Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

doi:10.21203/rs.3.rs-1646083/v1

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Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-1646083/v1

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Background: Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to assess the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

Methods: Cross-sectional, postal survey questionnaire. Inclusion criteria: ≥18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n=902 participated (participation rate ≈10%). CP measured with 10 items on pain lasting for ≥3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

Results: The overall prevalence of severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and depression) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

Conclusion: The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees’ health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

Trial registration: NCT03742128

refugees

Syria

mental health

pain

anxiety

depression

PTSD

functional impairment

A substantial body of evidence across various settings and populations has documented the close interconnectedness of psychological distress and somatic symptoms in general (1–3), and pain in particular (4–7). The underlying mechanisms behind the frequent co-occurrence of psychological distress and pain are complex, likely bidirectional and involve both genetic and environmental factors (7, 8). For traumatized individuals with post-traumatic stress symptoms, the experience of elevated levels of pain is thought to be linked to disturbances in the processing of pain stimuli (pain sensitization); hypermnesia or overconsolidation of traumatic memories (imprinting); and synergistic physiological effects between trauma-related anxiety and pain perception. Transcultural psychiatric approaches stress the importance of sociocultural elements when investigating psychological and somatic symptoms across populations and the need to understand local illness models and idioms of distress (9–11). Within this framework, variations in patterns of co-occurrence across ethnocultural groups documented in some studies are at least partly explained by cultural differences in how distress is experienced, represented and expressed, and relatedly, by fear of stigmatization (12–14).

Refugees are often exposed to a number of potentially traumatic experiences both before and during flight, and many experience post-migration hardships after resettling in a new country. The cumulative load of these stressors increases refugees’ risk of mental ill health (15–18). Elevated rates of post-traumatic stress disorder (PTSD), depression and anxiety have repeatedly been found in refugee populations (e.g., 19,20). High levels of pain have also been documented in studies on selected refugee groups – e.g. war-wounded refugees, refugees exposed to torture and refugees in clinical settings (21–25). However, studies on pain in general refugee populations are scant. One recent, two-wave, longitudinal study on resettled Syrian refugees in Norway found chronic pain to be fairly constant over time at around 30% (26), and pain was found to be frequently reported among refugees from Syria residing in Turkey (27) and among Rohingya refugees in Bangladesh (28).

In a work commissioned by the UNHCR on culture, context and the mental health and psychosocial well-being of Syrians from 2015, Hassan et al. note that “…most Arabic and Syrian idioms of distress do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (p. 22 in 29). They further note potential stigma against expressing certain negative emotions, especially in men and if emotions are labeled as ‘psychological’ or ‘psychiatric’. The issue of stigma against negative emotions is also pointed out by other researchers working with Arab populations (12). As a consequence, it has been noted that physical symptoms may be the initial and predominant presenting complaints for people with psychological or mental health issues (29). With several studies documenting a high burden of mental ill health among refugees from Syria in recent years (for an overview, please refer to 30), it seems vital, therefore, to expand knowledge on the co-occurrence and possible relationship of psychological and somatic symptoms in this population. This could be of value to healthcare providers by sensitizing them to the complex manifestations of distress, which in turn could help ensure needs are recognized and addressed adequately. Yet, there is notable shortage of studies addressing this topic, both among refugees from Syria and among other refugee populations.

The present study focuses on pain and the co-occurrence of pain and psychological distress in a general refugee population. Nonetheless, due to the limited number of studies on this topic, relevant evidence from a broader range of somatic symptoms, including the category formerly known as “somatoform disorders” in the DSM diagnostic systems, is at times included. Pain is both a central feature of most instruments used to measure somatic distress/somatization and one of the most frequently reported somatic symptoms in refugee populations (e.g., 27,31). Moreover, evidence suggests symptom groups (e.g. musculoskeletal, gastrointestinal) do not show differential association with psychological distress (1). Importantly, the “somatoform disorders” have been reconceptualized in the most recent versions of both major diagnostic frameworks (DSM-V and ICD-11), partly to remove “medically unexplained symptoms” as a diagnostic criterion, which was thought to be unreliable, stigmatizing to patients and ‘perilous in its reliance on mind-body dualism’ (p. 233 in 32). The latter point may be particularly relevant in the context of illness models with a less dichotomous understanding of body and mind. Therefore, evidence from studies on somatic distress/somatization in refugee populations should be interpreted with care. Interpretations must incorporate an understanding of and appreciation for local idioms and explanatory models of distress, and, even if no medical explanation is found for somatic symptoms, that does not mean that none exists (33). For example, many refugees have been exposed to torture which can have long-term consequences for, and a complex relationship with, pain (34, 35).

We have only identified one study exploring psychological distress and pain in a general refugee population, which was conducted on Syrian refugees resettled in Norway (36). Interestingly, the study found no associations between pain and mental ill health (i.e. anxiety, depression and PTSD) in the first wave of the study, when refugees were still residing in Lebanon, awaiting resettlement. However, fairly strong associations were found at the follow-up measurement about a year after resettlement. The latter finding is broadly supported by three recent and large cross-sectional studies on refugees and war-displaced persons which found clear associations between anxiety, depression and PTSD and somatic distress, as measured by the Patient Health Questionnaire (PHQ-15), where pain is a core component (27, 37, 38). Further support comes from a matched control study on Bhutanese torture survivors, which found that somatic complaints were associated with PTSD and depression (39), and from studies on clinical subsamples documenting close links between pain and mental ill health (24, 40–42).

The associations of pain with functional impairment and perceived general health are also understudied in refugee populations. The degree of pain experienced by severely traumatized and tortured refugees and the associated level of functional disability has been shown to be substantial compared to many non-refugee groups suffering from pain conditions (42, 43). Pain has also been strongly linked to low health-related wellbeing among female Yazidi refugees who experienced extreme violence by the “Islamic state” (31). Furthermore, in a general population of conflict-affected persons in the Republic of Georgia, somatic distress was strongly associated with increased functional disability, even after controlling for mental ill health (37). We know of no prior study that has investigated functional impairment in relation to pain and mental ill health (i.e. anxiety, depression and PTSD) in refugees.

An abundance of evidence from both refugee and non-refugee populations has documented that pain conditions and somatic distress/somatization are substantially more prevalent in women (e.g., 27,37,38,44,45), suggesting studies on this topic should investigate and report gender-specific patterns. This aligns with general recommendations for research on refugees which emphasize the importance of exploring the role of gender across studies, as this has been insufficiently prioritized in the past (20, 46). Recent evidence suggests gender is a key moderating factor between various migration-related stressors and mental health (47–49).

Using cross-sectional questionnaire data from adult refugees from Syria resettled in Norway, the primary aims of the present study were to assess the burden of chronic pain in this population and to explore the associations of chronic pain with anxiety, depression and PTSD. Secondary aims included to investigate unique and overlapping associations of chronic pain and mental health with perceived general health and functional impairment, and to test gender as an effect modifier in the above associations.

The primary aims were broadly outlined in the study’s pre-registration in ClinicalTrial.gov (NCT03742128, 15/11/2018)), though some data-handling decisions were made with data in-house and deviated slightly from the registered plan. All regression models were built with data at hand, and secondary aims were developed post-hoc, meaning these are hypothesis-generating rather than hypothesis-testing even if they are rooted in theory and prior research (50, 51).

Design and participants

The present study used a questionnaire-based cross-sectional design. Eligible participants included all adult (≥ 18 years old) refugees from Syria who were granted temporary or permanent residency in Norway between 2015 and 2017. A complete list of eligible participants was obtained from the population registry in Norway (N = 14,350), and from this list, 10,000 individuals were randomly sampled for participation. All sampled participants were sent a study invitation letter together with the actual questionnaire and an informed consent form to be signed and returned with the questionnaire, all in formal Arabic. The letter also contained contact information in the event of adverse reactions following participation. The invitations were sent out in November 2018. Due to a low response rate, the study did not close until September 2019. Several efforts were made to boost participation including one postal or telephone reminder to all non-responders. The Regional Committees for Medical and Health Research Ethics (REK) – Region Southeast (A) in Norway granted ethical approval for the study (reference number 2017/1252). All parts of the study were conducted in accordance with the protocol approved by REK and in line with relevant regulations.

Variables and measurements

Chronic pain (CP): questions on CP consisted of two parts. The first part concerned musculoskeletal pain- and stiffness and was taken from the Tromsø Study which has been used extensively in the last decades in many large epidemiological studies in Norway (e.g., 52,53). Specifically, participants were asked to indicate whether they had been troubled with pain or stiffness in muscle and joints for a minimum of three consecutive months in the last year. The question was asked for five different body regions (neck/shoulders; arms/hands; upper back; lower back; hips/legs/feet), all with the same three answer choices provided: not troubled (= 1); somewhat troubled (= 2); very troubled (= 3). In the second part, participants were asked to indicate whether they had been troubled with pain for more than three consecutive months in the last year in five other body regions (stomach; head; genital area; chest; other), using the same answer choices. These items were also based on the Tromsø study, though slight adapted. For each of the two parts, participants who answered 1 (not troubled) on all items and had a maximum of one missing, were categorized as “no CP”. Participants who answered at least one item with 2 (somewhat troubled) or 3 (very troubled), were categorized as “some CP” or “severe CP”, respectively, regardless of the number of missing. The two parts were then combined for an overall Chronic pain variable with 3 categories coded as follows: “No CP” = “not troubled” for both parts; “Some CP” = at least one part with “somewhat troubled” (and no part with “very troubled”); and “Severe CP” = at least one part with “very troubled”.

Perceived general health (PGH): question adapted from the European Social Survey 2010 (54). The question asks “How is your health in general” and provides six answer choices: very poor (= 1); poor (= 2); fair (= 3); good (= 4); very good (= 5) and don’t know (= 6). The variable was dichotomized into “Good PGH” (answer choices 4 and 5) and “Poor PGH” (answer choices 1–3). The “don’t know” category was recoded as missing.

Functional impairment (FI): question adapted from the European Social Survey 2010 (54). The question asks: “Are you hampered in your daily activities in any way by any longstanding illness, or disability, infirmity or mental health problem?”. There are four possible answer choices provided: no (= 1); yes, to some extent (= 2); yes, a lot (= 3); and don’t know (= 4).This variable was dichotomized into “No FI” (answer choice 1) vs. “Some/a lot FI” (answer choices 2 and 3), whereas the “don’t know” category was recoded as missing.

Mental ill health

symptoms of anxiety and depression were measured with the 25 item Hopkins Symptom Checklist, HSCL-25 (55), whereas PTSD symptoms were measured by the Harvard Trauma Questionnaire (HTQ) (56). The first ten items of HSCL-25 measure anxiety and the last 15 depression. All items are scored on a 4-point scale from 1 (“not at all”) to 4 (“extremely”). A mean-item score was estimated for participants with < 3 missing on each subscale, and two dichotomized variables, HSCL-anxiety and HSCL-depression, were created based on cut-offs of 1.75 and 1.80 for anxiety and depression, respectively (57). The 16 items used from the HTQ (section IV) are also scored from 1 (“not at all”) to 4 (“very much”), and a mean-item score was created for those with < 3 missing. A dichotomized HTQ-PTSD variable was created to indicate those with screen-positive PTSD using a cut-off of 2.06 (57). Both scales have been wildly used to measure mental health problems in refugees, and several studies have supported the scales’ validity and reliability across different refugee populations (e.g., 57–59).

Potentially traumatic experiences (PTEs): PTEs prior to- and during flight was measured with the Refugee Trauma History Checklist (RTHC), created and validated by Sigvardsdotter and colleagues (60, 61). The scale asks about eight PTEs prior to flight (“War at close quarter”, “Torture”) and the same PTEs during flight for a total of 16 items. Each item is answered with Yes/No. A new variable named PTE-adversity ratio (PTE-AR) was created based on the work by Steel et al. (15), which equaled the number of endorsed items (i.e. “Yes”) divided by 16. The variable was categorized into four groups: <0.2; 0.2–0.29; 0.3–0.39; and ≥ 0.4.

Sociodemographic and background variables: age and gender were obtained from Norwegian registry data, with age categorized into 18–29 years; 30–39 years; 40–49 years; 50–64 years; and ≥ 65 years in line with the study’s pre-registration. Self-reported data was used for marital status (categorized into: unmarried; married/registered partner; and divorced/separated/widow(er), years of education (categorized into: ≤9 years; 10–12 years; and > 12 years), refugee status (asylum seeker; quota refugee; and family reunion), and immigration year (categorized into: 2010–2015; 2016; and 2017).

The items used to measure CP, PGH, functional impairment and sociodemographic/background variables were translated into Arabic using a professional translation bureau. The translation was subsequently checked by two independent translators and discussed with an Arabic speaking reference group from Syria residing in Norway. The translations of the HSCL, HTQ and RTHC scales were obtained from collaborators at the Swedish Red Cross University College in Sweden, who used double-blind and back-translation procedures in addition to interviews with Arabic-speakers to ensure validity (62).

Statistical analysis

Data was first inspected for errors, outliers, missing and distributional properties. Frequency distributions and cross tabulations with chi-square test of equal proportions were used to make descriptive tables and investigate bivariate associations. Ordered and regular logistic regression models were used to investigate the secondary aims of the study. All regression models were built in a forward manner, with sociodemographic/background variables only included in adjusted models if they were associated with the respective outcomes in bivariate analyses (p-value < 0.05). Gender, age and PTE-AR were included in adjusted models for a priori reasons regardless of bivariate association. The PTE-AR categories 0.20–0.29 and 0.30–0.39 and the immigration year categories 2016 and 2017 were combined in regression analysis due to few observations in the individual categories. Due to a fairly high number with missing data across variables, the regression analyses were done on imputed data. The imputed values were obtained using multiple imputation by chained equations, MICE (63), with all variables included in the imputation model.

Crude and adjusted ordered logistic regressions were used to investigate the associations of anxiety, depression and PTSD with CP. The odds ratios (ORs) presented indicate the odds of being in the higher category of CP for different predictor levels, regardless of which of the two possible ways CP is dichotomized – i.e. (3 and 2) vs. 1 or 3 vs. (2 and 1). Crude and adjusted logistic regressions were used to investigate the association of mental health variables and CP with perceived general health and functional impairment. Spearman’s rank correlation was used to investigate possible multicollinearity between mental health variables and CP (deemed problematic if > 0.7)

The Wald test for interaction was used to test whether gender modified the associations of mental ill health with CP, and/or the associations of mental ill health and CP with perceived general health and functional impairment.

Analyses were performed with Stata version 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC).

Of the roughly 10,000 invitations for participation sent out, 1,235 were returned due to incorrect address. Of those who presumably received the invitation, 902 participated, giving a response rate of about 10%. Participants were older and a higher proportion were married compared to the sample populations, though there was no difference in gender distribution. For further statistics relating to representativity and possible selection bias problems, we refer to a prior publication (64). Overall, 64.5% of participants were men, with a mean age of 38.9 (SD = 11.6; min. age = 19; max. age = 83). The degree of exposure to PTEs was high with over 50% in the highest category (affirmative on ≥ 40% of individual PTEs inquired about). Men reported more PTEs than women (Chi-square test of equal PTE-AR across gender: p-value = 0.01). The unweighted prevalence of anxiety, depression and PTSD based on screening instruments were 31.7%, 40.0% and 34.7%, respectively, with no statistically significant difference between genders at the p = 0.05 threshold. Table 1 gives further descriptive statistics for all participants and stratified by gender.

Table 1

Descriptive statistics, all respondents and stratified by gender (n = 902)
		All respondents		Stratified by gender
				Men (n = 582)		Women (n = 320)
		n	(%)	n	(%)	n	(%)
Age (n = 902)	18–29 yrs	197	( 21.8)	119	(20.5)	78	(24.4)
	30–39 yrs	310	( 34.4)	205	(35.2)	105	(32.8)
	40–49 yrs	230	( 25.5)	144	(24.7)	86	(26.9)
	≥ 50	165	( 18.3)	114	(19.6)	51	(15.9)
Education (n = 882)	≤ 9 yrs	394	(44.7)	244	(43.0)	150	(47.8)
	10–12 yrs	158	(17.9)	91	(16.0)	67	(21.3)
	> 12 yrs	330	(37.4)	233	(41.0)	97	(30.9)
Marital status (n = 902)	Unmarried	236	(26.1)	199	(34.2)	37	(11.6)
	Married/partner	595	(66.0)	349	(60.0)	246	(76.9)
	Divorced/wid.	71	(7.9)	34	(5.8)	37	(11.6)
Refugee status (n = 860)	Asylum seeker	454	(52.8)	366	(65.8)	88	(29.0)
	Quota refugee	273	(31.7)	154	(27.7)	119	(39.1)
	Family reunion	133	(15.5)	36	(6.5)	97	(31.9)
Immigration year (n = 856)	2010–2015	509	(59.5)	394	(71.4)	115	(37.8)
	2016	163	(19.0)	72	(13.0)	91	(29.9)
	2017	184	(21.5)	86	(15.6)	98	(32.2)
PTE-AR (n = 819)	< 0.20	163	(19.9)	92	(17.4)	71	(24.5)
	0.20–0.29	79	(9.7)	44	(8.3)	35	(12.1)
	0.30–0.39	158	(19.3)	103	(19.5)	55	(19.0)
	≥ 0.40	419	(51.1)	290	(54.8)	129	(44.4)
HSCL-anxiety (n = 886)	No	605	(68.3)	403	(70.3)	202	(64.5)
	Yes	281	(31.7)	170	(29.7)	111	(35.5)
HSCL-depression (n = 877)	No	526	(60.0)	344	(60.3)	182	(59.5)
	Yes	351	(40.0)	227	(39.7)	124	(40.5)
HTQ-PTSD (n = 877)	No	573	(65.3)	361	(64.0)	212	(67.7)
	Yes	304	(34.7)	203	(36.0)	101	(32.3)
PTE-AR = Potentially Traumatic Experiences-Adversity Ratio; HSCL-anxiety mean score > 1.75; HSCL-depression mean score > 1.80; HTQ-PTSD mean score ≥ 2.06.

Table 2 shows the frequency distributions of CP, PGH and FI, and bivariate associations with predictors/covariates of interest. For the total sample, 43.1% reported severe CP, 39.9% poor PGH and 34.9% at least some degree of FI. Being a woman was positively associated with CP and poor PGH, but not FI. There was very strong evidence (p-value < 0.001) that anxiety, depression and PTSD were associated with elevated levels of CP, poor PGH and FI in bivariate analyses.

Table 2

Prevalence of chronic pain†, perceived overall health and impaired daily functioning due to longstanding illness
		Chronic pain^† (%)				Perceived general health (%)			Impaired functioning (%)
		No	Some	Severe	χ²	Very good/good	Fair/poor/very poor	χ²	No	Some/a lot	χ²
Total sample		19.8	37.1	43.1		60.1	39.9		65.1	34.9
Gender	Men	22.3	37.5	40.2	0.013	63.0	37.0	0.022	65.8	34.2	0.605
	Women	15.2	36.2	48.6		54.9	45.1		64.0	36.0
Age	18–29 yrs	31.3	37.4	31.3	< 0.001	77.9	22.1	< 0.001	80.6	19.4	< 0.001
	30–39 yrs	22.6	39.5	37.9		67.5	32.5		70.4	29.6
	40–49 yrs	15.5	37.2	47.3		56.4	43.6		65.4	34.7
	≥ 50	6.8	31.7	61.5		30.4	69.6		39.1	60.9
Education	≤ 9 yrs	15.5	37.5	47.0	0.061	54.3	45.7	0.007	60.1	39.9	0.028
	10–12 yrs	22.6	36.8	40.6		61.9	38.1		67.7	32.3
	> 12 yrs	23.3	37.1	39.6		65.8	34.2		70.0	30.0
Marital status	Unmarried	28.2	35.9	35.9	< 0.001	70.6	29.4	< 0.001	70.9	29.1	0.005
	Married/partner	18.6	37.9	43.5		58.4	41.6		65.0	35.0
	Divorced/widowed	2.9	33.3	63.8		38.7	61.3		48.4	51.6
Refugee status	Asylum seeker	21.6	39.1	39.3	0.211	61.5	38.5	0.806	69.7	30.3	0.098
	Quota refugee	16.7	35.2	48.1		59.2	40.8		61.5	38.5
	Family reunion	21.1	36.0	42.9		61.9	38.1		67.8	32.2
Year immigration	2010–2015	20.9	37.3	41.8	0.024	61.6	38.4	0.042	66.8	33.2	0.103
	2016	16.8	28.5	54.7		51.3	48.7		57.8	42.2
	2017	19.6	41.9	38.5		63.5	36.5		67.9	32.1
PTE-AR	< 0.20	30.2	39.0	30.8	< 0.001	70.9	29.1	< 0.001	79.9	20.1	< 0.001
	0.20–0.29	25.6	37.2	37.2		70.1	29.9		73.0	27.0
	0.30–0.39	20.5	40.4	39.1		62.8	37.3		67.7	32.4
	≥ 0.40	14.9	34.7	50.4		51.9	48.1		55.8	44.2
HSCL-anxiety	No	26.8	43.0	30.2	< 0.001	71.9	28.1	< 0.001	78.7	21.3	< 0.001
	Yes	5.4	25.1	69.5		34.6	65.4		35.5	64.5
HSCL-depression	No	28.1	45.1	26.8	< 0.001	75.5	24.5	< 0.001	81.2	18.8	< 0.001
	Yes	8.0	25.2	66.8		36.7	63.3		40.0	60.0
HTQ-PTSD	No	27.2	43.5	29.3	< 0.001	73.2	26.8	< 0.001	79.7	20.3	< 0.001
	Yes	6.3	25.6	68.1		34.1	65.9		36.3	63.7
PTE-AR = Potentially Traumatic Experiences-Adversity Ratio; HSCL-anxiety mean score > 1.75; HSCL-depression mean score > 1.80; HTQ-PTSD mean score ≥ 2.06. ^† Chronic pain (CP) was measured through 10 items answered on a 3-point Likert scale (no/somewhat/very troubled) and categorized into 3 groups: no CP (“no” on all 10 items); some CP (“somewhat troubled” on at least one item and no item as “very troubled”); and severe CP (“very troubled” on at least one item). All items asked about pain lasting for at least 3 months in the last year

Table 3 presents crude and adjusted ordered logistic regression models of CP. Being a woman was associated with roughly 50% higher odds of CP in both unadjusted and adjusted models (OR_{fully adjusted}=1.55; 95% CI 1.13–2.12). There was very strong evidence in both crude and adjusted models that all mental ill health variables (i.e. anxiety, depression and PTSD) were associated with increased odds of CP (anxiety: OR_{fully adjusted}=2.42, 95% CI 1.64–3.55; depression: OR_{fully adjusted}=2.28, 95% CI 1.53–3.42; and PTSD: OR_{fully adjusted}=1.97, 95% CI 1.32–2.94). Wald test for interaction between gender and each of mental ill health variables did not reach statistical significance, though there was a tendency for a stronger association of anxiety with CP in women (p-value = 0.085).

Table 3

Crude and adjusted ordered logistic regression models of chronic pain†
		Unadjusted		Partially adjusted						Fully adjusted
		Model 1		Model 2a		Model 2b		Model 2c		Model 3
		uOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	Wald‡
Gender‡	Women	1.46b	(1.13–1.89)	1.57b	(1.15–2.14)	1.55b	(1.14–2.12)	1.79c	(1.31–2.43)	1.55b	(1.13–2.12)
HSCL-Anxiety‡	Yes	5.45c	(4.04–7.35)	5.17c	(3.76–7.11)					2.42c	(1.64–3.55)	0.085
HSCL-Dep‡	Yes	5.46c	(4.12–7.23)			5.30c	(3.91–7.18)			2.28c	(1.53–3.42)	0.134
HTQ-PTSD‡	Yes	5.09c	(3.81–6.79)					4.90c	(3.57–6.73)	1.97b	(1.32–2.94)	0.536
Age	30–39 years	1.47a	(1.05–2.05)	1.62a	(1.11–2.37)	1.51a	(1.03–2.22)	1.57a	(1.07–2.30)	1.56a	(1.06–2.29)
	40–49 years	2.19c	(1.52–3.14)	2.53c	(1.64–3.92)	2.24c	(1.45–3.46)	2.28c	(1.47–3.53)	2.36c	(1.52–3.67)
	≥ 50 years	3.90c	(2.60–5.85)	3.90c	(2.37–6.41)	3.61c	(2.20–5.94)	3.77c	(2.30–6.19)	3.58c	(2.17–5.91)
Marital status	Married/partner	1.49b	(1.12–1.97)	0.97ns	(0.67–1.40)	1.07ns	(0.74–1.56)	0.98ns	(0.67–1.42)	1.13	(0.78–1.65)
	Prev. married§	3.73c	(2.19–6.36)	1.92a	(1.03–3.59)	1.90a	(1.02–3.56)	1.92a	(1.03–3.58)	2.12a	(1.12–3.99)
Immigration year	2016/2017	1.17	(0.90–1.50)	1.06ns	(0.79–1.42)	1.18ns	(0.88–1.59)	1.06ns	(0.79–1.42)	1.17	(0.86–1.58)
PTE-AR	0.20–0.39	1.44	(1.00−2.07)	1.34ns	(0.92–1.95)	1.33ns	(0.91–1.94)	1.21ns	(0.83–1.76)	1.21	(0.83–1.78)
	≥ 0.40	2.41c	(1.72–3.38)	1.65b	(1.15–2.36)	1.52a	(1.06–2.19)	1.41ns	(0.98–2.03)	1.26	(0.87–1.82)
Reference groups: men (gender); no (mental health variables); 18–29 years (age); unmarried (marital status); 2010–2015 (Immigration. year); <0.20 (PTE-AR) † Chronic pain (CP) was measured through 10 items answered on a 3-point Likert scale (no/somewhat/very troubled) and categorized into 3 groups: no CP (“no” on all 10 items); some CP (“somewhat troubled” on at least one item and no item as “very troubled”); and severe CP (“very troubled” on at least one item) ‡ Interaction between gender and each of the three mental health variables was tested using Wald test of H₀ = no interaction (ns = p > 0.10). Interactions were tested sequentially – i.e., only one interaction term was tested at a time. § Category included: divorced/separated/widow(er) a p < 0.05 b p < 0.01 c p < 0.001

The mean score for perceived general health (PGH) was 3.614 (SD = 1.063). Table 4 summarizes logistic regression models of PGH (poor = 1 vs. reference group good = 0), focusing on the predictors gender, mental ill health and CP. Gender was not associated with PGH in fully adjusted models at the p = 0.05 level, though there was weak evidence in unadjusted and partially adjusted models. Anxiety, depression and PTSD were all strongly associated with PGH in crude models and fairly strong associations were also found in partially adjusted models which included background variables and all mental ill health variables (but not CP). However, in the fully adjusted model, there was only moderate evidence of an association for PTSD OR = 1.98 (95% CI 1.19–3.32); weak evidence for depression OR = 1.76 (95% CI 1.05–2.96); and no evidence for anxiety OR = 1.49 (95% CI 0.92–2.41). There was very strong evidence in all models, that both moderate (OR = 3.80, 95% CI 1.84–7.86) and severe CP (OR = 19.1, 95% CI 9.22–39.5) were associated with poor PGH. Gender did not modify the associations of mental health or CP with PGH.

Table 4

Crude and adjusted logistic regression models of poor perceived general health†
		Unadjusted		Partially adjusted§		Partially adjusted§		Fully adjusted§
		Model 1		Model 2		Model 3		Model 4
		uOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	Wald‡
Poor perceived general health
Gender‡	Women	1.43a	(1.08–1.90)	1.64a	(1.11–2.41)			1.48	(0.97–2.28)
HSCL-Anxiety‡	Yes	4.81c	(3.54–6.54)	2.03b	(1.31–3.17)			1.49	(0.92–2.41)	0.241
HSCL-Depression‡	Yes	5.21c	(3.89–6.97)	2.43c	(1.53–3.87)			1.76a	(1.05–2.96)	0.224
HTQ-PTSD‡	Yes	5.18c	(3.80–7.06)	2.37c	(1.49–3.77)			1.98b	(1.19–3.32)	0.192
Chronic pain‡	Some	5.70c	(2.83–11.5)			4.58c	(2.24–9.40)	3.80c	(1.84–7.86)	0.100
	Severe	42.9c	(21.4–86.1)			32.4c	(15.9–66.2)	19.1c	(9.22–39.5)	0.209
Reference groups: men (gender); no (mental health variables); no (somatic pain) † Perceived general health: fair/poor/very poor vs. good/very good. ‡ Interaction between gender and each of the three mental health variables were tested using Wald test of H₀ = no interaction. Interactions were tested sequentially in adjusted models (i.e. one interaction term was tested at a time) § Adjusted models controlled for age, education, marital status, immigration year, PTE-AR and other variables estimated in the model a p < 0.05 b p < 0.01 c p < 0.001

Table 5 shows functional impairment (FI) regressed on gender, mental ill health variables, CP and background variables (not shown in table) using logistic regression. Gender was not associated with FI in any model. Anxiety, depression and PTSD showed very strong associations with FI in crude models and fairly strong associations in partially adjusted models. In fully adjusted models, there was fairly strong evidence of interaction between gender and all mental ill health variables – i.e. the associations of anxiety, depression and PTSD with FI were gender specific. For women, there was no evidence of an association between any of the mental ill health variables and FI (Model 5: Women). In contrast, for men, there was very strong evidence that both anxiety and PTSD were associated with more than three times higher odds of FI. No association, however, was found between depression and FI in men. Severe CP was strongly associated with FI in all models, though moderate CP was not significantly associated with FI in the fully adjusted model. Finally, gender did not modify the association between CP and FI.

Table 5

Crude and adjusted logistic regression models of functional impairment†
		Unadjusted		Partially adjusted§		Partially adjusted§		Fully adjusted§		Gender-specific (fully adjusted§)
		Model 1		Model 2		Model 3		Model 4		Model 5
										Men		Women
		uOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	aOR	95% CI	Wald‡
Functional impairment
Gender‡	Women	1.09	(0.81–1.48)	1.11	(0.73–1.69)			0.93	(0.59–1.48)	NA		NA
HSCL-Anxiety‡	Yes	6.24c	(4.48–8.70)	2.79c	(1.75–4.46)			2.25b	(1.31–3.87)	3.23c	(1.71–6.10)	1.21	(0.56–2.61)	0.027
HSCL-Dep‡	Yes	5.70c	(4.15–7.85)	1.94b	(1.19–3.16)			1.25	(0.72–2.20)	1.83	(0.95–3.52)	0.66	(0.30–1.46)	0.024
HTQ-PTSD‡	Yes	6.22c	(4.42–8.76)	2.54c	(1.56–4.13)			2.12b	(1.21–3.71)	3.12c	(1.62–6.02)	1.12	(0.51–2.43)	0.023
Chronic pain‡	Moderate	3.88b	(1.62–9.3)			3.22a	(1.32–7.9)	2.50	(1.00−6.27)	2.50	(1.00−6.27)	2.50	(1.00−6.27)	0.385
	Severe	44.1c	(19.6–99.0)			35.6c	(15.5–81.5)	20.3c	(8.56−48.0)	20.3c	(8.56−48.0)	20.3c	(8.56−48.0)	0.704
Reference groups: men (gender); no (mental health variables); no (somatic pain) † Functional impairment (daily activities): some/a lot vs. no impairment ‡ Interaction between gender and each of the three mental health variables were tested using Wald test of H₀ = no interaction (ns = p > 0.10). Interactions were tested sequentially in adjusted models (i.e. one interaction term was tested at a time) § Adjusted models controlled for age, education, marital status, PTE-AR and other variables estimated in the model a p < 0.05 b p < 0.01 c p < 0.001

The present cross-sectional survey of adult refugees from Syria recently resettled in Norway is one of only a few studies investigating the burden of chronic pain (CP) and how it relates to mental ill health in a general refugee population. The study found high levels of CP and clear associations between CP and mental ill health (i.e. anxiety, depression and PTSD). Being a woman was associated with higher odds of CP and there was some evidence that gender acted as an effect modifier in the links between mental ill health and functional impairment (FI). Specifically, findings suggested a strong association of anxiety and PTSD with functional impairment in men, though not in women.

The prevalence of CP in the present sample, estimated at 43.1%, is moderately higher than that found by Strømme et al. in their studies on resettled adult refugees from Syria in Norway, where CP was reported by about 30% of participants both at baseline and follow-up one year later (26). One possible explanation for this difference is that the study by Strømme et. al. measured CP with a single item whereas our measure was more comprehensive. Another possible explanation is the higher degree of exposure to potentially traumatic experiences (PTEs) and elevated levels of mental ill health in our sample compared with the sample in Strømme et. al. Our collaborating project in Sweden, with very similar study population, methodology and prevalence estimates of mental ill health (62, 65), however, also found that close to 30% of participating refugees experienced pain/discomfort at moderate/severe/extreme levels. Though, in the Swedish survey, pain was also measured by a single item from the standardized EQ-5D questionnaire developed by the EuroQol Group (66). Furthermore, the EQ-5D item does not specify any body region and asks about pain today – i.e. the chronicity of pain is not investigated. Perhaps of some comparative value, another large study on Syrian refugees in Turkey found that almost 40% reported pain causing distress in both “arms, legs or joints” and “back” based the PHQ-15 (27). However, the questionnaire-based level of anxiety differed slightly from our sample (34.7% vs. 30.1% respectively), and the levels of depression and PTSD were notably lower (36.5% vs. 45.2% and 19.6% vs. 29.7%, respectively). Our estimate for CP is considerably lower than estimates from studies on clinical or torture-exposed samples of refugees, which typically lie between 60% and 90% (21, 22, 24, 28, 67). However, the prevalence of severe CP among those reporting exposure to torture in our study (n = 231) was 57.8% (not shown in tables). As pain is a known long-term sequela of torture (e.g. 35), higher levels of CP among torture-exposed refugees is unsurprising.

Interestingly and importantly, the percentage with severe musculoskeletal pain/complaints (i.e. the first five items of the CP measure) in our study was markedly higher than that found for the Norwegian general population using the “identical” measure: 35.2% vs 15.8% (see Additional file 1). Since one item, “pain in other regions”, was left out in our study, the true difference is likely even larger. Part of the reason for the notably higher prevalence in refugees may be related to poor transcultural construct validity of the instrument used to measure pain – i.e. “pain” may be understood and communicated differently in different cultures, including in Syrians (68, 69). Another possible and related reason given local idioms of distress and social pressures against expressing negative feelings, is that the high level of pain reflects a more culturally acceptable expression of distress (12). Alternatively, it represents a fairly accurate and transculturally valid prevalence of chronic musculoskeletal pain as conceptualized and operationalized in the measure used to operationalize pain in the present study. Given the known and strong links between pain and psychopathology (e.g. 4) and the high levels of mental ill health in the study population as highlighted above, this is likely at least partially true. Furthermore, 38.0% of the sample reported having experienced physical violence, torture and/or sexual violence, which is known to be associated with subsequent pain (34, 35). Additionally, during the civil war and during their flight to Norway, most refuges will not only have been without adequate access to health care and medicine but also, for many, adequate nourishment and rest. This might increase the risk of a variety of acute and chronic illnesses including musculoskeletal pain. Tying into a greater debate on how traumatic stress, and in particular chronic or continuous traumatic stress (CTS), is linked to pain in more resource poor settings, the high prevalence of pain in our study may be a consequence of high levels of CTS in the study population (70). That is, as stress caused by pre- and peri-migratory traumatic experiences is compounded by stress from a range of well-known adverse social conditions in the post-migratory environment such as financial hardship, unemployment, discrimination and weak social networks, the overall allostatic load may exceed coping capacities, with resultant consequences for health – e.g. elevated levels of pain (71, 72). This resonates well with the currently dominating ecological/holistic approach to refugee health. This approach emphasizes the importance of investigating and addressing the full range of factors known to impact health: past trauma history, daily stressors and the disruption of psychosocial systems in the post-migration environment, and the interplay between them (18, 73). A few recent studies have exploratively used biomarkers (e.g. hair cortisol levels) to assess stress/allostatic load when investigating mental ill health in refugee populations, with promising results (74, 75). Given some of the inherent limitations of using self-report questionnaire data (e.g. information/recall bias), and that these limitations are likely exacerbated when working across languages, cultures and idioms of distress, the use of biomarkers could represent an interesting option for future research.

The strong association between mental ill health and CP in the present study is consistent with a large body of prior evidence from non-refugee populations (3–8) and a number of studies on torture-exposed refugees and refugees in treatment (24, 40, 42). It is also consistent with a biopsychosocial approach to pain in which physical disorders such as pain is seen to result from a dynamic interaction among physiologic, psychological and social factors (76). Very few prior studies on this topic exist on general refugee populations, adding to the uniqueness of the present study. The only study we are aware of, found relatively strong associations between CP and anxiety/depression and PTSD symptoms among resettled adult Syrian refugees in Norway (36). If comparative evidence is broadened to also include studies on somatic distress, where pain is a key component, several recent, large studies on refugees and internally displaced people have documented strong links between symptoms of anxiety, depression and PTSD and somatic distress (27, 37, 38). The clear reductions in the ORs when going from crude to fully adjusted models for all mental ill health variables in Table 3, suggests the associations between these variables and CP are overlapping, which is unsurprising given their known comorbidities. Nonetheless, each mental ill health variable was statistically significantly associated with CP in the fully adjusted model, suggesting a unique association above and beyond shared ones. Methodologically, comparing ORs across models with different predictors is not unproblematic due to scaling effects (77), thus this argument needs to be interpreted with caution. Our finding that being a woman was associated with increased risk of CP is consistent with prior evidence both in refugee (e.g. 27,37) and non-refugee populations (e.g. 44,45).

The mean value for perceived general health (PGH) in this study (3.614, SD = 1.063) was statistically significantly lower (though not necessarily clinically meaningfully lower) than that reported in a large study on general, adult (> 15 years), populations across 26 European countries using the identical instrument (p < 0.001), where the mean value was 3.724 (SD = 0.968) (78). Since refugees in our study were significantly younger that in the European study (mean age 38.9 vs. 48.5 years), and given the strong negative association between age and PGH, the age-standardized difference is likely notably larger. The proportion in our study who reported “fair/poor/very poor” PGH was 39.9%, which is slightly higher than that reported in a longitudinal study on resettled refugees (primarily of Middle eastern origin) in Australia, which found this percentage to be 35.7% at baseline (79). However, the scoring scale for PGH had six levels vs. five in our study. An interesting finding from the regression analyses on PGH was the weak evidence of association between the mental ill health variables and PGH after controlling for CP. This implies a high degree of overlap between the associations of mental ill health and CP with PGH, even if a moderately strong unique association was found between PTSD and PGH in the fully adjusted model. The strong association between CP and PGH is broadly in line with a study on female Yazidi refugees exposed to violence by the “Islamic State”, which found pain to be a strong predictor of overall health-related well-being (31).

The proportion of refugees who reported at least some degree of functional impairment (FI) due to longstanding illness in our study (34.9%) is fairly consistent with another study on resettled adult refugees from Syria in Norway, which found this proportion to be around 30%, both at baseline and one year later (26). A similar estimate (35.8%) was also found in the aforementioned Australian study (79), though the measurement used also included long term injury/health conditions (i.e. the focus was not on FI per se). Our finding that CP was strongly associated with FI in the fully adjusted model which included mental ill health, is broadly congruent with other studies on refugees (37, 42), though these studies investigated somatic distress and not CP. One important and hitherto unique finding in our study was that the associations between mental ill health and FI were highly gender specific, with a clear association in men, but none in women. We are unable to relate this directly to existing literature, though prior studies have highlighted the importance of taking a gendered perspective when exploring refugee mental health (47–49). Part of the explanation for this gender specificity may relate to the aforementioned tendency for mental ill health, or, specifically anxiety, to be more strongly linked to CP in women than men in our study. That is, when FI is regressed on both CP and mental ill health for women, any adverse associations of mental ill health may be too overlapping with that of CP to show a unique association. However, the tendency for gender-specific associations was also present in the partially adjusted models (without mental ill health), even if the statistical evidence from Wald test of interaction was weaker. Another possible explanation is that the gendered association may be related to differences in expected and actual daily tasks and demands for men and women given traditional gender roles in Arab culture (80). This is supported by the fact that 35% of men versus 12% of women in our study reported having paid employment at the time of the survey (result not published). In other words, significantly more men than women presumably had to leave the house and socially interact, which could amplify the known debilitating effects of anxiety and PTSD.

Limitations and strengths

A key and potentially serious limitation with the present study is selection bias. With a response rate of 10%, it is hard to gauge the generalizability of findings. In general, predictor-outcome associations are thought to be more robust to nonresponse than prevalence estimates (81), though we cannot exclude that selection bias has distorted results. The issue of selection bias in the present study has been addressed in previous papers (64, 65). Another limitation concerns the validity of the instruments used in a population of adult refugees from Syria. We have already discussed transcultural construct validity relating to how pain was measured, and the issue of validity is also relevant for the HSCL-25 and HTQ scales, even if both scales have been used extensively with refugee populations and psychometrically tested. Evidence is somewhat incongruent as to the cultural appropriateness and validity of the scales across settings and populations (59, 82). Overall, it appears that both scales are fairly robust across cultures in terms of content validity (configural invariance), however, their metric and scalar invariance have been questioned (83). Given that the present study focuses on the overall constructs of anxiety, depression and PTSD and their associations with chronic pain, rather than investigating individual items/clusters or prevalence, problems caused by scalar and matric invariance should be limited. Nonetheless, all mental ill health variables were modelled dichotomously based on cut-off scores. A further limitation concerns the cross-sectional design of the data, which prohibits causal interpretations. It is highly likely that CP and mental ill health are causally related, thus when placing both in the same regression model, there is a chance of overadjustment bias (84). For example, if anxiety leads to elevated levels of perceived pain because of shared physiological pathways (85), part of the “true” adverse effect of anxiety on PGH may be masked by overadjustment. Moreover, the association between anxiety and FI in men could be because men with FI get anxious if they cannot fulfil their role as breadwinner, rather the other way around. Lastly, since regression models were built with data at hand, without detailed pre-registered plans for data-handling and analyses, finding should be viewed as partly exploratory, with the associated risk of false-positive findings (51, 86).

Strengths of the study include the random sampling from total-population registries; the fairly thorough assessment of CP compared to available evidence, and the use of well-known and frequently used instruments to measure mental ill health (despite the abovenoted lingering issues of transcultural validity).

The present study shows a high burden of chronic pain in a general population of adult refugees from Syria with likely substantial adverse consequences for their daily functioning. The clear links found between chronic pain and mental ill health suggest that healthcare providers and others working with this population ought to be aware of, and sensitized to, the fact that pain often goes hand-in-hand with psychological strain (indeed, within the biopsychosocial framework, mental and physical health closely interact and share physiologic pathways and feedback loops, blurring the conceptual boundaries between them). This awareness may be particularly important with Syrian refugees given that illness models and expressions of distress of most Syrians do not clearly distinguish between the mental and physical and the cultural stigma against expressing psychological distress. Addressing the possible co-occurrence of pain and mental ill health may be required for interventions to effectively address either problem. The study further points to potential gender-specific associations between mental ill health and functional impairment, with associations seemingly stronger in men than in women, suggesting initiatives addressing mental ill health, chronic pain or functional impairment in refugee populations should consider gender in tailoring their content and outreach.

A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies. The fairly scant number of existing studies are characterized by marked methodological heterogeneity making comparison challenging and knowledge difficult to synthesize. Therefore, future research should aim towards harmonizing and standardizing methodologies for how pain is measured. Moreover, since pain is understood differently across cultures, it will be important for any such effort to take into consideration that pain is an ethnocultural construct in order to enhance transcultural validity.

CI = Confidence Intervals

CP = Chronic Pain

DSM = Diagnostic and Statistical Manual of Mental Disorders

FI = Functional Impairment

HSCL = Hopkins Symptom Checklist

HTQ = Harvard Trauma Questionnaire

ICD = International Classification of Diseases

PGH = Perceived General Health

PHQ = Patient Health Questionnaire

PSTD = Post-traumatic Stress Disorder

PTE = Potentially Traumatic Event

PTE-AR = Potentially Traumatic Event Adversity Ratio

RTHC = Refugee Trauma History Checklist

SD = Standard Deviation

Ethics approval and consent to participate:

all potential participants were given a detailed information letter and consent form, detailing the study and what participation entailed. The voluntary nature of the study was stressed and procedures for how participants could withdraw were described. All information was given in Arabic. The informed consent form had to be signed and returned together with the questionnaire. The Regional Committees for Medical and Health Research Ethics (REK) – Region Southeast (A) in Norway granted ethical approval for the study (reference number 2017/1252).

Consent for publication:

Availability of data and materials:

The datasets generated and/or analyzed during the current study are not publicly available due to agreements made with participants through the informed consent form and outlined procedures for data-handling therein. Anonymized data are available from the corresponding author on reasonable request.

Competing interests:

None

Funding:

The study was funded by the Norwegian Centre for Violence and Traumatic Stress Studies. No external funding was received.

Authors' contributions:

Planning and design of larger project/acquisition of data: MS, AN. Design/conception of study: all authors. Analyses/interpretation of data: KAH, MS, AN. Initial draft of manuscript: AN. Critical revising manuscript for intellectual content: all authors. All authors have approved final version.

Acknowledgements:

We would like to thank all Syrian refugees who participated in the study, and our faithful and trusted interpreter, Ahmed, for his invaluable work. Further, we would like to thank IPSOS for handling the logistical aspects of data-collection.

Simon G, Gater R, Kisely S, Piccinelli M. Somatic symptoms of distress: an international primary care study. Psychosom Med [Internet]. 1996 Sep;58(5):481–8. Available from: http://dx.doi.org/10.1097/00006842-199609000-00010
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med [Internet]. 1999 Oct 28;341(18):1329–35. Available from: http://dx.doi.org/10.1056/NEJM199910283411801
Pacella ML, Hruska B, Delahanty DL. The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord [Internet]. 2013 Jan;27(1):33–46. Available from: http://dx.doi.org/10.1016/j.janxdis.2012.08.004
Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med [Internet]. 2002 Sep;64(5):773–86. Available from: http://dx.doi.org/10.1097/01.psy.0000024232.11538.54
Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med [Internet]. 2003 Nov 10;163(20):2433–45. Available from: http://dx.doi.org/10.1001/archinte.163.20.2433
Asmundson GJG, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. Depress Anxiety [Internet]. 2009;26(10):888–901. Available from: http://dx.doi.org/10.1002/da.20600
Moeller-Bertram T, Keltner J, Strigo IA. Pain and post traumatic stress disorder - review of clinical and experimental evidence. Neuropharmacology [Internet]. 2012 Feb;62(2):586–97. Available from: http://dx.doi.org/10.1016/j.neuropharm.2011.04.028
Hooten WM. Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment. Mayo Clin Proc [Internet]. 2016 Jul;91(7):955–70. Available from: http://dx.doi.org/10.1016/j.mayocp.2016.04.029
Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med [Internet]. 1998 Jul;60(4):420–30. Available from: http://dx.doi.org/10.1097/00006842-199807000-00006
Kleinman AM. Depression, somatization and the “new cross-cultural psychiatry.” Soc Sci Med [Internet]. 1977 Jan 1;11(1):3–9. Available from: https://www.sciencedirect.com/science/article/pii/003778567790138X
Bagayogo IP, Interian A, Escobar JI. Transcultural aspects of somatic symptoms in the context of depressive disorders. Adv Psychosom Med [Internet]. 2013 Jun 25;33:64–74. Available from: http://dx.doi.org/10.1159/000350057
al-Krenawi A, Graham JR. Culturally sensitive social work practice with Arab clients in mental health settings. Health Soc Work [Internet]. 2000 Feb;25(1):9–22. Available from: http://dx.doi.org/10.1093/hsw/25.1.9
Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry [Internet]. 2001;62 Suppl 13:22–8; discussion 29-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11434415
United Nations High Commissioner for Refugees. Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict [Internet]. [cited 2021 Apr 27]. Available from: https://www.unhcr.org/protection/health/55f6b90f9/culture-context-mental-health-psychosocial-wellbeing-syrians-review-mental.html
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 [Internet]. 2009 Aug 5;302(5):537–49. Available from: http://dx.doi.org/10.1001/jama.2009.1132
Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights [Internet]. 2015 Oct 28;15:29. Available from: http://dx.doi.org/10.1186/s12914-015-0064-9
Gleeson C, Frost R, Sherwood L, Shevlin M, Hyland P, Halpin R, et al. Post-migration factors and mental health outcomes in asylum-seeking and refugee populations: a systematic review. Eur J Psychotraumatol [Internet]. 2020 Dec 1;11(1):1793567. Available from: http://dx.doi.org/10.1080/20008198.2020.1793567
Li SSY, Liddell BJ, Nickerson A. The Relationship Between Post-Migration Stress and Psychological Disorders in Refugees and Asylum Seekers. Curr Psychiatry Rep [Internet]. 2016 Sep;18(9):82. Available from: http://dx.doi.org/10.1007/s11920-016-0723-0
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 [Internet]. 2019 Jul 20;394(10194):240–8. Available from: http://dx.doi.org/10.1016/S0140-6736(19)30934-1
Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, et al. The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med [Internet]. 2020 Sep;17(9):e1003337. Available from: http://dx.doi.org/10.1371/journal.pmed.1003337
Olsen DR, Montgomery E, Bøjholm S, Foldspang A. Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study. Disabil Rehabil [Internet]. 2007 Jan 30;29(2):163–71. Available from: http://dx.doi.org/10.1080/09638280600747645
Williams AC de C, Peña CR, Rice ASC. Persistent pain in survivors of torture: a cohort study. J Pain Symptom Manage [Internet]. 2010 Nov;40(5):715–22. Available from: http://dx.doi.org/10.1016/j.jpainsymman.2010.02.018
Hermansson A-C, Timpka T, Thyberg M. The mental health of war-wounded refugees: An 8-year follow-up. J Nerv Ment Dis [Internet]. 2002;190(6):374–80. Available from: https://psycnet.apa.org/fulltext/2002-01997-005.pdf
Teodorescu D-S, Heir T, Siqveland J, Hauff E, Wentzel-Larsen T, Lien L. Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study. BMC Psychol [Internet]. 2015 Mar 15;3(1):7. Available from: http://dx.doi.org/10.1186/s40359-015-0064-5
Dahl S, Dahl C-I, Sandvik L, Hauff E. Chronic pain in traumatized refugees. Tidsskr Nor Laegeforen [Internet]. 2006 Feb 23;126(5):608–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16505872
Strømme EM, Haj-Younes J, Hasha W, Fadnes LT, Kumar B, Igland J, et al. Changes in health among Syrian refugees along their migration trajectories from Lebanon to Norway: a prospective cohort study. Public Health [Internet]. 2020 Sep;186:240–5. Available from: http://dx.doi.org/10.1016/j.puhe.2020.07.016
McGrath M, Acarturk C, Roberts B, Ilkkursun Z, Sondorp E, Sijbrandij M, et al. Somatic distress among Syrian refugees in Istanbul, Turkey: A cross-sectional study. J Psychosom Res [Internet]. 2020 May;132:109993. Available from: http://dx.doi.org/10.1016/j.jpsychores.2020.109993
Riley A, Varner A, Ventevogel P, Taimur Hasan MM, Welton-Mitchell C. Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcult Psychiatry [Internet]. 2017 Jun;54(3):304–31. Available from: http://dx.doi.org/10.1177/1363461517705571
Hassan G, Kirmayer LJ, Mekki-Berrada A, Quosh C, el Chammay R, Deville-Stoetzel JB, et al. Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict [Internet]. Geneva: UNHCR 2015; Available from: https://www.unhcr.org/protection/health/55f6b90f9/culture-context-mental-health-psychosocial-wellbeing-syrians-review-mental.html
Peconga EK, Høgh Thøgersen M. Post-traumatic stress disorder, depression, and anxiety in adult Syrian refugees: What do we know? Scand J Public Health [Internet]. 2020 Nov;48(7):677–87. Available from: http://dx.doi.org/10.1177/1403494819882137
Rometsch C, Denkinger JK, Engelhardt M, Windthorst P, Graf J, Gibbons N, et al. Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the “Islamic State” (IS). J Psychosom Res [Internet]. 2020 Mar;130:109931. Available from: http://dx.doi.org/10.1016/j.jpsychores.2020.109931
Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res [Internet]. 2013 Sep;75(3):223–8. Available from: http://dx.doi.org/10.1016/j.jpsychores.2013.06.033
Rohlof HG, Knipscheer JW, Kleber RJ. Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2014 Nov;49(11):1793–804. Available from: http://dx.doi.org/10.1007/s00127-014-0877-1
Williams AC de C, Amris K. Pain from torture. Pain [Internet]. 2007 Dec 15;133(1–3):5–8. Available from: http://dx.doi.org/10.1016/j.pain.2007.10.001
Williams AC de C, Amris K. Treatment of persistent pain from torture: review and commentary. Med Confl Surviv [Internet]. 2017 Jan 2;33(1):60–81. Available from: https://doi.org/10.1080/13623699.2016.1242050
Strømme EM, Igland J, Haj-Younes J, Kumar BN, Fadnes LT, Hasha W, et al. Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study. BMJ Open [Internet]. 2021 Sep 21;11(9):e046454. Available from: http://dx.doi.org/10.1136/bmjopen-2020-046454
Comellas RM, Makhashvili N, Chikovani I, Patel V, McKee M, Bisson J, et al. Patterns of somatic distress among conflict-affected persons in the Republic of Georgia. J Psychosom Res [Internet]. 2015 May;78(5):466–71. Available from: http://dx.doi.org/10.1016/j.jpsychores.2015.01.015
Cheung A, Makhashvili N, Javakhishvili J, Karachevsky A, Kharchenko N, Shpiker M, et al. Patterns of somatic distress among internally displaced persons in Ukraine: analysis of a cross-sectional survey. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2019 Oct;54(10):1265–74. Available from: http://dx.doi.org/10.1007/s00127-019-01652-7
Van Ommeren M, Sharma B, Sharma GK, Komproe I, Cardeña E, de Jong JTVM. The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: examination of comorbidity with anxiety and depression. J Trauma Stress [Internet]. 2002 Oct;15(5):415–21. Available from: http://dx.doi.org/10.1023/A:1020141510005
Morina N, Kuenburg A, Schnyder U, Bryant RA, Nickerson A, Schick M. The Association of Post-traumatic and Postmigration Stress with Pain and Other Somatic Symptoms: An Explorative Analysis in Traumatized Refugees and Asylum Seekers. Pain Med [Internet]. 2018 Jan 1;19(1):50–9. Available from: http://dx.doi.org/10.1093/pm/pnx005
Nordin L, Perrin S. Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs. Eur J Pain [Internet]. 2019 Sep;23(8):1497–506. Available from: http://dx.doi.org/10.1002/ejp.1415
Buhman C, Mortensen EL, Lundstrøm S, Ryberg J, Nordentoft M, Ekstrøm M. Symptoms, quality of life and level of functioning of traumatized refugees at psychiatric trauma clinic in Copenhagen. Torture [Internet]. 2014;24(1):25–39. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25590462
Harlacher U, Nordin L, Polatin P. Torture survivors’ symptom load compared to chronic pain and psychiatric in-patients. Torture [Internet]. 2016;26(2):74–84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27858781
Kroenke K, Spitzer RL. Gender Differences in the Reporting of Physical and Somatoform Symptoms. Psychosom Med [Internet]. 1998 [cited 2021 Jun 22];60(2):150. Available from: https://journals.lww.com/psychosomaticmedicine/Fulltext/1998/03000/Gender_Differences_in_the_Reporting_of_Physical.6.aspx
Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain [Internet]. 2009 May;10(5):447–85. Available from: http://dx.doi.org/10.1016/j.jpain.2008.12.001
Shishehgar S, Gholizadeh L, DiGiacomo M, Green A, Davidson PM. Health and Socio-Cultural Experiences of Refugee Women: An Integrative Review. J Immigr Minor Health [Internet]. 2017 Aug;19(4):959–73. Available from: http://dx.doi.org/10.1007/s10903-016-0379-1
Wu S, Renzaho AMN, Hall BJ, Shi L, Ling L, Chen W. Time-varying associations of pre-migration and post-migration stressors in refugees’ mental health during resettlement: a longitudinal study in Australia. Lancet Psychiatry [Internet]. 2021 Jan;8(1):36–47. Available from: http://dx.doi.org/10.1016/S2215-0366(20)30422-3
Stempel C, Sami N, Koga PM, Alemi Q, Smith V, Shirazi A. Gendered Sources of Distress and Resilience among Afghan Refugees in Northern California: A Cross-Sectional Study. Int J Environ Res Public Health [Internet]. 2016 Dec 28;14(1). Available from: http://dx.doi.org/10.3390/ijerph14010025
Nissen A, Sengoelge M, Solberg Ø. Post-migration Stressors and Subjective Well-Being in Adult Syrian Refugees Resettled in Sweden: A Gender Perspective. Front Public Health [Internet]. 2021 Sep 9;9:717353. Available from: http://dx.doi.org/10.3389/fpubh.2021.717353
Nosek BA, Ebersole CR, DeHaven AC, Mellor DT. The preregistration revolution. Proc Natl Acad Sci U S A [Internet]. 2018 Mar 13;115(11):2600–6. Available from: http://dx.doi.org/10.1073/pnas.1708274114
Forstmeier W, Wagenmakers E-J, Parker TH. Detecting and avoiding likely false-positive findings - a practical guide: Avoiding false-positive findings. Biol Rev [Internet]. 2017 Nov 23;92(4):1941–68. Available from: http://doi.wiley.com/10.1111/brv.12315
Andorsen OF, Ahmed LA, Emaus N, Klouman E. High prevalence of chronic musculoskeletal complaints among women in a Norwegian general population: the Tromsø study. BMC Res Notes [Internet]. 2014 Aug 8;7:506. Available from: http://dx.doi.org/10.1186/1756-0500-7-506
University of Tromsø. The Tromsø Study [Internet]. [cited 2022 Mar 4]. Available from: http://tromsoundersokelsen.uit.no/tromso/
European Social Survey [Internet]. [cited 2022 Mar 6]. Available from: http://www.europeansocialsurvey.org/
Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry [Internet]. 1987 Apr;144(4):497–500. Available from: http://dx.doi.org/10.1176/ajp.144.4.497
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis [Internet]. 1992 Feb;180(2):111–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/1737972
Oruc L, Kapetanovic A, Pojskic N, Miley K, Forstbauer S, Mollica RF, et al. Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist. Int J Cult Ment Health [Internet]. 2008 Dec 1;1(2):105–16. Available from: https://doi.org/10.1080/17542860802456620
Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, et al. Measuring trauma and health status in refugees: a critical review. JAMA [Internet]. 2002 Aug 7;288(5):611–21. Available from: http://dx.doi.org/10.1001/jama.288.5.611
Wind TR, van der Aa N, de la Rie S, Knipscheer J. The assessment of psychopathology among traumatized refugees: measurement invariance of the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 across five linguistic groups. Eur J Psychotraumatol [Internet]. 2017;8(sup2):1321357. Available from: https://www.tandfonline.com/doi/abs/10.1080/20008198.2017.1321357
Sigvardsdotter E, Malm A, Tinghög P, Vaez M, Saboonchi F. Refugee trauma measurement: a review of existing checklists. Public Health Rev [Internet]. 2016 Sep 9;37:10. Available from: http://dx.doi.org/10.1186/s40985-016-0024-5
Sigvardsdotter E, Nilsson H, Malm A, Tinghög P, Gottvall M, Vaez M, et al. Development and Preliminary Validation of Refugee Trauma History Checklist (RTHC)-A Brief Checklist for Survey Studies. Int J Environ Res Public Health [Internet]. 2017 Oct 4;14(10). Available from: http://dx.doi.org/10.3390/ijerph14101175
Tinghög P, Malm A, Arwidson C, Sigvardsdotter E, Lundin A, Saboonchi F. Prevalence of mental ill health, traumas and postmigration stress among refugees from Syria resettled in Sweden after 2011: a population-based survey. BMJ Open [Internet]. 2017 Dec 29;7(12):e018899. Available from: http://dx.doi.org/10.1136/bmjopen-2017-018899
White IR, Royston P, Wood AM. Multiple imputation using chained equations: Issues and guidance for practice. Stat Med [Internet]. 2011 Feb 20;30(4):377–99. Available from: http://dx.doi.org/10.1002/sim.4067
Nissen A, Cauley P, Saboonchi F, Andersen A, Solberg Ø. Cohort profile: Resettlement in Uprooted Groups Explored (REFUGE)-a longitudinal study of mental health and integration in adult refugees from Syria resettled in Norway between 2015 and 2017. BMJ Open [Internet]. 2020 Jul 1;10(7):e036101. Available from: http://dx.doi.org/10.1136/bmjopen-2019-036101
Nissen A, Cauley P, Saboonchi F, J Andersen A, Solberg Ø. Mental health in adult refugees from Syria resettled in Norway between 2015 and 2017: a nationwide, questionnaire-based, cross-sectional prevalence study. Eur J Psychotraumatol [Internet]. 2021 Jan 1;12(1):1994218. Available from: https://doi.org/10.1080/20008198.2021.1994218
Gottvall M, Sjölund S, Arwidson C, Saboonchi F. Health-related quality of life among Syrian refugees resettled in Sweden. Qual Life Res [Internet]. 2020 Feb;29(2):505–14. Available from: http://dx.doi.org/10.1007/s11136-019-02323-5
Hermansson AC, Thyberg M, Timpka T, Gerdle B. Survival with pain: an eight-year follow-up of war-wounded refugees. Med Confl Surviv [Internet]. 2001 Apr;17(2):102–11. Available from: http://dx.doi.org/10.1080/13623690108409564
Bäärnhielm S. The meaning of pain: A cultural formulation of a Syrian woman in Sweden. Transcult Psychiatry [Internet]. 2012 Feb 1;49(1):105–20. Available from: https://doi.org/10.1177/1363461511427781
Hinton DE, Howes D, Kirmayer LJ. Toward a Medical Anthropology of Sensations: Definitions and Research Agenda. Transcult Psychiatry [Internet]. 2008 Jun 1;45(2):142–62. Available from: https://doi.org/10.1177/1363461508089763
Frenkel L, Swartz L, Bantjes J. Chronic traumatic stress and chronic pain in the majority world: notes towards an integrative approach. Crit Public Health [Internet]. 2018 Jan 1;28(1):12–21. Available from: https://doi.org/10.1080/09581596.2017.1308467
Guidi J, Lucente M, Sonino N, Fava GA. Allostatic Load and Its Impact on Health: A Systematic Review. Psychother Psychosom [Internet]. 2021;90(1):11–27. Available from: http://dx.doi.org/10.1159/000510696
Ray O. How the mind hurts and heals the body. Am Psychol [Internet]. 2004 Jan;59(1):29–40. Available from: http://dx.doi.org/10.1037/0003-066X.59.1.29
Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry [Internet]. 2017 Jun;16(2):130–9. Available from: http://dx.doi.org/10.1002/wps.20438
Buchmüller T, Lembcke H, Busch J, Kumsta R, Wolf OT, Leyendecker B. Exploring hair steroid concentrations in asylum seekers, internally displaced refugees, and immigrants. Stress [Internet]. 2020 Sep;23(5):538–45. Available from: http://dx.doi.org/10.1080/10253890.2020.1737008
Dajani R, Hadfield K, van Uum S, Greff M, Panter-Brick C. Hair cortisol concentrations in war-affected adolescents: A prospective intervention trial. Psychoneuroendocrinology [Internet]. 2018 Mar;89:138–46. Available from: http://dx.doi.org/10.1016/j.psyneuen.2017.12.012
Gatchel RJ. Comorbidity of chronic pain and mental health disorders: the biopsychosocial perspective. Am Psychol [Internet]. 2004 Nov;59(8):795–805. Available from: http://dx.doi.org/10.1037/0003-066X.59.8.795
Norton EC, Dowd BE, Maciejewski ML. Odds Ratios-Current Best Practice and Use. JAMA [Internet]. 2018 Jul 3;320(1):84–5. Available from: http://dx.doi.org/10.1001/jama.2018.6971
Alvarez-Galvez J, Salvador-Carulla L. Perceived discrimination and self-rated health in Europe: evidence from the European Social Survey (2010). PLoS One [Internet]. 2013 Sep 5;8(9):e74252. Available from: http://dx.doi.org/10.1371/journal.pone.0074252
Dowling A, Enticott J, Kunin M, Russell G. The association of migration experiences on the self-rated health status among adult humanitarian refugees to Australia: An analysis of a longitudinal cohort study. Int J Equity Health [Internet]. 2019;18(1). Available from: http://dx.doi.org/10.1186/s12939-019-1033-z
Read JG. Cultural Influences on Immigrant Women’s Labor Force Participation: The Arab-American Case. Int Migr Rev [Internet]. 2004 Mar 1;38(1):52–77. Available from: https://doi.org/10.1111/j.1747-7379.2004.tb00188.x
Rothman KJ, Gallacher JEJ, Hatch EE. Why representativeness should be avoided. Int J Epidemiol [Internet]. 2013 Aug;42(4):1012–4. Available from: http://dx.doi.org/10.1093/ije/dys223
Darzi C. The Harvard Trauma Questionnaire: Reliability and validity generalization studies of the symptom scales [Internet]. Université d’Ottawa / University of Ottawa; 2017 [cited 2021 Mar 23]. Available from: http://ruor.uottawa.ca/handle/10393/36082
Rasmussen A, Verkuilen J, Ho E, Fan Y. Posttraumatic stress disorder among refugees: Measurement invariance of Harvard Trauma Questionnaire scores across global regions and response patterns. Psychol Assess [Internet]. 2015 Dec;27(4):1160–70. Available from: https://psycnet.apa.org/fulltext/2015-16476-001.pdf
Schisterman EF, Cole SR, Platt RW. Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology [Internet]. 2009 Jul;20(4):488–95. Available from: http://dx.doi.org/10.1097/EDE.0b013e3181a819a1
Morina N, Egloff N, Schnyder U, Cloitre M. The complexity of chronic pain in traumatized people: Dignostic an therapeutic challenges. In: Schnyder U, Cloitre M, editors. Evidence Based Treatments for Trauma-Related Psychological Disorders [Internet]. Cham: Springer Verlag; 2015 [cited 2021 Jun 21]. p. 347–60. Available from: https://www.zora.uzh.ch/id/eprint/110086/
Simmons JP, Nelson LD, Simonsohn U. False-positive psychology: undisclosed flexibility in data collection and analysis allows presenting anything as significant. Psychol Sci [Internet]. 2011 Nov;22(11):1359–66. Available from: http://dx.doi.org/10.1177/0956797611417632

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Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

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