High Prevalence of Head Trauma Among Refugees, Asylum Seekers

Refugees and asylum seekers are more at risk for head trauma, yet studies using systematic approaches to screening are lacking. These are the findings of a systematic review published in the journal Neurology. 

Individuals in displaced populations endure blows to their head because of challenging situations that require resettlement, including war, torture, and interpersonal violence, as well as throughout their oftentimes perilous journeys seeking refuge. Comparing the 2 groups of individuals on a legal basis, refugees have “their status already determined,” whereas asylum seekers are defined as those who are “awaiting adjudication of their asylum claim.”

For the study, researchers conducted a systematic literature review to evaluate the global prevalence of head trauma among refugees and asylum seekers, as well as to depict the common clinical characteristics of head trauma in this population.

Clinically, it is recognized that asylum seekers and refugees experience poorer health outcomes compared with the general population, such as posttraumatic stress disorder, cardiovascular disease, and depression, with these individuals at elevated risk for head trauma.

Of note, the researchers used the term head trauma, rather than traumatic brain injury (TBI), in an effort to avoid the challenge associated with differing definitions across studies and to offer a more expansive review of the relevant literature. The term TBI is used whenever specific criteria are indicated.

Studies were included in the review if they involved individuals of any age who were refugees or asylum seekers, and if they explored the characteristics or prevalence of head trauma among those in this population. The researchers decided not to conduct a meta-analysis after completion of the literature search due to the heterogeneity of the studies selected.

The researchers selected a total of 22 full-text articles, published between 1988 and 2021, for inclusion in the systematic review. Of the 22 studies included, 41% (9 of 22) of them were conducted in the United States, 23% (5 of 22) of them were conducted in the Middle East, and 18% (4 of 22) of them were conducted in Europe. The majority of the studies involved asylum seekers or refugees from the Middle East (41%), with refugees or asylum seekers from Latin America the least-represented group (14%).

The main recruitment settings were hospitals or clinics (in 64% of the settings), followed by refugee camps (in 14% of the settings), forensic medical-legal partnerships (in 14% of the settings), and civic/service organizations (in 9% of the settings).

The sample sizes of the refugees/asylum-seekers in the 22 studies ranged from 18 individuals to 1,735 individuals, with a mean number of 466 individuals and a median number of 175 individuals. Participants’ ages ranged from 2 months to 90 years. Overall, 64% of the studies comprised adult participants only. The majority of the studies (45%) involved more men than women, with 3 of the studies not specifying the gender of the participants and 3 including men only.

A total of 13 of the 22 studies (which comprised a total of 6038 refugees/asylum-seekers) reported the prevalence of head trauma. Estimates of head trauma incidence ranged between 9% and 78%. The “most common mechanism of injury was direct impact via a beating or blow to the head.” The studies varied widely regarding the definition and ascertainment of head trauma; none of the studies involved used a validated TBI-specific screening tool. Comorbidities involving mental health were more often documented that those involving physical health.

Study limitations included the risk for bias assessments that existed among the studies selected, with only 27% (6 of 22) of the studies receiving a score that was deemed to be of “good” quality. Further, only 2 of the 22 studies compared refugees/asylum seekers with their nonrefugee counterparts. Additionally, disproportionate recruitment from hospital or clinic settings may have led to underestimation of the true prevalence of head trauma.

The researchers concluded, “Increased attention to head trauma in displaced populations will allow for optimizing equitable care for this growing, vulnerable population.”