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BMC Med
. 2022 May 16;20:183. doi: 10.1186/s12916-022-02371-8
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TEN YEARS OF TRACKING MENTAL HEALTH IN REFUGEE PRIMARY HEALTH CARE SETTINGS: AN
UPDATED ANALYSIS OF DATA FROM UNHCR’S HEALTH INFORMATION SYSTEM (2009–2018)
Shoshanna L Fine
SHOSHANNA L FINE
1Department of Population, Family and Reproductive Health, Johns Hopkins
Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD USA
Find articles by Shoshanna L Fine
1,2,✉, Jeremy C Kane
JEREMY C KANE
2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD USA
3Department of Epidemiology, Columbia Mailman School of Public Health, New York,
NY USA
Find articles by Jeremy C Kane
2,3, Paul B Spiegel
PAUL B SPIEGEL
4Department of International Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD USA
Find articles by Paul B Spiegel
4, Wietse A Tol
WIETSE A TOL
2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD USA
5Department of Public Health, University of Copenhagen, Copenhagen, Denmark
6Athena Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the
Netherlands
7Arq International, Diemen, the Netherlands
Find articles by Wietse A Tol
2,5,6,7, Peter Ventevogel
PETER VENTEVOGEL
8Public Health Section, Division of Resilience and Solutions, United Nations
High Commissioner for Refugees, Geneva, Switzerland
Find articles by Peter Ventevogel
8
* Author information
* Article notes
* Copyright and License information
1Department of Population, Family and Reproductive Health, Johns Hopkins
Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD USA
3Department of Epidemiology, Columbia Mailman School of Public Health, New York,
NY USA
4Department of International Health, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD USA
5Department of Public Health, University of Copenhagen, Copenhagen, Denmark
6Athena Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the
Netherlands
7Arq International, Diemen, the Netherlands
8Public Health Section, Division of Resilience and Solutions, United Nations
High Commissioner for Refugees, Geneva, Switzerland
✉
Corresponding author.
Received 2021 Aug 20; Accepted 2022 Apr 8; Collection date 2022.
© The Author(s) 2022
Open AccessThis article is licensed under a Creative Commons Attribution 4.0
International License, which permits use, sharing, adaptation, distribution and
reproduction in any medium or format, as long as you give appropriate credit to
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made
available in this article, unless otherwise stated in a credit line to the data.
PMC Copyright notice
PMCID: PMC9109385 PMID: 35570266
ABSTRACT
BACKGROUND
This study examines mental, neurological, and substance use (MNS) service usage
within refugee camp primary health care facilities in low- and middle-income
countries (LMICs) by analyzing surveillance data from the United Nations High
Commissioner for Refugees Health Information System (HIS). Such information is
crucial for efforts to strengthen MNS services in primary health care settings
for refugees in LMICs.
METHODS
Data on 744,036 MNS visits were collected from 175 refugee camps across 24
countries between 2009 and 2018. The HIS documented primary health care visits
for seven MNS categories: epilepsy/seizures, alcohol/substance use disorders,
mental retardation/intellectual disability, psychotic disorders, severe
emotional disorders, medically unexplained somatic complaints, and other
psychological complaints. Combined data were stratified by 2-year period,
country, sex, and age group. These data were then integrated with camp
population data to generate MNS service utilization rates, calculated as MNS
visits per 1000 persons per month.
RESULTS
MNS service utilization rates remained broadly consistent throughout the 10-year
period, with rates across all camps hovering around 2–3 visits per 1000 persons
per month. The largest proportion of MNS visits were attributable to
epilepsy/seizures (44.4%) and psychotic disorders (21.8%). There were wide
variations in MNS service utilization rates and few consistent patterns over
time at the country level. Across the 10 years, females had higher MNS service
utilization rates than males, and rates were lower among children under five
compared to those five and older.
CONCLUSIONS
Despite increased efforts to integrate MNS services into refugee primary health
care settings over the past 10 years, there does not appear to be an increase in
overall service utilization rates for MNS disorders within these settings.
Healthcare service utilization rates are particularly low for common mental
disorders such as depression, anxiety, post-traumatic stress disorder, and
substance use. This may be related to different health-seeking behaviors for
these disorders and because psychological services are often offered outside of
formal health settings and consequently do not report to the HIS. Sustained and
equitable investment to improve identification and holistic management of MNS
disorders in refugee settings should remain a priority.
SUPPLEMENTARY INFORMATION
The online version contains supplementary material available at
10.1186/s12916-022-02371-8.
Keywords: Refugee, Refugee camps, Service utilization, Health information
system, Global mental health
BACKGROUND
The past decade has seen unprecedented growth in the number of refugees
worldwide, with an estimated 82.4 million individuals forcibly displaced by
conflict, violence, and persecution as of 2020 [1]. A robust body of literature
has documented elevated rates of common mental disorders among refugees and
other forcibly displaced populations, including depression, anxiety, and
post-traumatic stress disorder (PTSD) [2]. A recent systematic review of mental
health among conflict-affected populations found that more than one in five
(22.1%) people living in humanitarian settings suffer from a mental disorder
[6]. This estimate is considerably higher than the global average [2–5],
highlighting the need to strengthen mental health interventions in refugee
contexts.
While there is extensive evidence documenting the epidemiology of these common
mental disorders among refugees, there is much less information about the full
spectrum of mental, neurological, and substance use (MNS) problems, including
epilepsy, psychotic disorders, and substance use disorders [7]. This represents
an important gap, as existing studies have suggested the salience of such MNS
problems in humanitarian environments. The burden of epilepsy is substantially
higher in low- and middle-income countries (LMICs) [8], and existing treatment
gaps in these settings may be further pronounced in populations affected by
conflict and forced displacement [13]. Psychotic disorders have been found to be
particularly disabling in humanitarian environments [9, 10], and there is
emerging evidence that refugees may have an elevated risk of developing
psychosis [11, 12] and may also be vulnerable to PTSD with secondary psychotic
features [14, 15]. Finally, there is some indication that substance use
disorders are more prevalent among forcibly displaced populations, although few
studies have been conducted among refugees living in LMICs [16, 17].
Over the past few decades, such findings have spurred efforts to improve mental
health coverage among refugee populations [18, 19]. These include the widespread
adoption of the Inter-Agency Standing Committee (IASC) Guidelines for Mental
Health and Psychosocial Support in Emergency Settings, which are intended to
support multisectoral humanitarian actors in planning and managing coordinated
responses for addressing mental health and psychosocial well-being during
complex emergencies [20]. In addition, the World Health Organization (WHO) and
the United Nations High Commissioner for Refugees (UNHCR) promote the use of
their Humanitarian Intervention Guide (HIG) as part of the Mental Health Gap
Action Programme (mhGAP), which aims to reduce the global treatment gap for MNS
conditions [21]. The mhGAP-HIG offers evidence-based practices to aid
non-specialist providers in assessing and treating common MNS disorders among
conflict-affected populations and has been used to build MNS capacity in a range
of humanitarian environments [22–26].
A critical component in efforts to scale up mental health programs in refugee
settings is the routine collection of data on MNS service usage [27]. Such data
can be used to identify treatment gaps for particular populations and
conditions, guide resource allocation, and inform evidence-based policies and
programs targeting MNS problems in these complex environments [28]. In response
to the need for routine collection of MNS service information, UNHCR began
including MNS indicators in its existing health information system (HIS) in
2009. The HIS captures ongoing data on contact with primary health care services
in refugee camps [29]. An analysis of HIS data collected between January 2009
and March 2013 examined MNS service usage in 90 refugee camps and found that
while rates were extremely variable across countries, the highest proportion of
overall visits were attributable to epilepsy/seizures (40.6%) and psychotic
disorders (22.7%) [30]. The authors concluded that (1) refugee primary health
care systems must be better equipped to manage severe neuropsychiatric problems
and (2) they were likely missing common mental disorders (i.e., depression,
anxiety, and PTSD) given the relatively low visit rates for these issues.
Furthermore, they suggested that the marked disparities observed across
countries may be attributable to an insufficient capacity to identify and treat
MNS disorders among providers in some settings.
The current study expands on this previous work by incorporating nearly 6 years
of additional data (through December 2018). There have been several important
changes since the original publication which warrant this updated analysis.
First, there have been unprecedented increases in the global population of
refugees over the past decade. For instance, between 2012 and 2018, the number
of refugees more than doubled in Ethiopia (from 356,000 to 870,000) and more
than quadrupled in Uganda (from 225,000 to 1.19 million) [31]. This influx of
new refugees may have variable rates of MNS disorders due to differential
exposures to specific risk factors: for example, the outbreak of violence in the
Central African Republic (CAR) in 2013 has forced thousands of people into
neighboring countries, and ethnic conflict in Myanmar triggered a mass exodus of
Rohingya refugees to Bangladesh in 2017 [32]. Second, since the original
publication, UNHCR has expanded the HIS into additional countries, including
Burkina Faso, Cameroon, CAR, the Democratic Republic of Congo (DRC), the
Republic of Congo, Sudan, and South Sudan. Finally, with the publication of the
mhGAP-HIG in 2015, UNHCR and its partners have intensified capacity building for
the identification and management of MNS problems within refugee primary health
care settings.
The aim of this study was to examine MNS service usage within primary health
care settings since the initiation of the MNS HIS in 2009, and to explore the
extent to which this has changed over the past 10 years. It is important to note
that in January 2019, UNHCR gradually introduced a new tablet-based system, the
integrated Refugee Health Information System (iRHIS), which has several updated
features that were not available in the old HIS. The iRHIS improvements make it
challenging to compare data between the old and new systems. As such, the
current study is only able to report on data collected through the end of
December 2018.
METHODS
SETTING
The present study is a secondary analysis of MNS data collected through the HIS
from January 2009 through December 2018. It includes 175 refugee camps in 24
participating countries representing three UNHCR regions. These comprise (1)
Africa (Burkina Faso, Burundi, Cameroon, CAR, Chad, DRC, Djibouti, Eritrea,
Ethiopia, Ghana, Kenya, Liberia, Namibia, Republic of the Congo, Rwanda, South
Sudan, Sudan, Tanzania, Uganda, Zambia); (2) Asia and the Pacific (Bangladesh,
Nepal, Thailand); and (3) Middle East and North Africa (Yemen). Importantly,
most countries in the Middle East document consultations of refugees to health
services through national health information systems, which generally collect
limited MNS data. Consequently, this study was unable to include data from Iraq,
Jordan, Lebanon, and Turkey, which host the most Syrian and Iraqi refugees, and
Iran and Pakistan, which host millions of refugees from Afghanistan.
DATA COLLECTION
HIS data were collected within each refugee camp through outpatient primary
health care facilities and were entered onto standardized reporting forms by
clinicians (see Supplemental Material). These forms included seven MNS
categories, which were developed through consultation with mental health experts
from the WHO and international non-governmental organizations [29]. Categories
were intended to capture the most important mental health issues in humanitarian
settings and included (1) epilepsy/seizures, (2) alcohol/substance use
disorders, (3) mental retardation/intellectual disability, (4) psychotic
disorders, (5) severe emotional disorders (including depression and PTSD), (6)
medically unexplained somatic complaints, and (7) other psychological
complaints. Case definitions were based on the IASC Guidelines [20]. They were
developed to suggest a probable diagnosis in the absence of detailed diagnostic
procedures and did not necessarily conform with international classification
systems (Table 1). These case definitions were purposely left broad, to make
them easy to use by non-specialists working in primary health care settings. For
example, other psychological complaints were designed to capture general
psychological distress comprising emotional (e.g., depressed mood, anxiety),
cognitive (e.g., rumination, poor concentration), or behavioral (e.g.,
inactivity, aggression) symptoms. The HIS standardized reporting form stratified
cases by sex and age but did not distinguish between new and revisit cases.
TABLE 1.
HIS case definitions for mental, neurological, and substance use disorders
Disorder Case definition Epilepsy/seizures At least two episodes of seizures not
provoked by any apparent cause such as fever, infection, injury, or alcohol
withdrawal. Episodes are characterized by loss of consciousness with shaking of
limbs, and sometimes associated with physical injuries, bowel/bladder
incontinence, and tongue biting. Alcohol/substance use disorder Consumption of
alcohol (or other addictive substances) on a daily basis with difficulties
controlling consumption. Personal relationships, work performance, and physical
health often deteriorate but consumption continues despite these problems.
Mental retardation/intellectual disability Very low intelligence causing
problems in daily living. As a child, this person is slow in learning to speak.
As an adult, the person can work if tasks are simple. This person will rarely be
able to live independently or look after themselves/children without support
from others. When severe, this person may have difficulties speaking and
understanding others and may require constant assistance. Psychotic disorder
Hearing or seeing things that are not there, or strongly believing things that
are not true. This person may talk to themselves, their speech may be confused
or incoherent, and their appearance unusual. They may neglect themselves, but
may also go through periods of being extremely happy, irritable, energetic,
talkative, and reckless. This person’s behavior is considered “crazy” or “highly
bizarre” by others from the same culture. Severe emotional disorder Daily
functioning is markedly impaired for more than 2 weeks due to (a) overwhelming
sadness/apathy and/or (b) exaggerated, uncontrollable anxiety/fear. Personal
relationships, appetite, sleep, and concentration are often affected. The person
may be unable to initiate or maintain conversations. The person may complain of
severe fatigue and be socially withdrawn, often staying in bed for much of the
day. Suicidal thinking is common. Medical unexplained somatic complaint Any
somatic/physical complaint that does not have an apparent organic cause. Should
only be applied (a) after conducting necessary physical examinations, (b) if the
person is not positive for any of the other categories, and (c) if the person is
requesting help for the complaint. Other psychological complaint This category
covers complaints related to emotions (e.g., depressed mood, anxiety), thoughts
(e.g., ruminating, poor concentration) or behaviors (e.g., inactivity,
aggression). The person tends to be able to function in all or almost all
activities of daily living. The complaint may be a symptom of a less severe
emotional disorder or may represent normal distress not associated with a
disorder.
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ANALYSIS
Data from all 175 refugee camps were combined and were then stratified by 2-year
periods (2009–2010, 2011–2012, 2013–2014, 2015–2016, 2017–2018), country, sex,
and age group (children younger than 5 years versus individuals 5 years and
older). The proportion of MNS problems attributable to each of the seven
categories across the entire 10-year study period was calculated. In addition,
the service utilization rate for each of the MNS problems was estimated,
calculated as the rate of those receiving services relative to the total camp
population. Notably, this rate does not include the underlying mental health
burden in these refugee camps and therefore cannot be used to assess gaps in
coverage between those who need versus those who are accessing services. In the
absence of robust prevalence information, however, it has been suggested that
service utilization rates are advantageous for service planning, tracking
changes over time, and making comparisons between different settings, especially
if there is some preexisting knowledge regarding the health burden from
epidemiological studies [33].
Category-specific and overall MNS service utilization rates for each 2-year
period were first estimated at the camp level. Camp-level rates were calculated
by dividing the total number of visits in each MNS category within a given
2-year period by the total number of person-time contributed by the camp in the
same period. Person-time reflected the camp’s monthly population during each
month that the HIS was active in the 2-year period. The ensuing rate was then
multiplied by 1000 to yield MNS visits per 1000 refugees per month for the camp.
Weighted mean rates and standard deviations were calculated at the country
level, as well as by sex and age categories. Country-level weights were
calculated as the ratio of a camp’s contributed person-time to all camps’
contributed person-time within a country. Sex- and age-specific weights were
calculated as the ratio of a camp’s contributed person-time to all camps’
contributed person-time within the HIS. In each case, the weighted camp rates
were summed to produce the final weighted mean rates: across all camps in a
country for the country-level rates, and across all camps in all countries in
the HIS for the sex- and age-specific rates. Population estimates used in the
calculation of these rates were extracted from a separate HIS population
database. All analyses were conducted using Stata 14.2 [34].
RESULTS
The HIS captured information from an increasing number of refugees over the
course of the 10-year study period, starting with a total population of 338,349
from 14 participating camps in January 2009 and ending with a total population
of 3,775,658 from 114 participating camps in December 2018. During this time,
there were a total of 744,036 reported visits for any MNS disorder: 38,469
visits in 2009–2010, 116,354 visits in 2011–2012, 134,662 visits in 2013–2014,
196,528 visits in 2015–2016, and 258,023 visits in 2017–2018. The weighted mean
service utilization rates across all camps in terms of visits per 1000 persons
per month were 2.06 in 2009–2010 (SD = 2.35), 3.05 in 2011–2012 (SD = 3.20),
2.46 in 2013–2014 (SD = 2.93), 2.67 in 2015–2016 (SD = 2.95), and 2.68 in
2017–2018 (SD = 3.26). Of the overall visits during this period, most were due
to epilepsy/seizures (44.4%), followed by psychotic disorders (21.8%), and
severe emotional disorders (11.6%). The smallest number of visits was due to
alcohol/substance use disorders (2.2%), mental retardation/intellectual
disability (3.7%), medically unexplained somatic complaints (7.4%), and other
psychological complaints (9.0%).
COUNTRY
The weighted mean service utilization rates of MNS visits per 1000 refugees per
month for each country and MNS category within 2-year periods are presented in
Table 2. In 2009–2010, these weighted mean rates ranged from 0.00 in Sudan to
11.13 in Nepal; in 2011–2012, they ranged from 0.00 in Burkina Faso, the
Republic of the Congo, Sudan, and South Sudan to 26.28 in Liberia (SD = 13.80);
in 2013–2014, they ranged from 0.00 in Cameroon and Sudan to 14.04 in Nepal (SD
= 1.20); in 2015–2016, they ranged from 0.00 in CAR and the Republic of the
Congo to 21.40 in Nepal (SD = 1.02); and in 2017–2018, they ranged from 0.84 in
South Sudan (SD = 1.30) to 22.40 in Nepal (SD = 5.37). Nepal, Liberia, and
Burundi consistently had the highest weighted mean rates of total reported MNS
visits across all 2-year periods. Conversely, Bangladesh, Burkina Faso,
Cameroon, CAR, the Republic of the Congo, Eritrea, Ghana, South Sudan, Sudan,
and Zambia consistently had the lowest weighted mean rates of total reported MNS
visits across all of the 2-year periods (i.e., rates of less than 1.00 visit per
1000 refugees per month).
TABLE 2.
Weighted mean rates of MNS visits per 1000 refugees per month for each
participating HIS country from 2009 to 2018
Country (number of camps) Years Epilepsy/seizures Alcohol/substance Intellectual
disability Psychotic disorder Emotional disorder Somatic complaint Other
complaint Total Weighted mean visit rate per 1000 per month (weighted SD)a
Bangladesh (5) 2009–2010 0.01 (0.01) 0.00 (0.00) 0.004 (0.005) 0.04 (0.04) 0.003
(0.01) 0.001 (0.002) 0.03 (0.03) 0.08 (0.07) 2011–2012 0.08 (0.06) 0.001 (0.001)
0.09 (0.12) 0.05 (0.03) 0.06 (0.07) 0.02 (0.02) 0.06 (0.06) 0.35 (0.35)
2013–2014 0.07 (0.04) 0.00 (0.00) 0.04 (0.05) 0.13 (0.12) 0.14 (0.18) 0.02
(0.01) 0.12 (0.17) 0.53 (0.57) 2015–2016 0.25 (0.02) 0.01 (0.01) 0.02 (0.003)
0.16 (0.04) 0.01 (0.01) 0.08 (0.02) 0.21 (0.07) 0.74 (0.07) 2017–2018 0.24
(0.18) 0.01 (0.01) 0.07 (0.04) 0.20 (0.14) 0.19 (0.13) 0.13 (0.09) 0.29 (0.19)
1.13 (0.50) Burkina Faso (2) 2011–2012 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 2013–2014 0.06 (0.04)
0.00 (0.00) 0.002 (0.002) 0.05 (0.05) 0.00 (0.00) 0.00 (0.00) 0.03 (0.03) 0.14
(0.12) 2015–2016 0.26 (0.15) 0.00 (0.00) 0.02 (0.01) 0.28 (0.10) 0.02 (0.02)
0.01 (0.01) 0.06 (0.04) 0.66 (0.34) 2017–2018 0.11 (0.02) 0.00 (0.00) 0.01
(0.01) 0.29 (0.17) 0.00 (0.00) 0.01 (0.005) 0.07 (0.05) 0.49 (0.24) Burundi (4)
2011–2012 5.50 (0.69) 0.11 (0.07) 1.00 (0.73) 3.03 (1.02) 0.83 (0.86) 0.71
(0.61) 1.76 (1.15) 12.94 (1.68) 2013–2014 4.67 (1.53) 0.02 (0.02) 1.00 (0.75)
2.36 (0.71) 0.61 (0.74) 0.17 (0.13) 0.97 (0.66) 9.81 (3.14) 2015–2016 4.47
(1.22) 0.04 (0.02) 1.01 (0.45) 1.86 (0.18) 0.44 (0.69) 0.32 (0.17) 0.80 (0.26)
8.93 (1.81) 2017–2018 2.40 (1.15) 0.04 (0.02) 0.54 (0.15) 0.97 (0.60) 0.27
(0.46) 0.05 (0.05) 0.40 (0.25) 4.67 (2.21) Cameroon (17) 2009–2010 0.00 (0.00)
0.02 (0.03) 0.005 (0.01) 0.01 (0.02) 0.04 (0.06) 0.01 (0.02) 0.01 (0.02) 0.11
(0.15) 2011–2012 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.001 (0.01) 0.002 (0.02)
0.00 (0.00) 0.00 (0.00) 0.002 (0.03) 2013–2014 0.00 (0.00) 0.00 (0.00) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 2015–2016
0.02 (0.02) 0.01 (0.01) 0.00 (0.00) 0.01 (0.02) 0.01 (0.02) 0.004 (0.01) 0.003
(0.01) 0.05 (0.05) 2017–2018 0.23 (0.17) 0.03 (0.02) 0.00 (0.00) 0.30 (0.21)
0.29 (0.21) 0.08 (0.06) 0.06 (0.05) 1.01 (0.72) CAR (3) 2011–2012 0.04 (0.05)
0.00 (0.00) 0.00 (0.00) 0.04 (0.05) 0.00 (0.00) 0.00 (0.00) 0.04 (0.05) 0.12
(0.14) 2015–2016 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Chad (31) 2009–2010
0.48 (0.67) 0.05 (0.07) 0.06 (0.12) 0.12 (0.20) 0.19 (0.38) 0.01 (0.03) 0.35
(0.36) 1.27 (1.41) 2011–2012 1.00 (0.74) 0.05 (0.10) 0.15 (0.15) 0.46 (0.32)
0.29 (0.27) 0.09 (0.32) 0.10 (0.08) 2.13 (1.52) 2013–2014 1.01 (0.71) 0.06
(0.05) 0.15 (0.14) 0.40 (0.29) 0.17 (0.19) 0.06 (0.06) 0.08 (0.08) 1.93 (1.18)
2015–2016 2.01 (1.56) 0.07 (0.10) 0.26 (0.47) 0.61 (0.41) 0.27 (0.52) 0.09
(0.14) 0.11 (0.11) 3.40 (2.00) 2017–2018 1.98 (1.18) 0.08 (0.12) 0.24 (0.42)
0.72 (0.30) 0.23 (0.37) 0.07 (0.10) 0.17 (0.16) 3.47 (1.43) DRC (6) 2013–2014
0.04 (0.17) 0.01 (0.02) 0.002 (0.003) 0.03 (0.05) 0.004 (0.01) 0.01 (0.005) 0.00
(0.00) 0.09 (0.21) 2015–2016 1.34 (0.81) 1.48 (1.24) 0.27 (0.28) 0.31 (0.22)
0.17 (0.21) 0.30 (0.20) 0.78 (0.64) 4.66 (3.12) 2017–2018 0.88 (0.67) 0.42
(0.51) 0.19 (0.34) 0.35 (0.25) 0.20 (0.31) 0.33 (0.46) 0.46 (0.66) 2.83 (2.93)
Republic of Congo (2) 2011–2012 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 2013–2014 0.001 (0.001) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.001 (0.001) 0.00 (0.00) 0.00 (0.00) 0.003
(0.002) 2015–2016 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Djibouti (2) 2009–2010
2.58 0.01 0.20 0.56 0.62 0.91 0.43 5.31 2011–2012 1.57 0.03 0.10 0.37 0.41 1.89
0.50 4.86 2013–2014 2.22 (0.45) 0.04 (0.004) 0.05 (0.04) 0.13 (0.02) 0.06 (0.01)
1.16 (0.06) 0.19 (0.04) 3.84 (0.52) 2015–2016 3.01 (0.35) 0.02 (0.01) 0.09
(0.03) 0.29 (0.08) 0.06 (0.05) 1.67 (0.20) 0.37 (0.11) 5.50 (0.66) Eritrea (1)
2013–2014 0.00 0.00 0.00 0.06 0.00 0.00 0.17 0.23 2015–2016 0.00 0.00 0.00 0.00
0.00 0.42 0.00 0.42 Ethiopia (28) 2009–2010 0.78 (0.82) 0.04 (0.11) 0.06 (0.16)
0.26 (0.54) 0.11 (0.22) 0.07 (0.22) 0.10 (0.17) 1.41 (1.78) 2011–2012 0.34
(0.51) 0.02 (0.04) 0.09 (0.21) 0.37 (0.77) 0.09 (0.12) 0.07 (0.10) 0.06 (0.11)
1.03 (1.52) 2013–2014 0.78 (1.19) 0.01 (0.02) 0.09 (0.26) 0.35 (0.73) 0.10
(0.24) 0.02 (0.03) 0.05 (0.08) 1.39 (2.31) 2015–2016 0.82 (1.13) 0.01 (0.06)
0.07 (0.26) 0.32 (0.47) 0.18 (0.24) 0.06 (0.16) 0.06 (0.11) 1.52 (2.08)
2017–2018 0.73 (1.06) 0.02 (0.09) 0.05 (0.16) 0.28 (0.51) 0.16 (0.26) 0.03
(0.09) 0.06 (0.18) 1.33 (1.95) Ghana (4) 2011–2012 0.12 (0.18) 0.00 (0.00) 0.00
(0.00) 0.09 (0.19) 0.00 (0.00) 0.00 (0.00) 0.12 (0.25) 0.33 (0.44) 2013–2014
0.005 (0.01) 0.005 (0.01) 0.005 (0.01) 0.01 (0.01) 0.02 (0.04) 0.01 (0.03) 0.00
(0.00) 0.06 (0.10) 2015–2016 0.15 (0.43) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.15 (0.43) Kenya (7) 2009–2010 0.48 (0.42)
0.04 (0.02) 0.08 (0.04) 0.42 (0.21) 0.29 (0.24) 0.11 (0.08) 0.38 (0.34) 1.81
(1.15) 2011–2012 1.44 (1.10) 0.05 (0.04) 0.12 (0.06) 0.94 (0.39) 0.63 (0.78)
0.20 (0.19) 0.24 (0.23) 3.61 (2.46) 2013–2014 1.67 (1.28) 0.03 (0.04) 0.07
(0.03) 0.94 (0.50) 0.58 (0.81) 0.28 (0.32) 0.07 (0.07) 3.64 (2.54) 2015–2016
1.59 (1.15) 0.02 (0.02) 0.06 (0.04) 0.92 (0.65) 0.27 (0.31) 0.27 (0.42) 0.09
(0.09) 3.22 (2.05) 2017–2018 2.40 (1.38) 0.05 (0.03) 0.13 (0.05) 1.24 (0.83)
0.22 (0.18) 0.30 (0.51) 0.10 (0.13) 4.44 (2.43) Liberia (3) 2011–2012 2.59
(1.36) 0.82 (0.43) 1.21 (0.64) 2.20 (1.15) 11.97 (6.29) 0.92 (0.48) 6.56 (3.45)
26.28 (13.80) 2013–2014 3.22 (0.41) 0.51 (0.46) 0.76 (0.78) 0.83 (0.51) 0.99
(0.77) 0.64 (0.50) 0.60 (0.49) 7.55 (3.52) 2015–2016 6.41 (1.61) 0.39 (0.13)
1.21 (0.93) 0.94 (0.54) 2.05 (0.65) 0.48 (0.36) 0.63 (0.42) 12.10 (1.67) Namibia
(1) 2009–2010 1.31 0.15 0.07 0.87 0.00 0.00 0.00 2.40 2011–2012 0.77 0.09 0.50
1.05 0.00 0.01 0.00 2.42 2013–2014 0.60 0.00 0.02 0.96 0.00 0.02 0.09 1.69 Nepal
(2) 2009–2010 2.56 0.04 0.22 3.11 0.31 0.09 4.79 11.13 2011–2012 2.55 (0.54)
0.28 (0.06) 0.19 (0.11) 3.27 (0.41) 0.77 (0.30) 2.76 (0.88) 2.27 (0.34) 12.08
(0.15) 2013–2014 2.34 (0.59) 0.30 (0.01) 0.13 (0.17) 3.04 (0.14) 1.58 (0.42)
3.53 (0.06) 3.12 (1.62) 14.04 (1.20) 2015–2016 3.19 (0.38) 1.27 (0.19) 0.10
(0.04) 4.57 (0.71) 3.30 (0.42) 6.31 (0.61) 2.66 (1.32) 21.40 (1.02) 2017–2018
3.79 (0.51) 1.47 (1.12) 0.27 (0.04) 5.45 (2.25) 3.98 (0.83) 7.45 (2.27) 0.00
(0.00) 22.40 (5.37) Rwanda (6) 2009–2010 1.34 (1.07) 0.02 (0.02) 0.16 (0.02)
0.59 (0.47) 0.37 (0.04) 0.42 (0.26) 0.42 (0.33) 3.32 (2.22) 2011–2012 1.26
(0.83) 0.002 (0.002) 0.02 (0.02) 0.79 (0.66) 0.46 (0.52) 0.07 (0.04) 0.50 (0.47)
3.11 (2.50) 2013–2014 1.80 (0.85) 0.03 (0.02) 0.05 (0.05) 1.11 (0.85) 0.09
(0.07) 0.33 (0.17) 0.40 (0.30) 3.80 (2.19) 2015–2016 2.15 (0.49) 0.03 (0.02)
0.05 (0.04) 0.84 (0.42) 0.34 (0.23) 0.42 (0.44) 0.37 (0.24) 4.21 (1.18)
2017–2018 2.83 (0.78) 0.05 (0.05) 0.11 (0.10) 1.03 (0.26) 0.34 (0.11) 0.20
(0.09) 0.53 (0.39) 5.08 (0.80) South Sudan (13) 2011–2012 0.00 (0.00) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)
2013–2014 0.002 (0.003) 0.00 (0.00) 0.00 (0.00) 0.001 (0.002) 0.0002 (0.001)
0.00 (0.00) 0.03 (0.05) 0.03 (0.05) 2015–2016 0.38 (0.67) 0.01 (0.01) 0.004
(0.01) 0.12 (0.24) 0.01 (0.03) 0.01 (0.02) 0.04 (0.08) 0.56 (1.02) 2017–2018
0.54 (0.78) 0.02 (0.04) 0.004 (0.01) 0.11 (0.22) 0.03 (0.05) 0.03 (0.07) 0.11
(0.22) 0.84 (1.30) Sudan (7) 2009–2010 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 2011–2012 0.00 (0.00)
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00
(0.00) 2013–2014 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)
0.00 (0.00) 0.00 (0.00) 0.00 (0.00) 2015–2016 0.03 (0.08) 0.00 (0.00) 0.01
(0.02) 0.08 (0.23) 0.001 (0.004) 0.00 (0.00) 0.01 (0.01) 0.12 (0.34) 2017–2018
1.30 (1.02) 0.01 (0.02) 0.09 (0.11) 0.78 (0.70) 0.29 (0.25) 0.02 (0.02) 0.18
(0.19) 2.67 (1.85) Tanzania (3) 2009–2010 6.12 0.01 0.09 1.27 0.53 0.05 0.03
8.10 2011–2012 6.54 0.002 0.17 1.58 1.08 0.05 0.02 9.43 2013–2014 3.99 0.00 0.04
0.98 0.54 0.01 0.01 5.56 2015–2016 3.13 (1.28) 0.09 (0.19) 0.10 (0.15) 0.91
(0.16) 0.51 (0.22) 0.29 (0.57) 0.08 (0.11) 5.11 (0.55) 2017–2018 1.59 (0.96)
0.15 (0.16) 0.12 (0.12) 0.71 (0.39) 0.56 (0.28) 0.73 (0.66) 1.37 (1.51) 5.23
(2.16) Thailand (9) 2009–2010 1.09 (0.73) 0.03 (0.05) 0.01 (0.01) 0.79 (0.41)
0.06 (0.09) 0.06 (0.11) 0.15 (0.15) 2.19 (0.87) 2011–2012 1.22 (0.55) 0.04
(0.08) 0.12 (0.28) 1.28 (0.88) 0.07 (0.13) 0.13 (0.19) 0.22 (0.35) 3.09 (1.32)
2013–2014 1.21 (0.48) 0.03 (0.04) 0.06 (0.23) 1.44 (1.04) 0.08 (0.13) 0.18
(0.18) 0.53 (1.08) 3.53 (1.56) 2015–2016 1.56 (0.53) 0.14 (0.13) 0.07 (0.12)
1.74 (0.91) 0.13 (0.14) 0.19 (0.19) 0.81 (1.27) 4.65 (1.72) 2017–2018 1.51
(0.57) 0.46 (0.45) 0.16 (0.43) 1.89 (1.08) 0.39 (0.56) 0.37 (0.52) 1.25 (4.59)
6.02 (6.16) Uganda (14) 2009–2010 0.25 (0.40) 0.02 (0.05) 0.02 (0.03) 0.06
(0.08) 0.09 (0.06) 0.27 (0.16) 0.16 (0.07) 0.87 (0.62) 2011–2012 0.97 (1.09)
0.03 (0.05) 0.04 (0.06) 0.46 (0.83) 0.26 (0.29) 0.59 (0.29) 0.19 (0.27) 2.54
(2.51) 2013–2014 0.65 (0.80) 0.03 (0.08) 0.06 (0.10) 0.28 (0.66) 0.21 (0.27)
0.14 (0.25) 0.19 (0.29) 1.57 (2.18) 2015–2016 0.56 (0.58) 0.06 (0.05) 0.08
(0.08) 0.27 (0.55) 0.25 (0.34) 0.18 (0.23) 0.19 (0.20) 1.59 (1.85) 2017–2018
0.86 (0.48) 0.06 (0.04) 0.08 (0.08) 0.22 (0.35) 0.24 (0.31) 0.16 (0.30) 0.25
(0.32) 1.87 (1.45) Yemen (3) 2009–2010 0.67 (0.48) 0.01 (0.01) 0.10 (0.05) 0.92
(0.45) 1.21 (0.66) 0.56 (0.57) 1.45 (1.84) 4.91 (3.29) 2011–2012 0.74 (0.31)
0.04 (0.03) 0.07 (0.02) 0.82 (0.27) 1.61 (0.57) 0.47 (0.34) 0.63 (0.31) 4.37
(1.67) 2013–2014 0.67 (0.18) 0.01 (0.01) 0.08 (0.02) 0.92 (0.13) 1.91 (0.42)
0.53 (0.06) 0.22 (0.06) 4.35 (0.58) 2015–2016 0.91 (0.92) 0.01 (0.01) 0.13
(0.18) 1.01 (0.42) 2.73 (2.68) 0.55 (0.08) 0.48 (0.42) 5.83 (4.38) 2017–2018
1.67 (2.97) 0.01 (0.02) 0.33 (0.69) 1.58 (1.40) 4.30 (6.80) 0.78 (0.54) 1.22
(1.71) 9.89 (13.86) Zambia (2) 2009–2010 0.04 (0.03) 0.05 (0.04) 0.005 (0.004)
0.04 (0.04) 0.002 (0.002) 0.03 (0.02) 0.002 (0.003) 0.16 (0.01) 2011–2012 0.28
(0.24) 0.01 (0.01) 0.00 (0.00) 0.08 (0.05) 0.00 (0.00) 0.01 (0.005) 0.01 (0.01)
0.38 (0.19) 2013–2014 0.01 (0.01) 0.01 (0.01) 0.00 (0.00) 0.05 (0.04) 0.00
(0.00) 0.00 (0.00) 0.00 (0.00) 0.07 (0.02) 2015–2016 0.003 (0.003) 0.003 (0.003)
0.00 (0.00) 0.22 (0.20) 0.00 (0.00) 0.02 (0.02) 0.00 (0.00) 0.24 (0.21)
Open in a new tab
aRates were first calculated at the camp level. For each camp, the numerator of
the rate was the total number of visits in each MNS category within a given
2-year period. The denominator was the total number of person-time contributed
by the camp in the same period, which reflected the camp’s monthly population
during the months that the HIS was active. The resulting rate was multiplied by
1000. For each country, weighted mean rates and standard deviations were
calculated from the camp-level rates within that country. Weights were
calculated as the ratio of a camp’s contributed person-time to all camp’s
contributed person-time within a country. Therefore, the weights summed to 1.
MNS, mental, neurological, and substance use; HIS, health information system
Of the 14 countries with weighted mean rates of greater than 1.00 MNS visit per
1000 refugees per month, there were six in which there was a generally
increasing pattern in total reported MNS visits between 2009 and 2019 (Chad,
Kenya, Nepal, Rwanda, Thailand, and Yemen). There was one country in which there
was a generally decreasing pattern in total reported MNS visits between 2009 and
2019 (Burundi). In the remaining seven countries, there were no clear patterns
in total reported MNS visits during this time period (DRC, Djibouti, Ethiopia,
Liberia, Namibia, Tanzania, and Uganda). Of the same 14 countries, there were
ten in which epilepsy/seizures had the highest rate of all MNS categories across
most of the 2-year periods (Burundi, Chad, DRC, Djibouti, Ethiopia, Kenya,
Liberia, Rwanda, Tanzania, and Uganda). There were two countries in which
psychotic disorders had the highest rates (Namibia and Thailand), one country in
which severe emotional disorders had the highest rates (Yemen), and one country
in which medically unexplained somatic complaints had the highest rates (Nepal).
SEX
Table 3 displays the weighted mean MNS service utilization rates separately by
sex during the study period. Across all of the 2-year periods, females had
higher overall mean MNS service utilization rates per 1000 per month than males:
2.17 (SD = 2.73) compared to 1.94 (SD = 2.06) in 2009–2010, 3.12 (SD = 3.57)
compared to 2.98 (SD = 3.00) in 2011–2012, 2.50 (SD = 3.26) compared to 2.42 (SD
= 2.80) in 2013–2014, 2.69 (SD = 3.29) compared to 2.64 (SD = 2.77) in
2015–2016, and 2.75 (SD = 3.66) compared to 2.61 (SD = 3.01) in 2017–2018. When
broken down by MNS categories, females had higher service utilization rates for
severe emotional disorders, medically unexplained somatic complaints, and other
psychological complaints across all of the 2-year periods, whereas males had
higher service utilization rates for epilepsy/seizures, alcohol/substance use
disorders, mental retardation/intellectual disability, and psychotic disorders.
These disparities are also reflected in differences between males and females in
the proportion of overall visits attributable to each MNS category:
epilepsy/seizures (males: 48.9%; females: 40.2%), alcohol/substance use
disorders (males: 3.3%; females: 1.1%), mental retardation/intellectual
disability (males: 4.1%; females: 3.3%), psychotic disorders (males: 24.2%;
females: 19.7%), severe emotional disorders (males: 8.5%, females: 14.5%),
medically unexplained somatic complaints (males: 4.9%; females: 9.6%), and other
psychological complaints (males: 6.2%; females: 11.6%). Despite these
differences, epilepsy/seizures had the highest service utilization rates for the
duration of the study period among both males and females, ranging from 0.83 (SD
= 1.26) to 1.37 (SD = 1.64) among males, and 0.72 (SD = 1.29) to 1.19 (SD =
1.35) among females. Likewise, alcohol/substance use disorders had the lowest
service utilization rates, ranging from 0.05 (SD = 0.07) to 0.11 (SD = 0.45)
among males, and 0.01 (SD = 0.02) to 0.05 (SD = 0.23) among females.
TABLE 3.
Weighted mean rates of MNS visits per 1000 refugees per month by sex and age
group from 2009 to 2018
MNS category Years Male Female <5 years old 5 and above Total <5 years old 5 and
above Total Weighted mean visit rate per 1000 per month (weighted SD)a
Epilepsy/seizures 2009–2010 0.44 (0.86) 0.91 (1.37) 0.83 (1.26) 0.33 (0.71) 0.80
(1.44) 0.72 (1.29) 2011–2012 0.59 (0.99) 1.53 (1.81) 1.37 (1.64) 0.47 (0.88)
1.24 (1.55) 1.11 (1.42) 2013–2014 0.48 (0.89) 1.36 (1.62) 1.20 (1.46) 0.45
(0.98) 1.08 (1.25) 0.97 (1.16) 2015–2016 0.50 (0.96) 1.53 (1.71) 1.34 (1.52)
0.48 (0.93) 1.33 (1.50) 1.19 (1.35) 2017–2018 0.56 (0.86) 1.44 (1.51) 1.29
(1.36) 0.45 (0.68) 1.28 (1.21) 1.13 (1.09) Alcohol/substance 2009–2010 0.00
(0.00) 0.06 (0.08) 0.05 (0.07) 0.00 (0.00) 0.01 (0.03) 0.01 (0.02) 2011–2012
0.003 (0.02) 0.08 (0.14) 0.07 (0.12) 0.001 (0.01) 0.02 (0.04) 0.01 (0.03)
2013–2014 0.002 (0.03) 0.06 (0.14) 0.05 (0.12) 0.003 (0.05) 0.02 (0.07) 0.02
(0.06) 2015–2016 0.003 (0.03) 0.14 (0.57) 0.11 (0.45) 0.003 (0.02) 0.06 (0.28)
0.05 (0.23) 2017–2018 0.002 (0.01) 0.12 (0.28) 0.10 (0.23) 0.004 (0.02) 0.05
(0.17) 0.04 (0.14) Intellectual disability 2009–2010 0.04 (0.09) 0.07 (0.08)
0.07 (0.08) 0.02 (0.03) 0.04 (0.06) 0.04 (0.06) 2011–2012 0.11 (0.27) 0.12
(0.17) 0.12 (0.18) 0.06 (0.15) 0.10 (0.21) 0.09 (0.19) 2013–2014 0.07 (0.29)
0.09 (0.22) 0.09 (0.22) 0.06 (0.25) 0.08 (0.24) 0.08 (0.23) 2015–2016 0.08
(0.44) 0.12 (0.33) 0.11 (0.30) 0.09 (0.42) 0.10 (0.29) 0.10 (0.26) 2017–2018
0.10 (0.39) 0.12 (0.26) 0.11 (0.25) 0.09 (0.29) 0.10 (0.21) 0.09 (0.20)
Psychotic disorder 2009–2010 0.01 (0.05) 0.61 (0.65) 0.51 (0.56) 0.01 (0.04)
0.49 (0.60) 0.41 (0.52) 2011–2012 0.004 (0.01) 1.02 (0.99) 0.84 (0.83) 0.01
(0.02) 0.83 (1.04) 0.69 (0.88) 2013–2014 0.01 (0.02) 0.80 (0.98) 0.65 (0.83)
0.01 (0.06) 0.66 (0.93) 0.54 (0.78) 2015–2016 0.01 (0.05) 0.74 (0.89) 0.61
(0.75) 0.01 (0.05) 0.64 (0.85) 0.53 (0.71) 2017–2018 0.01 (0.02) 0.68 (1.02)
0.56 (0.86) 0.005 (0.02) 0.58 (0.80) 0.48 (0.67) Emotional disorder 2009–2010
0.02 (0.11) 0.21 (0.27) 0.18 (0.23) 0.01 (0.05) 0.36 (0.59) 0.30 (0.49)
2011–2012 0.01 (0.06) 0.36 (0.60) 0.30 (0.49) 0.01 (0.05) 0.66 (1.17) 0.55
(0.97) 2013–2014 0.002 (0.01) 0.26 (0.47) 0.21 (0.38) 0.001 (0.004) 0.49 (0.96)
0.41 (0.82) 2015–2016 0.003 (0.01) 0.26 (0.53) 0.21 (0.44) 0.002 (0.01) 0.41
(0.98) 0.34 (0.82) 2017–2018 0.002 (0.01) 0.25 (0.68) 0.21 (0.57) 0.01 (0.02)
0.46 (1.74) 0.38 (1.46) Somatic complaint 2009–2010 0.003 (0.01) 0.11 (0.17)
0.09 (0.14) 0.004 (0.03) 0.21 (0.41) 0.17 (0.35) 2011–2012 0.01 (0.03) 0.17
(0.31) 0.14 (0.27) 0.01 (0.04) 0.40 (0.90) 0.33 (0.78) 2013–2014 0.01 (0.04)
0.14 (0.29) 0.12 (0.24) 0.01 (0.08) 0.31 (0.83) 0.26 (0.71) 2015–2016 0.01
(0.08) 0.16 (0.36) 0.13 (0.31) 0.02 (0.14) 0.31 (0.97) 0.26 (0.83) 2017–2018
0.02 (0.07) 0.16 (0.38) 0.13 (0.32) 0.02 (0.08) 0.29 (0.78) 0.24 (0.66) Other
complaint 2009–2010 0.03 (0.07) 0.25 (0.52) 0.21 (0.44) 0.03 (0.06) 0.61 (1.34)
0.52 (1.15) 2011–2012 0.03 (0.08) 0.17 (0.34) 0.15 (0.29) 0.02 (0.06) 0.39
(0.83) 0.33 (0.71) 2013–2014 0.02 (0.07) 0.12 (0.28) 0.10 (0.24) 0.01 (0.06)
0.27 (0.97) 0.23 (0.84) 2015–2016 0.02 (0.11) 0.15 (0.27) 0.13 (0.23) 0.02
(0.09) 0.27 (0.72) 0.23 (0.62) 2017–2018 0.03 (0.33) 0.25 (0.70) 0.21 (0.60)
0.04 (0.26) 0.45 (1.57) 0.38 (1.33) Total 2009–2010 0.55 (1.00) 2.22 (2.31) 1.94
(2.06) 0.40 (0.76) 2.51 (3.11) 2.17 (2.73) 2011–2012 0.75 (1.23) 3.46 (3.42)
2.98 (3.00) 0.58 (1.02) 3.63 (4.09) 3.12 (3.57) 2013–2014 0.60 (1.13) 2.82
(3.20) 2.42 (2.80) 0.55 (1.24) 2.91 (3.71) 2.50 (3.26) 2015–2016 0.63 (1.31)
3.08 (3.21) 2.64 (2.77) 0.63 (1.28) 3.13 (3.78) 2.69 (3.29) 2017–2018 0.72
(1.31) 3.01 (3.43) 2.61 (3.01) 0.62 (1.00) 3.20 (4.25) 2.75 (3.66)
Open in a new tab
aRates were first calculated at the camp level. For each camp, the numerator of
the rate was the total number of visits in each MNS category within a given
2-year period within each age/sex category. The denominator was the total number
of person-time contributed by the camp in the same period, which reflected the
camp’s monthly population during the months that the HIS was active within each
age/sex category. The resulting rate was multiplied by 1000. Weighted mean rates
and standard deviations were calculated within each age/sex category. Weights
were calculated as the ratio of a camp’s contributed person-time to all camp’s
contributed person-time within the HIS. Therefore, the weights summed to 1. MNS,
mental, neurological, and substance use; HIS, health information system; CAR,
Central African Republic; DRC, Democratic Republic of Congo
CHILDREN UNDER FIVE
Table 3 shows the weighted mean MNS service utilization rates separately for
those younger and older than 5 years. Across all categories, MNS service
utilization rates per 1000 per month were lower among children under five,
compared to those five and older. For four of the 2-year periods, boys under
five had higher overall MNS service utilization rates per 1000 compared to girls
under five: 0.55 (SD = 1.00) compared to 0.40 (SD = 0.76) in 2009–2010, 0.75 (SD
= 1.23) compared to 0.58 (SD = 1.02) in 2011–2012, 0.60 (SD = 1.13) compared to
0.55 (SD = 1.24) in 2013–2014, and 0.72 (SD = 1.31) compared to 0.62 (SD = 1.00)
in 2017–2018. In 2015–2016, the overall MNS service utilization rates were equal
between boys (0.63, SD = 1.31) and girls (0.63, SD = 1.28). For both boys and
girls under five, epilepsy/seizures had the highest visits rates for the
duration of the study period, ranging from 0.44 (SD = 0.86) to 0.59 (SD = 0.99)
among boys, and 0.33 (SD = 0.71) to 0.48 (SD = 0.93) among girls. Mental
retardation/intellectual disability had the second highest service utilization
rates, ranging from 0.04 (SD = 0.09) to 0.11 (SD = 0.27) among boys, and 0.02
(SD = 0.03) to 0.09 (SD = 0.29) among girls. Service utilization rates for
alcohol/substance use disorders, psychotic disorders, severe emotional
disorders, medically unexplained somatic complaints, and other psychological
complaints were negligible for boys and girls under five years.
DISCUSSION
The current study evaluated MNS service usage within primary health care
facilities among refugees living in 175 refugee camps in 24 countries between
2009 and 2018 using UNHCR HIS data. Extending results from a prior study of HIS
data, we assessed the service utilization rates for seven MNS problems within
2-year periods, stratified by country, sex, and age. We found that the overall
MNS service utilization rates remained consistent during the 10-year period,
with weighted mean rates across all camps hovering around 2–3 visits per 1000
persons per month. This suggests that despite a sharp increase in the total
population of refugees, UNHCR and its partners were able to maintain a
consistent level of MNS support across all refugee camps. While this temporal
stability can be seen as an achievement by itself given unprecedented levels of
global displacement [32], the average numbers of MNS consultations remain lower
than desired and are an indication that MNS disorders may not be adequately
addressed within refugee primary health care settings.
Over the last decade, various new tools have been developed with the goal of
scaling-up delivery of MNS services through task-sharing approaches aimed at
improving mental health coverage among refugee populations (e.g., the mhGAP-HIG)
[21] and considerable efforts have been made to train and supervise staff with
these methods in some regions [22, 35–37]. An evaluation of mhGAP-HIG capacity
building efforts in refugee camps in seven sub-Saharan African countries showed
various effects such as (1) strengthened capacities by facility- and
community-based staff to deliver mental health and psychosocial support
interventions, (2) positive changes in their attitudes towards people suffering
from MNS conditions, and (3) improved collaboration among health and non-health
staff regarding people suffering from MNS conditions [22]. The authors also
remark, however, that capacity building is a “process” and not an “event” and
that mhGAP trainings constitute only one element in a spectrum of activities
aimed at integrating mental health into primary health care, including regular
supervision, continuing on-the-job training, and sufficient human resources.
While our data cannot be used to directly evaluate such efforts, in our view,
the sustained low MNS service utilization rates speak to the major challenges in
integrating mental health services into primary health care in low-resource
humanitarian settings due to factors such as staff attrition, lack of sufficient
training, lack of supportive clinical supervision, time limitations among
primary health care workers, insufficient funding, and variable health-seeking
behaviors for MNS problems [38–42].
At the country level, there were very few consistent observed trends in overall
MNS service utilization rates over the 10-year period. Within several countries,
however, noteworthy patterns emerged. Specifically, within Chad, Kenya, Nepal,
Rwanda, Thailand, and Yemen, there were generally increasing patterns in total
reported MNS visit rates, whereas in Burundi, there was an overall decreasing
pattern. By contrast, MNS visit rates largely remained stable in DRC, Djibouti,
Ethiopia, Liberia, Namibia, Tanzania, and Uganda. To further illustrate the
types of factors that may underlie these patterns, we have selected three
refugee camps with differential results to examine as case studies. All three
camps are located in East African countries with significant refugee
populations: (1) Hagadera refugee camp in Kenya where MNS service utilization
rates showed a gradual increase over the 10-year period, (2) Musasa refugee camp
in Burundi where they showed a gradual decrease, and (3) Nakivale refugee
settlement in Uganda where they showed no clear pattern. While these case
studies cannot provide any conclusive evidence, their purpose is to help
contextualize these data and generate hypotheses regarding potential drivers of
these differences.
Tables 4 and 5 illustrate the overall MNS visit rates per 1000 per month for the
three selected locations alongside the most significant mental health activities
that took place from 2009 through 2018. The specific MNS conditions that account
for these patterns are further illustrated in Fig. 1. Mental health activities
were collected through UNHCR health officers and other health care organizations
in the selected camps, who provided annual activity reports, training reports,
and other relevant health statistics beyond those collected in the HIS. We
examined these documents for information on (1) the organization of mental
health services, (2) staffing for mental health activities, (3) training and
supervision for mental health activities (e.g., using the mhGAP-HIG), (4) mental
health community engagement activities, and (5) intersectoral collaboration with
other services providers. While these cases studies are not exhaustive, and
findings cannot be generalized to all 175 refugee camps, they provide some
interesting observations. Posting a mental health professional in a
camp/settlement, which happened in all three sites, is in itself insufficient to
explain the substantial camp-level differences. Additional factors, including
regular mental health trainings, supportive supervision of primary health care
staff, consistent efforts to engage refugee volunteers in mental health work,
strong coordination efforts, and robust referral systems with other
organizations, seem to be particularly important for success.
TABLE 4.
Case studies of Hagadera, Musasa, and Nakivale refugee camps
Refugee camp Years MNS visit rate per 1000 per month Mental health training for
general staff Active community engagement for mental health Intersectoral
collaboration Hagadera, Kenya 2009–2010 2.22 No No Limited 2011–2012 3.34 No Yes
Limited 2013–2014 4.42 Yes Yes Intensive 2015–2016 5.20 Yes Yes Intensive
2017–2018 7.76 Yes Yes Intensive Musasa, Burundi 2009–2010 - Yes Yes Intensive
2011–2012 10.52 Yes Yes Intensive 2013–2014 9.21 No No Limited 2015–2016 8.34 No
No Limited 2017–2018 5.51 No No Limited Nakivale, Uganda 2009–2010 0.90 No No
Limited 2011–2012 1.49 No No Limited 2013–2014 1.06 No No Limited 2015–2016 1.72
Yes No Limited 2017–2018 1.89 Yes No Intensive
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MNS, mental, neurological, and substance use
TABLE 5.
Mental health activities in Hagadera, Musasa, and Nakivale refugee camps from
2009 to 2018
Hagadera, Kenya
Context: Hagadera refugee camp in northeastern Kenya was established in 1992 for
Somali refugees. From the onset, mental health services were integrated within
the primary health care services delivered by an NGO. Initially, mental health
services were concentrated in the camp’s main health center but starting in
2011, satellite mental health clinics were opened in three additional health
posts.
Staffing: One psychiatric nurse worked in the camp starting in 2010 and was
supported by a team of six trained refugee mental health workers who were
actively supervised by the psychiatric nurse. Case identifications and home
follow-up visits were conducted by general community health workers.
Training and supervision: Brief mental health trainings were organized annually
for health staff. Five-day basic mental health trainings were also organized for
mental health workers with the mhGAP-HIG in 2013 and 2018. Clinical supervision
was organized by the psychiatric nurse. During weekly trainings for community
health workers, mental health was a regular topic.
Community engagement: Every month there were an average of 12 community
engagement activities, including meetings with community leaders, youth groups,
teachers, religious leaders, and family members of people with severe mental
health issues in different parts of the camp.
Intersectoral collaboration: There were close relationships with organizations
across sectors including gender-based violence, child protection, and social
work, with clear referral pathways. Starting in 2013, a mental health technical
working group for all regional camps met regularly.
Musasa, Burundi
Context: Musasa refugee camp in northern Burundi was established in 2005.
Medical services were provided by an NGO. Until 2009, a specialized NGO provided
additional mental health services. After 2009, these were integrated within
primary health care services.
Staffing: One nurse was trained in mental health but did not have a formal
mental health diploma. There was also one psychologist attached to the clinic.
Until 2011, there was a community outreach team of psychosocial volunteers which
was discontinued due to budget cuts.
Training and supervision: From 2009 to 2011, a specialized NGO provided a series
of mental health trainings for health and protection services staff and refugee
volunteers. Health staff were supervised by a physician from the provincial
health department.
Community engagement: Until 2012, there were monthly community meetings around
mental health, and counselors organized recreational activities for youth and
conducted home visits for people with severe mental disorders. These decreased
over time due to staff attrition and lack of training for new staff.
Intersectoral collaboration: There were no formal coordination meetings around
mental health.
Nakivale, Uganda
Context: Nakivale refugee settlement in southwestern Uganda was established in
1958. The settlement is 80 km2, with refugees scattered over dozens of
“villages.” From 2009 to 2018, one NGO organized health services in seven health
facilities.
Staffing: From 2009 to 2014, there was one psychiatric nurse, and from 2015 to
2019, there were two psychiatric nurses.
Training and supervision: In 2017, a mhGAP training of trainers was conducted,
followed by a training for primary health care workers. In 2018, a mhGAP
training for primary health care workers was conducted. Until 2015, a
psychiatric clinical officer from the regional hospital did monthly supervision.
Community engagement: A total of 385 community health workers received trained
on mental health in 2018.
Intersectoral collaboration: After 2017, an NGO started providing psychosocial
services and a mental health coordination group was established.
Open in a new tab
NGO, non-governmental organization; mhGAP, Mental Health Gap Action Programme;
HIG, Humanitarian Intervention Guide
FIG. 1.
Open in a new tab
MNS visits per 1000 refugees per month in Hagadera, Musasa, and Nakivale refugee
camps from 2009 to 2018
In terms of specific MNS problems, across most of the countries and among both
males and females, we found greater service utilization rates for
epilepsy/seizures and psychotic disorders compared to the other MNS problems
over the 10-year period, which is consistent with results from the previous HIS
study [2] as well as other studies conducted in humanitarian settings [11].
Furthermore, epilepsy/seizures (44.4%) and psychotic disorders (21.8%) were
responsible for the highest proportion of overall MNS visits. Although service
utilization rates provide no information about underlying prevalence, previous
research has suggested that while these types of serious mental and neurological
disorders can be immensely disabling in humanitarian settings, they account for
a relatively low percentage of overall MNS problems [30]. For instance,
according to a recent systematic review, 5.1% of people living in humanitarian
settings suffered from a severe mental disorder compared to 17.0% with a mild or
moderate mental disorder [2, 7, 11, 12]. As such, the higher service utilization
rates for these serious disorders are promising: they indicate that many
refugees experiencing these issues are able to find their way to treatment.
However, these data do not reflect whether or not care for epilepsy/seizures or
psychotic disorders is being sustained over time, suggesting that UNHCR and its
partners should prioritize keeping these individuals in ongoing care.
By contrast, there were much lower service utilization rates for common mental
disorders, including severe emotional problems, alcohol/substance use disorders,
and other psychological complaints. Given the elevated prevalence of these
problems in humanitarian settings [2, 3, 17], this overall lack of service
utilization within primary health care settings is concerning, particularly
given the recent global focus on integrating mental health into primary health
care through mhGAP [21]. We hypothesize that this low service utilization in
health facilities may relate to differences in illness beliefs and
health-seeking behaviors for emotional distress and substance use problems
compared to neurological and psychotic disorders. Specifically, if individuals
do not view these more common problems as medical issues, they may be less
likely to seek care through formal health services and more likely to turn
towards informal psychosocial supports within the community. Indeed, one
qualitative study conducted among conflict-affected adults in three countries
found that whereas symptoms related to psychotic disorders were seen as
abnormalities in need of medical treatment, those related to general
psychological distress were expected to improve solely through social and
emotional support [43]; similar findings have been documented in other LMICs
[47]. Overall, this suggests that to improve MNS coverage for refugee
populations, it may be important to place an increased emphasis on the
availability of non-medicalized, community-based interventions [44–46]. For
example, there is a growing body of evidence regarding the effectiveness of
brief, psychotherapeutic interventions that target symptoms across a range of
common mental health problems and can be delivered by trained non-specialist
providers [53–55]. Unfortunately, despite several calls to action, research has
lagged in generating evidence around promising approaches for addressing
substance use in humanitarian settings [48–52].
Finally, our findings around sex and age differences in MNS service utilization
rates remained largely consistent with the previous study. While females had
slightly higher service utilization rates compared to males across the 10-year
period, there were marked differences in the drivers of these MNS visits.
Notably, females were more likely to utilize services for MNS problems related
to emotional distress, including severe emotional disorders, medically
unexplained somatic complaints, and other psychological complaints; this is
consistent with epidemiologic studies drawn from refugee populations [56, 57].
Males were more likely to utilize services for alcohol/substance use disorders,
which again aligns with existing literature [16, 17]. Monthly service
utilization rates for children under five were negligible for all of the MNS
problems besides epilepsy/seizures, which was slightly higher among boys (0.44
per 1000) compared to girls (0.33 per 1000).
LIMITATIONS
This study has several limitations that are important to mention. First, the HIS
reporting forms made no differentiation between new and revisit consultations.
It was therefore impossible to calculate the incidence rates of MNS problems,
limiting the epidemiologic conclusions that can be drawn from these data. We
also cannot assume the independence of data collected over different years and
are therefore unable to assess the statistical significance of observed trends.
Second, the HIS did not capture information on comorbidity despite the high
level of co-occurrence among many MNS problems. Third, the HIS included no
measure of problem severity. Fourth, whereas the HIS MNS visit data included
four age group categories (0–4, 5–17, 18–59, and 60+), available population data
only differentiated between those younger and older than 5 years old. As such,
we were unable to analyze differences in service utilization rates by these more
specific age groups. Fifth, there was substantial variation in terms of how many
months the HIS was active across camps. We addressed this, however, by
calculating weighted service utilization rates which accounted for the total
person-time contributed by each camp.
A final major limitation of HIS data is that they are restricted to the
provision of MNS care within primary health care facilities. At its essence, the
HIS is a method to record consultations between a patient and a health worker in
a health center. Comprehensive mental health and psychosocial support programs
within refugee settings consist of a range of activities that take place outside
of primary health care facilities and are therefore not captured by the HIS.
These frequently include (1) community-based mental health activities, e.g.,
mental health promotion activities or home visits by community health
volunteers; (2) mental health activities conducted by non-health organizations,
e.g., school- or faith-based counseling programs; and (3) referrals to nearby
health facilities, such as hospitalization in a psychiatric ward of a regional
hospital [58–60]. It is also important to note that while health partners that
are funded through UNHCR are required to use the HIS to report MNS
consultations, those that are funded externally (e.g., Doctors Without Borders)
do not consistently use this system. We hypothesize that this important
limitation may have contributed to an underestimation in MNS service utilization
rates, particularly for common mental health problems which may be more amenable
to treatment outside of primary health care facilities (e.g., mild-to-moderate
emotional disorders, substance use conditions, other psychological complaints),
or in refugee camps where community-based organizations are particularly active
[61, 62].
In response to many of the abovementioned limitations, the HIS underwent a
significant revision process in 2019, which resulted in several important
changes [29]. First, the number of MNS categories was increased from seven to
nine, with the addition of “suicide/self-harm” and “dementia/delirium.” The new
system also allows for multiple categories to be selected for a single patient
at a single consultation and is therefore able to register comorbidity. In
addition, it includes an option to add specifiers for trained mental health
workers (e.g., psychiatric nurses, mental health outpatient clinicians) to make
specific diagnoses when possible. The new system also differentiates between new
cases and revisits and includes more refined age categories. Finally, the new
system relies on electronic rather than paper data collection, thereby improving
data accuracy and timeliness of reporting.
CONCLUSIONS
The findings from this study describe how, overall, MNS service utilization
rates in primary health care facilities in refugee camps around the world
remained consistent over a 10-year period. Given the enormous increase in the
number of global refugees during this time, this can be considered a formidable
achievement by itself. It is clear, however, that more significant and sustained
efforts are warranted to ensure that refugees in remote and resource-constrained
settings can access mental health services. UNHCR’s new Global Strategy for
Public Health 2021–2025 includes the following priority actions to reach this
goal [63]:
1. Continued integration of mental health into primary health care facilities
for refugees. This includes regularly organizing trainings for primary
health care staff in identifying and managing mental health conditions, and
arranging for mental health professionals to both treat people with complex
conditions and provide clinical supervision to primary health care workers.
Efforts towards this action are already underway. In 2021 alone, UNHCR and
its partners used the mhGAP-HIG [21] to train 1330 primary health care
workers (including doctors, nurses, and medical assistants) in refugee camps
across nine countries (DRC, Ethiopia, Jordan, Kenya, Niger, Rwanda, South
Sudan, Sudan, and Uganda) (UNHCR Public Health Section, oral communication,
March 2022).
2. Provision of evidence-based psychotherapeutic interventions. Not only do
primary health care workers within refugee contexts need to be better
equipped to address common mental health conditions (e.g., depression,
anxiety, PTSD, and substance use), but more also needs to be done to provide
treatment and support outside of health facilities. As mentioned previously,
the recent surge in research around “scalable psychological interventions”
in humanitarian settings provides increasing opportunities to administer
brief, evidence-based psychological therapies that can be delivered by
trained and supervised non-specialist providers, including refugees
themselves [49–51, 64]. Again, efforts towards this action are ongoing. In
2021, UNHCR and its partners organized trainings in such interventions for
361 staff in refugee camps in Angola, Bangladesh, Cameroon, DRC, Ethiopia,
Jordan, Kenya, Mauritania, Niger, Nigeria, Republic of Congo, Rwanda,
Tanzania, and Uganda (UNHCR Public Health Section, oral communication, March
2022).
3. Integration of mental health and psychosocial support into community health
work. This includes training community health workers and other community
volunteers in the identification and follow-up of people with severe or
complex mental health conditions, and training community health workers in
basic psychosocial skills, including the provision of Psychological First
Aid.
Beyond these actions, it is clear that additional research and investment are
needed to address neglected issues such as substance use and suicide prevention
[53, 65]. Notably, a toolkit to address substance use in humanitarian settings
is expected to be released in 2022 by the United Nations Office on Drugs and
Crime with support from UNHCR and WHO. Furthermore, UNHCR will release the
following new guidance in 2022: Planning for Suicide Prevention and Mitigation
in Refugee Settings: A Toolkit for Multisectoral Action.
These activities by UNHCR fit within major efforts by a range of organizations
to strengthen mental health and psychosocial support in humanitarian settings.
Importantly, a major new development is the Mental Health and Psychosocial
Support Minimum Services Package by UNHCR, WHO, and other collaborating agencies
(www.mhpssmsp.org). This multi-sectoral package describes key actions needed to
improve mental health and well-being among conflict-affected populations by
fully integrating mental health and psychosocial support services into health,
education, and protection activities.
This analysis of 10 years of MNS consultations in refugee primary health care
settings underscores that more needs to be done to enable primary health care
services to address the needs of refugees with MNS disorders. Overall, this
requires sustained investments into supportive clinical training and supervision
of primary health care workers, and increased efforts to ensure that refugees
have access to a wider range of mental health and psychosocial support services
within community settings.
SUPPLEMENTARY INFORMATION
Additional file 1. (54.2KB, pdf)
ACKNOWLEDGEMENTS
The authors would like to thank Dr. Pepe Beavogui (UNHCR Burundi), Dr. Gerald
Naluwairo (UNHCR Uganda), and John Kivelenge (International Rescue Committee
Kenya) for providing the required documentation for the included case studies.
ABBREVIATIONS
CAR
Central African Republic
DRC
Democratic Republic of Congo
HIG
Humanitarian Intervention Guide
HIS
Health information system
IASC
Inter-Agency Standing Committee
iRHIS
Integrated Refugee Health Information System
LMIC
Low- and middle-income country
mhGAP
Mental Health Gap Action Programme
MNS
Mental, neurological, and substance use
PTSD
Post-traumatic stress disorder
UNHCR
United Nations High Commissioner for Refugees
WHO
World Health Organization
AUTHORS’ CONTRIBUTIONS
SLF conducted the statistical analysis and wrote the first draft of the
manuscript. JCK assisted with statistical analysis and made substantive
contributions to the manuscript. PV developed the case studies and made
substantive contributions to the manuscript. PS and WT provided substantive
feedback on the manuscript. All authors read and approved the final manuscript.
The opinions expressed in this paper are those of the authors and do not
necessarily represent the decisions, policies, or views of the organizations
they serve.
FUNDING
SLF’s contribution was supported in part by the National Institute of Mental
Health’s Global Mental Health Training Program (T32MH10321) and by a National
Research Service Award through the Eunice Kennedy Shriver National Institute of
Child Health & Human Development (F31HD100161). JCK’s contribution was supported
in part by the National Institute on Alcohol Abuse and Alcoholism (K01AA026523).
The content is solely the responsibility of the authors and does not necessarily
represent the official views of the organizations they serve including the
National Institutes of Health or the United Nations High Commissioner for
Refugees.
AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are available from UNHCR, but
restrictions apply to the availability of these data, which were used under
license for the current study, and so are not publicly available.
DECLARATIONS
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Not applicable.
CONSENT FOR PUBLICATION
Not applicable.
COMPETING INTERESTS
The authors declare that they have no competing interests.
FOOTNOTES
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
REFERENCES
* 1.UNHCR . Global trends: forced displacement in 2020. Geneva: United Nations
High Commissioner for Refugees; 2021. [Google Scholar]
* 2.Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New
WHO prevalence estimates of mental disorders in conflict settings: a
systematic review and meta-analysis. Lancet. 2019;394:240–248. doi:
10.1016/S0140-6736(19)30934-1. [DOI] [PMC free article] [PubMed] [Google
Scholar]
* 3.Lindert J, von Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and
anxiety in labor migrants and refugees--a systematic review and
meta-analysis. Soc Sci Med. 1982;2009(69):246–257. doi:
10.1016/j.socscimed.2009.04.032. [DOI] [PubMed] [Google Scholar]
* 4.Reed RV, Fazel M, Jones L, Panter-Brick C, Stein A. Mental health of
displaced and refugee children resettled in low-income and middle-income
countries: risk and protective factors. Lancet. 2012;379:250–265. doi:
10.1016/S0140-6736(11)60050-0. [DOI] [PubMed] [Google Scholar]
* 5.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;302:537–549. doi:
10.1001/jama.2009.1132. [DOI] [PubMed] [Google Scholar]
* 6.Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, et al.
Global, regional, and national incidence, prevalence, and years lived with
disability for 328 diseases and injuries for 195 countries, 1990–2016: a
systematic analysis for the Global Burden of Disease Study 2016. Lancet.
2017;390:1211–1259. doi: 10.1016/S0140-6736(17)32154-2. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 7.Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an
overview of mental health challenges. World Psychiatry. 2017;16:130–139. doi:
10.1002/wps.20438. [DOI] [PMC free article] [PubMed] [Google Scholar]
* 8.Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Estimation of
the burden of active and life-time epilepsy: a meta-analytic approach.
Epilepsia. 2010;51:883–890. doi: 10.1111/j.1528-1167.2009.02481.x. [DOI] [PMC
free article] [PubMed] [Google Scholar]
* 9.Mateen FJ, Carone M, Nyce S, Ghosn J, Mutuerandu T, Al-Saedy H, et al.
Neurological disorders in Iraqi refugees in Jordan: data from the United
Nations Refugee Assistance Information System. J Neurol. 2012;259:694–701.
doi: 10.1007/s00415-011-6248-x. [DOI] [PubMed] [Google Scholar]
* 10.Meyer A-C, Dua T, Ma J, Saxena S, Birbeck G. Global disparities in the
epilepsy treatment gap: a systematic review. Bull World Health Organ.
2010;88:260–266. doi: 10.2471/BLT.09.064147. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 11.Jones L, Asare JB, El Masri M, Mohanraj A, Sherief H, van Ommeren M.
Severe mental disorders in complex emergencies. Lancet Lond Engl.
2009;374:654–661. doi: 10.1016/S0140-6736(09)61253-8. [DOI] [PubMed] [Google
Scholar]
* 12.Silove D, Bateman CR, Brooks RT, Fonseca CAZ, Steel Z, Rodger J, et al.
Estimating clinically relevant mental disorders in a rural and an urban
setting in postconflict Timor Leste. Arch Gen Psychiatry. 2008;65:1205–1212.
doi: 10.1001/archpsyc.65.10.1205. [DOI] [PubMed] [Google Scholar]
* 13.Brandt L, Henssler J, Müller M, Wall S, Gabel D, Heinz A. Risk of
psychosis among refugees: a systematic review and meta-analysis. JAMA
Psychiatry. 2019. 10.1001/jamapsychiatry.2019.1937. [DOI] [PMC free article]
[PubMed]
* 14.Nygaard M, Sonne C, Carlsson J. Secondary psychotic features in refugees
diagnosed with post-traumatic stress disorder: a retrospective cohort study.
BMC Psychiatry. 2017;17:1–11. doi: 10.1186/s12888-016-1166-1. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 15.Rathke H, Poulsen S, Carlsson J, Palic S. PTSD with secondary psychotic
features among trauma-affected refugees: The role of torture and depression.
Psychiatry Res. 2020;287:112898. doi: 10.1016/j.psychres.2020.112898. [DOI]
[PubMed] [Google Scholar]
* 16.Ezard N. Substance use among populations displaced by conflict: a
literature review. Disasters. 2012;36:533–557. doi:
10.1111/j.1467-7717.2011.01261.x. [DOI] [PubMed] [Google Scholar]
* 17.Horyniak D, Melo JS, Farrell RM, Ojeda VD, Strathdee SA. Epidemiology of
substance use among forced migrants: a global systematic review. PloS One.
2016;11:e0159134. doi: 10.1371/journal.pone.0159134. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 18.Jones L, Ventevogel P. From exception to the norm: how mental health
interventions have become part and parcel of the humanitarian response. World
Psychiatry. 2021;20:2–3. doi: 10.1002/wps.20808. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 19.Silove D. Challenges to mental health services for refugees: a global
perspective. World Psychiatry. 2021;20:131–132. doi: 10.1002/wps.20818. [DOI]
[PMC free article] [PubMed] [Google Scholar]
* 20.Inter-Agency Standing Committee . IASC Guidelines on Mental Health and
Psychosocial Support in Emergency Settings. Geneva: IASC; 2007. [DOI]
[PubMed] [Google Scholar]
* 21.World Health Organization, United Nations High Commissioner for Refugees .
mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of
mental, neurological and substance use conditions in humanitarian
emergencies. Geneva: World Health Organization; 2015. [Google Scholar]
* 22.Echeverri C, Le Roy J, Worku B, Ventevogel P. Mental health capacity
building in refugee primary health care settings in Sub-Saharan Africa:
impact, challenges and gaps. Glob Ment Health C. 2018;5:e28. [DOI] [PMC free
article] [PubMed]
* 23.Hughes P, Hijazi Z, Saeed K. Improving access to mental healthcare for
displaced Syrians: case studies from Syria, Iraq and Turkey. BJPsych Int.
2016;13:84–86. doi: 10.1192/S2056474000001392. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 24.Momotaz H, Ahmed HU, Uddin MMJ, Karim R, Khan MA, Al-Amin R, et al.
Implementing the mental health gap action programme in Cox’s Bazar,
Bangladesh. Intervention. 2019;17:243. doi: 10.4103/INTV.INTV_14_19. [DOI]
[Google Scholar]
* 25.Sherchan S, Samuel R, Marahatta K, Anwar N, Van Ommeren MH, Ofrin R.
Post-disaster mental health and psychosocial support: experience from the
2015 Nepal earthquake. WHO South East Asia J Public Health. 2017;6:22–29.
doi: 10.4103/2224-3151.206160. [DOI] [PubMed] [Google Scholar]
* 26.Tarannum S, Elshazly M, Harlass S, Ventevogel P. Integrating mental health
into primary health care in Rohingya refugee settings in Bangladesh:
experiences of UNHCR. Intervention. 2019;17:130. doi:
10.4103/INTV.INTV_34_19. [DOI] [Google Scholar]
* 27.Ryan G, De Silva M, Terver JS, Ochi OP, Eaton J. Information systems for
global mental health. Lancet Psychiatry. 2015;2:372–373. doi:
10.1016/S2215-0366(15)00097-8. [DOI] [PubMed] [Google Scholar]
* 28.Haskew C, Spiegel P, Tomczyk B, Cornier N, Hering H. A standardized health
information system for refugee settings: rationale, challenges and the way
forward. Bull World Health Organ. 2010;88:792–794. doi:
10.2471/BLT.09.074096. [DOI] [PMC free article] [PubMed] [Google Scholar]
* 29.Ventevogel P, Ryan GK, Kahi V, Kane JC. Capturing the essential: revising
the mental health categories in UNHCR’s Refugee Health Information System.
Intervention. 2019;17:13. doi: 10.4103/INTV.INTV_66_18. [DOI] [Google
Scholar]
* 30.Kane JC, Ventevogel P, Spiegel P, Bass JK, van Ommeren M, Tol WA. Mental,
neurological, and substance use problems among refugees in primary health
care: analysis of the Health Information System in 90 refugee camps. BMC Med.
2014;12:228. doi: 10.1186/s12916-014-0228-9. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 31.UNHCR. Refugee Data Finder. Refugee Data Finder. 2020.
https://www.unhcr.org/refugee-statistics/. Accessed 31 Jul 2020.
* 32.UNHCR . Global trends: forced displacement in 2018. Geneva: United Nations
High Commissioner for Refugees; 2019. [Google Scholar]
* 33.De Silva MJ, Lee L, Fuhr DC, Rathod S, Chisholm D, Schellenberg J, et al.
Estimating the coverage of mental health programmes: a systematic review. Int
J Epidemiol. 2014;43:341–353. doi: 10.1093/ije/dyt191. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 34.StataCorp. Stata Statistical Software: Release 14. College Station:
StataCorp LP; 2015. [Google Scholar]
* 35.Hughes P, Thomson S. mhGAP – the global scenario. Prog Neurol Psychiatry.
2019;23:4–6. doi: 10.1002/pnp.546. [DOI] [Google Scholar]
* 36.van Ommeren M, Hanna F, Weissbecker I, Ventevogel P. Mental health and
psychosocial support in humanitarian emergencies. East Mediterr Health J.
2015;21:498–502. doi: 10.26719/2015.21.7.498. [DOI] [PubMed] [Google Scholar]
* 37.Karaoğlan Kahiloğulları A, Alataş E, Ertuğrul F, Malaj A. Responding to
mental health needs of Syrian refugees in Turkey: mhGAP training impact
assessment. Int J Ment Health Syst. 2020;14:1–9. doi:
10.1186/s13033-020-00416-0. [DOI] [PMC free article] [PubMed] [Google
Scholar]
* 38.Faregh N, Lencucha R, Ventevogel P, Dubale BW, Kirmayer LJ. Considering
culture, context and community in mhGAP implementation and training:
challenges and recommendations from the field. Int J Ment Health Syst.
2019;13:58. doi: 10.1186/s13033-019-0312-9. [DOI] [PMC free article] [PubMed]
[Google Scholar]
* 39.Humayun A, Haq I, Khan FR, Azad N, Khan MM, Weissbecker I. Implementing
mhGAP training to strengthen existing services for an internally displaced
population in Pakistan. Glob Ment Health. 2017;4:e6. [DOI] [PMC free article]
[PubMed]
* 40.Pérez-Sales P, Férnandez-Liria A, Baingana F, Ventevogel P. Integrating
mental health into existing systems of care during and after complex
humanitarian emergencies: rethinking the experience. Intervention.
2011;9:345–357. [Google Scholar]
* 41.Nguyen AJ, Rykiel N, Murray L, Amin A, Haroz E, Lee C, et al. Stakeholder
perspectives on integration of mental health services into primary care: a
mixed methods study in Northern Iraq. Int J Ment Health Syst. 2019;13:75.
doi: 10.1186/s13033-019-0330-7. [DOI] [PMC free article] [PubMed] [Google
Scholar]
* 42.Schubert J. Mental health & psychosocial support for Syrian refugees in
Jordan – a capacity analysis of the national implementation of WHO’s mhGAP.
University of North Carolina at Chapel Hill; 2018. [Google Scholar]
* 43.Ventevogel P, Jordans M, Reis R, de Jong J. Madness or sadness? Local
concepts of mental illness in four conflict-affected African communities.
Confl Health. 2013;7:3. doi: 10.1186/1752-1505-7-3. [DOI] [PMC free article]
[PubMed] [Google Scholar]
* 44.Andersson LMC, Schierenbeck I, Strumpher J, Krantz G, Topper K, Backman G,
et al. Help-seeking behaviour, barriers to care and experiences of care among
persons with depression in Eastern Cape, South Africa. J Affect Disord.
2013;151:439–448. doi: 10.1016/j.jad.2013.06.022. [DOI] [PubMed] [Google
Scholar]
* 45.Menberu M, Mekonen T, Azale T, Ayano G, Yimer S, Getnet A, et al. Health
care seeking behavior for depression in Northeast Ethiopia: depression is not
considered as illness by more than half of the participants. Ann Gen
Psychiatry. 2018;17:34. doi: 10.1186/s12991-018-0205-3. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 46.Nsereko JR, Kizza D, Kigozi F, Ssebunnya J, Ndyanabangi S, Flisher AJ, et
al. Stakeholder’s perceptions of help-seeking behaviour among people with
mental health problems in Uganda. Int J Ment Health Syst. 2011;5:5. doi:
10.1186/1752-4458-5-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
* 47.Tay AK, Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, et al.
The culture, mental health and psychosocial wellbeing of Rohingya refugees: a
systematic review. Epidemiol Psychiatr Sci. 2019;28:489–494. doi:
10.1017/S2045796019000192. [DOI] [PMC free article] [PubMed] [Google Scholar]
* 48.Bolton P, Lee C, Haroz EE, Murray LK, Dorsey S, Robinson C, et al. A
transdiagnostic community-based mental health treatment for comorbid
disorders: development and outcomes of a randomized controlled trial among
Burmese refugees in Thailand. PLoS Med. 2014;11:e1001757. doi:
10.1371/journal.pmed.1001757. [DOI] [PMC free article] [PubMed] [Google
Scholar]
* 49.Greene MC, Likindikoki S, Rees S, Bonz A, Kaysen D, Misinzo L, et al.
Evaluation of an integrated intervention to reduce psychological distress and
intimate partner violence in refugees: Results from the Nguvu cluster
randomized feasibility trial. PloS One. 2021;16:e0252982. doi:
10.1371/journal.pone.0252982. [DOI] [PMC free article] [PubMed] [Google
Scholar]
* 50.Tol WA, Leku MR, Lakin DP, Carswell K, Augustinavicius J, Adaku A, et al.
Guided self-help to reduce psychological distress in South Sudanese female
refugees in Uganda: a cluster randomised trial. Lancet Glob Health.
2020;8:e254–e263. doi: 10.1016/S2214-109X(19)30504-2. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 51.Tay AK, Miah MAA, Khan S, Mohsin M, Alam AM, Ozen S, et al. A naturalistic
evaluation of group integrative adapt therapy (IAT-G) with Rohingya refugees
during the emergency phase of a mass humanitarian crisis in Cox's Bazar,
Bangladesh. EClinicalMedicine. 2021;38:100999. [DOI] [PMC free article]
[PubMed]
* 52.Acarturk C, Uygun E, Ilkkursun Z, Yurtbakan T, Kurt G, Adam-Troian J, et
al. Group problem management plus (PM+) to decrease psychological distress
among Syrian refugees in Turkey: a pilot randomised controlled trial. BMC
Psychiatry. 2022;22:1–11. doi: 10.1186/s12888-021-03645-w. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 53.Greene MC, Ventevogel P, Kane JC. Substance use services for refugees.
Bull World Health Organ. 2019;97:246–246A. doi: 10.2471/BLT.18.225086. [DOI]
[PMC free article] [PubMed] [Google Scholar]
* 54.Kane JC, Greene MC. Addressing alcohol and substance use disorders among
refugees: a desk review of intervention approaches. Geneva: United Nations
High Commissioner for Refugees; 2018. [Google Scholar]
* 55.Roberts B, Ezard N. Why are we not doing more for alcohol use disorder
among conflict-affected populations? Addict Abingdon Engl. 2015;110:889–890.
doi: 10.1111/add.12869. [DOI] [PubMed] [Google Scholar]
* 56.Chung RC, Bemak F, Kagawa-Singer M. Gender differences in psychological
distress among Southeast Asian refugees. J Nerv Ment Dis. 1998;186:112–119.
doi: 10.1097/00005053-199802000-00007. [DOI] [PubMed] [Google Scholar]
* 57.Kamau M, Silove D, Steel Z, Catanzaro R, Bateman C, Ekblad S. Psychiatric
disorders in an African refugee camp. Intervention. 2004;2:84–89. [Google
Scholar]
* 58.Weissbecker I, Hanna F, El Shazly M, Gao J, Ventevogel P. Integrative
mental health and psychosocial support interventions for refugees in
humanitarian crisis settings. In: Wenzel T, Drožđek B, editors. An Uncertain
Safety: Integrative Health Care for the 21st Century Refugees. Cham: Springer
International Publishing; 2019. pp. 117–153. [Google Scholar]
* 59.Barbui C, Purgato M, Abdulmalik J, Acarturk C, Eaton J, Gastaldon C, et
al. Efficacy of psychosocial interventions for mental health outcomes in
low-income and middle-income countries: an umbrella review. Lancet
Psychiatry. 2020;7:162–172. doi: 10.1016/S2215-0366(19)30511-5. [DOI]
[PubMed] [Google Scholar]
* 60.Haroz EE, Nguyen AJ, Lee CI, Tol WA, Fine SL, Bolton P. What works in
psychosocial programming in humanitarian contexts in low- and middle-income
countries: a systematic review of the evidence. Intervention. 2020;18:3.
[Google Scholar]
* 61.UNHCR . Operational guidance: mental health & psychosocial support
programming for refugee operations. Geneva: United Nations High Commissioner
for Refugees; 2013. [Google Scholar]
* 62.UNHCR . Strengthening mental health and psychosocial support in 2021.
Geneva: United Nations High Commissioner for Refugees; 2021. [Google Scholar]
* 63.UNHCR . UNHCR Global Strategy for Public Health 2021-2025. Geneva: United
Nations High Commissioner for Refugees; 2021. [Google Scholar]
* 64.Bryant RA, Bawaneh A, Awwad M, Al-Hayek H, Giardinelli L, Whitney C, et
al. Effectiveness of a brief group behavioral intervention for common mental
disorders in Syrian refugees in Jordan: A randomized clinical trial. PLoS
Med. 2022;19:e1003949. doi: 10.1371/journal.pmed.1003949. [DOI] [PMC free
article] [PubMed] [Google Scholar]
* 65.Haroz EE, Decker E, Lee C, Bolton P, Spiegel P, Ventevogel P. Evidence for
suicide prevention strategies with populations in displacement: a systematic
review. Intervention (Amstelveen) 2020;18:37–44. doi: 10.7202/1073219ar.
[DOI] [PMC free article] [PubMed] [Google Scholar]
ASSOCIATED DATA
This section collects any data citations, data availability statements, or
supplementary materials included in this article.
SUPPLEMENTARY MATERIALS
Additional file 1. (54.2KB, pdf)
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from UNHCR, but
restrictions apply to the availability of these data, which were used under
license for the current study, and so are not publicly available.
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