The UCL-Lancet Commission on Migration and Health: the health of a world on the move

Why it is unethical to charge migrant women for pregnancy care in the National Health Service

Pregnancy care is chargeable for migrants who do not have indefinite leave to remain in the UK. Women who are not 'ordinarily resident', including prospective asylum applicants, some refused asylum-seekers, unidentified victims of trafficking and undocumented people are required to pay substantial charges in order to access antenatal, intrapartum and postnatal services as well as abortion care within the National Health Service. In this paper, we consider the ethical issues generated by the exclusion of pregnancy care from the raft of services which are free to all. We argue that charging for pregnancy care amounts to sex discrimination, since without pregnancy care, sex may pose a barrier to good health. We also argue that charging for pregnancy care violates bodily autonomy, entrenches the sex asymmetry of sexual responsibility, centres the male body and produces health risks for women and neonates. We explore some of the ideological motivations for making maternity care chargeable, and suggest that its exclusion responds to xenophobic populism. We recommend that pregnancy care always be free regardless of citizenship or residence status, and briefly explore how these arguments bear on the broader moral case against chargeable healthcare for migrants.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context

OBJECTIVE

Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice.

DESIGN

Systematic review and meta-synthesis of published findings from qualitative studies.

DATA SOURCES

Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched.

ELIGIBILITY CRITERIA

Studies employing qualitative methods published in English.

SETTINGS

EDs in high-income countries.

PARTICIPANTS

ECPs included doctors, nurses and paramedics.

TOPIC OF ENQUIRY

Staff views on migrant care in ED settings.

DATA EXTRACTION AND SYNTHESIS

Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice.

RESULTS

Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants.

CONCLUSION

ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

Culturally competent healthcare - A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

BACKGROUND

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

METHODS AND FINDINGS

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare-Individual level; Components of culturally competent healthcare-Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

CONCLUSION

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

Occupational health outcomes among international migrant workers: a systematic review and meta-analysis

BACKGROUND

Globally, there are more than 150 million international migrant workers-individuals who are employed outside of their country of origin-comprising the largest international migrant group. A substantial number of migrants work in hazardous and exploitative environments, where they might be at considerable risk of injury and ill health. However, little data on occupational health outcomes of migrant workers exist, with which to inform global policy making and delivery of health services.

METHODS

For this systematic review and meta-analysis, we searched Embase, MEDLINE, Ovid Global Health, and PsychINFO databases for primary research published between Jan 1, 2008, and Jan 24, 2018, reporting occupational health outcomes among international migrant workers (defined as individuals who are or have been employed outside their country of origin), without language or geographical restrictions. We excluded studies containing mixed cohorts of migrants and native workers in which migrant data could not be disaggregated, and studies that did not explicitly report migrant status. The main outcome was prevalence of occupational health outcomes (defined as any injury, mortality, or physical or psychiatric morbidity due to an individual's work or workplace environment) among international migrant workers. Summary estimates were calculated using random-effects models. The study protocol has been registered with PROSPERO, number CRD42018099465.

FINDINGS

Of the 1218 studies identified by our search, 36 studies were included in our systematic review, and 18 studies were included in the meta-analysis. The systematic review included occupational health outcomes for 12 168 international migrant workers employed in 13 countries and territories, mostly employed in unskilled manual labour. Migrant workers originated from 25 low-income and middle-income countries, and worked in the following sectors: agriculture; domestic, retail, and service sectors; construction and trade; and manufacturing and processing. Migrant workers had various psychiatric and physical morbidities, and workplace accidents and injuries were relatively common. In the meta-analysis, among 7260 international migrant workers, the pooled prevalence of having at least one occupational morbidity was 47% (95% CI 29-64; I2=99·70%). Among 3890 migrant workers, the prevalence of having at least one injury or accident, including falls from heights, fractures and dislocations, ocular injuries, and cuts was 22% (7-37; I2=99·35%).

INTERPRETATION

International migrant workers are at considerable risk of work-related ill health and injury, and their health needs are critically overlooked in research and policy. Governments, policy makers, and businesses must enforce and improve occupational health and safety measures, which should be accompanied by accessible, affordable, and appropriate health care and insurance coverage to meet the care needs of this important working population.

FUNDING

Wellcome Trust.

Unraveling common threads in obesity risk among racial/ethnic minority and migrant populations

BACKGROUND

Epidemic obesity poses a major threat to global health. This phenomenon reflects the inability of the average person to cope, biologically and behaviorally, with environmental contexts that promote caloric overconsumption and inadequate caloric expenditure. There is still much to be learned about how to improve these contexts nationally and within-countries for sociodemographic groups with above-average obesity risks.

METHODS

Higher obesity risks relative to respective white majority populations were identified among diverse indigenous, other native-born, or migrant 'racial' or ethnic minority (hereafter, ethnic minority) populations in the United States, Canada, Australia, New Zealand, and the Netherlands, using publicly available national survey data or other sources. Cross-national comparisons were of interest for identifying common risk pathways associated with social and economic inequities. Potential explanations were explored through a narrative review of peer-reviewed literature, informed by the World Health Organization's Conceptual Framework for Action on The Social Determinants of Health.

MAIN FINDINGS

Identifying viable solutions to the high risk of obesity in ethnic minority populations in these high-income countries requires examination of national-level social, economic, and health system contexts, food systems, and built environments for physical activity, as well as patterns of social stratification and cultural biases related to ethnicity, migration, and other determinants of social disadvantage. These factors can be linked to mediators of exposure or vulnerability to obesity-related risks, such as poverty, being an 'outsider', stress and trauma resulting from historical and current oppression, exposure to bias and discrimination, related biological or behavioral consequences, and inadequate health and social care.

CONCLUSIONS

Focusing on ethnic minority populations in high-income countries is critical for public health efforts to address epidemic obesity. Mitigating intersecting risk pathways arising from stratification and bias based on ethnicity and migrant status should be prominent in these efforts.

Intersectoral and integrated approaches in achieving the right to health for refugees on resettlement: a scoping review

BACKGROUND

Better understanding, documentation and evaluation of different refugee health interventions and their means of health system integration and intersectoral collaboration are needed.

OBJECTIVES

Explore the barriers and facilitators to the integration of health services for refugees; the processes involved and the different stakeholders engaged in levaraging intersectoral approaches to protect refugees' right to health on resettlement.

DESIGN

Scoping review.

METHODS

A search of articles from 2000 onward was done in MEDLINE, Web of Science, Global Health and PsycINFO, Embase. Two frameworks were applied in our analysis, the 'framework for analysing integration of targeted health interventions in systems' and 'Health in All Policies' framework for country action. A comprehensive description of the methods is included in our published protocol.

RESULTS

6117 papers were identified, only 18 studies met the inclusion criteria. Facilitators in implementation included: training for providers, colocation of services, transportation services to enhance access, clear role definitions and appropriate budget allocation and financing. Barriers included: lack of a participatory approach, insufficient resources for providers, absence of financing, unclear roles and insufficient coordination of interprofessional teams; low availability and use of data, and turf wars across governance stakeholders. Successful strategies to address refugee health included: networks of service delivery combining existing public and private services; system navigators; host community engagement to reduce stigma; translation services; legislative support and alternative models of care for women and children.

CONCLUSION

Limited evidence was found overall. Further research on intersectoral approaches is needed. Key policy insights gained from barriers and facilitators reported in available studies include: improving coordination between existing programmes; supporting colocation of services; establishing formal system navigator roles that connect relevant programmes; establishing formal translation services to improve access and establishing training and resources for providers.

A systematic literature review of reported challenges in health care delivery to migrants and refugees in high-income countries - the 3C model

BACKGROUND

Migrants and refugees have important health needs and face inequalities in their health status. Health care delivery to this patient group has become a challenging public health focus in high income countries. This paper summarizes current knowledge on health care delivery to migrants and refugees in high-income countries from multiple perspectives.

METHODS

We performed a systematic literature review including primary source qualitative and quantitative studies between 2000 and 2017. Articles were excluded if the study setting was in low- or middle-income countries or focused on skilled migration. Quality assessment was done for qualitative and quantitative studies separately. Predefined variables were extracted in a standardized form. Authors were approached to provide missing information.

RESULTS

Of 185 identified articles, 35 were included in the final analysis. We identified three main topics of challenges in health care delivery: communication, continuity of care and confidence. All but one study included at least one of the three main topics and in 21/35 (60%) all three topics were mentioned. We further developed the 3C model and elaborated the interrelatedness of the three topics. Additional topics identified showed that the specific regional context with legal, financial, geographical and cultural aspects is important and further influences the 3C model.

CONCLUSIONS

The 3C model gives a simple and comprehensive, patient-centered summary of key challenges in health care delivery for refugees and migrants. This concept is relevant to support clinicians in their day to day practice and in guiding stakeholders in priority setting for refugee and migrant health policies.

Challenges for immigrant health in the USA-the road to crisis

The USA is home to more immigrants than any other country-about 46 million, just less than a fifth of the world's immigrants. Immigrant health and access to health care in the USA varies widely by ethnicity, citizenship, and legal status. In recent decades, several policy and regulatory changes have worsened health-care quality and access for immigrant populations. These changes include restrictions on access to public health insurance programmes, rhetoric discouraging the use of social services, aggressive immigration enforcement activities, intimidation within health-care settings, decreased caps on the number of admitted refugees, and rescission of protections from deportation. A receding of ethical norms has created an environment favourable for moral and public health crises, as evident in the separation of children from their parents at the southern US border. Given the polarising immigration rhetoric at the national level, individual states rather than the country as a whole might be better positioned to address the barriers to improved health and health care for immigrants in the USA.

Next steps towards universal health coverage call for global leadership

Gerald Bloom and colleagues argue that the G20 is uniquely placed to facilitate crucial actions to accelerate progress towards universal health coverage

Estimating dementia cases amongst migrants living in Europe

BACKGROUND AND PURPOSE

The phenomenon of dementia amongst migrants and ethnic minorities represents an emerging concern for European healthcare systems, posing additional challenges in terms of clinical approach, access to care and resource utilization. The aim of the present study was to estimate the cases of dementia amongst immigrant older subjects living in Europe and in each European country.

METHODS

The estimated cases of dementia amongst older (i.e. 65+) migrants living in the European Union (EU-28) and European Free Trade Association member states were calculated by multiplying the number of migrants (obtained through the data provided by Eurostat) with the age- and sex-specific prevalence rates (derived by a recent meta-analysis).

RESULTS

Overall, 6 507 360 older migrants lived in Europe in 2017. In addition, 1 204 671 migrants were registered in Germany in 2010. Nearly 475 000 dementia cases (329 028 women, 147 410 men) were estimated in this population by applying age- and sex-specific prevalence rates. When considering each European country, the number of estimated cases ranged from 108 (Iceland) to 119 161 (France). In parallel, the proportion of dementia cases occurring in migrants ranged from 0.9% (Czech Republic) to 51.2% (Liechtenstein).

CONCLUSIONS

The issue of dementia in migrants and ethnic minorities is emerging but already relevant for European healthcare systems. The magnitude of this phenomenon and its complexities reinforce the need for coordinated initiatives both at a national and continental level. These epidemiological data should ideally be integrated with those coming from 'real world' services in order to better calibrate these actions.

Cost-utility of screening for depression among asylum seekers: a modelling study in Germany

BACKGROUND

Asylum seekers have a high burden of mental illness owing to traumatic experiences before, during and after flight. Screening has been suggested to identify asylum seekers with psychosocial needs. However, little is known about the costs of screening relative to expected gains. We assessed the cost-utility of population-based screening for depression in German asylum reception centres compared to case-finding by self-referral.

METHODS

Explorative modelling study using a decision tree over 15 months to estimate the incremental cost per quality-adjusted life-year gained. Data points were taken from the published literature. Deterministic and probabilistic sensitivity analyses were used to address uncertainty around parameter estimates. Value of information analyses were performed to indicate the value of future research.

RESULTS

The model demonstrates a high probability (p = 83%) of the screening intervention being cost-effective at a Є 50,000/QALY threshold. Cost-utility depends on the process of care following screening: when acceptability and adherence parameters were decreased by 40%, the resulting ICER increased by 27-131%. Eliminating uncertainty was most valuable for the screening process and cost parameters, at Є 3·0 and Є 4·4 million respectively.

CONCLUSIONS

Screening asylum seekers for depression may be a cost-effective strategy to identify those in need of care. However, there is considerable value in conducting further research in this area, especially regarding resource requirements and the process of care following screening.

Measuring mobility, disease connectivity and individual risk: a review of using mobile phone data and mHealth for travel medicine

RATIONALE FOR REVIEW

The increasing mobility of populations allows pathogens to move rapidly and far, making endemic or epidemic regions more connected to the rest of the world than at any time in history. However, the ability to measure and monitor human mobility, health risk and their changing patterns across spatial and temporal scales using traditional data sources has been limited. To facilitate a better understanding of the use of emerging mobile phone technology and data in travel medicine, we reviewed relevant work aiming at measuring human mobility, disease connectivity and health risk in travellers using mobile geopositioning data.

KEY FINDINGS

Despite some inherent biases of mobile phone data, analysing anonymized positions from mobile users could precisely quantify the dynamical processes associated with contemporary human movements and connectivity of infectious diseases at multiple temporal and spatial scales. Moreover, recent progress in mobile health (mHealth) technology and applications, integrating with mobile positioning data, shows great potential for innovation in travel medicine to monitor and assess real-time health risk for individuals during travel.

CONCLUSIONS

Mobile phones and mHealth have become a novel and tremendously powerful source of information on measuring human movements and origin-destination-specific risks of infectious and non-infectious health issues. The high penetration rate of mobile phones across the globe provides an unprecedented opportunity to quantify human mobility and accurately estimate the health risks in travellers. Continued efforts are needed to establish the most promising uses of these data and technologies for travel health.

Imaginary Numbers of Climate Change Migrants?

Within the extensive scientific and policy discussions about climate change migrants, detailed analyses continue to highlight the lack of evidence thus far for climate change directly causing migration. To understand better how climate change might or might not lead to migration, this paper explores possibilities for developing a robust, repeatable, and verifiable method to count or calculate the number of people migrating or not migrating due to climate change. The discussion starts by examining definitions of “climate change” and “migration”, then looking at how to determine numbers of climate change migrants based on those definitions. These points lead to descriptions of the subjectivity and arbitrariness of the decisions needed for counting or calculating climate change migrants and non-migrants. While the scientific study of working out numbers of climate change migrants and non-migrants is challenging and interesting, especially due to its complexity, changing baselines alongside legitimate concerns about necessary assumptions lead to questions regarding the usefulness of the calculations for policy and action. Ultimately, labelling, counting, and calculating climate change migrants and non-migrants depend on political choices, so any numbers reached might not be scientifically robust. Improved understanding of people’s motivations for migrating and not migrating under different circumstances, including under climate change and perceptions thereof, would be preferable to a starting point assuming that climate change inevitably causes migration.

Asylum seekers health and wellbeing (TERTTU) survey: study protocol for a prospective total population health examination survey on the health and service needs of newly arrived asylum seekers in Finland

INTRODUCTION

Health, well-being and health service needs of asylum seekers have emerged as urgent topics following the arrival of 2.5 million asylum seekers to the European Union (EU) between 2015 and 2016. However, representative information on the health, well-being and service needs of asylum seekers is scarce. The Asylum Seekers Health and Wellbeing (TERTTU) Survey aims to: (1) gather population-based representative information; (2) identify key indicators for systematic monitoring; (3) produce the evidence base for development of systematic screening of asylum seekers' health, well-being and health service needs.

METHODS AND ANALYSIS

TERTTU Survey is a population-based prospective study with a total population sample of newly arrived asylum seekers to Finland, including adults and children. Baseline data collection is carried out in reception centres in 2018 and consists of a face-to-face interview, self-administered questionnaire and a health examination following a standardised protocol. Altogether 1000 asylum seekers will be included into the study. Baseline data will be followed up with national electronic health record data encompassing the entire asylum process and later with national register data among persons who receive residency permits.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Coordinating Ethics Committee of the Helsinki and Uusimaa Hospital District. Participation is voluntary and based on written informed consent. Results will be widely disseminated on a national and international level to inform health and welfare policy as well as development of services for asylum seekers. Results of the study will constitute the evidence base for development and implementation of the initial health assessment for asylum seekers on a national level.

The Devil Is in the Detail-Understanding Divergence between Intention and Implementation of Health Policy for Undocumented Migrants in Thailand

Migrants’ access to healthcare has attracted attention from policy makers in Thailand for many years. The most relevant policies have been (i) the Health Insurance Card Scheme (HICS) and (ii) the One Stop Service (OSS) registration measure, targeting undocumented migrants from neighbouring countries. This study sought to examine gaps and dissonance between de jure policy intention and de facto implementation through qualitative methods. In-depth interviews with policy makers and local implementers and document reviews of migrant-related laws and regulations were undertaken. Framework analysis with inductive and deductive coding was undertaken. Ranong province was chosen as the study area as it had the largest proportion of migrants. Though the government required undocumented migrants to buy the insurance card and undertake nationality verification (NV) through the OSS, in reality a large number of migrants were left uninsured and the NV made limited progress. Unclear policy messages, bureaucratic hurdles, and inadequate inter-ministerial coordination were key challenges. Some frontline implementers adapted the policies to cope with their routine problems resulting in divergence from the initial policy objectives. The study highlighted that though Thailand has been recognized for its success in expanding insurance coverage to undocumented migrants, there were still unsolved operational challenges. To tackle these, in the short term the government should resolve policy ambiguities and promote inter-ministerial coordination. In the long-term the government should explore the feasibility of facilitating lawful cross-border travel and streamlining health system functions between Thailand and its neighbours.

Million Migrants study of healthcare and mortality outcomes in non-EU migrants and refugees to England: Analysis protocol for a linked population-based cohort study of 1.5 million migrants

Background: In 2017, 15.6% of the people living in England were born abroad, yet we have a limited understanding of their use of health services and subsequent health conditions. This linked population-based cohort study aims to describe the hospital-based healthcare and mortality outcomes of 1.5 million non-European Union (EU) migrants and refugees in England. Methods and analysis: We will link four data sources: first, non-EU migrant tuberculosis pre-entry screening data; second, refugee pre-entry health assessment data; third, national hospital episode statistics; and fourth, Office of National Statistics death records. Using this linked dataset, we will then generate a population-based cohort to examine hospital-based events and mortality outcomes in England between Jan 1, 2006, and Dec 31, 2017. We will compare outcomes across three groups in our analyses: 1) non-EU international migrants, 2) refugees, and 3) general population of England. Ethics and dissemination: We will obtain approval to use unconsented patient identifiable data from the Secretary of State for Health through the Confidentiality Advisory Group and the National Health Service Research Ethics Committee. After data linkage, we will destroy identifying data and undertake all analyses using the pseudonymised dataset. The results will provide policy makers and civil society with detailed information about the health needs of non-EU international migrants and refugees in England.

Health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis

BACKGROUND

Globally, a growing number of children and adolescents are left behind when parents migrate. We investigated the effect of parental migration on the health of left behind-children and adolescents in low-income and middle-income countries (LMICs).

METHODS

For this systematic review and meta-analysis we searched MEDLINE, Embase, CINAHL, the Cochrane Library, Web of Science, PsychINFO, Global Index Medicus, Scopus, and Popline from inception to April 27, 2017, without language restrictions, for observational studies investigating the effects of parental migration on nutrition, mental health, unintentional injuries, infectious disease, substance use, unprotected sex, early pregnancy, and abuse in left-behind children (aged 0-19 years) in LMICs. We excluded studies in which less than 50% of participants were aged 0-19 years, the mean or median age of participants was more than 19 years, fewer than 50% of parents had migrated for more than 6 months, or the mean or median duration of migration was less than 6 months. We screened studies using systematic review software and extracted summary estimates from published reports independently. The main outcomes were risk and prevalence of health outcomes, including nutrition (stunting, wasting, underweight, overweight and obesity, low birthweight, and anaemia), mental health (depressive disorder, anxiety disorder, conduct disorders, self-harm, and suicide), unintentional injuries, substance use, abuse, and infectious disease. We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs) using random-effects models. This study is registered with PROSPERO, number CRD42017064871.

FINDINGS

Our search identified 10 284 records, of which 111 studies were included for analysis, including a total of 264 967 children (n=106 167 left-behind children and adolescents; n=158 800 children and adolescents of non-migrant parents). 91 studies were done in China and focused on effects of internal labour migration. Compared with children of non-migrants, left-behind children had increased risk of depression and higher depression scores (RR 1·52 [95% CI 1·27-1·82]; SMD 0·16 [0·10-0·21]), anxiety (RR 1·85 [1·36-2·53]; SMD 0·18 [0·11-0·26]), suicidal ideation (RR 1·70 [1·28-2·26]), conduct disorder (SMD 0·16 [0·04-0·28]), substance use (RR 1·24 [1·00-1·52]), wasting (RR 1·13 [1·02-1·24]) and stunting (RR 1·12 [1·00-1·26]). No differences were identified between left-behind children and children of non-migrants for other nutrition outcomes, unintentional injury, abuse, or diarrhoea. No studies reported outcomes for other infectious diseases, self-harm, unprotected sex, or early pregnancy. Study quality varied across the included studies, with 43% of studies at high or unclear risk of bias across five or more domains.

INTERPRETATION

Parental migration is detrimental to the health of left-behind children and adolescents, with no evidence of any benefit. Policy makers and health-care professionals need to take action to improve the health of these young people.

FUNDING

Wellcome Trust.