Linda Piwowarczyk

Prevalence of torture survivors among foreign-born patients presenting to an urban ambulatory care practice

AbstractBACKGROUND: The prevalence of torture among foreign-born patients presenting to urban medical clinics is not well documented. OBJECTIVE: To determine the prevalence of torture among foreign-born patients presenting to an urban primary care practice. DESIGN: A survey of foreign-born patients. PATIENTS: Foreign-born patients, age ≥ 18, presenting to the Primary Care Clinic at Boston Medical Center. MEASUREMENTS: Self-reported history of torture as defined by the UN, and history of prior disclosure of torture. RESULTS: Of the 308 eligible patients, 88 (29%) declined participation, and 78 (25%) were not included owing to lack of a translator. Par ticipants had a mean age of 47 years (range 19 to 76), were mostly female (82/142, 58%), had been in the United States for an average of 14 years (range 1 month to 53 years), and came from 35 countries. Fully, 11% (16/142, 95 percent confidence interval 7% to 18%) of participants reported a history of torture that was consistent with the UN definition of torture. Thirty-nine percent (9/23) of patients reported that their health care provider asked them about torture. While most patients (15/23, 67%) reported discussing their experience of torture with someone in the United States, 8 of 23 (33%) reported that this survey was their first disclosure to anyone in the United States. CONCLUSION: Among foreign-born patients presenting to an urban primary care center, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture may have significant psychological and physical sequelae, these data underscore the necessity for primary care physicians to screen for a torture history among foreign-born patients.

Asylum seekers seeking mental health services in the United States: clinical and legal implications

Asylum seekers flee their countries in search of safety due to persecution at home. Characteristics were assessed of 134 consecutive asylum seekers who sought mental health services at a program caring for survivors of torture and refugee trauma, using a chart review of patients seen between January 1999 and December 2002. Two-thirds of the sample were female, and 82% came from Africa. Eighty-four percent of the sample reported a history of torture, and one-half experienced rape or attempted rape. Most common diagnoses included posttraumatic stress disorder and depression. Predictors of torture included: posttraumatic stress disorder [odds ratio (OR) = 4.93, p = 0.03], rape (OR = 4.23, p = 0.035), and political persecution (OR = 9.28, p = 0.006). Most common self-reported health problems were headaches (29.9%), sexual dysfunction (26.1%), chronic pain (12.7%), and gastrointestinal symptoms (11.2%).

Congolese and Somali beliefs about mental health services.

Abstract Despite high levels of traumatic exposure, refugees often do not seek mental health services upon resettlement. The purpose of this study was to examine both concepts of mental illness in addition to attitudes and beliefs about treatment as well as potential barriers to accessing mental health services. To that end, qualitative research was done using focus groups with Congolese and Somali men and women in the United States (n = 48) in addition to a community survey with women from those communities (n = 296) administered by staff of a community-based organization. Mental health concerns, although identified, were often dealt with first in the communities themselves with the help of family or friends. Great emphasis was placed on their respective communities of faith. The actual role of mental health professionals was not well understood, and there was apparent hesitancy to use services, which also relates to issues of stigma.

Impact of September 11 on Refugees and Those Seeking Asylum

September 11, 2001 profoundly affected the American public. We share the views of a cohort of refugees and those seeking asylum from the Boston Center for Refugee Health and Human Rights. Of the 63 individuals from 18 countries interviewed, many had concerns about their personal safety following September 11, as well as fears related to deportation, arrest, detention, imprisonment, discrimination, physical violence and the destruction of property, and war. Asylum seekers were more likely than refugees to have concerns about their safety before their departure and during flight, as well as fear deportation and arrest after September 11. In the wake of September 11, most common coping strategies utilized included prayer (77.8%), speaking with friends from their own social group (47.6%), family (44.4%), and belief in fate (42.9%).

Torture and Public Health

Historically, the practice of torture focused on the dyad of the torturer and his or her victim in the quest to obtain information. In the past few decades it has become clear that the impact of torture is far beyond the individual and includes society as a whole. The practice of torture is an attempt to instill fear in the community, not merely to oppress a single individual, and as such, the public health impact of torture is far reaching. In response to increasing recognition of torture as a public health problem, a field of research is evolving which seeks how best to help survivors. International law has also provided mechanisms to hold perpetrators accountable. However, the ultimate human rights and public health goal is to prevent torture from occurring at all.

Learning from UJAMBO: Perspectives on Gynecologic Care in African Immigrant and Refugee Women in Boston, Massachusetts

African-born immigrant women, and particularly refugees and asylum seekers, are at risk for reproductive health disparities but inadequately use relevant gynecologic services. We sought to elucidate perspectives on gynecologic care in a population of Congolese and Somali immigrants. We conducted a secondary qualitative analysis of focus group data using a grounded theory approach and the Integrated Behavioral Model as our theoretical framework. Thirty one women participated in six focus groups. Participant beliefs included the states of pregnancy and/or pain as triggers for care, preferences included having female providers and those with familiarity with female genital cutting. Barriers included stigma, lack of partner support, and lack of resources to access care. Experiential attitudes, normative beliefs, and environmental constraints significantly mediated care preferences for/barriers to gynecologic health service utilization in this population. Centering of patient perspectives to adapt delivery of gynecologic care to immigrants and refugees may improve utilization and reduce disparities.