees in Greece: experience with violence, mental health status, and access to information during the journey and while in Greece

      Ben Farhat, J; Blanchet, K; Juul Bjertrup, P; Veizis, A; Perrin, C; Coulborn, RM; Mayaud, P; Cohuet, S (BioMed Central, 2018-03-13)
      BACKGROUND: Since 2015, Europe has been facing an unprecedented arrival of refugees and migrants: more than one million people entered via land and sea routes. During their travels, refugees and migrants often face harsh conditions, forced detention, and violence in transit countries. However, there is a lack of epidemiological quantitative evidence on their experiences and the mental health problems they face during their displacement. We aimed to document the types of violence experienced by migrants and refugees during their journey and while settled in Greece, and to measure the prevalence of anxiety disorders and access to legal information and procedures. METHODS: We conducted a cross-sectional population-based quantitative survey combined with an explanatory qualitative study in eight sites (representing the range of settlements) in Greece during winter 2016/17. The survey consisted of a structured questionnaire on experience of violence and an interviewer-administered anxiety disorder screening tool (Refugee Health Screener). RESULTS: In total, 1293 refugees were included, of whom 728 were Syrians (41.3% females) of median age 18 years (interquartile range 7-30). Depending on the site, between 31% and 77.5% reported having experienced at least one violent event in Syria, 24.8-57.5% during the journey to Greece, and 5-8% in their Greek settlement. Over 75% (up to 92%) of respondents ≥15 years screened positive for anxiety disorder, which warranted referral for mental health evaluation, which was only accepted by 69-82% of participants. Access to legal information and assistance about asylum procedures were considered poor to non-existent for the majority, and the uncertainty of their status exacerbated their anxiety. CONCLUSIONS: This survey, conducted during a mass refugee crisis in a European Community country, provides important data on experiences in different refugee settings and reports the high levels of violence experienced by Syrian refugees during their journeys, the high prevalence of anxiety disorders, and the shortcomings of the international protective response.
    • A systematic review of intimate partner violence interventions focused on improving social support and/ mental health outcomes of survivors.

      Ogbe, E; Harmon, S; Van den Bergh, R; Degomme, O (Public Library of Sciences, 2020-06-25)
      Background: Intimate partner violence (IPV) is a key public health issue, with a myriad of physical, sexual and emotional consequences for the survivors of violence. Social support has been found to be an important factor in mitigating and moderating the consequences of IPV and improving health outcomes. This study's objective was to identify and assess network oriented and support mediated IPV interventions, focused on improving mental health outcomes among IPV survivors. Methods: A systematic scoping review of the literature was done adhering to PRISMA guidelines. The search covered a period of 1980 to 2017 with no language restrictions across the following databases, Medline, Embase, Web of Science, PROQUEST, and Cochrane. Studies were included if they were primary studies of IPV interventions targeted at survivors focused on improving access to social support, mental health outcomes and access to resources for survivors. Results: 337 articles were subjected to full text screening, of which 27 articles met screening criteria. The review included both quantitative and qualitative articles. As the focus of the review was on social support, we identified interventions that were i) focused on individual IPV survivors and improving their access to resources and coping strategies, and ii) interventions focused on both individual IPV survivors as well as their communities and networks. We categorized social support interventions identified by the review as Survivor focused, advocate/case management interventions (15 studies), survivor focused, advocate/case management interventions with a psychotherapy component (3 studies), community-focused, social support interventions (6 studies), community-focused, social support interventions with a psychotherapy component (3 studies). Most of the studies, resulted in improvements in social support and/or mental health outcomes of survivors, with little evidence of their effect on IPV reduction or increase in healthcare utilization. Conclusion: There is good evidence of the effect of IPV interventions focused on improving access to social support through the use of advocates with strong linkages with community based structures and networks, on better mental health outcomes of survivors, there is a need for more robust/ high quality research to assess in what contexts and for whom, these interventions work better compared to other forms of IPV interventions.
    • Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety

      Housen, T; Lenglet, A; Shah, S; Sha, H; Richardson, A; Pintaldi, G; Shabnum, A; MSF OCA and MSF India (Springer Science and Business Media LLC, 2019-12-12)
      Background The negative psychological impact of living in a setting of protracted conflict has been well studied, however there is a recognized need to understand the role that non-conflict related factors have on mediating exposure to trauma and signs of psychological distress. Methods We used data from the 2015 Kashmir Mental Health Survey and conducted mediation analysis to assess the extent to which daily stressors mediated the effect of traumatic experiences on poor mental health outcomes. Outcomes of interest were probable diagnosis of anxiety, depression, or PTSD; measured using the pre-validated Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Results Total effect mediated were statistically significant but the proportions of effect mediated were found to be small in practical terms. Financial stress mediated 6.8% [95% Confidence Interval (CI) 6∙0–8∙4], 6.7% [CI 6.2–7∙7] and 3.6% [CI 3∙4–4∙0] of the effect of experiencing multiple traumaticogenic events on symptoms of anxiety, depression and PTSD, respectively. Family stress mediated 11.3% [CI 10.3–13.8], 10.3% [CI 9.5–11.9] and 6.1% [CI 5.7–6.7] of the effect of experiencing multiple traumatogenic events on symptoms of anxiety, depression and PTSD, respectively. Poor physical health mediated 10.0% [CI 9.1–12∙0], 7.2% [CI 6.6–8.2] and 4.0% [CI 3.8,4.4] of the effect of experiencing more than seven traumatic events on symptoms of anxiety, depression and PTSD, respectively. Conclusion Our findings highlight that not only do we need to move beyond a trauma-focussed approach to addressing psychological distress in populations affected by protracted conflict but we must also move beyond focussing on daily stressors as explanatory mediators.
    • Trauma of Chechnya's ongoing war on internally displaced people.

      de Jong, K; van der Kam, S; Ford, N; Hargreaves, S; van Oosten, R; Cunningham, D; Boots, G (Elsevier, 2004)
    • The Trauma of Ongoing Conflict and Displacement in Chechnya: Quantitative Assessment of Living Conditions, and Psychosocial and General Health Status Among War Displaced in Chechnya and Ingushetia.

      de Jong, K; van der Kam, S; Ford, N; Hargreaves, S; van Oosten, R; Cunningham, D; Boots, G; Andrault, E; Kleber, R; Médecins Sans Frontières, Plantage Middenlaan 14, 1018 DD Amsterdam, The Netherlands. kaz.de.jong@amsterdam.msf.org. (2007)
      ABSTRACT: BACKGROUND: Conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia. METHODS: Surveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status. RESULTS: The average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (C): 13.3%, Ingushetia (I): 11.3%), and there was a high degree of dependency on outside help (C: 95.4%, I: 94.3%). Most people (C: 94%, I: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (C: 22.7%, I: 24.1%) and nearly half of people interviewed witnessed arrests (C: 53.1%, I: 48.4%) and maltreatment (C: 56.2%, I: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed - one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) - rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (C: 12.5%, I: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (C: 201, 78.5%, CI: 73.0% - 83.4%; I: 230, 81.3%, CI: 76.2% - 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (C: 54.3%, I: 46.6%). DISCUSSION: The study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.
    • The trauma of war in Sierra Leone.

      de Jong, K; Mulhern, M; Ford, N; van der Kam, S; Kleber, R; Institute of Psychotrauma, University of Utrecht, The Netherlands. (Elsevier, 2000-06-10)
    • Trauma-related psychological disorders among Palestinian children and adults in Gaza and West Bank, 2005-2008

      Espié, E; Gaboulaud, V; Baubet, T; Casas, G; Mouchenik, Y; Yun, O; Grais, RF; Moro, M R; Epicentre, Paris, France; Hôpital Avicenne, Assistance Publique Hôpitaux de Paris, Bobigny, France; Médecins Sans Frontières, Paris, France; Université Toulouse Le Mirail, Toulouse, France; Médecins Sans Frontières/Doctors Without Borders, New York, USA; Hôpital Cochin, Maison des adolescents, Université Paris Descartes, AP-HP, France (2009-09-23)
      BACKGROUND: Trauma from war and violence has led to psychological disorders in individuals living in the Gaza strip and West Bank. Few reports are available on the psychiatric disorders seen in children and adolescents or the treatment of affected populations. This study was conducted in order to describe the occurrence and treatment of psychiatric disorders in the Palestinian populations of the Gaza strip and Nablus district in the West Bank. METHODS: From 2005 to 2008, 1369 patients aged more than 1 year were identified through a local mental health and counseling health network. All were clinically assessed using a semi-structured interview based on the DSM-IV-TR criteria. RESULTS: Among 1254 patients, 23.2% reported post-traumatic stress disorder [PTSD], 17.3% anxiety disorder (other than PTSD or acute stress disorder), and 15.3% depression. PTSD was more frequently identified in children < or = 15 years old, while depression was the main symptom observed in adults. Among children < or = 15 years old, factors significantly associated with PTSD included being witness to murder or physical abuse, receiving threats, and property destruction or loss (p < 0.03). Psychological care, primarily in the form of individual, short-term psychotherapy, was provided to 65.1% of patients, with about 30.6% required psychotropic medication. Duration of therapy sessions was higher for children < or = 15 years old compared with adults (p = 0.05). Following psychotherapy, 79.0% had improved symptoms, and this improvement was significantly higher in children < or = 15 years old (82.8%) compared with adults (75.3%; p = 0.001). CONCLUSION: These observations suggest that short-term psychotherapy could be an effective treatment for specific psychiatric disorders occurring in vulnerable populations, including children, living in violent conflict zones, such as in Gaza strip and the West Bank.
    • Traumatic Events and Symptoms of Post-Traumatic Stress Disorder Amongst Sudanese Nationals, Refugees and Ugandans in the West Nile.

      Karunakara, U; Neuner, F; Schauer, M; Singh, K; Hill, K; Elbert, T; Burnham, G; Médecins sans Frontières, PO Box 10014, 1001 EA Amsterdam, The Netherlands. (2004-08)
      Objectives: To compare the incidence of traumatic events and its association with symptoms of post-traumatic stress disorder in three population groups in northern Uganda and southern Sudan. Methods: Household and individual level data collected through a single-round cross-sectional demographic survey. Setting: The sub-counties of Yivu, Odupi and Midia in the northern Ugandan district of Arua and of Otogo in Yei River district in southern Sudan. Participants: Residents of these Ugandan and Sudanese sub-counties were categorized on the basis of citizenship and refugee status (i.e. as Ugandan nationals, Sudanese nationals or Sudanese refugees). The random sample population consisted of 3,323 adults (mean age: 30 years; 75% female) from 1,831 national and refugee households. Results: Sudanese refugees reported the highest number of violent events experienced or witnessed ever and in the past one year . Witnessing of traumatic events, ever and in the past year , significantly predicted PTSD in surveyed population. Sex, age, education and occupation were also significantly associated with the development of PTSD symptoms. The population prevalence of PTSD was estimated to be 48% for Sudanese stayees, 46% for Sudanese refugees and 18% for Ugandan nationals. Conclusions: Symptoms of PTSD in war-affected Sudanese populations can be partly explained by traumatic event exposures. The high prevalence of violence and symptoms of PTSD in refugee populations highlight the need for better protection and security in refugee settlements. Humanitarian agencies must consider the provision of mental health services for populations affected by war and forced migration.
    • Treating schizophrenia with DOTS in developing countries: one size does not fit all.

      Souza, R; Yasuda, S; Cristofani, S (BioMed Central, 2007-09)
    • A Two-Phase Approach for the Identification of Refugees with Priority Need for Mental Health Care in Lebanon: A Validation Study

      Llosa, AE; Van Ommeren, M; Kolappa, K; Ghantous, Z; Souza, R; Bastin, P; Slavuckij, A; Grais, RFF (BioMed Central, 2017-01-18)
      Time and resource efficient mental disorder screening mechanisms are not available to identify the growing number of refugees and other forcibly displaced persons in priority need for mental health care. The aim of this study was to identify efficient screening instruments and mechanisms for the detection of moderate and severe mental disorders in a refugee setting.