Changes in self-rated health and quality of life among Syrian refugees migrating to Norway: a prospective longitudinal study

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Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study

Background The health of forcibly displaced individuals changes along their migration path and estimates of disease burden are essential to develop health care policies and practices adequately corresponding to their health care needs. This study aims to describe the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. Further, we aim to investigate the associations between migration related exposures and both chronic pain and mental health among Syrian refugees. Methods This is a cross-sectional study based on survey data collected among 827 adult Syrian refugees in Lebanon and Norway during 2017–2018. The survey instrument included items measuring somatic status (including chronic pain), mental health (using the HSCL-10 and HTQ items), use of medication and migration related exposures. We used descriptive statistics to calculate standardised prevalence proportions and regression analyses to study associations between migration related exposures and health outcomes. Results The response rate was 85%. The mean age in the sample was 33 years and 41% were women. Half of the participants reported that they had never had any health problems. The prevalence of non-communicable diseases was 12%. Headache and musculoskeletal complaints were the most prevalent conditions reported, with 30% reporting chronic pain lasting for more than six months. Symptoms indicating anxiety and/or depression were presented by 35%, while 7% revealed symptoms compatible with post-traumatic stress disorder. Among those reporting non-communicable diseases a substantial share did not seem to receive adequate treatment. Trauma experiences were associated with both chronic pain and anxiety/depression symptoms, and the latter were also associated with migrating without family members. Conclusions Migrant-friendly public health policies and practises should acknowledge migration related risks, address discontinuity in care of chronic conditions and target common complaints such as chronic pain and mental health problems among forcibly displaced individuals.publishedVersio

Use of health care services among Syrian refugees migrating to Norway: a prospective longitudinal study

Background Understanding the differential utilization of healthcare services is essential to address the public health challenges. Through the migration process, refugees move from one set of health risk factors to another and can face multiple healthcare challenges along their journey. Yet how these changing risk factors influence refugees’ use of health care services is poorly understood. Methods A longitudinal survey assessing health care utilization of 353 adult Syrian refugees was conducted; first in a transit setting in Lebanon and after one year of resettlement in Norway. The main outcomes are the utilization of general practitioner services, emergency care, outpatient and/or specialist care and hospitalization during the previous 12 months. Associations between use of healthcare services and several sociodemographic, migration-related and health status variables at both time points were found using regression analysis. We also analyzed longitudinal changes in utilization rates using generalized estimating equations. Results The use of general practitioner and emergency care increased after resettlement while outpatient/specialist care markedly dropped, and hospitalization rates remained the same. Undocumented status and poor self-rated health (SRH) prior to resettlement were identified as predictors for use of health care after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and quality of life were significantly associated with use of healthcare services. Conclusions Utilization of health services changes post migration to the destination country and are associated with migration-related and socio-demographic factors. Poor SRH is associated with use of services, both pre-arrival and post-resettlement. Our findings have implications for future resettlements, health care policies and service provision to newly arrived refugees with regard to both health needs as well as delivery of services.publishedVersio

Effect of a self-help group intervention using Teaching Recovery Techniques to improve mental health among Syrian refugees in Norway: a randomized controlled trial

Background Mental health symptoms among refugees are common, often related to chronic pain disorders, and their management is usually challenging. Studies evaluating the effect of group therapies among adult refugees to improve mental health symptoms are scarce. Aims To assess the effect of Teaching Recovery Techniques (TRT) on mental health and to reduce pain disorder among adult Syrian refugees. Method A randomized controlled trial was designed to study the effect of a self-help group intervention using TRT. The outcomes, mental health symptoms measured by Impact of Event Scale-Revised (IES-R) and General Health Questionnaire (GHQ-12) and chronic pain measured by Brief Pain Inventory (BPI), were reported as regression coefficients (B) with 95% confidence intervals. Results Seventy-six adults participated: 38 in the intervention and 38 in the control groups. Intention-to-treat analyses showed a significant effect on general mental health as measured by GHQ-12 with B (95% CI) of -3.8 (-7.2, -0.4). There was no effect of TRT on mental health when assessed by IES-R (-1.3 (-8.7, 6.2)) or on pain levels assessed by BPI (-0.04 (-4.0, 3.9)). Conclusions This self-help group intervention significantly improved general mental health symptoms among adult refugees but had no effect on trauma symptoms or chronic pain. Higher participation rates might be necessary to achieve the full potential of TRT.publishedVersio

Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study

Objectives This study aims to examine associations, predictors and pharmacological treatment of chronic pain and mental health problems among Syrian refugees in a longitudinal perspective. Design Prospective cohort study. Setting We collected survey data among Syrian refugees in Lebanon granted resettlement to Norway (self-administered questionnaires) and at follow-up 1 year after arrival in Norway (structured telephone interviews). Participants Adult Syrian refugees attending mandatory pretravel courses in Lebanon in 2017–2018 were invited to participate. In total, 353 individuals participated at both time points. Primary and secondary outcomes We examined the cross-sectional associations between pain, mental health and migration-related exposures at baseline and follow-up and assessed whether associations changed significantly with time. Furthermore, we investigated the longitudinal association between mental health at baseline and pain at follow-up. We also evaluated temporal changes in use of analgesics and psychotropic drugs. Results While most refugees reported improved health from the transit phase in Lebanon to the early resettlement phase in Norway, a few had persisting and intertwined health problems. Most migration-related stressors were more closely associated with chronic pain and mental health problems after resettlement as compared with the transit phase. In parallel, poor mental health was associated with chronic pain in the follow-up (adjusted risk ratio (ARR) 1.5 (1.0, 2.2)), but not at baseline (ARR 1.1 (0.8, 1.5)). Poor mental health at baseline was a statistically significant predictor of chronic pain at follow-up among those not reporting chronic pain at baseline. At both timepoints, one in four of those with chronic pain used analgesics regularly. None with mental health problems used antidepressants daily. Conclusions Providers of healthcare services to refugees should be attentive to the adverse effect of postmigration stressors and acknowledge the interrelations between pain and mental health. Possible gaps in pharmacological treatment of pain and mental health problems need further clarification.publishedVersio

Development of 3D Printed Scaffolds for Bone Regeneration

The 3D printing process can produce bioengineered scaffolds with a 100% interconnected porous structure layer-by-layer with the help of computer-aided design. In this study we utilized a 3D bio plotter system to fabricate 3D interconnected porous scaffolds for bone tissue engineering. Poly (L-lactide-co-caprolactone (PLCL)) was selected to fabricate the scaffold due to its biocompatibility and printability. Two scaffolds were produced for comparative study with a layer rotation of 45° and 90° and a distance of either 1000 µm or 1200 µm between the printed fibers. Micro computed tomography (µ-CT) was utilized to study the interconnected porous structure of the scaffolds. Protein adsorption on the surface of the scaffolds was examined using a protein assay kit. Human osteoblast-like cells (HOB) were seeded onto the two different scaffolds and cellular activities (attachment, morphology, and proliferation) were investigated using scanning electron microscopy (SEM), live/dead stain, lactate dehydrogenase enzyme (LDH), and methylthiazol tetrazolium (MTT). Gene expression of apoptotic (Bax and Bcl2) and osteogenic markers (ALP and OC) were investigated by qRT-PCR. The µ-CT results confirmed the open porous structure of the two scaffolds and no significant difference was found in protein adsorption between the two designs. SEM, LDH and MTT analysis confirmed that HOB cells adhered, spread and proliferated well on both scaffolds. The qRT-PCR analysis showed that cells seeded on the scaffold with 1200 µm between the fibers expressed higher mRNA levels of Bcl2 (day 1, 3, 7 and 14), ALP and OC than cells seeded on the scaffold with 1000 µm between fibers (day 14). In conclusion, the newly designed 3D printed scaffolds are biocompatible with HOBs, and no adverse effect on cell attachment and proliferation was seen. Rather, enhanced osteoblast proliferation and differentiation were seen using the scaffold with 1200 µm between the printed fibers. Therefore, 1200 3D printed poly (L-lactide-co-caprolactone) scaffolds may be suitable candidates for bone regeneration

The Effect of Two Different Interventions on Chronic Pain and Mental Health Symptoms among Syrian Refugees

The main aim of this PhD project is to assess the effect of two different interventions among adult Syrian refugees suffering from pain and/or post-traumatic symptoms: (i) Physiotherapy Activity and Awareness Intervention (PAAI) in reducing pain disorders and mental health symptoms (if present), and (ii) a self-help group intervention using Teaching Recovery Techniques (TRT) to improve mental health and reduce pain (if present). The interventions were adapted for our participants in cooperation with the municipality of Bergen, municipality of Fjell, the Centre for Crisis Psychology, and the users. Both treatments were tested using a randomized controlled trial (RCT) design implemented from August 2018 to December 2019. In addition, a qualitative assessment was performed through an embedded process evaluation and through personal interviews with participants after the completion of the interventions. The first paper in this thesis is the study protocol for both interventions and it describes in detail the methodology used. The second paper presents, primarily, the effect of PAAI in reducing pain disorders and secondarily in improving general mental health among 101 Syrian refugees. Although PAAI had no effect on reducing either pain symptoms or improving mental health among refugees by intention-to-treat (ITT), this paper also includes the qualitative experiences among participants, including self-perceived benefits of the intervention and challenges/barriers to attending the intervention. The third paper presents the effect of a self-help group using TRT to improve mental health and secondarily reduce the pain disorder among 76 adult Syrian refugees reporting mental health symptoms. Our study found that the self-help group intervention statistically improved general mental health among adults’ refugees in ITT analysis measured by the 12-item General Health Questionnaire (GHQ-12). However, there was no effect of TRT on either mental health when measured by the 22-item Impact of Event Scale-Revised (IES-R 22) or on pain levels measured by the Brief Pain Inventory (BPI). Our research contributes to the evidence base needed to develop focused and effective healthcare services for refugees and indicates that the tested interventions might have some positive effects but are generally not as effective as expected on the primary outcomes. Thus, further research on how to improve health among refugees is needed

Changes in self-rated health and quality of life among Syrian refugees migrating to Norway: a prospective longitudinal study

Background Forced migrants can be exposed to various stressors that can impact their health and wellbeing. How the different stages in the migration process impacts health is however poorly explored. The aim of this study was to examine changes in self-rated health (SRH) and quality of life (QoL) among a cohort of adult Syrian refugees before and after resettlement in Norway. Method We used a prospective longitudinal study design with two assessment points to examine changes in health among adult Syrian resettlement refugees in Lebanon accepted for resettlement in Norway. We gathered baseline data in 2017/2018 in Lebanon and subsequently at follow-up one year after arrival. The main outcomes were good SRH measured by a single validated item and QoL measured by WHOQOL-BREF. We used generalized estimating equations to investigate changes in outcomes over time and incorporated interaction terms in the models to evaluate effect modifications. Results In total, 353 subjects participated in the study. The percentage of participants reporting good SRH showed a non-significant increase from 58 to 63% RR, 95%CI: 1.1 (1.0, 1.2) from baseline to follow-up while mean values of all four QoL domains increased significantly from baseline to follow-up; the physical domain from 13.7 to 15.7 B, 95%CI: 1.9 (1.6, 2.3), the psychological domain from 12.8 to 14.5 B, 95%CI: 1.7 (1.3, 2.0), social relationships from 13.7 to 15.3 B, 95%CI: 1.6 (1.2, 2.0) and the environmental domain from 9.0 to 14.0 5.1 B, 95%CI: (4.7, 5.4). Positive effect modifiers for improvement in SRH and QoL over time include male gender, younger age, low level of social support and illegal status in transit country. Conclusion Our results show that good SRH remain stable while all four QoL domains improve, most pronounced in the environment domain. Understanding the dynamics of migration and health is a fundamental step in reaching health equity

Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study

Background The health of forcibly displaced individuals changes along their migration path and estimates of disease burden are essential to develop health care policies and practices adequately corresponding to their health care needs. This study aims to describe the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. Further, we aim to investigate the associations between migration related exposures and both chronic pain and mental health among Syrian refugees. Methods This is a cross-sectional study based on survey data collected among 827 adult Syrian refugees in Lebanon and Norway during 2017–2018. The survey instrument included items measuring somatic status (including chronic pain), mental health (using the HSCL-10 and HTQ items), use of medication and migration related exposures. We used descriptive statistics to calculate standardised prevalence proportions and regression analyses to study associations between migration related exposures and health outcomes. Results The response rate was 85%. The mean age in the sample was 33 years and 41% were women. Half of the participants reported that they had never had any health problems. The prevalence of non-communicable diseases was 12%. Headache and musculoskeletal complaints were the most prevalent conditions reported, with 30% reporting chronic pain lasting for more than six months. Symptoms indicating anxiety and/or depression were presented by 35%, while 7% revealed symptoms compatible with post-traumatic stress disorder. Among those reporting non-communicable diseases a substantial share did not seem to receive adequate treatment. Trauma experiences were associated with both chronic pain and anxiety/depression symptoms, and the latter were also associated with migrating without family members. Conclusions Migrant-friendly public health policies and practises should acknowledge migration related risks, address discontinuity in care of chronic conditions and target common complaints such as chronic pain and mental health problems among forcibly displaced individuals