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This article describes the process of integrating trauma-informed behavioral health practices into a pediatric primary care clinic serving low-income and minority families while facing barriers of financial, staffing, and time limitations common to many community healthcare clinics. By using an iterative approach to evaluate each step of the implementation process, the goal was to establish a feasible system in which primary care providers take the lead in addressing traumatic stress. This article describes (1) the process of implementing trauma-informed care into a pediatric primary care clinic, (2) the facilitators and challenges of implementation, and (3) the impact of this implementation process at patient, provider, and community levels. Given the importance of trauma-informed care, especially for families who lack access to quality care, the authors conceptualize this paper as a guide for others attempting to integrate best behavioral health practices into pediatric clinics while working with limited resources. [ABSTRACT FROM AUTHOR]

The U.S. war with Iraq led to the displacement of millions of Iraqis, many of whom have resettled in the United States as refugees. We explore the challenges Iraqi families face after resettlement, with a particular focus on the agency of refugees and challenges/opportunities of familial social reproduction in a transnational context. We conducted 181 qualitative interviews with 38 Iraqis (11 youth, 27 adults) and 5 service providers. Our findings highlight the importance of exploring refugee agency and illuminate how the interplay between structure and agency in transnational contexts is a useful framework for understanding transformations around social roles. [ABSTRACT FROM AUTHOR]

Culturally and contextually valid measurement of psychological distress is critical, given the increasing numbers of forcibly displaced people and transnational migration. This study replicates an inductive process that elicited culturally specific expressions, understandings, and idioms of distress among Afghans to develop culturally specific measures of distress for Great Lakes Africans and Iraqis and expands this methodology to include a focus on the contexts of refugees resettled in the United States. To create the measures, we adapted Miller et al.'s (2006) model for the Afghan Symptom Checklist (ASCL) and conducted 18 semistructured qualitative interviews that attended to refugees' multiple settings; the impact of potentially traumatic events initially and postresettlement; and the experiences and impact of resettlement stressors. We tested the newly developed measures and existing ASCL with 280 recently resettled refugees (<3 years) from Afghanistan, the Great Lakes region of Africa, and Iraq to assess factor structure, reliability, and construct validity. We successfully replicated and adapted a process for creating culturally specific measures of distress to create reliable and valid scales that consider culturally and contextually specific distress among several groups of forcibly displaced people. Our results highlight the salience of individuals' social contexts and how they are manifested as idioms of distress, bringing together two key areas of research: the social construction of mental health and social determinants of mental health. These findings have implications for improving measurement of psychological distress and for developing multilevel interventions that are culturally resonant and address factors beyond the individual level. Public Policy Relevance Statement: Addressing the mental health of the rapidly increasing numbers of forcibly displaced people is urgently needed, and effective interventions require an accurate understanding of the sources and experiences of psychological distress. This study highlights a process for assessing culturally and contextually specific distress among three refugee groups and provides measures that can be used with Afghan, Great Lakes African, and Iraqi refugees in the United States. The symptoms of distress revealed in the newly created measures demonstrate the relevance of including contextually specific items that measure postresettlement stressors and the importance of multilevel and structural interventions that attend to social isolation, family separation, language barriers, and resource access. [ABSTRACT FROM AUTHOR]

Highlights: Multilevel strengths‐based intervention decreases refugee distress and improves protective factors.Holistic focus on psychological, material, social, educational, and cultural needs is effective.High recruitment/retention rates support importance of non‐stigmatizing universal interventions.Refugee Well‐being Project (RWP) intervention reaches refugees unlikely to access formal mental health services.RWP circumvents typical barriers to services (stigma, trust, linguistic/cultural appropriateness). Understanding processes that support the well‐being of the unprecedented numbers of forcibly displaced people throughout the world is essential. Growing evidence documents post‐migration stressors related to marginalization as key social determinants of refugee mental health. The goal of this RCT was to rigorously test a social justice approach to reducing high rates of distress among refugees in the United States. The 6‐month multilevel, strengths‐based Refugee Well‐being Project (RWP) intervention brought together university students enrolled in a 2‐semester course and recently resettled refugees to engage in mutual learning and collaborative efforts to mobilize community resources and improve community and systems responsiveness to refugees. Data collected from 290 Afghan, Great Lakes African, Iraqi, and Syrian refugees at four time points over 12 months were used to test the effectiveness of RWP to reduce distress (depression and anxiety symptoms) and increase protective factors (English proficiency, social support, connection to home and American cultures). Intention‐to‐treat analyses using multilevel modeling revealed significant intervention effects for all hypothesized outcomes. Results provide evidence to support social justice approaches to improving refugee mental health. Findings have implications for refugees worldwide, and for other immigrant and marginalized populations who experience inequities in resources and disproportionate exposure to trauma/stress. [ABSTRACT FROM AUTHOR]

Using a mixed-method design with Bosnian students ( n = 63, ages 16-19) and their primary caregivers ( n = 50), we explored the impact of post-war adversities on adolescent adjustment, adolescent-caregiver relationships, and future outlook 8 years after the 1992-1995 Bosnian civil war. Adolescents and caregivers identified themes linking the war and its aftermath to ongoing emotional adjustment difficulties, relationships challenges, and negative future outlook. Adolescents' posttraumatic stress symptoms were positively correlated with self-report measures of interpersonal stressors, existential stressors, parental psychological control, and anxious/withdrawn symptoms. Parental psychological control partially mediated the association between interpersonal post-war adversities and posttraumatic stress symptoms. [ABSTRACT FROM AUTHOR]

Methods are needed for quantifying the potency and differential effects of risk factors to identify at-risk groups for theory building and intervention. Traditional methods for constructing war exposure measures are poorly suited to “unpack” differential relations between specific types of exposure and specific outcomes. This study of 881 Bosnian adolescents compared both common factor–effect indicator (using exploratory factor analysis) versus composite causal–indicator methods for “unpacking” dimensions of war exposure and their respective paths to postwar adjustment outcomes. The composite method better supported theory building and most intervention applications, showing how multitiered interventions can enhance treatment effectiveness and efficiency in war settings. Used together, the methods may unpack the elements and differential effects of “caravans” of risk and promotive factors that co-occur across development. [ABSTRACT FROM AUTHOR]