Journal of Community Medicine & Public Health (ISSN: 2577-2228)

Article / Research Article

"Determining Physical and Mental Health Conditions Present in Refugees Age 0-59 Years Arriving in Utah"

Hayder Allkhenfr1*, Susan E Dearden2, Caren J Frost3, Lisa H Gren4, Scott L Benson5

1Refugee Health and TB Program Manager, TB Controller, Refugee Health Coordinator, Utah, USA

2Research Program Manager, University of Utah, USA

3Research Professor, University of Utah, USA

4Center for Research on Migration & Refugee Integration, University of Utah, USA

5Associate Professor, University of Utah, USA

*Corresponding author: Hayder Allkhenfr, Refugee Health and TB Program Manager, TB Controller, Refugee Health Coordinator, Utah, USA

Received Date: April 05, 2021; Accepted Date: April 15, 2021; Published Date: April 20, 2021

Abstract

Purpose: The aim of this study was to report the prevalence of physical and mental health conditions identified for newly arrived refugees in Utah.

Methods: The Utah Refugee Health Screener is a standardized form used to screen all refugees resettled in Utah. Prevalence was calculated for mental and physical health conditions. Comparisons were made by age, sex, and geographic region.

Results: Between 2012 and 2017, 6,842 refugees (ages 0-59 years) were resettled in Utah and included in this analysis. The prevalence of mental health findings was higher for adults than children (36.9% vs 18.0%). Among adults, women had higher prevalence of mental health findings than men (Prevalence Ratio (PR) of 1.3-1.9), while refugees from the Middle East had consistently higher prevalence than those from other regions. Similarly, the prevalence of physical health findings was generally higher for adults than children (66.2% vs 41.5%). Differences between men and women were most notable for the categories of pulmonology (PR=3.6 for men vs women), endocrinology (PR=2.0 for women vs men), and neurology (PR=2.0 for women vs men).

Conclusions: Adult refugees have higher prevalence of both mental and physical health findings on screening exam. Screening identifies conditions that are largely treatable. However, these conditions typically don’t resolve without treatment and if left untreated, result in increased morbidity and mortality. The initial domestic screening is an opportunity to connect refugees with appropriate treatment to address health concerns, thus facilitating their ability to successfully engage in other resettlement activities, such as work and school.

Keywords: Epidemiology; LTBI; Mental health; RHS15; Refugees; Refugee health screening; Refugee domestic examination; Utah refugee health

As of 2019, over 70 million people are living as internationally displaced persons, with approximately 26 million of these individuals designated as refugees worldwide [1,2]. Between 2012 and 2017, 644,083 refugees were resettled around the world [3]. Of these 396,400 were resettled in the US, 3 and 7,017 of those were resettled in Utah [4,5].

The US Federal Refugee Resettlement Program requires every refugee to participate in a medical screening (which includes physical and mental health data collection) that is comprehensive, culturally sensitive, and linguistically appropriate within 30 days of arrival in the US.5 Primary care providers and public health officials can utilize the information from these screenings to (a) follow-up on conditions of public health concern and (b) manage acute and chronic conditions refugees have upon arrival. The overseas refugee screening exam primarily focuses on identifying conditions of public health concern that would disqualify refugees from entering the US. The domestic health screening is a more comprehensive exam that is conducted by primary care providers experienced in refugee healthcare service delivery. The findings on the latter exam guide development of a management plan to address acute and chronic health conditions.

Refugee health screening is necessary to ensure the health of both immigrant and host populations. Many refugees arrive in resettlement countries with pre-existing conditions and may develop new health issues [6-8]. Addressing physical and mental health needs early after resettlement is important to prevent the progression to increasingly serious health conditions [9]. To better understand the distribution of health conditions at arrival by age, sex, and regions where refugees arrive from, we analyzed the domestic health screening exam data for refugees resettled in Utah between the years 2012 and 2017.

Materials and Methods

Participants and Procedures

The Utah Department of Health (UDOH) provided data from the initial domestic screening for refugees age 0-59 years, resettled in Utah from 2012-17. Three clinics conducted screening and reported the results to UDOH using the Utah Refugee Health Screening Form (U-RHSF). The U-RHSF includes demographic information; findings from history, physical exam, and laboratory results (based on the CDC guidelines for domestic screening 10); and the Refugee Health Screener-15 (RHS-15) for mental health. The physical exam is completed for refugees of all ages, and the RHS-15 is completed for those age 14 years and older. We used a cut-off of >12 on the RHS-15 section I (assessing anxiety, depression, and posttraumatic stress disorder) and >5 on RHS-15 section II (assessing general stress) to identify a positive screen, as recommended [11]. For reporting to UDOH, specific findings were grouped by the corresponding body system. For example, the endocrine system contains findings for diabetes and thyroid disorders. The prevalence of positive findings on the U-RHSF included any diagnosis written by the provider; signs or symptoms related to a diagnosis; provider’s referral for further diagnosis or treatment; or lab results outside the normal range, based on age- and sex-specific reference ranges for normal values. This study was approved by the University of Utah and UDOH Institutional Review Boards.

Demographic Information

Since most of the countries of origin have a large number of ethnicities, the UDOH created a categorical variable (Nativity and Culture) to report nationalities and preserve data on ethnicities. For analysis, we grouped refugees by geographic region (Africa, Middle East, Non-Middle East Asia), based on the Nativity and Culture variable. Statistical Analysis Descriptive statistics for prevalence of positive findings were calculated and reported by body system. We assessed differences in prevalence by age, gender, and geographic region using tests of means or medians for continuous variables, and chi-square test for dichotomous variables. Analyses were completed using SAS University Edition (SAS Institute, Inc.).

Results

Demographics of refugees resettled between 2012 and 2017 in Utah, are in Table 1. The majority of refugees were from Iraq (19.8%), Somalia (18.7%), the Democratic Republic of the Congo (11.0%), Bhutan (7.9%), and Afghanistan (5.7%). No significant difference in age was noted for women and men, with a mean of 21.6 years (SD: 14.6) (Table 2).

Denominators are provided here to indicate where there are missing observations in the calculation of percent with the condition: Children - n=651 (all mental health conditions, since only those age 14 and older received this exam); n=3124 (any physical health condition); n=1486 (gynecology); n=3120 (gastroenterology, urology); n=3122 (dental, ENT); n=3123 (hematology, ophthalmology); n=3124 (nutrition); n=3125 (dermatology, endocrinology, LTBI, neurology, pulmonology); n=3128 (cardiology); n=3136 (hepatitis B, musculoskeletal); n=1478 (HIV) Adults – n=3714 (urology); n=3716 (anxiety, endocrinology); n=3717 (gastroenterology, hepatitis B, pulmonology); n=1728 (gynecology); n=3718 (any physical health condition, cardiology, dental, depression, ENT, hematology, LTBI, musculoskeletal, neurology, nutrition, RHS-II); n=3719 (dermatology, ophthalmology, RHS-I, torture/violence); n=3718 (HIV).

Differences in disease prevalence by gender, are reported in Table 3. With the exception of ear, nose and throat (ENT) and urology, there were no significant differences in conditions by gender among children (data not shown). Positive findings in the ENT category were more common in boys than girls (7.0% vs 5.2%, prevalence ratio (PR) =1.36, p=0.033), while findings in the urology category were more common in girls than boys (1.7% vs 0.9%, PR=1.98, p=0.038).

Denominators are provided here to indicate where there are missing observations in the calculation of percent with the condition: Adults-n=3714 (urology); n=3716 (anxiety, endocrinology); n=3717 (gastroenterology, hepatitis B, pulmonology); n=1728 (gynecology) n=3718 (cardiology, dental, depression, ENT, hematology, LTBI, musculoskeletal, neurology, nutrition, RHS-II); n=3719 (dermatology, ophthalmology, RHS-I, torture/violence); n=3733 (HIV).

Adult women had higher prevalence of mental health findings than adult men (excepting exposure to torture/violence). Women had 42-48% higher prevalence of a positive screen on the RHS-15 screening exam, and higher prevalence of anxiety and depression compared to men (34% vs 89%).

For physical health, there were no significant differences between adult men and women in most areas. Men had a higher prevalence of findings in the pulmonology category (PR=3.58, p<0.001) predominantly representing COPD and asthma, and for LTBI (PR=1.25, p<0.001). Women had a higher prevalence of findings in the other categories where differences were noted (Table 3); the greatest differences seen were for endocrinology (PR=2.01, p<0.001) predominantly representing diabetes, and neurology (PR=1.95, p<0.001) predominantly representing headaches.

Differences in prevalence of mental health findings by region from which refugees originated, are found in Figure 1. Refugees from the Middle East had significantly higher prevalence, relative to those coming from Africa or Non-Middle East Asia, for anxiety, depression, and both screening scores (RHS-I, RHS-II). The prevalence of reported torture and/or violence was similar for refugees coming from Africa and the Middle East, and were significantly higher relative to refugees from Non-Middle East Asia.

Differences in physical health findings by region from which refugees originated was also evaluated. The most common condition was latent tuberculosis infection (LTBI), with prevalence of 24.2% for Africa, 11.7% for Middle East, and 26.7% for Non-Middle East Asia (Middle East statistically lower than the other regions). Other infectious diseases noted were HIV (Africa: 1.3%; Middle East: no cases; Non-Middle East Asia: 0.4%; Africa statistically higher than Non-Middle East Asia) and hepatitis B (Africa: 4.0%, Middle East: 0.8%, Non-Middle East Asia: 3.4%; Middle East statistically lower than the other regions). The remaining physical health findings were grouped by organ system (Figure 2).

 Relative to the other Regions, Refugees from Africa had Higher Prevalence for Dental and Nutrition Findings

Relative to the other regions, refugees from the Middle East had higher prevalence for cardiology and musculoskeletal findings; Relative to the other regions, refugees from Africa had lower prevalence for endocrinology (predominantly diabetes), ophthalmology and pulmonology (predominantly COPD and asthma) findings; Relative to the other regions, refugees from the Middle East had lower prevalence for dermatology and hematology findings; Relative to the other regions, refugees from Non-Middle East Asia had lower prevalence for gynecology findings; Refugees from Africa had statistically higher prevalence of gastroenterology and ENT findings relative to refugees from the Middle East.

Discussion

Understanding the variation in prevalence of health problems experienced by refugees is critical to healthcare professionals and community workers. The Utah Refugee Health Screener captured the physical and mental health conditions for refugee’s age 0-59 years in this study. The condition identified are treatable, and swift resolution of these conditions will aid refugees in achieving other goals of resettlement, such as successful participation in work and school. Almost one third of these refugees had at least one finding on the RHS-15. The RHS-15 has good sensitivity (range .81 to .95) and specificity (range .86 to .89) for Iraqis, Nepali and Burmese, and is assumed to perform well for other groups [11]. Although adult women scored significantly higher than men on the RHS-15, both had similar rates of reporting torture and violence. Refugees from the Middle East, mainly Iraqis, were more likely to screen positive. This is likely related to the nature of trauma, which has included air bombardments, rocket attacks, witnessing a shooting, interrogation and harassment by militias [12].Others have reported that refugees can be hesitant to talk about mental health, which may result in under-reporting [13].Thus, primary care providers should consider repeat screening after establishing rapport with refugee patients.

Among adults, the prevalence of hypertension was >12%. Hypertension is categorized as: previously undiagnosed, diagnosed but untreated, or treated but not at goal. This screening is a single measurement, and those without a prior diagnosis of hypertension, but with elevated blood pressure at screening, should be further evaluated. Hypertension is a global silent epidemic [14]. Prompt and effective treatment of hypertension reduces the risk of stroke, heart failure, renal disease, poor vision and dementia [15-18]. These preventable conditions represent expensive and increased care needs that can be avoided if hypertension is identified early and treated effectively [19-21]. Diabetes was found in a number of refugees. The prompt diagnosis and effective treatment of diabetes reduces the risk of additional comorbid conditions such as cardiovascular disease, renal disease, neuropathies and retinopathy.

The prevalence of dental problems among refugees was 7.8%, however, we believe that this number underestimates the magnitude of the problem in refugees. Refugee screening didn’t include a dental screening for most of the adults. The dental issues were identified through history taking and examination by primary care providers.

The prevalence of LTBI was similar between male and female youth (10.9% and 10.2%), however, adult males had higher prevalence of LTBI than adult females (31.3% and 25.1%, respectively, p<0.001). Sex disparities in LTBI have been reported globally, which can be explained by differences in gender roles in countries of origin [22]. The prevalence of pulmonology conditions was higher in adult males than females, and consisted mainly of COPD and asthma. This higher prevalence is likely explained by the higher rates of smoking among men [23]. The prevalence of pulmonology conditions among Middle East and Non-Middle East Asia refugees (4.8% and 5.6% respectively) were higher than African refugees (2.0%), which follows the relative rates of smoking [23].

Literature Search and Data Sources

Our search strategy was focused on identifying the most recent data. A comprehensive literature review was completed using the key words “refugee health, refugee mental health, refugee health screening findings, domestic refugee health screening, LTBI among refugees, presumptive parasites treatment for refugees, blood lead levels in refugees, immigrant’s health, mental health screening for refugees and immigrants”. The data sources include Cochrane, PubMed, CDC guidelines for refugee health screening, states and federal published refugee statistics, and national refugee health programs websites.


Figure 1: Prevalence of mental health conditions by geographic region.


Figure 2: Prevalence of physical health conditions by geographic region.




Table 1: Demographic characteristics of refugees, age 0-59 years, arriving in Utah between 2012 and 2017.

Condition

Number with condition (%)

Prevalence ratio increased for

Children,

Adults,

Children

Adults

p-value

0-17 years

18-59 years

Mental Health

 

 

 

 

 

Any mental health finding

117 (18.0)

1372 (36.9)

 

2.05

<0.001

RHS-I positive

67 (10.3)

991 (26.7)

 

2.59

<0.001

RHS-II positive

61 (9.4)

744 (20.0)

 

2.14

<0.001

Torture/violence history

44 (6.8)

399 (10.7)

 

1.59

0.002

Depression diagnosis

17 (2.6)

306 (8.2)

 

3.15

<0.001

Anxiety diagnosis

14 (2.2)

301 (8.1)

 

3.77

<0.001

Physical Health

 

 

 

 

 

Any physical health finding

1297 (41.5)

2462 (66.2)

 

1.59

<0.001

LTBI

330 (10.6)

1077 (29.0)

 

2.74

<0.001

Nutrition

433 (13.9)

322 (8.7)

1.6

 

<0.001

Dermatology

295 (9.4)

357 (9.6)

 

1.02

0.822

Ophthalmology

158 (5.1)

460 (12.4)

 

2.44

<0.001

Gastroenterology

122 (3.9)

465 (12.5)

 

3.2

<0.001

Cardiology

76 (2.4)

487 (13.1)

 

5.39

<0.001

Dental

232 (7.4)

303 (8.2)

 

1.1

0.269

Musculoskeletal

37 (1.2)

486 (13.1)

 

11.08

<0.001

Neurology

80 (2.6)

380 (10.2)

 

3.99

<0.001

Hematology

228 (7.3)

216 (5.8)

1.26

 

0.013

ENT

192 (6.2)

177 (4.8)

1.29

 

0.011

Pulmonology

50 (1.6)

200 (5.4)

 

3.36

<0.001

Hepatitis B

37 (1.2)

155 (4.2)

 

3.53

<0.001

Endocrinology

10 (0.3)

165 (4.4)

 

13.88

<0.001

Urology

39 (1.3)

91 (2.5)

 

1.96

<0.001

Gynecology

23 (1.55)

71 (4.11)

 

2.65

<0.001

HIV

3 (0.2)

28 (0.8)

 

4

0.031

Abbreviations: ENT: Ear, Nose & Throat; HIV: Human Immunodeficiency Virus; LTBI: Latent Tuberculosis Infection; RHS-I: Refugee Health Screener-Section 1 is a 14-item assessment of symptoms associated with post-traumatic stress disorder, anxiety, depression, and coping skills; RHS-II: Refugee Health Screener-Section 2 is a single item assessment of general distress.


Table 2: Mental and physical health findings by age group and prevalence ratio comparing age groups, presented in decreasing order of overall prevalence.




Table 3: Mental and physical health findings by gender for adults (age 18-59 years) and prevalence ratio comparing gender, presented in order of prevalence used in Table 2.

1.       (2018) UNHCR. Refugee Resettlement Facts.

2.       (2019) UNHCR. Resettlement Data.

3.       (2019) IBIS-PH. Health indicator report of refugee arrivals. Public Health Indicator Based Information System (IBIS).

4.       (2012) Office of Refugee Resettlement.

5.       Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC (2009) Healthcare barriers of refugees post-resettlement. J Community Health 34: 529-538.

6.       Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, et al. (2011) Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ 183: E959-E967.

7.       Deacon Z, Sullivan C (2009) Responding to the Complex and Gendered Needs of Refugee Women. Affilia 24: 272-284.

8.       Tiong ACD, Patel MS, Gardiner J, Ryan R, Linton KS, et al. (2006) Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 185: 602-606.

9.       (2019) (CDC) CfDCaP. Guidelines for the U.S. Domestic Medical Examination for Newly Arriving Refugees.

10.    Hollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, et al. (2013) The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry 35: 202-209.

11.    Ghareeb E, Ranard, D, Tutunji, J. Refugees from Iraq. COR Center Enhanced Refugee Backgrounder No. 12008.

12.    Shannon PJ, Wieling E, Simmelink-McCleary J, Becher E (2015) Beyond stigma: Barriers to discussing mental health in refugee populations. Journal of Loss and Trauma 20: 281-296.

13.    (2017) NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet 389: P37-55.

14.    Hong K-S (2017) Blood Pressure Management for Stroke Prevention and in Acute Stroke. J Stroke 19:152-165.

15.    Georgiopoulou VV, Kalogeropoulos AP, Butler J (2012) Heart Failure in Hypertension. Drugs 72: 1373-1398.

16.    Liu L, Quang ND, Banu R, Kumar H, Tham YC, et al. (2020) Hypertension, blood pressure control and diabetic retinopathy in a large population-based study. PLoS One 15: e0229665.

17.    Forette F, Seux M-L, Staessen JA, Thijs L, Babarskiene MR, et al. (2002) The Prevention of Dementia with Antihypertensive Treatment: New Evidence From the Systolic Hypertension in Europe (Syst-Eur) Study. Archives of Internal Medicine 162: 2046-2052.

18.    Vasudeva E, Moise N, Huang C, Mason A, Penko J,  et al. (2016) Comparative Cost-Effectiveness of Hypertension Treatment in Non-Hispanic Blacks and Whites According to 2014 Guidelines: A Modeling Study. American Journal of Hypertension 29: 1195-1205.

19.    Jaspers L, Colpani V, Chaker L, Muka T, Imo D, et al. (2015) the global impact of non-communicable diseases on households and impoverishment: a systematic review. Eur J Epidemiol 30: 163-188.

20.    Oni T, Unwin N (2015) Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition. International health 7: 390-399.

21.    Ting W-Y, Huang S-F, Lee M-C, Lin YY, Lee YC, et al. (2014) Gender disparities in latent tuberculosis infection in high-risk individuals: a cross-sectional study. PLoS One 9: e110104.

22.    Abdulrahim S, Jawad M (2018) socioeconomic differences in smoking in Jordan, Lebanon, Syria, and Palestine: A cross-sectional analysis of national surveys. PLoS One 13: e0189829.

Allkhenfr H, Dearden SE, Frost CJ, Gren LH, Benson SL (2021) Determining Physical and Mental Health Conditions Present in Refugees Age 0-59 Years Arriving in Utah. J Community Med Public Health 5: 211. DOI: 10.29011/2577-2228.100211

free instagram followers instagram takipçi hilesi