Mental Health and Forced Displacement: Difference between revisions

No edit summary
m (Removed protection from "Mental Health and Forced Displacement": Retired Course page)
 
(23 intermediate revisions by 4 users not shown)
Line 1: Line 1:
<div class="editorbox">  
<div class="editorbox">  
'''Original Editor '''- Shaimaa Eldib  
 
'''Original Editor '''- [[User:Shaimaa Eldib|Shaimaa Eldib]]
 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div><div align="justify">
</div>
== Introduction ==
== Introduction ==
Mental health illness is considered as a leading cause for [[Disability-Adjusted Life Year|disability]] all over the world. It accounts for around 13 %of the global burden of disease and responsible for 33% of total years lived with disability<ref>Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2197-223</ref><ref>Funk M. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on. 2016 Oct;30.</ref>. It is estimated that people who suffer from severe mental illness, for example, severe [[depression]], bipolar disorder and [[schizophrenia]]<ref name=":1">Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet. 2009 Jan 31;373(9661):408-15.</ref> are more likely to die prematurely than those who have not been affected. The problems of mental health are highly prevalent globally, affecting people across all regions of the world as it is expected to affect at least 1 of 3 people all over their life time<ref>Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International journal of epidemiology. 2014 Apr 1;43(2):476-93.</ref><ref>Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry. 2016 Feb 1;3(2):171-8.</ref>. Also, there are major economic consequences of this high prevalence. Around $16.3 trillion was estimated to be the cost of mental ill-health globally between 2011 and 2030 <ref>Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Hamandi A, Mowafi M, O’Farrell D. The global economic burden of noncommunicable diseases. Program on the Global Demography of Aging; 2012 Jan.</ref> and this has serious implications on standers of livings and socioeconomic development<ref name=":0">Caulfield A, Vatansever D, Lambert G, Van Bortel T. WHO guidance on mental health training: a systematic review of the progress for non-specialist health workers. BMJ open. 2019 Jan 1;9(1):bmjopen-2018.</ref>. There are many barriers in treating mental illness, for example, [[Mental Health and the Stigma|stigma]], discrimination <ref>Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, Van Weeghel J, Reneses B, Germanavicius A. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet. 2013 Jan 5;381(9860):55-62.</ref><ref name=":1" /> and governmental apathy<ref name=":0" /> which exacerbating the current state of [[Mental Health Outcome Measures (for Physiotherapists in clinical practice)|mental]] healthcare all over the world.
According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community".<ref>The world health report 2001 – Mental Health: New Understanding, New Hope"(PDF). WHO. Retrieved 4 May 2014.</ref><ref>Mental health: strengthening our response. World Health Organization. August 2014. Retrieved 4 May 2014.</ref> 
 
Mental health conditions are considered a leading cause for [[Disability-Adjusted Life Year|disability]] globally, accounting for around 13% of the global burden of disease, and 33% of total years lived with disability.<ref name=":8">Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2197-223</ref><ref name=":9">Funk M. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on. 2016 Oct;30.</ref> It is estimated that people who have severe mental health disorders, for example, severe [[depression]], [[Bipolar Disorder|bipolar disorder]] and [[schizophrenia]]<ref name=":1">Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet. 2009 Jan 31;373(9661):408-15.</ref> are more likely to die prematurely than those who have not been affected. The problems of mental health are highly prevalent globally, affecting people across all regions of the world. They are expected to affect at least 1 out of 3 people across their life-time.<ref>Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International journal of epidemiology. 2014 Apr 1;43(2):476-93.</ref><ref>Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry. 2016 Feb 1;3(2):171-8.</ref>
 
There are major economic consequences of this high prevalence in mental health conditions; it is estimated that mental ill-health will lead to the loss of $US16.1 trillion between 2011 and 2030.<ref>Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Hamandi A, Mowafi M, O’Farrell D. The global economic burden of noncommunicable diseases. Program on the Global Demography of Aging; 2012 Jan.</ref> This cost has serious implications on standards of livings and socioeconomic development.<ref name=":0">Caulfield A, Vatansever D, Lambert G, Van Bortel T. WHO guidance on mental health training: a systematic review of the progress for non-specialist health workers. BMJ open. 2019 Jan 1;9(1):bmjopen-2018.</ref> There are many barriers to treating mental illness including [[Mental Health and the Stigma|stigma]], discrimination<ref>Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, Van Weeghel J, Reneses B, Germanavicius A. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet. 2013 Jan 5;381(9860):55-62.</ref><ref name=":1" /> and governmental apathy,<ref name=":0" /> which further exacerbate the current state of mental health care all over the world.  


== Refugees Crisis ==
== Displaced Person Crisis ==
The UN Refugee Agency (UNHCR)<ref>https://emergency.unhcr.org/entry/55772/refugee-definition</ref> defines a refugee as set out in the 1951 Convention<ref name=":2">Fitzpatrick J. Revitalizing the 1951 refugee convention. Harv. Hum. Rts. J.. 1996;9:229.</ref><ref>Zimmermann A, Dörschner J, Machts F, editors. The 1951 Convention relating to the status of refugees and its 1967 protocol: A commentary. Oxford University Press; 2011 Jan 27.</ref>[[File:Refugees.jpg|thumb]]''The 1951 Convention and its 1967 Protocol :''
According to the United Nations High Commissioner for Refugees (UNHCR), 89.3 million people have been forcibly displaced worldwide as a result of conflicts, violence, fear of persecution and human rights violations in 2021; it is estimated that there will be more than than 100 million people displaced in 2022.<ref name=":4">Müller M, Khamis D, Srivastava D, Exadaktylos AK, Pfortmueller CA. Understanding refugees' health. InSeminars in neurology 2018 Apr (Vol. 38, No. 02, pp. 152-162). Thieme Medical Publishers.</ref> There were 20 people newly displaced every minute of 2016.<ref name=":5">Ellis BH, Winer JP, Murray K, Barrett C. Understanding the mental health of refugees: Trauma, stress, and the cultural context. InThe Massachusetts General Hospital textbook on diversity and cultural sensitivity in mental health 2019 (pp. 253-273). Humana, Cham.</ref> Those who are forced to leave their home countries often live in overcrowded reception facilities while waiting for resettlement or asylum decisions.<ref name=":3">Fotaki M. A crisis of humanitarianism: refugees at the gates of Europe. International journal of health policy and management. 2019 Jun;8(6):321.</ref> These facilities have, in effect, turned into long-term detention centres and have poor health and safety conditions.<ref>Blitz BK, d’Angelo A, Kofman E, Montagna N. Health challenges in refugee reception: dateline Europe 2016. International journal of environmental research and public health. 2017 Dec;14(12):1484.</ref> All these factors create medical challenges and an increased need for displaced persons to utilise health services. <ref>Kotsiou OS, Kotsios P, Srivastava DS, Kotsios V, Gourgoulianis KI, Exadaktylos AK. Impact of the refugee crisis on the Greek healthcare system: A long road to Ithaca. International journal of environmental research and public health. 2018 Aug;15(8):1790.</ref>


The primary and universal definition of a refugee that applies to States is contained in Article 1(A)(2) of the 1951 Convention, as amended by its 1967 Protocol, defines a refugee as someone who:
== Mental Health and Displacement ==
Migrants can be exposed to various stress factors which affect their mental health and well-being before and during their migration journey and during their settlement and integration. While most migrants do not experience mental health problems, people displaced as a result of conflicts, violence, fear of persecution and human rights violations can lead to at increased risk of mental health problems. This is particularly true for persons who have experienced violence and trauma, including exploitation, torture or sexual and gender-based violence. Issues can range from low to moderate levels of anxiety and depression through to more severe mental disorders.


''"owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable or, owing to such fear, is unwilling to return to it''<ref name=":2" />''.''
Currently, the responsibility of mental health support for displaced persons is shared by a wide network of organisations depending on where the displaced person is based. These organisations include: the World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), Governments and Non‐Governmental Organisations.<ref name=":7" />  


According to the United Nations Refugee Agency (UNHCR), 65.6 million people have been forcibly displaced worldwide<ref name=":4">Müller M, Khamis D, Srivastava D, Exadaktylos AK, Pfortmueller CA. Understanding refugees' health. InSeminars in neurology 2018 Apr (Vol. 38, No. 02, pp. 152-162). Thieme Medical Publishers.</ref>. There were 20 people newly displaced every minute of 2016<ref name=":5">Ellis BH, Winer JP, Murray K, Barrett C. Understanding the mental health of refugees: Trauma, stress, and the cultural context. InThe Massachusetts General Hospital textbook on diversity and cultural sensitivity in mental health 2019 (pp. 253-273). Humana, Cham.</ref>. Europe Initially welcomed more than a million refugees and forced migrants between 2015 and 2016 <ref name=":3">Fotaki M. A crisis of humanitarianism: refugees at the gates of Europe. International journal of health policy and management. 2019 Jun;8(6):321.</ref>. Those who forced to leave their home countries lived in overcrowded reception facilities that have an effect, turned into long term detention centres with poor health and safety conditions<ref>Blitz BK, d’Angelo A, Kofman E, Montagna N. Health challenges in refugee reception: dateline Europe 2016. International journal of environmental research and public health. 2017 Dec;14(12):1484.</ref> while waiting for resettlement or asylum decisions<ref name=":3" />. All these conditions created medical challenges and excessive need for the usage of health systems<ref>Kotsiou OS, Kotsios P, Srivastava DS, Kotsios V, Gourgoulianis KI, Exadaktylos AK. Impact of the refugee crisis on the Greek healthcare system: A long road to Ithaca. International journal of environmental research and public health. 2018 Aug;15(8):1790.</ref>.
When individuals and families seek safety by leaving their homes, cultures, and communities because of the threat of violence and persecution, emotional distress can be heightened. About one third of displaced persons will experience high rates of [[depression]], [[Generalized Anxiety Disorder|anxiety]], and [[Post-traumatic Stress Disorder|post-traumatic stress disorders]] (PTSD) as a result of the circumstances they faced during their migration, which can significantly affect the quality of their life.<ref name=":7">Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017 Jun;16(2):130-9.</ref> <ref>Wilker S, Catani C, Wittmann J, Preusse M, Schmidt T, May T, Ertl V, Doering B, Rosner R, Zindler A, Neuner F. The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT). Trials. 2020 Dec;21(1):1-6.</ref> However, systematic reviews show that prevalence estimates of mental health disorders vary widely from 4% to 80% including:<ref>Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights. 2015;15:29. 11. </ref><ref name=":2">Keyes EF. Mental health status in refugees: an integrative review of current research. Issues Ment Health Nurs. 2000;21(4):397–410.</ref>


== Refugees Mental Health ==
* 4 to 40% for anxiety<ref name=":2" />
Currently, the responsibility of mental health support for the refugee is shared by a network of organizations like World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), government and non‐profit organizations<ref name=":7" />. Most of the refugees suffer from [https://www.physio-pedia.com/Post-traumatic_Stress_Disorder post-traumatic stress disorder] (PTSD) due to the circumstances that they faced which might affect the quality of their life<ref>Wilker S, Catani C, Wittmann J, Preusse M, Schmidt T, May T, Ertl V, Doering B, Rosner R, Zindler A, Neuner F. The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT). Trials. 2020 Dec;21(1):1-6.</ref><ref name=":7">Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017 Jun;16(2):130-9.</ref>.  
* 5 to 44% for depression<ref name=":2" />
* 9 to 36% for PTSD<ref name=":10">Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–49 13. </ref><ref name=":11">Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467):1309–14. 14. </ref><ref>Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees—a systematic review and metaanalysis. Soc Sci Med. 2009;69(2):246–57 15. </ref><ref>Slewa-Younan S, Uribe Guajardo MG, Heriseanu A, Hasan T. A systematic review of post-traumatic stress disorder and depression amongst Iraqi refugees located in western countries. J Immigr Minor Health. 2015;17(4):1231–9.</ref>
<br>While most displaced persons with PTSD and depression show a reduction in symptoms over time, particularly if there are low resettlement stressors,<ref>Oppedal, B., & Idsoe, T. (2015). The role of social support in the acculturation and mental health of unaccompanied minor asylum seekers. Scandinavian Journal of Psychology, 56, 203–211. 17.  


</ref><ref>Betancourt, T., Borisova, I., Williams, T., Meyers-Ohki, S., RubinSmith, J., Annan, J., & Kohrt, B. (2013). Psychosocial adjustment and mental health in former child soldiers: Systematic review of the literature and recommendations for future research.Journal of ChildPsychologyandPsychiatry,54,17–36</ref> others may experience years of symptoms, particularly those with PTSD.<ref>Beiser, M., & Wickrama, K. (2004). Trauma, time and mental health: A study of temporal reintegration and Depressive Disorder among Southeast Asian refugees. Psychological Medicine, 34, 899–910.</ref><ref>Sack, W., Him, C., & Dickason, D. (1999). Twelve-year followup study of Khmer youths who suffered massive war trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1173–1179</ref> Because of this, early access to mental health care should be prioritised, as post-migration stressors such as prolonged detention, insecure immigration status, and limitations on work and education, can worsen mental health.
=== Post-Traumatic Stress Disorder ===
=== Post-Traumatic Stress Disorder ===
<blockquote>''"When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen."''<ref>Post-traumatic stress disorder (PTSD). Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/ (Accessed 18 May 2020).
<blockquote>''"When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen."'' <ref>Post-traumatic stress disorder (PTSD). Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/ (Accessed 18 May 2020).
</ref></blockquote>PTSD can be defined as persisting, recurrent and disturbing memories or flashbacks of a witnessed or experienced trauma, along with other symptoms such as difficulty sleeping, feeling detached from people and current experiences, as well as exaggerated startle responses.<ref>Ringold S, Burke A, Glass RM. Refugee mental health. JAMA. 2005 Aug 3;294(5):646</ref> This disorder is considered the only major mental disorder that may have a known cause. Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened.<ref name=":6">Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, Milad MR, Liberzon I. Biological studies of post-traumatic stress disorder. nature Reviews neuroscience. 2012 Nov;13(11):769-87.</ref> Difficulties in emotional regulation, cognitive functioning, self-perception, relationships, somatisation and hopelessness may occur due to severe stress as a result of overwhelming circumstances and disturbing experiences <ref>McFARLANE AC. The long‐term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry. 2010 Feb;9(1):3-10.</ref>. The prevalence of traumatic experiences is common. It is found that more than two-thirds of persons in the general population may experience a significant traumatic event at some point in their lives.<ref>Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychological medicine. 1991 Aug;21(3):713-21.</ref> Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, there were also studies that obtained results showing 30% among tested cases whom suffered from PTSD.<ref name=":7" /> These findings suggest that most refugees are in a traumatized state and are in need of counselling<ref name=":7" />.              
</ref></blockquote>According to the American Psychiatric Association (APA) and the DSM-5, Post Traumatic Stress Disorder is defined as a “psychiatric disorder in which patients have experienced or witnessed a significant traumatic event. Examples of such an event include natural disasters, serious accidents, terrorist acts, war/combat, rape, or other violent personal assaults. PTSD presents with persistent, recurrent and disturbing memories or flashbacks of a witnessed or experienced trauma, avoidance of reminders of the traumatic event along with other symptoms such as negative thoughts and feelings, difficulty with concentration and sleep, feeling detached from people and current experiences, as well as exaggerated startle responses and arousal / reactive symptoms such as irritability, and angry outbursts.<ref>Ringold S, Burke A, Glass RM. Refugee mental health. JAMA. 2005 Aug 3;294(5):646</ref> Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened.<ref name=":6">Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, Milad MR, Liberzon I. Biological studies of post-traumatic stress disorder. nature Reviews neuroscience. 2012 Nov;13(11):769-87.</ref> Difficulties in emotional regulation, cognitive functioning, self-perception, relationships, somatisation and hopelessness may occur due to severe stress as a result of overwhelming circumstances and disturbing experiences.<ref>McFARLANE AC. The long‐term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry. 2010 Feb;9(1):3-10.</ref>
 
The prevalence of traumatic experiences is common. It is found that more than two-thirds of persons in the general population may experience a significant traumatic event at some point in their lives.<ref>Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychological medicine. 1991 Aug;21(3):713-21.</ref> Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, other studies suggest that the prevalence of PTSD is around 30%.<ref name=":7" /> These findings suggest that many refugees are in a traumatised state and are in need of counselling.<ref name=":7" />             


Some studies explored the biological effect of this disorder, the findings showed :       
It has been found that the biological effects of PTSD include:       
* Higher heart rate to sudden loud tones which suggests central sensitization.
* Higher heart rate to sudden loud tones which suggests central sensitisation.
* Diminished the volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.<ref name=":6" />  
* Diminished volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.<ref name=":6" />
* Changes in brain and pre-existing vulnerability and neurotoxicity as origins of brain volume reductions in PTSD.  
* Changes in brain and pre-existing vulnerability and neurotoxicity as origins of brain volume reductions in PTSD.
* Amygdala and dorsal anterior cingulate cortex are hyper(re)active, whereas the ventral medial prefrontal cortex is hypo(re)active in PTSD and this may explain attentional bias towards the threat, impaired emotional regulation.<ref name=":6" />
* Amygdala and dorsal anterior cingulate cortex are hyper(re)active, whereas the ventral medial prefrontal cortex is hypo(re)active in PTSD and this may explain attentional bias towards the threat, impaired emotional regulation.<ref name=":6" />
The evidence showed that trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of PTSD<ref>Bisson J, Andrew M. Psychological treatment of post‐traumatic stress disorder (PTSD). Cochrane database of systematic reviews. 2007(3).</ref>. Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy , pharmacotherapies, and psychosocial interventions.<ref name=":7" />
<br>Evidence suggests that trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of PTSD.<ref>Bisson J, Andrew M. Psychological treatment of post‐traumatic stress disorder (PTSD). Cochrane database of systematic reviews. 2007(3).</ref> Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy, pharmacotherapies, and psychosocial interventions.<ref name=":7" />


=== Gaps in Refugee Health ===
=== Gaps in Refugee Mental Health ===
These videos describe the gaps in refugee health and their experiences.
These videos describe the gaps in refugee health and their experiences.
<div class="row">
<div class="row">
Line 36: Line 48:
<div class="col-md-4">{{#ev:youtube|0g0S34XE2b8|250}} <div class="text-right"><ref>TED. How we can bring mental health support to refugees | Essam Daod. Available from: http://www.youtube.com/watch?v=0g0S34XE2b8[last accessed 28/07/2020]</ref></div></div>
<div class="col-md-4">{{#ev:youtube|0g0S34XE2b8|250}} <div class="text-right"><ref>TED. How we can bring mental health support to refugees | Essam Daod. Available from: http://www.youtube.com/watch?v=0g0S34XE2b8[last accessed 28/07/2020]</ref></div></div>
</div>
</div>
== Physiotherapists, Healthcare Professionals, and Refugees ==
== Role of Rehabilitation Professionals ==
Healthcare professionals should be aware that there are several factors that have a major influence on asylum seekers [[Health Information And Education For All|health]]:
Person-centred rehabilitation services for mental health are implemented in many different health and mental health settings: psychiatry and psychosomatic medicine cater for children, adolescents, adults and older people with mild to severe, acute and chronic mental health problems, in primary and community care, inpatient and outpatient settings.
* The experiences that the refugee exposed to in the origin country or in the refugee camps.   
 
* The experiences in the route to the host country, the process of immigration and the experience of the new life in the host country.
Mental health rehabilitation professionals provide a wide range of services including health promotion, preventive health care, treatment and rehabilitation for individuals, groups and in‐group therapeutic settings. They create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment applying a model including biological and psychosocial aspects. Rehabilitation professionals in mental health aim to optimise well-being and empower the individual by promoting functional movement, movement awareness, physical activity and exercises, bringing together physical and mental aspects. It is based on the available scientific and best clinical evidence. Physiotherapists in mental health contribute to the multidisciplinary team and inter-professional care.<ref>Michel Probst. [https://www.intechopen.com/chapters/54472 Physiotherapy and Mental Health], Chapter 9, Clinical Physical Therapy Toshiaki Suzuki, IntechOpen, 2017.</ref>
* Limited or poor health literacy<ref>Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden–a cross-sectional study. BMC public health. 2014 Dec 1;14(1):1030.</ref>.
 
* Refugees health is also affected by [[Communicable Diseases|infectious diseases]], [[Neurological Disorders|neurological diseases]], [[Cancer Pain|cancer]] and [[Chronic Disease|chronic diseases]] that could result in poly-morbidity.
Rehabilitation professionals should be aware that there are several factors that have a major influence on mental health in displaced persons:
* Also neurological injuries/ diseases, [[Overview of Traumatic Brain Injury|traumatic injuries]] (e.g., spinal cord injuries ) or post-traumatic(e.g., chronic pain syndrome).
* Experiences within their home country that caused the forced displacement
* Infections      
* Experiences of living in camps for displaced persons
* Result of starvation ( e.g., epilepsy, [[ataxia]], and paraesthesia)
* Experiences on route to the host country
* [[Communication in healthcare|Communication Problems]], intercultural problems<ref>Uba L. Cultural barriers to health care for southeast Asian refugees. Public health reports. 1992 Sep;107(5):544.</ref> and demand [[Attention Deficit Disorders|attention]] problems<ref>Dadzie GM. Healthcare Accessibility for Syrian Refugees: Understanding Trends, Host Countries’ Responses and Impacts on Refugees’ Health.</ref>.
* Experience of their new life in the host country
* [[Psychological Approaches to Pain Management|Psychological problems]].<ref name=":4" /> <ref name=":5" />  
* Limited or poor [[Health Literacy|health literacy]] <ref>Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden–a cross-sectional study. BMC public health. 2014 Dec 1;14(1):1030.</ref>
* [[Overview of Traumatic Brain Injury|Traumatic injuries]] (e.g., spinal cord injuries ) or post-traumatic (e.g., chronic pain syndrome)
* Infections
* Malnutrition
*[[Communication in healthcare|Communication problems]], intercultural problems<ref>Uba L. Cultural barriers to health care for southeast Asian refugees. Public health reports. 1992 Sep;107(5):544.</ref> and demand [[Attention Deficit Disorders|attention]] problems<ref>Dadzie GM. Healthcare Accessibility for Syrian Refugees: Understanding Trends, Host Countries’ Responses and Impacts on Refugees’ Health.</ref>
*[[Psychological Approaches to Pain Management|Psychological problems]]<ref name=":4" /> <ref name=":5" />
<br>
A study on mental health and service needs among a group of displaced persons in Malaysia showed that displaced persons emphasise concerns about accessing opportunities for permanent resettlement and worries about economic survival.<ref>Shaw, S.A., Pillai, V. and Ward, K.P., 2019. Assessing mental health and service needs among refugees in Malaysia. ''International Journal of Social Welfare'', ''28''(1), pp.44-52.</ref> Almost all participants in the study reported that they would be interested in taking part in supportive group services. Therefore, as service providers, high attention to mental well-being and coping strategies must be incorporated while evaluating basic needs, even in temporary settings.
 
Physiotherapists are effective members of multidisciplinary teams of doctors, nurses, dietitians, therapists and social workers. Physiotherapy management can complement medication and psychotherapy within the multidisciplinary team. The role and tasks of physiotherapists in these teams will vary, from management of pain, increasing joint mobility, relaxation exercises, improvement of strength, endurance and balance, gait training and to devise exercise programmes tailored to patient needs. Interventions might include: relaxation and deep breathing exercises;<ref name=":1" /> various stretching exercises, callisthenics, walking, running, aerobic exercises and swimming. These can be performed either indoors or outdoors and may be useful for patients with substance abuse disorders,<ref name=":7" /> gynaecological disorders and other conditions; range of motion, strength, endurance and coordination exercises.
 
Postural management: Regular changes in body positions are essential to prevent poor posture, muscle tightness, spasms and decreased joint movement.<ref name=":10" /> Balance, equilibrium and gait training may be beneficial as is ergonomic advice. This advice might include adaptations at home and equipment to make patients independent.<ref name=":10" />  


A study on mental health and service needs among a group of refugees in Malaysia showed that refugees emphasized concerns about accessing opportunities for permanent resettlement and worries about economic survival<ref>Shaw, S.A., Pillai, V. and Ward, K.P., 2019. Assessing mental health and service needs among refugees in Malaysia. ''International Journal of Social Welfare'', ''28''(1), pp.44-52.</ref>. Close to all the participants in the study reported that they would be interested in taking part in supportive group services. Therefore, as service providers, high attention to mental well-being and coping strategies must be incorporated while evaluating basic needs, even in temporary settings.
The burden of depression, anxiety and other mental disorders call for concerted, intersectoral responses. The aim is not only to raise public awareness, but also to provide treatment and prevention strategies that can reduce this large and growing health problem and its associated economic cost.<ref name=":8" /> The correlations between poor mental health and an increased prevalence of musculoskeletal conditions, multiple areas of pain, chronic and preventable diseases emphasise the need for an effective and holistic multidisciplinary approach to managing these conditions.<ref name=":9" /><ref name=":11" />


== References ==
== References ==
Line 54: Line 77:


[[Category:PREP Content Development Project]]
[[Category:PREP Content Development Project]]
[[Category:Course Pages]]
[[Category:Displaced Persons]]
[[Category:Mental Health]]
[[Category:Mental Health]]

Latest revision as of 14:01, 8 May 2023

Original Editor - Shaimaa Eldib

Top Contributors - Shaimaa Eldib, Naomi O'Reilly, Kim Jackson, Candace Goh, Jess Bell, Vidya Acharya and Carin Hunter

Introduction[edit | edit source]

According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community".[1][2]

Mental health conditions are considered a leading cause for disability globally, accounting for around 13% of the global burden of disease, and 33% of total years lived with disability.[3][4] It is estimated that people who have severe mental health disorders, for example, severe depression, bipolar disorder and schizophrenia[5] are more likely to die prematurely than those who have not been affected. The problems of mental health are highly prevalent globally, affecting people across all regions of the world. They are expected to affect at least 1 out of 3 people across their life-time.[6][7]

There are major economic consequences of this high prevalence in mental health conditions; it is estimated that mental ill-health will lead to the loss of $US16.1 trillion between 2011 and 2030.[8] This cost has serious implications on standards of livings and socioeconomic development.[9] There are many barriers to treating mental illness including stigma, discrimination[10][5] and governmental apathy,[9] which further exacerbate the current state of mental health care all over the world.

Displaced Person Crisis[edit | edit source]

According to the United Nations High Commissioner for Refugees (UNHCR), 89.3 million people have been forcibly displaced worldwide as a result of conflicts, violence, fear of persecution and human rights violations in 2021; it is estimated that there will be more than than 100 million people displaced in 2022.[11] There were 20 people newly displaced every minute of 2016.[12] Those who are forced to leave their home countries often live in overcrowded reception facilities while waiting for resettlement or asylum decisions.[13] These facilities have, in effect, turned into long-term detention centres and have poor health and safety conditions.[14] All these factors create medical challenges and an increased need for displaced persons to utilise health services. [15]

Mental Health and Displacement[edit | edit source]

Migrants can be exposed to various stress factors which affect their mental health and well-being before and during their migration journey and during their settlement and integration. While most migrants do not experience mental health problems, people displaced as a result of conflicts, violence, fear of persecution and human rights violations can lead to at increased risk of mental health problems. This is particularly true for persons who have experienced violence and trauma, including exploitation, torture or sexual and gender-based violence. Issues can range from low to moderate levels of anxiety and depression through to more severe mental disorders.

Currently, the responsibility of mental health support for displaced persons is shared by a wide network of organisations depending on where the displaced person is based. These organisations include: the World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), Governments and Non‐Governmental Organisations.[16]

When individuals and families seek safety by leaving their homes, cultures, and communities because of the threat of violence and persecution, emotional distress can be heightened. About one third of displaced persons will experience high rates of depression, anxiety, and post-traumatic stress disorders (PTSD) as a result of the circumstances they faced during their migration, which can significantly affect the quality of their life.[16] [17] However, systematic reviews show that prevalence estimates of mental health disorders vary widely from 4% to 80% including:[18][19]


While most displaced persons with PTSD and depression show a reduction in symptoms over time, particularly if there are low resettlement stressors,[24][25] others may experience years of symptoms, particularly those with PTSD.[26][27] Because of this, early access to mental health care should be prioritised, as post-migration stressors such as prolonged detention, insecure immigration status, and limitations on work and education, can worsen mental health.

Post-Traumatic Stress Disorder[edit | edit source]

"When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen." [28]

According to the American Psychiatric Association (APA) and the DSM-5, Post Traumatic Stress Disorder is defined as a “psychiatric disorder in which patients have experienced or witnessed a significant traumatic event. Examples of such an event include natural disasters, serious accidents, terrorist acts, war/combat, rape, or other violent personal assaults. PTSD presents with persistent, recurrent and disturbing memories or flashbacks of a witnessed or experienced trauma, avoidance of reminders of the traumatic event along with other symptoms such as negative thoughts and feelings, difficulty with concentration and sleep, feeling detached from people and current experiences, as well as exaggerated startle responses and arousal / reactive symptoms such as irritability, and angry outbursts.[29] Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened.[30] Difficulties in emotional regulation, cognitive functioning, self-perception, relationships, somatisation and hopelessness may occur due to severe stress as a result of overwhelming circumstances and disturbing experiences.[31]

The prevalence of traumatic experiences is common. It is found that more than two-thirds of persons in the general population may experience a significant traumatic event at some point in their lives.[32] Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, other studies suggest that the prevalence of PTSD is around 30%.[16] These findings suggest that many refugees are in a traumatised state and are in need of counselling.[16]

It has been found that the biological effects of PTSD include:

  • Higher heart rate to sudden loud tones which suggests central sensitisation.
  • Diminished volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.[30]
  • Changes in brain and pre-existing vulnerability and neurotoxicity as origins of brain volume reductions in PTSD.
  • Amygdala and dorsal anterior cingulate cortex are hyper(re)active, whereas the ventral medial prefrontal cortex is hypo(re)active in PTSD and this may explain attentional bias towards the threat, impaired emotional regulation.[30]


Evidence suggests that trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of PTSD.[33] Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy, pharmacotherapies, and psychosocial interventions.[16]

Gaps in Refugee Mental Health[edit | edit source]

These videos describe the gaps in refugee health and their experiences.

[34]
[35]
[36]

Role of Rehabilitation Professionals[edit | edit source]

Person-centred rehabilitation services for mental health are implemented in many different health and mental health settings: psychiatry and psychosomatic medicine cater for children, adolescents, adults and older people with mild to severe, acute and chronic mental health problems, in primary and community care, inpatient and outpatient settings.

Mental health rehabilitation professionals provide a wide range of services including health promotion, preventive health care, treatment and rehabilitation for individuals, groups and in‐group therapeutic settings. They create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment applying a model including biological and psychosocial aspects. Rehabilitation professionals in mental health aim to optimise well-being and empower the individual by promoting functional movement, movement awareness, physical activity and exercises, bringing together physical and mental aspects. It is based on the available scientific and best clinical evidence. Physiotherapists in mental health contribute to the multidisciplinary team and inter-professional care.[37]

Rehabilitation professionals should be aware that there are several factors that have a major influence on mental health in displaced persons:


A study on mental health and service needs among a group of displaced persons in Malaysia showed that displaced persons emphasise concerns about accessing opportunities for permanent resettlement and worries about economic survival.[41] Almost all participants in the study reported that they would be interested in taking part in supportive group services. Therefore, as service providers, high attention to mental well-being and coping strategies must be incorporated while evaluating basic needs, even in temporary settings.

Physiotherapists are effective members of multidisciplinary teams of doctors, nurses, dietitians, therapists and social workers. Physiotherapy management can complement medication and psychotherapy within the multidisciplinary team. The role and tasks of physiotherapists in these teams will vary, from management of pain, increasing joint mobility, relaxation exercises, improvement of strength, endurance and balance, gait training and to devise exercise programmes tailored to patient needs. Interventions might include: relaxation and deep breathing exercises;[5] various stretching exercises, callisthenics, walking, running, aerobic exercises and swimming. These can be performed either indoors or outdoors and may be useful for patients with substance abuse disorders,[16] gynaecological disorders and other conditions; range of motion, strength, endurance and coordination exercises.

Postural management: Regular changes in body positions are essential to prevent poor posture, muscle tightness, spasms and decreased joint movement.[20] Balance, equilibrium and gait training may be beneficial as is ergonomic advice. This advice might include adaptations at home and equipment to make patients independent.[20]

The burden of depression, anxiety and other mental disorders call for concerted, intersectoral responses. The aim is not only to raise public awareness, but also to provide treatment and prevention strategies that can reduce this large and growing health problem and its associated economic cost.[3] The correlations between poor mental health and an increased prevalence of musculoskeletal conditions, multiple areas of pain, chronic and preventable diseases emphasise the need for an effective and holistic multidisciplinary approach to managing these conditions.[4][21]

References[edit | edit source]

  1. ↑ The world health report 2001 – Mental Health: New Understanding, New Hope"(PDF). WHO. Retrieved 4 May 2014.
  2. ↑ Mental health: strengthening our response. World Health Organization. August 2014. Retrieved 4 May 2014.
  3. ↑ 3.0 3.1 Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2197-223
  4. ↑ 4.0 4.1 Funk M. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on. 2016 Oct;30.
  5. ↑ 5.0 5.1 5.2 Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet. 2009 Jan 31;373(9661):408-15.
  6. ↑ Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International journal of epidemiology. 2014 Apr 1;43(2):476-93.
  7. ↑ Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry. 2016 Feb 1;3(2):171-8.
  8. ↑ Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Hamandi A, Mowafi M, O’Farrell D. The global economic burden of noncommunicable diseases. Program on the Global Demography of Aging; 2012 Jan.
  9. ↑ 9.0 9.1 Caulfield A, Vatansever D, Lambert G, Van Bortel T. WHO guidance on mental health training: a systematic review of the progress for non-specialist health workers. BMJ open. 2019 Jan 1;9(1):bmjopen-2018.
  10. ↑ Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, Van Weeghel J, Reneses B, Germanavicius A. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet. 2013 Jan 5;381(9860):55-62.
  11. ↑ 11.0 11.1 Müller M, Khamis D, Srivastava D, Exadaktylos AK, Pfortmueller CA. Understanding refugees' health. InSeminars in neurology 2018 Apr (Vol. 38, No. 02, pp. 152-162). Thieme Medical Publishers.
  12. ↑ 12.0 12.1 Ellis BH, Winer JP, Murray K, Barrett C. Understanding the mental health of refugees: Trauma, stress, and the cultural context. InThe Massachusetts General Hospital textbook on diversity and cultural sensitivity in mental health 2019 (pp. 253-273). Humana, Cham.
  13. ↑ Fotaki M. A crisis of humanitarianism: refugees at the gates of Europe. International journal of health policy and management. 2019 Jun;8(6):321.
  14. ↑ Blitz BK, d’Angelo A, Kofman E, Montagna N. Health challenges in refugee reception: dateline Europe 2016. International journal of environmental research and public health. 2017 Dec;14(12):1484.
  15. ↑ Kotsiou OS, Kotsios P, Srivastava DS, Kotsios V, Gourgoulianis KI, Exadaktylos AK. Impact of the refugee crisis on the Greek healthcare system: A long road to Ithaca. International journal of environmental research and public health. 2018 Aug;15(8):1790.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017 Jun;16(2):130-9.
  17. ↑ Wilker S, Catani C, Wittmann J, Preusse M, Schmidt T, May T, Ertl V, Doering B, Rosner R, Zindler A, Neuner F. The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT). Trials. 2020 Dec;21(1):1-6.
  18. ↑ Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights. 2015;15:29. 11.
  19. ↑ 19.0 19.1 19.2 Keyes EF. Mental health status in refugees: an integrative review of current research. Issues Ment Health Nurs. 2000;21(4):397–410.
  20. ↑ 20.0 20.1 20.2 Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302(5):537–49 13.
  21. ↑ 21.0 21.1 Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467):1309–14. 14.
  22. ↑ Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees—a systematic review and metaanalysis. Soc Sci Med. 2009;69(2):246–57 15.
  23. ↑ Slewa-Younan S, Uribe Guajardo MG, Heriseanu A, Hasan T. A systematic review of post-traumatic stress disorder and depression amongst Iraqi refugees located in western countries. J Immigr Minor Health. 2015;17(4):1231–9.
  24. ↑ Oppedal, B., & Idsoe, T. (2015). The role of social support in the acculturation and mental health of unaccompanied minor asylum seekers. Scandinavian Journal of Psychology, 56, 203–211. 17.
  25. ↑ Betancourt, T., Borisova, I., Williams, T., Meyers-Ohki, S., RubinSmith, J., Annan, J., & Kohrt, B. (2013). Psychosocial adjustment and mental health in former child soldiers: Systematic review of the literature and recommendations for future research.Journal of ChildPsychologyandPsychiatry,54,17–36
  26. ↑ Beiser, M., & Wickrama, K. (2004). Trauma, time and mental health: A study of temporal reintegration and Depressive Disorder among Southeast Asian refugees. Psychological Medicine, 34, 899–910.
  27. ↑ Sack, W., Him, C., & Dickason, D. (1999). Twelve-year followup study of Khmer youths who suffered massive war trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1173–1179
  28. ↑ Post-traumatic stress disorder (PTSD). Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/ (Accessed 18 May 2020).
  29. ↑ Ringold S, Burke A, Glass RM. Refugee mental health. JAMA. 2005 Aug 3;294(5):646
  30. ↑ 30.0 30.1 30.2 Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, Milad MR, Liberzon I. Biological studies of post-traumatic stress disorder. nature Reviews neuroscience. 2012 Nov;13(11):769-87.
  31. ↑ McFARLANE AC. The long‐term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry. 2010 Feb;9(1):3-10.
  32. ↑ Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychological medicine. 1991 Aug;21(3):713-21.
  33. ↑ Bisson J, Andrew M. Psychological treatment of post‐traumatic stress disorder (PTSD). Cochrane database of systematic reviews. 2007(3).
  34. ↑ TED Ex Talks. Bridging the Refugee Health Gap | Claire Jones | TEDxUQ. Available from: http://www.youtube.com/watch?v=3iogISgezbQ[last accessed 28/07/2020]
  35. ↑ Tanishq Suryavanshi. What is the Refugee Mental Health Crisis and How Can We Address it?. Available from: http://www.youtube.com/watch?v=eRfyQl_mSGs[last accessed 28/07/2020]
  36. ↑ TED. How we can bring mental health support to refugees | Essam Daod. Available from: http://www.youtube.com/watch?v=0g0S34XE2b8[last accessed 28/07/2020]
  37. ↑ Michel Probst. Physiotherapy and Mental Health, Chapter 9, Clinical Physical Therapy Toshiaki Suzuki, IntechOpen, 2017.
  38. ↑ Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden–a cross-sectional study. BMC public health. 2014 Dec 1;14(1):1030.
  39. ↑ Uba L. Cultural barriers to health care for southeast Asian refugees. Public health reports. 1992 Sep;107(5):544.
  40. ↑ Dadzie GM. Healthcare Accessibility for Syrian Refugees: Understanding Trends, Host Countries’ Responses and Impacts on Refugees’ Health.
  41. ↑ Shaw, S.A., Pillai, V. and Ward, K.P., 2019. Assessing mental health and service needs among refugees in Malaysia. International Journal of Social Welfare, 28(1), pp.44-52.
Retrieved from "https://www.physio-pedia.com/index.php?title=Mental_Health_and_Forced_Displacement&oldid=333255"