Refugee Populations Research Articles

Government-Assisted Syrian Refugees' Perceptions of Dietary Acculturation in Canada

Diet acculturation is a complicated process where refugees must discover new ways of consuming traditional foods, adopt new foods, or eliminate other foods from their diets in a host country. The purpose of this phenomenological case study was to explore the ways in which Syrian refugees describe diet acculturation since their arrival to a city in Southern Ontario. Individuals eligible to participate were government-assisted Syrian refugees who were at least 18 years old. Purposive and snowball sampling methods were used to recruit participants. Researcher-constructed, semi-structured, face-to-face interviews were used to collect data in Arabic. Data were recorded and transcribed verbatim in Arabic and then translated to English. Inductive coding, second-cycle coding and thematic analysis were used to analyze the data. Using the dietary acculturation model as a lens, the study found participants sought to maintain a connection to their Syrian identity through food, yet food prices, access, and quality and perceptions of health, along with children’s peer influence resulting in bicultural eating patterns impacted the participants’ experiences with dietary acculturation. The results of the study will assist food and nutrition professionals in understanding dietary acculturation in the Syrian refugee population.

A Systematic Review of the Healthcare Access and Utilization Barriers Faced by Refugees in Uganda

The increasing number of refugees in Uganda is putting a significant strain on the country’s already limited resources, particularly those for healthcare. The government has implemented policies in response to the crisis. However, numerous obstacles have hampered these efforts. The aim of this article is to review previously published research by synthesising global evidence on factors that impede refugees’ access to healthcare services across the country. Articles published between 2016 and 2022 were searched in the Google Scholar and PubMed central databases. Google Scholar yielded 21,300, PubMed Central 637, and 5 articles from cross-references, however. The PRISMA framework was used to structure the selection, and 21 studies from different fields and settings met the inclusion criteria. The most frequently cited factors that impede access to and utilisation of needed healthcare services were sociocultural considerations such as stigma and discrimination, health system anomalies that led to mistrust of healthcare services and workers by refugee populations, and financial difficulties. In order to overcome these obstacles, the government and humanitarian organisations ought to carry out a comprehensive screening with leaders of refugee communities and local refugee organisations in order to comprehend the conditions of refugees. They ought to pay particular attention to the differences between the various cultures and settings, as well as the flow of the healthcare system, in order to sensitise people and raise awareness about the healthcare system. To make it easier for refugees to access and use the necessary healthcare services, specific health policies should be implemented. When looking for healthcare, equal rights and freedom of movement should be top priorities

The Mental Health Crisis in Refugee Populations.

The Mental Health Crisis in Refugee Populations.

Ukrainian refugees and the Swedish sports movement – new opportunities and challenges

ABSTRACT Research Question The war in Ukraine has forced approximately eight million people into neighboring European countries. As part of sports clubs’ societal commitment, many have received Ukrainian refugees. However, compared to previous so-called ‘refugee waves’, forced migration from Ukraine is different in terms of demographics, culture, and (sports) traditions. This paper aimed to assess these ‘new’ nuances and their implications for the European sports movement. Research Methods Data were gathered through 17 semi-structured interviews with Swedish sports club representatives, analyzed with a critical realist-inspired thematic analysis, and interpreted with Bronfenbrenner’s process-person-context-time framework. Results and Findings The representatives expressed that Ukrainian refugees are more in-tune with organized sports compared to other refugee populations; however, there are also culturally discrepant ideas about sports. Specifically, there seems to be an influx of skilled (youth) refugees, who approach sports in ways incompatible with Swedish conventions about youth sports. While the sporting capital often enables easier inclusion, it also presents challenges in extreme cases. Implications The findings show that the European sports movement must be attentive to new challenges and opportunities associated with the current humanitarian crisis. Sports representatives need to balance culturally sensitive approaches with ethical considerations regarding youth sports.

Community-based participatory research initiative to assess the scope of alcohol use within the community of refugees from Burma in the greater Denver area

Introduction For over fifty years, minorities in Burma have faced severe persecution and violence, forcing them to flee their homeland. In the past ten years there has been an influx in the number of refugees resettled in Denver, Colorado. Refugees often struggle to navigate the complexities of the American health care system and adapt to life in a foreign culture. The development of programs and partnerships to assist refugees in their pursuit of health and integration is essential to building stronger communities.Objectives This community based participatory research (CBPR) project was developed in collaboration with the refugee community from Burma living in the Denver area. After regular meetings with a group of motivated teenagers and young adults from this community to form our Youth Advisory Board (YAB), they identified alcohol use and misuse as a health concern within their community. With this identified issue, the project aimed to gather data from community members that could be leveraged to create, implement, and evaluate a culturally competent intervention to effectively address risky alcohol use in this community.MethodsData collection involved formal one-on-one, semi-structured, audio-recorded interviews with community members. Participants were recruited voluntarily at health information nights held by the student researchers at their local apartment complex. The interviews were conducted by one medical student researcher with one translator present and were transcribed afterward. The interview data was analyzed using Immersion Crystallization methodology.ResultsInitial results from the community meetings with the YAB, local organizations, formative community surveys, and key informant interviews highlighted the vulnerability of the refugee population, scarcity of culturally appropriate resources for alcohol abuse, and urgency of addressing problematic alcohol use. The analysis of the ten audio-recorded surveys showed several themes including negative consequences of alcohol use, specifically negative impacts on familial relationships, employment, and financial resources, and a perceived personal responsibility for managing one’s own alcohol consumption.ConclusionsThis project corroborates current literature regarding the scope and breadth of hazardous alcohol use within the community of refugees from Burma. Our data has expanded our understanding of the values of community members including the influence of religion and family on behaviors, and the negative impact on employment as the most impactful negative consequence. These findings need to be shared with the community to move forward in mapping the most effective and appropriate interventions.Disclosure of InterestNone Declared

Posttraumatic Stress Disorder in Refugees.

The number of refugees and internally displaced people in 2022 is the largest since World War II, and meta-analyses demonstrate that these people experience elevated rates of mental health problems. This review focuses on the role of posttraumatic stress disorder (PTSD) in refugee mental health and includes current knowledge of the prevalence of PTSD, risk factors, and apparent differences that exist between PTSD in refugee populations and PTSD in other populations. An emerging literature on understanding mechanisms of PTSD encompasses neural, cognitive, and social processes, which indicate that these factors may not function exactly as they have functioned previously in other PTSD populations. This review recognizes the numerous debates in the literature on PTSD in refugees, including those on such issues as the conceptualization of mental health and the applicability of the PTSD diagnosis across cultures, as well as the challenge of treating PTSD in low- and middle-income countries that lack mental health resources to offer standard PTSD treatments.

Immigration Protocols and Extralegal Demands: A Comparison Between the U.S.-Mexican Borderlands and South Africa

This paper presents a comparative case analysis arguing that undocumented immigrants in the U.S.-Mexican borderlands and in South Africa become criminalised by navigating host and recipient country legal protocols and norms. The immigrants (often bonafide asylum seekers and refugees) live in host countries without the necessary legal immigrant papers and therefore lack legal status. Illegality attaches to this status and creates economic demands satisfied by those who produce unauthorised (or authorised) immigrant papers. At times, government functionaries participate in these extralegal economies, adding to the robustness of the illicit economies and further harming this vulnerable population of immigrants, refugees, asylum seekers, and undocumented migrants. (For this paper, the term immigrants is an umbrella term for all the migrants.) The criminalisation of immigrants is rooted in the actions or inactions of government actors in the Global North and Global South who deny immigrants legal standing in the host country or in transit. These government functionaries and their smuggler counterparts, in turn, create an extralegal demand for papers and profit from restrictive immigration protocols.

Attitudes and experiences of asylum seekers and refugees to the COVID-19 vaccination: a qualitative study.

COVID-19 disproportionately affected asylum seeker and refugee (ASR) populations owing to language and cultural barriers, lower health literacy, polytraumas and mental health needs, and increased exposure. Despite this, there was vaccine hesitancy and low vaccination rates in ASR populations. To explore the attitudes to and experiences of the COVID-19 vaccination among ASRs. Qualitative study of 12 diverse purposively recruited ASRs in Bristol. Semi-structured interviews were conducted, transcribed verbatim, and analysed thematically to identify emergent themes. Eight refugees and four asylum seekers were recruited, five of whom were female and seven male, aged between 23 years and 48 years; together representing seven countries. Six were part of a UK Home Office (UKHO) resettlement programme, and six had arrived in the UK by independent means. Analysis showed delayed uptake rather than vaccine refusal owing to the following three main themes: systemic asylum issues (repeated relocation, uncertainty, and dependency on the charity sector); fear (secondary to social isolation, misinformation, and mental illness); and trust (surrounding access to care and community relationships). Fear, trauma, and isolation propagated by systemic issues are primary factors impacting healthcare decision making, and standard approaches to increasing vaccination uptake must be reconsidered in light of these issues. General practice must appreciate and invest in providing security in healthcare access for ASR populations. Barriers to practice registration must be overcome to enable ASRs to access care both around vaccination and afterwards. Communication must be clear and accessible to aid individuals in making informed decisions, balancing the benefits and potential risks of vaccinations.

Sustainable innovations for humanitarian operations in refugee camps

PurposeAlthough the UN Sustainable Development Goals (SDGs) emphasize the importance of leaving no one behind, the opposite is happening for the world's 89 million forcibly displaced people who are mostly left out of SDGs’ reporting and progress. A key reason for this poor outcome is that host country governments plan refugee camps as short-term shelters, but refugees stay in these camps for more than a decade on average due to ongoing conflicts in their home country. This disparity between intent and reality prevents sustainable living conditions for refugee populations. Operational innovations are needed to find sustainable solutions that ensure a higher quality of life and progress toward sustainability in refugee camps.Design/methodology/approachThrough an abductive case study, the authors develop a theoretical framework on sustainable operational innovations for refugee camps. The authors use this framework to analyze four sustainable operational innovations implemented in three refugee camps in Jordan.FindingsThe authors develop three research propositions that describe the conditions required for these operational innovations to succeed: they need to include specific needs and cultural preferences of refugees, they must accommodate host governments' restrictions that limit permanent settlement, and finally, technological innovations require careful data management policies to protect refugees. Doing this, the authors account for the broader political-economic and ecological environments that refugee camps are embedded in.Originality/valueThis paper opens a new area of research on sustainable innovation in humanitarian operations. It provides insights into key contingency factors moderating the link between operational innovations and sustainability outcomes. It represents one of the few studies that build their theorizing upon field data collected in refugee camps.

Immunity Against Measles in Urban Refugee Children, Adolescents, and Young Adults in Eastleigh, Kenya

Background: Kenya has made progress towards the elimination of measles through routine and supplementary immunisation activities; however, sporadic outbreaks still occur. Studies on measles seroprevalence in Kenya are few and extensive analysis of refugee and migrant populations’ immunity against measles is lacking. This cross-sectional study aimed at assessing the presence of immunity against measles in children, adolescents and young adults living in the high urban refugee area of Eastleigh Nairobi, Kenya. Method: A total of 384 samples serum samples were collected from consenting respondents and tested for measles IgG antibodies. Syncytium Inhibition Assay, a neutralisation assay was used to determine functionality. The establishment of herd immunity was calculated using the Plans- Rubio formulae. Results: Seropositive rate for all respondents were 84.38%, while equivocal and negative were 4.95% and 10.68%, respectively. None of the factors analysed was a significant predictor of positive measles antibodies. 87.76% of the total sera were neutralising, while 12.23 % were negative. There was a significant correlation between the neutralisation titres and ELISA values. Conclusion: This study highlights age-specific measles immunity gaps in an urban refugee population. Although measles antibodies are present in all age groups, none has established herd immunity. In order to avert outbreaks in the study population, it is necessary to direct immunisation interventions to increase the measles antibody prevalence to recommended levels.

A training program to increase collaboration between interpreter and therapists in psychotherapy with resettled refugees.

Drawing from the framework of community-academic partnerships, we describe the development and implementation of a training module to increase collaboration between interpreters and therapists in interpreter-mediated psychotherapy with refugees. Beginning with community engagement with local agencies and leaders to identify barriers to accessing psychotherapy services in the resettled refugee populations, this project involved multiple layers of collaboration to include multiple perspectives. The program was funded by a local community foundation and was implemented in three phases. In the first phase we identified key community partners and stakeholders with first-hand knowledge of the needs of refugee populations. Phase two involved a two-day workshop for student therapists from different disciplines and interpreters working in the field. Phase three included a follow up to re-assess challenges in the field and refine our training. The need to build early collaboration between therapists and interpreters was highlighted throughout the development and implementation of the project. We discuss the project’s impact, challenges encountered, and implications of lessons learned in developing community-engaged partnerships for graduate programs as a way of promoting social justice in practitioner training.

Refugee secondary migration from small cities: evidence from Utica, New York

ABSTRACT Refugees in the US have increasingly been resettled in small cities, many of which have viewed refugee resettlement as a means of economic development. Using a unique geo-coded data set of almost 600 refugees from over 30 countries resettled in Utica, New York, our study offers primary evidence on the determinants of refugee intentions to migrate from their resettlement community. We find that human capital, co-ethnic enclaves, length of time in the US, and multigenerational integration play a key role in refugees’ intentions to migrate. While the neighbourhood density of refugees has no impact, increases in the density of co-ethnic enclaves have a strong negative effect on the intent to leave in the near future. This effect is particularly strong during refugees’ first five years in the US. Generation 1.5 refugees are significantly more likely to plan to move than those who arrived to their resettlement community at an older age. Our findings highlight the effects of country of origin, education, age, past family migration, and religious affiliation. For small-city governments and resettlement agencies seeking to retain resettled refugees, our results suggest a focus on building stronger co-ethnic enclaves over an emphasis on the diversity of the resettled refugee population.

Prevalence of otolaryngological disease in a refugee population compared to US-born patients.

Limited data exists regarding otolaryngological (ENT) disease in refugees and we aim to characterize its prevalence. This is a retrospective descriptive chart review of adult US-born, immigrant, and refugee patients receiving care at a primary care clinic between 2014 and 2017. We report the prevalence of ENT disease by immigration status. Bivariable and multivariable logistic regression models were conducted to assess differences in prevalence of ENT disease by immigration status. Of 995 patients included, 202 US-born, 450 immigrants, and 343 were refugees. Immigrants were older (46 years vs. 34 years among refugees, 35.5 years among US-born, p< .001) and more likely to be women (64% vs. 52% among refugees and 56% among US-born, p= .003). Among refugees, 27% were Central American, 22% Chinese, and 9.3% Middle Eastern. Hearing loss and allergic rhinitis were the top two diagnoses among the three groups of immigration status. More refugees had at least 1 ENT diagnosis compared to the other groups (16% vs 14% among immigrants and 6% US-born, p< .001). Refugees were more likely to have at least 1 ENT diagnosis compared to US-born individuals (age and gender adjusted [aOR] 3.40, 95% CI [1.80-6.95], p< .001) and immigrants (aOR 1.62, [1.05-2.51], p= .03). ENT disease is prevalent among refugees, necessitating standardized evaluation during refugee health assessments and identifying barriers to referral and treatment. 2b.

Cross-cultural validity and psychometric properties of the International Trauma Questionnaire in a clinical refugee sample

ABSTRACT Background: The ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD diagnoses have been examined in several studies using the International Trauma Questionnaire (ITQ). The cross-cultural validity of the ITQ has not previously been studied using item responses theory methods focused on the issue of equal item functioning and thus comparability of scores across language groups. Objective: To investigate the cross-cultural validity of the ITQ scales considering specifically local independence of items and differential item functioning (DIF) in a cross-cultural sample of refugees. Method: Data from 490 treatment-seeking refugees were included, covering Danish, Arabic, and Bosnian languages and different levels of interpreter-assisted administration. Rasch and graphical log-linear Rasch models were used. Results: There was strong local dependence among items from the same symptom clusters in the PTSD and disorders in self-organization (DSO) scales, except between affective dysregulation items. Weak local dependence was discovered between an item from the affective dysregulation cluster and an item from the disturbed relationship cluster. There was no evidence of DIF related to language or interpreter assistance. There was evidence of DIF for two PTSD items relative to gender and time since the traumatic event. The targeting of the scales to the study population was not optimal. Reliability varied from 0.55 to 0.78 for subgroups. Conclusions: The PTSD and the DSO scales have stable psychometric properties across the Danish, Arabic, and Bosnian language versions and different levels of assisted administration. Scores are comparable across these groups. However, DIF relative to gender and time since trauma introduces considerable measurement bias. DIF-adjusted summed scale scores or estimated person parameters should be used to avoid measurement bias. Future research should investigate whether scales including more and/or alternative items that require higher levels of PTSD and DSO to be endorsed will improve targeting and measurement precision for refugee populations.

Impact of chronic war trauma exposure on PTSD diagnosis from 2006 -2021: a longitudinal study in Palestine

BackgroundTrauma and Post-Traumatic Stress Disorders (PTSD) are a common result of the occurrence of natural and man-made disasters, the refugees are one of these traumas in which some resulted from political conflicts. Today, Palestinians are the largest refugee population in the world after the Nakba in 1948. This study aims to discover the impact of chronic war traumas on PTSD diagnosis and symptoms from 2006 to 2021. The current study is a follow-up of 607 adolescents and adults, aged between 10–30 years of which are also those children who participated in the 2006 study. This research used an adapted PTSD scale (PTSD-SRII, 33 items) from a validated original questionnaire developed by Altawil in 2008 to measure PTSD based on symptoms reported in DSM-IV and ICD-10.ResultsThe main findings show at least 97.2% of participants had experienced at least 6 traumatic experiences up to the year 2006 and 100% of the participants were exposed to traumas in 2021. This study found four categories of responses to chronic war trauma: (a) Acute group (n = 321, 52.9%) shows high PTSD symptoms in 2006 and in 2021; (b) Remitters group (n = 54, 8.9%) shows high PTSD symptoms in 2006 but did not show significant PTSD symptoms in 2021; (c) Delayed group (n = 204, 33.6%) shows no PTSD symptoms in 2006 but showed significant PTSD symptoms in 2021; (d) Resilient group (n = 28, 4.6%) had no PTSD symptoms in 2006 and did not show PTSD symptoms in 2021.ConclusionsThe authors conclude that Palestinian children, youth, adults and their families in the Gaza Strip are continually at a huge risk of developing PTSD and other psychological problems.This means that Palestinians will suffer for a long time from PTSD, which should be called Chronic Traumatic Stress Disorder (CTSD) rather than PTSD. This PTSD or CTSD cannot be changed unless the root of the problem is solved by ending the 74 years of living under occupation.

Indicators of Healthcare Services Utilization among the Syrian Refugee Population in Jordan: An Observational Study.

Sufficient healthcare services utilization among the Syrian refugee population is one of the most important human rights. Vulnerable populations, such as refugees, are often deprived of sufficient access to healthcare services. Even when healthcare services are accessible, refugees vary in their level of utilization of these services and their health-seeking behavior. This study aims to examine the status and indicators of healthcare service access and utilization among adult Syrian refugees with non-communicable diseases residing in two refugee camps. The cross-sectional descriptive design was conducted by enrolling 455 adult Syrian refugees residing in the Al-Za'atari and Azraq camps in northern Jordan, using demographical data, perceived health, and the "Access to healthcare services" module, which is a part of the Canadian Community Health Survey (CCHS). A logistic regression model with binary outcomes was used to explore the accuracy of the variables influencing the utilization of healthcare services. The individual indicators were examined further out of 14 variables, according to the Anderson model. Specifically, the model consisted of healthcare indicators and demographic variables to find out if they have any effect on healthcare services utilization. Descriptive data showed that the mean age of the study participants (n = 455) was 49.45 years (SD = 10.48), and 60.2% (n = 274) were females. In addition, 63.7% (n = 290), of them were married; 50.5% (n = 230) held elementary school-level degrees; and the majority 83.3% (n = 379) were unemployed. As expected, the vast majority have no health insurance. The mean overall food security score was 13 out of 24 (±3.5). Difficulty in accessing healthcare services among Syrian refugees in Jordan's camps was significantly predicted by gender. "Transportation problems, other than fee problems" (mean 4.25, SD = 1.11) and "Unable to afford transportation fees" (mean 4.27, SD = 1.12) were identified as the most important barriers to accessing healthcare services. Healthcare services must imply all possible measures to make them more affordable to refugees, particularly older, unemployed refugees with large families. High-quality fresh food and clean drinking water are needed to improve health outcomes in camps.

Hyperlipidaemia and Weight Amongst Afghani Refugees Attending a General Practice Clinic in Regional Australia

Obesity and chronic disease are increasing problems in refugee populations. Afghani refugees undergoing hepatitis B vaccination between January 2015 and December 2017 at a general practice clinic received dietary counselling sessions in Dari by native speaking clinicians. Anthropometry, blood pressure, fasting lipids and liver function tests were measured at both visits with results compared over time. 110/119 refugees requiring hepatitis B vaccination were recruited into the study. Mean BMI was lower at follow up visits (25.4 vs 26.1 by wilcoxon signed rank test p 0.04) with 72 of 110 participants losing a median of 2 kg between visits (range 0.5–14 kg) a mean of 206 days after the initial consultation. Median triglyceride levels were lower at the second visit than the first (1.4 vs 1.3 mmol/L Wilcoxon signed rank test Z = 3.5, p 0.0004). This cohort of refugees lost weight and showed a small improvement in triglyceride levels between visits.

Prevalence of Malnutrition among Syrian Refugee Children from Lebanon

Today, the situation of Syrian refugees is one of the world's worst humanitarian crises. To estimate the prevalence of malnutrition among pediatric populations of Syrian refugees, 176 Syrian refugee children, with stays of more than two years at three refugee camps (Zalhé, Deddeh, and Kfar Jouz) or from the town of Yohmor, Lebanon were authorized by their parents to participate in this study. The children were anthropometrically evaluated and height-for-age Z-score (HAZ), weight-for-age Z-score (WAZ), and weight-for-height (WHZ) Z-scores were obtained and compared with WHO standards. Furthermore, mid-upper arm circumference (MUAC) was analyzed for screening children 6-59 months old. According to the anthropometric measures, no child met the criteria for chronic, global, acute malnutrition (CGAM), severe acute malnutrition (SAM), or moderate acute malnutrition (MAM). In the total sample, 49.4% of participants were moderately thin, with girls presenting a higher prevalence of thinness than that of boys. Thus, the absence of high rates of malnutrition was verified despite the magnitude of the Syrian refugee's problem. The data provided by this study identify the need to carry out further research to assess anthropometric growth and nutritional status among long-staying refugee children in order to prevent any health issues that may arise in the future.

Dismantling European Values

Abstract Since 2015, the mobilization of refugee and migrant populations towards the European Union has at times monopolised public debate, and the so-called ‘refugee crisis’ has put fundamental European values, such as solidarity, to the test. In this article, the authors focus on Greece with the aim of examining the extent to which manifestations of discriminatory discourses crop up in the discussion of the ‘refugee crisis’ in two mainstream news portals (i.e., Próto Théma and Efimerída ton Syntaktón) with different ideological orientations (i.e., center-right vs. center-left, respectively). In doing so, the authors specifically focus on the framing of the EU and its institutions as main actors in the management of the situation, showcasing how the discursive emergence of discriminatory attitudes in the context of the mainstream media discussing EU policy forms a solid argumentative basis on which European solidarity is continuously challenged.

Factors associated with fruit and vegetable consumption among Burmese refugees.

The Burmese population is one of the fast-growing refugee populations in the USA. This study investigated behavioural and environmental factors associated with fruit and vegetable (FV) consumption among Burmese refugees. We conducted a cross-sectional interview survey in 2018-2019. The 24-h recall was used to assess dietary behaviour. Multivariable logistic regression models were constructed with meeting the daily FV consumption recommendation (two or more servings of fruits and three or more servings of vegetables) as the outcome variable. We selected socio-economics, nutritional knowledge, food shopping frequency, ethnicity of preferred food store owners, perceived neighbourhood food environment and network distance to preferred food stores as potential explanatory variables. Two Upstate New York counties. Burmese refugees (n 173) aged ≥18 years. Forty-five percentage of respondents met the daily FV consumption recommendation, and nearly all respondents identified ethnic (Burmese, Chinese/pan-Asian, or South Asian/halal) stores as their preferred stores to purchase FV. In the best-fit model, age (OR 1·08, 95 % CI (1·04, 1·12)) and shopping frequency (OR 1·51, 95 % CI (1·01, 2·26)) were positively associated, and network distance to preferred stores in kilometres (OR 0·81, 95 % CI (0·73, 0·90)) was negatively associated with meeting the daily FV consumption recommendation. No significant effect modifications by car ownership, poverty, length of stay in the USA and Supplemental Nutrition Assistance Program participation were detected. The findings suggested that having Asian ethnic food stores within a short, walkable distance from home and shopping at these stores often can promote healthy dietary behaviour among Burmese refugees.