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1.  Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1) 
This paper is a part of the work of the group that carried out the report "The state of the mental health in Europe" (European Commission, DG Health and Consumer Protection, 2004) and deals with the mental health issues related to the migration in Europe.
The paper tries to describe the social, demographical and political context of the emigration in Europe and tries to indicate the needs and (mental) health problems of immigrants. A review of the literature concerning mental health risk in immigrant is also carried out. The work also faces the problem of the health policy toward immigrants and the access to health care services in Europe.
Migration during the 1990s has been high and characterised by new migrations. Some countries in Europe, that have been traditionally exporters of migrants have shifted to become importers. Migration has been a key force in the demographic changes of the European population. The policy of closed borders do not stop migration, but rather seems to set up a new underclass of so-called "illegals" who are suppressed and highly exploited. In 2000 there were also 392.200 asylum applications.
The reviewed literature among mental health risk in some immigrant groups in Europe concerns: 1) highest rate of schizophrenia; suicide; alcohol and drug abuse; access of psychiatric facilities; risk of anxiety and depression; mental health of EU immigrants once they returned to their country; early EU immigrants in today disadvantaged countries; refugees and mental health
Due to the different condition of migration concerning variables as: motivation to migrations (e.g. settler, refugees, gastarbeiters); distance for the host culture; ability to develop mediating structures; legal residential status it is impossible to consider "migrants" as a homogeneous group concerning the risk for mental illness. In this sense, psychosocial studies should be undertaken to identify those factors which may under given conditions, imply an increased risk of psychiatric disorders and influence seeking for psychiatric care.
Comments and Remarks
Despite in the migrants some vulnerable groups were identified with respect to health problems, in many European countries there are migrants who fall outside the existing health and social services, something which is particularly true for asylum seekers and undocumented immigrants. In order to address these deficiencies, it is necessary to provide with an adequate financing and a continuity of the grants for research into the multicultural health demand. Finally, there is to highlight the importance of adopting an integrated approach to mental health care that moves away from psychiatric care only.
PMCID: PMC1236945  PMID: 16135246
2.  Psychiatry's Catch 22, Need For Precision, And Placing Schools In Perspective 
Mens Sana Monographs  2013;11(1):42-58.
The catch 22 situation in psychiatry is that for precise diagnostic categories/criteria, we need precise investigative tests, and for precise investigative tests, we need precise diagnostic criteria/categories; and precision in both diagnostics and investigative tests is nonexistent at present. The effort to establish clarity often results in a fresh maze of evidence. In finding the way forward, it is tempting to abandon the scientific method, but that is not possible, since we deal with real human psychopathology, not just concepts to speculate over. Search for clear-cut definitions/diagnostic criteria in psychiatry must be relentless. There is a greater need to be ruthless and blunt in this, rather than being accommodative of diverse opinions. Investigative tests – psychological, serum, CSF, or neuroimaging - are only corroborative at present; they need to become definitive.
Medicalisation appears most prominent in psychiatry; so, diagnostic proliferation and fuzziness appear inevitable. And yet, the established diagnostic entities need to forward greater and conclusive precision. Also, the need for clarity and precision must outweigh pandering to and mollifying diverse interests, moreso in the upcoming revision of diagnostic manuals. This is specially because the DSM-5, being an Association manual, may need to accommodate powerful member lobbies; and ICD-11 may similarly need to cater to diverse country lobbies.
Finding precise biological correlates of psychiatric phenomena, whether through neuroimaging, molecular neurobiology and/or neurogenomics, is the right way forward. It is in the 1.5-kg structure in the cranium that all secrets of psychiatric conditions lie. Social forces, behavioural modification, psychosocial restructuring, study of intrapsychic processes, and philosophical insights are not to be discounted, but they are supplementary to the primary goal – studying and deciphering those brain processes that result in psychiatric malfunction.
Experimental breakthroughs, both in psychiatric aetiology and therapeutics, will come mainly from biology and its adjunct, psychopharmacology; while supplementary and complementary breakthroughs will come from the psychosocial, cognitive and behavioural approaches; the support base will come from phenomenology, epidemiology, nosology and diagnostics; while insights and leads can hopefully come from many fields, especially the psychosocial, the behavioural, the cognitive and the philosophical.
Major energies must now be marshalled towards finding biomarkers and deciphering the precise phenotype–genotype–endophenotype axis of psychiatric disorders. Energies also need to be focussed on unravelling those critical processes in the brain that tip the scale towards psychiatric disorders. At how those critical processes are set into motion by forces de novo, in utero, in the genes and their expression, by the environment's psychopathological social forces – stress, peer pressure, poverty, deprivation, alienation, malnutrition, discrimination of various types (caste, gender, race, etc.), mass conflicts (war, terror attacks, etc.), disasters (natural and man-made), religious/ideological fascism – or social institutions like marriage, family, work place, political governance, etc.
Ultimately, we must decipher how the brain goes into malfunction when such varied forces impinge on it, which precise cortical areas and neuronal cellular and molecular processes are involved in such malfunction and its manifestation, as also which of these are involved when malfunction ceases and health is restored, and the psychosocial processes and institutions which aid such health restoration, as also those which promote well-being and help in primary prevention.
Emphasis on the brain and its intimate neurological and molecular mechanisms will not impinge on, or nullify, importance of the ‘mind,’ wherein subtle and gross brain functions in the form of behaviour, thought and emotions in all their ramifications will continue to be the focus of psychological, cognitive, sociological, psychopharmacological, behavioural and philosophical research. Progress in brain research must move in tandem with progress in ‘mind’ research.
PMCID: PMC3653234  PMID: 23678237
Brain; Biology; Control; Diagnostic Categories; Disorder; DSM-5; ICD-11; Investigative tests; Mind; Medicalisation; Neurobiological correlates; Psychosocial factors; Schools of psychiatry; Well-being
3.  Migration experiences, employment status and psychological distress among Somali immigrants: a mixed-method international study 
BMC Public Health  2012;12:749.
The discourse about mental health problems among migrants and refugees tends to focus on adverse pre-migration experiences; there is less investigation of the environmental conditions in which refugee migrants live, and the contrasts between these situations in different countries. This cross-national study of two samples of Somali refugees living in London (UK) and Minneapolis, Minnesota, (USA) helps to fill a gap in the literature, and is unusual in being able to compare information collected in the same way in two cities in different countries.
There were two parts to the study, focus groups to gather in-depth qualitative data and a survey of health status and quantifiable demographic and material factors. Three of the focus groups involved nineteen Somali professionals and five groups included twenty-eight lay Somalis who were living in London and Minneapolis. The quantitative survey was done with 189 Somali respondents, also living in London and Minneapolis. We used the MINI International Neuropsychiatric Interview (MINI) to assess ICD-10 and DSM-IV mental disorders.
The overall qualitative and quantitative results suggested that challenges to masculinity, thwarted aspirations, devalued refugee identity, unemployment, legal uncertainties and longer duration of stay in the host country account for poor psychological well-being and psychiatric disorders among this group.
The use of a mixed-methods approach in this international study was essential since the quantitative and qualitative data provide different layers and depth of meaning and complement each other to provide a fuller picture of complex and multi-faceted life situations of refugees and asylum seekers. The comparison between the UK and US suggests that greater flexibility of access to labour markets for this refugee group might help to promote opportunities for better integration and mental well-being.
PMCID: PMC3489604  PMID: 22954304
4.  Examination of Spatial Polygamy among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: The P18 Cohort Study 
The few previous studies examining the influence of the neighborhood context on health and health behavior among young gay, bisexual, and other men who have sex with men (YMSM) have predominantly focused on residential neighborhoods. No studies have examined multiple neighborhood contexts among YMSM or the relationships between sociodemographic characteristics, psychosocial factors, social support network characteristics, health behaviors, and neighborhood concordance. In this study, we assessed spatial polygamy by determining the amount of concordance between residential, social, and sex neighborhoods (defined as boroughs) in addition to examining individual-level characteristics that may be associated with neighborhood concordance. These data come from the baseline assessment of Project 18, a cohort of racially and ethnically diverse YMSM residing in the New York City metropolitan area. Participants (N = 598) provided information on their residential, social, and sex boroughs as well as information on their sociodemographic characteristics, psychosocial factors, social support network characteristics, and health behaviors (e.g., substance use and condomless sex). Descriptive analyses were conducted to examine the distribution of boroughs reported across all three contexts, i.e., residential, social, and sex boroughs. Next, concordance between: (1) residential and social boroughs; (2) residential and sex boroughs; (3) social and sex boroughs; and (4) residential, social, and sex boroughs was assessed. Finally, bivariable analyses were conducted to examine the relationships between sociodemographic characteristics, psychosocial factors, social support network characteristics, and health behaviors in relation to borough concordance. Approximately two-thirds of participants reported concordance between residential/socializing, residential/sex, and sex/socializing boroughs, whereas 25% reported concordance between all three residential/socializing/sex boroughs. Borough concordance varied by some individual-level characteristics. For example, White YMSM and YMSM reporting lower perceived socioeconomic status were significantly more likely to report residential/socializing/sex borough concordance (p < 0.001). With regard to psychosocial factors, YMSM who reported experiencing gay-related stigma in public forums were more likely to report discordant socializing/sex and residential/socializing/sex boroughs (p < 0.001). Greater frequency of communication with network members (≥weekly) was associated with less residential/social borough concordance (p < 0.05). YMSM who reported residential/socializing/sex borough concordance were more likely to report recent (last 30 days) alcohol use, recent marijuana use, and recently engaging in condomless oral sex (all p < 0.05). These findings suggest that spatial polygamy, or an individual moving across and experiencing multiple neighborhood contexts, is prevalent among urban YMSM and that spatial polygamy varies by multiple individual-level characteristics. Future research among YMSM populations should consider multiple neighborhood contexts in order to provide a more nuanced understanding of how and which neighborhood contexts influence the health and well-being of YMSM. This further examination of spatial polygamy (and individual-level characteristics associated with it) may increase understanding of the most appropriate locations for targeted disease prevention and health promotion interventions (e.g., HIV prevention interventions).
PMCID: PMC4199000  PMID: 25170685
spatial polygamy; neighborhoods; gay men’s health
5.  Do Children Who Move Home and School Frequently Have Poorer Educational Outcomes in Their Early Years at School? An Anonymised Cohort Study 
PLoS ONE  2013;8(8):e70601.
Frequent mobility has been linked to poorer educational attainment. We investigated the association between moving home and moving school frequently and the early childhood formal educational achievement. We carried out a cohort analysis of 121,422 children with anonymised linked records. Our exposure measures were: 1) the number of residential moves registered with a health care provider, and 2) number of school moves. Our outcome was the formal educational assessment at age 6–7. Binary regression modeling was used to examine residential moves within the three time periods: 0 – <1 year; 1 – <4 years and 4 – <6 years. School moves were examined from age 4 to age 6. We adjusted for demographics, residential moves at different times, school moves and birth related variables. Children who moved home frequently were more likely not to achieve in formal assessments compared with children not moving. Adjusted odds ratios were significant for 3 or more moves within the time period 1 –<4 years and for any number of residential moves within the time period 4–<6 years. There was a dose response relationship, with increased odds ratios with increased frequency of residential moves (2 or more moves at 4–<6 years, adjusted odds ratio 1.16 (1.03, 1.29). The most marked effect was seen with frequent school moves where 2 or more moves resulted in an adjusted odds ratio of 2.33 (1.82, 2.98). This is the first study to examine the relationship between residential and school moves in early childhood and the effect on educational attainment. Children experiencing frequent mobility may be disadvantaged and should be closely monitored. Additional educational support services should be afforded to children, particularly those who frequently change school, in order to help them achieve the expected educational standards.
PMCID: PMC3734306  PMID: 23940601
6.  Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11 
PLoS Medicine  2009;6(8):e1000121.
Holly Prigerson and colleagues tested the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.
Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.
Methods and Findings
A total of 291 bereaved respondents were interviewed three times, grouped as 0–6, 6–12, and 12–24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment.
The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11.
Please see later in the article for Editors' Summary
Editors' Summary
Virtually everyone loses someone they love during their lifetime. Grief is an unavoidable and normal reaction to this loss. After the death of a loved one, bereaved people may feel sadness, anger, guilt, anxiety, and despair. They may think constantly about the deceased person and about the events that led up to the person's death. They often have physical reactions to their loss—problems sleeping, for example—and they may become ill. Socially, they may find it difficult to return to work or to see friends and family. For most people, these painful emotions and thoughts gradually diminish, usually within 6 months or so of the death. But for a few people, the normal grief reaction lingers and becomes increasingly debilitating. Experts call this complicated grief or prolonged grief disorder (PGD). Characteristically, people with PGD have intrusive thoughts and images of the deceased person and a painful yearning for his or her presence. They may also deny their loss, feel desperately lonely and adrift, and want to die themselves.
Why Was This Study Done?
PGD is not currently recognized as a mental disorder although it meets the requirements for one given in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and in the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, 10thEdition (ICD-10). Before PGD can be recognized as a mental disorder (and included in DSM-V and ICD-11), bereavement and mental-health experts need to agree on standardized criteria for PGD. Such criteria would be useful because they would allow researchers and clinicians to identify risk factors for PGD and to find ways to prevent PGD. They would also help to ensure that people with PGD get appropriate treatments such as psychotherapy to help them change their way of thinking about their loss and re-engage with the world. Recently, a panel of experts agreed on a consensus list of symptoms for PGD. In this study, the researchers undertake a field trial to develop and evaluate algorithms (sets of rules) for diagnosing PGD based on these symptoms.
What Did the Researchers Do and Find?
The researchers used “item response theory” (IRT) to derive the most informative PGD symptoms from structured interviews of nearly 300 people who had recently lost a close family member. These interviews contained questions about the consensus list of symptoms; each participant was interviewed two or three times during the two years after their spouse's death. The researchers then used “combinatoric” analysis to identify the most sensitive and specific algorithm for the diagnosis of PGD. This algorithm specifies that a bereaved person with PGD must experience yearning (physical or emotional suffering because of an unfulfilled desire for reunion with the deceased) and at least five of nine additional symptoms. These symptoms (which include emotional numbness, feeling that life is meaningless, and avoidance of the reality of the loss) must persist for at least 6 months after the bereavement and must be associated with functional impairment. Finally, the researchers show that individuals given a diagnosis of PGD 6–12 months after a death have a higher subsequent risk of mental health and functional impairment than people not diagnosed with PGD.
What Do These Findings Mean?
These findings validate a set of symptoms and a diagnostic algorithm for PGD. Because most of the study participants were elderly women who had lost their husband, further validation is needed to check that these symptoms and algorithm also apply to other types of bereaved people such as individuals who have lost a child. For now, though, these findings support the inclusion of PGD in DSM-V and ICD-11 as a recognized mental disorder. Furthermore, the availability of a standardized way to diagnose PGD will help clinicians identify the minority of people who fail to adjust successfully to the loss of a loved one. Hopefully, by identifying these people and helping them to avoid the onset of PGD (perhaps by providing psychotherapy soon after a death) and/or providing better treatment for PGD, it should now be possible to reduce the considerable personal and societal costs associated with prolonged grief.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Stephen Workman
The Dana Farber Cancer Institute has a page describing its Center for Psycho-oncology and Palliative Care Research
The UK Royal College of Psychiatrists has a leaflet on bereavement (in English, Welsh, Urdu, and Chinese)
The US National Cancer Institute also has information about coping with bereavement for patients and health professionals (in English and Spanish)
MedlinePlus has links to other information about bereavement (in English and Spanish)
The Journal of the American Medical Association has a patient page on abnormal grief
Harvard Medical School provides a short family health guide about complicated grief
Information on DSM-IV and ICD-10 is available
PMCID: PMC2711304  PMID: 19652695
7.  Prevalence of mental disorders among adolescents in German youth welfare institutions 
Multiple psycho-social risk factors are common in children and adolescents in youth welfare, especially in residential care. In this survey study we assessed the prevalence of behavioral, emotional symptoms and mental disorders in a German residential care population.
20 residential care institutions including 689 children and adolescents (age 4 – 18 years; mean 14.4; SD = 2.9) participated. A two-step design was performed. First, the children and adolescents and their residential caregivers answered a standard symptom checklist (CBCL/YSR). For those participants scoring more than one standard deviation above the mean of their German population reference group, a standardized clinical examination was performed to specify an ICD-10 diagnosis.
The study population reached high average scores in almost all scales and subscales of the CBCL and YSR (mean CBCL total score T = 64.3, SD = 9.7, Median = 66.0). The prevalence of mental disorders according to the diagnostic criteria of ICD-10 was 59.9%, with a predominance of externalizing and disruptive disorders. High rates of co-morbidity were observed.
Children and adolescents in youth welfare and residential care are a neglected high risk population. Providing adequate psychiatric diagnosis and multimodal treatment for this group is necessary.
PMCID: PMC2262059  PMID: 18226213
8.  The Effect of Rural-to-Urban Migration on Obesity and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2010;7(4):e1000268.
Shah Ebrahim and colleagues examine the distribution of obesity, diabetes, and other cardiovascular risk factors among urban migrant factory workers in India, together with their rural siblings. The investigators identify patterns of change of cardiovascular risk factors associated with urban migration.
Migration from rural areas of India contributes to urbanisation and may increase the risk of obesity and diabetes. We tested the hypotheses that rural-to-urban migrants have a higher prevalence of obesity and diabetes than rural nonmigrants, that migrants would have an intermediate prevalence of obesity and diabetes compared with life-long urban and rural dwellers, and that longer time since migration would be associated with a higher prevalence of obesity and of diabetes.
Methods and Findings
The place of origin of people working in factories in north, central, and south India was identified. Migrants of rural origin, their rural dwelling sibs, and those of urban origin together with their urban dwelling sibs were assessed by interview, examination, and fasting blood samples. Obesity, diabetes, and other cardiovascular risk factors were compared. A total of 6,510 participants (42% women) were recruited. Among urban, migrant, and rural men the age- and factory-adjusted percentages classified as obese (body mass index [BMI] >25 kg/m2) were 41.9% (95% confidence interval [CI] 39.1–44.7), 37.8% (95% CI 35.0–40.6), and 19.0% (95% CI 17.0–21.0), respectively, and as diabetic were 13.5% (95% CI 11.6–15.4), 14.3% (95% CI 12.2–16.4), and 6.2% (95% CI 5.0–7.4), respectively. Findings for women showed similar patterns. Rural men had lower blood pressure, lipids, and fasting blood glucose than urban and migrant men, whereas no differences were seen in women. Among migrant men, but not women, there was weak evidence for a lower prevalence of both diabetes and obesity among more recent (≤10 y) migrants.
Migration into urban areas is associated with increases in obesity, which drive other risk factor changes. Migrants have adopted modes of life that put them at similar risk to the urban population. Gender differences in some risk factors by place of origin are unexpected and require further exploration.
Please see later in the article for the Editors' Summary
Editors' Summary
India, like the rest of the world, is experiencing an epidemic of diabetes, a chronic disease characterized by dangerous levels of sugar in the blood that cause cardiovascular and kidney disease, which lower life expectancy. The prevalence of diabetes (the proportion of the population with diabetes) has been increasing steadily in India over recent decades, particularly in urban areas. In 1984, only 5% of adults living in the towns and cities of India had diabetes, but by 2004, 15% of adults in urban areas were affected by diabetes. In rural areas of India, diabetes is less common than in urban areas but even here, the prevalence of diabetes is now 6%. Obesity—too much body fat—is a major risk factor for diabetes and, in parallel with the greater increase in diabetes in urban India compared to rural India, there has been a greater increase in obesity in urban areas than in rural areas.
Why Was This Study Done?
Experts think that the increasing prevalence of obesity and diabetes in India (and in other developing countries) is caused in part by increased consumption of saturated fats and sugars and by reduced physical activity, and that these changes are related to urbanization—urban expansion into the countryside and migration from rural to urban areas. If living in an urban setting is a major determinant of obesity and diabetes risk, then people migrating into urban areas should acquire the high risk of the urban population for these two conditions. In this cross-sectional study (a study in which participants are studied at a single time point), the researchers investigate whether rural to urban migrants in India have a higher prevalence of obesity and diabetes than rural nonmigrants. They also ask whether migrants have a prevalence of obesity and diabetes intermediate between that of life-long urban and rural dwellers and whether a longer time since migration is associated with a higher prevalence of obesity and diabetes.
What Did the Researchers Do and Find?
The researchers recruited rural-urban migrants working in four Indian factories in north, central, and south regions and their spouses (if they were living in the same town) into their study. Each migrant worker and spouse asked one nonmigrant brother or sister (sibling) still living in their place of origin to join the study. The researchers also enrolled nonmigrant factory workers and their urban siblings into the study. All the participants (more than 6,500 in total) answered questions about their diet and physical activity and had their fasting blood sugar and their body mass index (BMI; weight in kg divided by height in meters squared) measured; participants with a fasting blood sugar of more than 7.0 nmol/l or a BMI of more than 25 kg/m2 were classified as diabetic or obese, respectively. 41.9% and 37.8% of the urban and migrant men, respectively, but only 19.0% of the rural men were obese. Similarly, 13.5% and 14.3% of the urban and migrant men, respectively, but only 6.2% of the rural men had diabetes. Patterns of obesity and diabetes among the women participants were similar. Finally, although the prevalence of diabetes and obesity was lower in the most recent male migrants than in those who had moved more than 10 years previously, this difference was small and not seen in women migrants.
What Do These Findings Mean?
These findings show that rural-urban migration in India is associated with rapid increases in obesity and in diabetes. They also show that the migrants have adopted modes of life (for example, reduced physical activity) that put them at a similar risk for obesity and diabetes as the urban population. The findings do not show, however, that migrants have an intermediate prevalence of obesity and diabetes compared to urban and rural dwellers and provide only weak support for the idea that a longer time since migration is associated with a higher risk of obesity and diabetes. Although the study's cross-sectional design means that the researchers could not investigate how risk factors for diabetes evolve over time, these findings suggest that urbanization is helping to drive the diabetes epidemic in India. Thus, targeting migrants and their families for health promotion activities and for treatment of risk factors for obesity and diabetes might help to slow the progress of the epidemic.
Additional Information
Please access these Web sites via the online version of this summary at
The International Diabetes Federation provides information about all aspects of diabetes, including information on diabetes in Southeast Asia (in English, French, and Spanish) provides information on the Indian Task Forces on diabetes care in India
Diabetes Foundation (India) has an international collaborative research focus and provides information about health promotion for diabetes; it has also produced consensus guidelines on dietary change for prevention of diabetes in India
The US National Diabetes Information Clearinghouse provides detailed information about diabetes for patients, health care professionals, and the general public (in English and Spanish)
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
PMCID: PMC2860494  PMID: 20436961
9.  Violence and reproductive health preceding flight from war: accounts from Somali born women in Sweden 
BMC Public Health  2014;14(1):892.
Political violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.
Qualitative semi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.
Before migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.
Several factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and enhancement of well-being and sexual and reproductive health and rights in receiving countries after migration.
PMCID: PMC4168062  PMID: 25174960
Somalia; War; Violence; Refugee; Sexual and reproductive health and rights; Qualitative method; Thematic analysis
10.  Costs of day hospital and community residential chemical dependency treatment 
Evidence suggests that expensive hospital-based inpatient chemical dependency programs do not deliver outcomes that are superior to less costly day hospital programs, but patient placement criteria developed by the Addiction Society of Medicine (ASAM) nonetheless have identified a need for low-intensity residential treatment for patients with higher levels of severity. Community-based residential programs may represent a low-cost inpatient alternative that satisfies the ASAM criteria, but research is lacking in this area. A recent clinical trial has found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on the costs associated with treatment in that study.
This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs. It also studies costs separately for men and women, and for Whites and non-Whites, subgroups not included or identified in prior cost effectiveness work.
This paper reports on clients who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Clients were eligible if they met the first five dimensions of the ASAM criteria for low-intensity residential treatment and had not been mandated to residential treatment due to dangerous home environment (the sixth ASAM dimension). The five day hospital programs included here are typical of mainstream private chemical dependency programs that were developed as an alternative to inpatient treatment. The seven residential programs are typical of those historically developed by members of alcohol mutual-help programs. Cost data for the study sites were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP) which produces estimates of average costs per week per client treated at a particular treatment program. Lengths of stay were derived from program records. Costs per episode for each study subject were calculated by multiplying the DATCAP-based program-specific costs (per week) by the number of weeks the subject stayed in the program to which they had been randomly assigned. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects using the Brown-Forsythe robust test of the equality of means.
Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in the disaggregated analyses for both genders and for both Whites and non-Whites. This difference was especially marked among non-Whites, who had quite short stays in day hospital. The average cost per week was $575 per week at day hospital, versus $370 per week at the residential programs. However, because of the longer stays in residential programs, this lower cost per week did not always translate to lower per-episode costs. Instead, the per-episode costs were significantly higher for those treated in residential programs than in day hospital in the sample overall, and among non-Whites. Costs were comparable for Whites and for women treated in either setting, but were marginally higher for men randomized to residential programs.
These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs in this study, in the overall sample and by gender and race/ethnicity: That is, the longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. An important component of the cost differential arose from especially short stays in day hospital among non-Whites, calling into question the attractiveness of day hospital for minority clients.
Outcomes and costs at residential versus day hospital programs were similar for women and for Whites in a randomized trial of pre-paid health plan members who met ASAM criteria for low-intensity residential treatment but were not at environmental risk. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost.
Implications for health care provision and use
Lengths of stay in residential treatment are significantly longer than in day hospital, but costs per week are lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly.
Implications for health policy formulation
Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk, although it will be important that the current study be replicated with different samples and study programs.
Implications for further research
The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.
PMCID: PMC2744443  PMID: 18424874
11.  Associations of homelessness and residential mobility with length of stay after acute psychiatric admission 
BMC Psychiatry  2012;12:121.
A small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures.
Cross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression.
Residential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor.
Homelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.
PMCID: PMC3505156  PMID: 22905674
Length of stay; Hospitals psychiatric; Mental disorders; Residential mobility; Homeless persons
12.  Gender-specific profiles of tobacco use among non-institutionalized people with serious mental illness 
BMC Psychiatry  2010;10:101.
In many countries, smoking remains the leading preventable cause of death. In North America, reductions in population smoking levels are stabilising and, in recent years, those involved in tobacco control programming have turned their attention to particular segments of society that are at greatest risk for tobacco use. One such group is people with mental illness. A picture of tobacco use patterns among those with mental illness is beginning to emerge; however, there are several unanswered questions. In particular, most studies have been limited to particular in-patient groups. In addition, while it is recognised that men and women differ in relation to their reasons for smoking, levels of addiction to nicotine, and difficulties with cessation, these sex and gender differences have not been fully explored in psychiatric populations.
Community residents with serious mental illness were surveyed to describe their patterns of tobacco use and to develop a gender-specific profile of their smoking status and its predictors.
Of 729 respondents, almost one half (46.8%) were current tobacco users with high nicotine dependence levels. They spent a majority of their income on tobacco, and reported using smoking to cope with their psychiatric symptoms. Current smokers, compared with non-smokers, were more likely to be: diagnosed with a schizophrenia spectrum disorder (rather than a mood disorder); male; relatively young; not a member of a racialised group (e.g., Aboriginal, Asian, South Asian, Black); poorly educated; separated or divorced; housed in a residential facility, shelter, or on the street; receiving social assistance; and reporting co-morbid substance use. There is evidence of a gender interaction with these factors; in the gender-specific multivariate logistic regression models, schizophrenia spectrum disorder versus mood disorder was not predictive of women's smoking, nor was education, marital status or cocaine use. Women, and not men, however, were more likely to be smokers if they were young and living in a residential facility.
For men only, the presence of schizophrenia spectrum disorder is a risk factor for tobacco use. Other factors, of a social nature, contribute to the risk of smoking for both men and women with serious mental illness. The findings suggest that important social determinants of smoking are "gendered" in this population, thus tobacco control and smoking cessation programming should be gender sensitive.
PMCID: PMC3002315  PMID: 21118563
13.  How complete is influenza immunization coverage? A study in 75 nursing and residential homes for elderly people. 
BACKGROUND. Elderly people in residential accommodation are particularly susceptible to outbreaks of influenza. Up to 70% of residents can become ill and many will develop complications or die. Immunization can prevent such outbreaks and is cost-effective. AIM. A study was undertaken to measure influenza immunization coverage in residential accommodation for elderly people and to identify factors that might influence uptake. METHOD. In March 1992, a questionnaire survey was conducted of all 113 registered nursing and residential homes for elderly people, in South Glamorgan. It asked about the demographic characteristics of people resident on 1 October 1991, their influenza immunization history and the homes' arrangements for administering immunizations. RESULTS. Questionnaires were returned by respondents from 75 homes (66%). Mean influenza vaccine uptake was 67%. Uptake was higher in nursing homes (mean of 82% in eight nursing homes) than in homes registered as both nursing and residential homes (mean of 76% in six homes) or in residential homes (mean of 65% in 61 homes). Nearly all of those immunized (94%) had been immunized by the end of November 1991. Residents who were reported to have underlying disease that increased their risk of complications if they contracted influenza were no more likely to have been immunized than those without risk factors. Immunization coverage varied considerably both between homes and between general practices. Most general practices in South Glamorgan had several elderly people in residential accommodation on their list, but only nine out of 64 practices had immunized all the elderly residents on their list and 12 practices had immunized fewer than half. Routine recording of immunization status in nursing and residential homes was variable, often as a consequence of poor communication between the primary health care team and staff at the home. Even where recorded, retrieval of the data was sometimes a problem. CONCLUSION. Influenza immunization coverage could be improved if general practices held a case register of all at-risk patients including elderly residents, and if nursing and residential homes were encouraged to keep better immunization records. These measures would facilitate year-on-year monitoring of influenza immunization coverage and the targeting of homes with low immunization coverage.
PMCID: PMC1239336  PMID: 7576847
14.  Attrition and bias in the MRC cognitive function and ageing study: an epidemiological investigation 
BMC Public Health  2004;4:12.
Any hypothesis in longitudinal studies may be affected by attrition and poor response rates. The MRC Cognitive Function and Ageing study (MRC CFAS) is a population based longitudinal study in five centres with identical methodology in England and Wales each recruiting approximately 2,500 individuals. This paper aims to identify potential biases in the two-year follow-up interviews.
Initial non-response: Those not in the baseline interviews were compared in terms of mortality to those who were in the baseline interviews at the time of the second wave interviews (1993–1996). Longitudinal attrition: Logistic regression analysis was used to examine baseline differences between individuals who took part in the two-year longitudinal wave compared with those who did not.
Initial non-response: Individuals who moved away after sampling but before baseline interview were 1.8 times more likely to die by two years (95% Confidence interval(CI) 1.3–2.4) compared to respondents, after adjusting for age. The refusers had a slightly higher, but similar mortality pattern to responders (Odds ratio 1.2, 95%CI 1.1–1.4).
Longitudinal attrition: Predictors for drop out due to death were being older, male, having impaired activities of daily living, poor self-perceived health, poor cognitive ability and smoking. Similarly individuals who refused were more likely to have poor cognitive ability, but had less years of full-time education and were more often living in their own home though less likely to be living alone. There was a higher refusal rate in the rural centres. Individuals who moved away or were uncontactable were more likely to be single, smokers, demented or depressed and were less likely to have moved if in warden-controlled accommodation at baseline.
Longitudinal estimation of factors mentioned above could be biased, particularly cognitive ability and estimates of movements from own home to residential homes. However, these differences could also affect other investigations, particularly the estimates of incidence and longitudinal effects of health and psychiatric diseases, where the factors shown here to be associated with attrition are risk factors for the diseases.
All longitudinal studies should investigate attrition and this may help with aspects of design and with the analysis of specific hypotheses.
PMCID: PMC419705  PMID: 15113437
15.  Medical and social factors influencing admission to residential care. 
The increasing number of people aged over 75 in Britain makes heavy demands on health and social services. To obtain accurate information for rational allocation of resources to domiciliary and residential services a group of 98 housebound women over 75 were compared with a group of 99 women of the same age in residential care. They had a similar range of physical disorders with the exception that deafness was more common among women in residential care. A much higher proportion in residential care were demented. Though in many respects women in residential care had less physical incapacity, a higher proportion needed help at times of crisis. Important social factors were that women at home were more likely to be living with others, and that the principal helper was more likely to be a husband or relative than a neighbour. Both groups received the same amount of support from home helps and community nurses. Any reduction in the number of residential care places for elderly women whose relatives are not available or are unable to cope would require the establishment of an effective community psychogeriatric service and a system for providing appropriate subjects with 24 hour care and supervision.
PMCID: PMC1444399  PMID: 6230134
16.  Risk of Mycobacterium tuberculosis Transmission in a Low-Incidence Country Due to Immigration from High-Incidence Areas 
Journal of Clinical Microbiology  2001;39(3):855-861.
Does immigration from a high-prevalence area contribute to an increased risk of tuberculosis in a low-incidence country? The tuberculosis incidence in Somalia is among the highest ever registered. Due to civil war and starvation, nearly half of all Somalis have been forced from their homes, causing significant migration to low-incidence countries. In Denmark, two-thirds of all tuberculosis patients are immigrants, half from Somalia. To determine the magnitude of Mycobacterium tuberculosis transmission between Somalis and Danes, we analyzed DNA fingerprint patterns of isolates collected in Denmark from 1992 to 1999, comprising >97% of all culture-positive patients (n = 3,320). Of these, 763 were Somalian immigrants, 55.2% of whom shared identical DNA fingerprint patterns; 74.9% of these were most likely infected before their arrival in Denmark, 23.3% were most likely infected in Denmark by other Somalis, and 1.8% were most likely infected by Danes. In the same period, only 0.9% of all Danish tuberculosis patients were most likely infected by Somalis. The Somalian immigrants in Denmark could be distributed into 35 different clusters with possible active transmission, of which 18 were retrieved among Somalis in the Netherlands. This indicated the existence of some internationally predominant Somalian strains causing clustering less likely to represent recent transmission. In conclusion, M. tuberculosis transmission among Somalis in Denmark is limited, and transmission between Somalis and Danes is nearly nonexistent. The higher transmission rates between nationalities found in the Netherlands do not apply to the situation in Denmark and not necessarily elsewhere, since many different factors may influence the magnitude of active transmission.
PMCID: PMC87841  PMID: 11230395
17.  Relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units, and alternative residential options: a cross sectional survey, one day census data, and staff interviews. 
BMJ : British Medical Journal  1997;314(7076):262-266.
OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.
PMCID: PMC2125745  PMID: 9022489
18.  Khat Use, PTSD and Psychotic Symptoms among Somali Refugees in Nairobi – A Pilot Study 
In East-African and Arab countries, khat leaves are traditionally chewed in social settings. They contain the amphetamine-like alkaloid cathinone. Especially among Somali refugees, khat use has been associated with psychiatric symptoms. We assessed khat-use patterns and psychiatric symptoms among male Somali refugees living in a disadvantaged urban settlement area in Kenya, a large group that has not yet received scientific attention. We wanted to explore consume patterns and study the associations between khat use, traumatic experiences, and psychotic symptoms. Using privileged access sampling, we recruited 33 healthy male khat chewers and 15 comparable non-chewers. Based on extensive preparatory work, we assessed khat use, khat dependence according to DSM-IV, traumatic experiences, posttraumatic stress disorder (PTSD), and psychotic symptoms using standardized diagnostic instruments that had been adapted to the Somali language and culture. Hazardous use patterns like chewing for more than 24 h without interruption were frequently reported. All khat users fulfilled the DSM-IV-criteria for dependence and 85% reported functional khat use, i.e., that khat helps them to forget painful experiences. We found that the studied group was heavily burdened by traumatic events and posttraumatic symptoms. Khat users had experienced more traumatic events and had more often PTSD than non-users. Most khat users experience khat-related psychotic symptoms and in a quarter of them we found true psychotic symptoms. In contrast, among control group members no psychotic symptoms could be detected. We found first evidence for the existence and high prevalence of severely hazardous use patterns, comorbid psychiatric symptoms, and khat use as a self-medication of trauma-consequences among male Somali refugees in urban Kenyan refugee settlements. There is a high burden by psychopathology and adequate community-based interventions urgently need to be developed.
PMCID: PMC4075009  PMID: 25072043
khat; PTSD; psychotic symptoms; khat-related psychosis; Somali refugees in Kenya
19.  Sustainable effects of a low-threshold physical activity intervention on health-related quality of life in residential aged care 
Mobility is a main issue for health-related quality of life in old age. There is evidence for effects of physical activity (PA) interventions on several dimensions of health for the aged and also, some specific evidence for vulnerable populations, like residents of residential aged care. Research on low-threshold PA interventions for users of residential aged care and documentation of their sustainability are scarce. “Low threshold” implies moderate demands on the qualification of trainers and low frequency of conduct, implying low demands on the health status and discipline of users. Yet the investigation of low-threshold interventions in residential aged care seems important as they might foster participation of users and implementation in everyday routines of provider organizations. An initial study (October 2011 to June 2012) had found intervention effects on health-related quality of life. The objective of this study was to examine sustainability of the effects of a low-threshold PA intervention on health-related quality of life in residential aged care.
Data collection took place in three residential aged care homes in Vienna, Austria. At 1-year follow-up (June 2013), participants from the intervention group were interviewed using a standardized questionnaire. Using general mixed linear models and Friedman tests followed by paired t- and Wilcoxon signed-rank tests, we compared outcome measures at follow-up with measures obtained at baseline and at the end of the intervention.
At the 1-year follow-up assessment, participants’ (mean age 84.7 years; 89.7% female) subjective health status was still significantly increased, equaling a small sustainable intervention effect (Cohen’s d=0.38, P=0.02). In comparison with baseline, a significant decline of reported pain/discomfort (P=0.047) was found. Regarding the subdimensions of health-related quality of life, favorable trends could be observed.
The study indicates that effects of a low-threshold PA intervention on health-related quality of life in residential aged care can be sustainable. Addressing hindering factors like poor health status and implementing proactive support and individualization of the program to enable PA for residents might foster sustainability of effects.
PMCID: PMC4224093  PMID: 25395841
exercise group; long term care; effectiveness; follow-up; highly aged
20.  The effects of house moves during early childhood on child mental health at age 9 years 
BMC Public Health  2012;12:583.
Residential mobility is common in families with young children; however, its impact on the social development of children is unclear. We examined associations between the number, timing and type of house moves in childhood and child behaviour problems using data from an ongoing longitudinal study.
Complete data on residential mobility and child behaviour was available for 403 families. Three aspects of mobility were considered: (a) number of house moves from birth to <2 years, 2 to <5 years and 5 to 9 years; (b) lifetime number of house moves; and (c) moves associated with different housing trajectories characterized by changes in housing tenure. The primary outcomes were internalizing and externalizing behaviour problems at 9 years derived from Achenbach’s Child Behaviour Checklist. Linear regression analyses were used to investigate the effect of the housing variables on internalizing and externalizing behaviour problem scores with adjustment for a range of sociodemographic and household covariates.
Moving house ≥2 times before 2 years of age was associated with an increased internalizing behaviour score at age 9 years. This association remained after adjustment for sociodemographic and household factors. There was no association between increased residential mobility in other time periods and internalizing behaviour, or mobility in any period and externalizing behaviour. There was no effect of lifetime number of moves, or of an upwardly or downwardly mobile housing trajectory. However, a housing trajectory characterized by continuous rental occupancy was associated with an increased externalizing behaviour score.
These findings may suggest that there is a sensitive period, in the first few years of life, in which exposure to increased residential mobility has a detrimental effect on mental health in later childhood.
PMCID: PMC3490785  PMID: 22853693
Residential mobility; Child behaviour; Child development; Housing; Longitudinal studies
21.  Coming home to die? The association between migration and mortality in rural Tanzania before and after ART scale-up 
Global Health Action  2014;7:10.3402/gha.v7.22956.
Prior to the scale-up of antiretroviral therapy (ART), demographic surveillance cohort studies showed higher mortality among migrants than residents in many rural areas.
This study quantifies the overall and AIDS-specific mortality between migrants and residents prior to ART, during ART scale-up, and after widespread availability of ART in Rufiji district in Tanzania.
In Health and Demographic Surveillance System (HDSS), the follow-up of individuals aged 15–59 years was categorized into three periods: before ART (1998–2003), during ART scale-up (2004–2007), and after widespread availability of ART (2008–2011). Residents were those who never migrated within and beyond HDSS, internal migrants were those who moved within the HDSS, and external migrants were those who moved into the HDSS from outside. Mortality rates were estimated from deaths and person-years of observations calculated in each time period. Hazard ratios were estimated to compare mortality between migrants and residents. AIDS deaths were identified from verbal autopsy, and the odds ratio of dying from AIDS between migrants and residents was estimated using the multivariate logistic regression model.
Internal and external migrants experienced higher overall mortality than residents before the introduction of ART. After widespread availability of ART overall mortality were similar for internal and external migrants. These overall mortality experiences observed were similar for males and females. In the multivariate logistic regression model, adjusting for age, sex, education, and social economic status, internal migrants had similar likelihood of dying from AIDS as residents (adjusted odds ratio [AOR]=1.14, 95% confidence interval [CI]: 0.70–1.87) while external migrants were 70% more likely to die from AIDS compared to residents prior to the introduction of ART (AOR=1.70, 95% CI: 1.06–2.73). After widespread availability of ART with the same adjustment factors, the odds of dying from AIDS were similar for internal migrants and residents (AOR=1.56, 95% CI: 0.80–3.04) and external migrants and residents (AOR=1.42, 95% CI: 0.76–2.66).
Availability of ART has reduced the number of HIV-infected migrants who would otherwise return home to die. This has reduced the burden on rural communities who had cared for the return external migrants.
PMCID: PMC4032507  PMID: 24857612
residents; internal migration; external migration; rural-urban migrants; mortality; HIV; ART; ARV; Tanzania
22.  The impact of living arrangements and deinstitutionalisation in the health status of persons with intellectual disability in Europe 
Despite progress in the process of deinstitutionalisation, very little is known about the health conditions of people with intellectual disability (PWID) who live in large institutions and PWID living in small residential services, family homes or independent living within the community. Furthermore, there are no international comparison studies at European level of the health status and health risk factors of PWID living in fully staffed residential services with formal support and care compared with those living in unstaffed family homes or independent houses with no formal support.
A total of 1269 persons with ID and/or their proxy respondents were recruited and face-to-face interviewed in 14 EU countries with the P15, a multinational assessment battery for collecting data on health indicators relevant to PWID. Participants were grouped according to their living arrangements, availability of formal support and stage of deinstitutionalisation.
Obesity and sedentary lifestyle along with a number of illnesses such as epilepsy, mental disorders, allergies or constipation were highly prevalent among PWID. A significantly higher presence of myocardial infarctions, chronic bronchitis, osteoporosis and gastric or duodenal ulcers was found among participants in countries considered to be at the early stage of deinstitutionalisation. Regardless of deinstitutionalisation stage, important deficits in variables related to such medical health promotion measures as vaccinations, cancer screenings and medical checks were found in family homes and independent living arrangements. Age, number of people living in the same home or number of places in residential services, presence of affective symptoms and obesity require further attention as they seem to be related to an increase in the number of illnesses suffered by PWID.
Particular illnesses were found to be highly prevalent in PWID. There were important differences between different living arrangements depending on the level of formal support available and the stage of deinstitutionalisation. PWID are in need of tailored primary health programs that guarantee their access to quality health and health promotion and the preventative health actions of vaccination programs, systematic health checks, specific screenings and nutritional controls. Extensive national health surveys and epidemiological studies of PWID in the EC member states are urgently needed in order to reduce increased morbidity rates among this population.
PMCID: PMC3166640  PMID: 21726319
deinstitutionalisation; health; health indicators; intellectual disability; living arrangements
23.  A systematic mapping review of Randomized Controlled Trials (RCTs) in care homes 
BMC Geriatrics  2012;12:31.
A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.
A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.
3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.
This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.
PMCID: PMC3503550  PMID: 22731652
24.  Housing and neighborhood quality among undocumented Mexican and Central American immigrants 
Social science research  2013;42(6):10.1016/j.ssresearch.2013.07.011.
Extensive research has documented the challenges that undocumented immigrants face in navigating U.S. labor markets, but relatively little has explored the impact of legal status on residential outcomes despite their widespread repercussions for social well-being. Using data from the 1996–2008 panels of the Survey of Income and Program Participation to impute documentation status among Mexican and Central American immigrants, we examine group differences in residential outcomes, including homeownership, housing crowding, satisfaction with neighborhood and housing quality, problems with neighborhood crime/safety, governmental services, and environmental issues, and deficiencies with housing units. Results from our analysis indicate that undocumented householders are far less likely to be homeowners than documented migrants, and also live in more crowded homes, report greater structural deficiencies with their dwellings, and express greater concern about the quality of public services and environmental conditions in their neighborhoods. In comparison to native whites, undocumented migrants’ residential circumstances are lacking, but their residential outcomes tend to be superior to those of native-born blacks. Overall, our results highlight the pervasive impact of legal status on stratifying Mexicans’ and Central Americans’ prospects for successful incorporation, but also underscore the rigidity of the black/nonblack divide structuring American residential contexts.
PMCID: PMC3860281  PMID: 24090862
Undocumented migration; Legal status; Housing quality; Neighborhood quality; Residential attainment; Immigration
25.  Disparities in Use of Mental Health and Substance Abuse Services by Persons with Co-occurring Disorders 
Individuals with co-occurring mental and substance use disorders require psychiatric and substance abuse treatments. A critical question is whether these individuals are treated for both disorders.
This study prospectively examined 24-month service utilization patterns of 224 persons with co-occurring disorders who were recruited from crisis residential programs in the mental health treatment system (N=106) and from crisis residential detoxification programs in the substance abuse treatment system (N=118) in San Francisco. Utilization data were collected from the billing-information systems of both treatment systems. Demographic and clinical data were obtained in interviews with participants. Data were analyzed for group differences with chi square tests and logistic, linear, and zero-truncated negative binomial regression.
After the analyses controlled for demographic and clinical factors, participants recruited from the substance abuse treatment system were less likely than those from the mental health treatment system to obtain any mental health services, mental health day treatment, transitional residential care, case management, and other outpatient services (p<.001 for all comparisons). They were more likely to obtain crisis residential detoxification (p=.003), had more days of drug residential treatment (p=.028), but received fewer hours of outpatient services (p=.012).
There were disparities in patterns of service utilization, although there were no significant diagnostic differences between the two groups. These findings should be valuable in considering systems development and modification. Furthermore, they can contribute to research about factors that underlie results. Study replications should be conducted to assess the robustness of these findings in other locales. (Psychiatric Services 60:217–223, 2009)
PMCID: PMC4065170  PMID: 19176416

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