[Health examination of asylum seekers: A nationwide analysis of state policies in Germany : § 62 of the asylum law]

"We assist the health system doing the work that should be done by others" - a qualitative study on experiences of grassroots level organizations providing refugee health care during the 2015 migration event in Germany

Background

In Germany, the 2015 mass displacement and resulting population migration exposed regulatory and structural shortcomings with respect to refugee healthcare provision. Existing research on Germany’s crisis response has largely focused on the roles played by public and health system actors. The roles and contributions of non-governmental actors operating at the grassroots level have so far been given little attention. The purpose of this qualitative study was to explore the involvement of grassroots level actors with refugee healthcare provision in Germany.

Methods

In 2017, we conducted in-depth interviews with 13 representatives of different non-governmental organizations providing refugee healthcare provision in Germany. This included humanitarian relief organizations operating at the grassroots level that offer various forms of medical and psychological care. Transcribed interview content was analyzed using both deductive and inductive coding approaches.

Results

Grassroots level involvement changed over the course of the reporting period. During the initial emergency response, locally organized groups supported federal states and municipalities to guarantee the provision of legally defined refugee healthcare. During the following less acute phase, grassroots organizations attended to health needs of refugees the public health system was unable to address due to legal or structural limitations. In the subsequent integration phase, grassroots organizations shifted their relief focus towards care for the most vulnerable among refugees, including rejected asylum seekers and undocumented migrants with no or limited health coverage, as well as for those suffering from mental health problems.

Conclusion

Grassroots actors perceived their contributions largely as addressing those bottlenecks that resulted from healthcare restrictions imposed by German refugee legislation. Such bottlenecks could be addressed by offering those medical services for free that otherwise were not covered by law. Further, volunteers contributed to closing existing information and communication gaps between public actors, serving as intermediaries between public officials, healthcare providers, and refugee patients. To increase Germany’s efficiency and preparedness with respect to refugee healthcare, more integrated approaches at the local level, patient-centered interpretation and implementation of refugee law, and a stronger focus on post-traumatic mental health disorders should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07683-2.

A Qualitative Evaluation of a Mother and Child Center Providing Psychosocial Support to Newly Arrived Female Refugees in a Registration and Reception Center in Germany

Female refugees are frequently exposed to sexualized, gender-based violence and harassment before, during, and after their flight. Yet female refugee-specific care and protection needs are rarely addressed in host countries. This study aimed to evaluate a mother and child center (MUKI) for female refugees in a reception and registration center in Germany. In 2017, we conducted semi-structured qualitative interviews with 16 female refugees attending the MUKI and with its five main staff members. We asked the participants about the MUKI’s relevance, encountered difficulties, and suggestions for improvement. The interviewees appreciated the MUKI’s sheltered environment, care services, and socializing opportunities, as well as its women-only concept. Overall, the participants saw overexertion, social engagement-related difficulties, and the MUKI’s noisy environment as key attendance barriers. Interviewed staff primarily reported problems regarding the working conditions, including the high staff and attendee turnover and low general service awareness. The participants advocated an expansion of the MUKI program. The MUKI project underlines that providing newly arrived, vulnerable female refugees with sheltered surroundings and psychosocial services is an essential step toward addressing female refugees’ specific care needs.

[COVID-19 in collective accommodation centres for refugees: assessment of pandemic control measures and priorities from the perspective of authorities]

Hintergrund

Die Eindämmung der COVID-19-Pandemie in Sammelunterkünften für Geflüchtete ist für die Wahrung deren körperlicher und psychischer Gesundheit enorm wichtig. Unklar ist, welche Maßnahmen in diesem Setting ergriffen werden, um das Infektionsrisiko zu senken, zusätzliche Stressoren in der Pandemie zu minimieren und über ergriffene Maßnahmen aufzuklären.

Ziel

Situationsanalyse der Maßnahmen, die zur Prävention und Eindämmung des SARS-CoV-2-Virus in Sammelunterkünften für Geflüchtete ergriffen wurden, sowie Identifizierung von Unterstützungsbedarfen der Aufnahmebehörden.

Methoden

Qualitative Interviewstudie mit 48 für die Unterbringung von Geflüchteten zuständigen Ansprechpartner*innen in den Aufnahmebehörden. Einzelinterviews wurden wörtlich transkribiert und mittels Framework-Analyse ausgewertet.

Ergebnisse

In Bezug auf Maßnahmen des Infektionsschutzes, gesundheitlicher Information und Aufklärung, sozialer und gesundheitlicher Angebote, Testung auf SARS-CoV‑2 und Quarantäne zeichnet sich ein heterogenes Bild ab. Zur Abstimmung und Durchführung der Maßnahmen erwies sich eine effektive intersektorale Kooperation als besonders wichtig. Unterstützungsbedarfe bestehen in der Verbesserung der Unterbringung, dem vermehrten Einsatz von Sprachmittler*innen sowie der lokalen Stärkung gesundheitlicher Fachexpertise.

Fazit

Aufgrund der hohen Anzahl an Akteur*innen und der Komplexität von Strukturen und Prozessen übernehmen Aufnahmebehörden ad hoc essenzielle Aufgaben des Infektionsschutzes, für die sie unzureichend aufgestellt sind. Für die Eindämmung der Pandemie sind eine settingspezifische Bündelung fachlicher Empfehlungen und Information auf Bundesebene sowie deren lokale Translation durch die proaktive Einbindung des öffentlichen Gesundheitsdienstes unabdingbar.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03284-2) enthalten.

[Healthcare provision for asylum seekers in reception centres : Qualitative survey from the perspective of healthcare providers]

Im Zuge der gestiegenen Zahlen Asylsuchender in den Jahren 2015/2016 haben sich in Deutschland, geprägt durch lokale Akteur*innen, sehr unterschiedliche Konzepte zur medizinischen Versorgung in Aufnahmeeinrichtungen (AE) etabliert. Ziel unserer Studie war es, unterschiedliche Versorgungskonzepte in AE abzubilden und die Herausforderungen der Verstetigung bedarfsgerechter medizinischer Versorgungsstrukturen herauszuarbeiten.

Daten wurden aus 13 semistrukturierten Interviews und im Rahmen einer Fachtagung mit Workshops und Gruppendiskussionen erhoben und durch eine qualitative Inhaltsanalyse ausgewertet. Teilnehmer*innen waren Akteur*innen der medizinischen Versorgung in AE, darunter ärztliches und Gesundheitsfachpersonal, Verwaltungsbeauftragte, Vertreter*innen des öffentlichen Gesundheitsdienstes und Wissenschaftler*innen.

Als Antwort auf die gesundheitlichen Bedarfe von Asylsuchenden und die komplexen Rahmenbedingungen der Versorgung haben sich unterschiedliche Ambulanzkonzepte gebildet, deren Zweck, Organisation und Management in vielen Aspekten über das Angebot einer ärztlichen Sprechstunde hinausgehen. Die Ambulanzen unterschieden sich in organisationsbezogenen Aspekten z. B. hinsichtlich des Betreibers, der Personalstruktur und des Umfangs der Versorgung. Gemeinsame Herausforderungen stellen eine adäquate Bedarfsplanung, der Mangel einheitlicher Leitlinien und fehlende Schnittstellen zwischen den in der Ambulanz tätigen Akteur*innen dar. Dringender Handlungsbedarf im Sinne eines strukturierten und kontinuierlichen Erfahrungsaustauschs sowie in der Implementierung bundesweiter Standards ist geboten, um Ad-hoc-Initiativen in resiliente Ambulanzstrukturen zu überführen. Die erarbeiteten Handlungsbedarfe und Lösungsvorschläge können hierfür als Grundlage dienen.

Implications of a change in case definition and screening of asylum seekers for hepatitis B surveillance in Germany in 2015 and 2016

Since 2015, the number of hepatitis B virus (HBV) cases increased substantially in Germany. In 2015, a more sensitive HBV case definition was introduced. This coincided with an asylum seeker influx with differing screening strategies. Information on the asylum seeker status has been collected since 09/2015. We investigated this increase to interpret HBV notification data in Germany. We compared HBV surveillance data from 2010–2013 (baseline) with 2015–2016, excluding 2014 due to beginning of asylum seeker influx. We estimated the excess above the mean case number (baseline) using Poisson regression and compared asylum seeker cases and the excess of cases with the unknown asylum seeker status. HBV cases increased from 1855 (mean baseline) to 3873 (2015) and 3466 (2016) with 1903 asylum seeker cases and 1099 excess-cases with the unknown asylum seeker status in 2015–2016. Cases only fulfilling the changed case definition increased from 60% (1119) in baseline to 81% (P < 0.01) in 2015–2016; 69% of asylum seeker cases and 61% of excess-cases were males <40 years compared to 27% (baseline) (P < 0.01). Changed case definition increased the number of cases in official statistics substantially. Demographic and geographical distributions suggest that screening of asylum seekers increased the case numbers even to a higher extent than surveillance data indicates.

Evaluation of the German surveillance system for hepatitis B regarding timeliness, data quality, and simplicity, from 2005 to 2014

OBJECTIVES

Germany has a mandatory surveillance system for acute hepatitis B (AHB) with the Protection against Infection Act as the legal basis in place since 2001. An amendment was introduced in 2013. We aimed at evaluating the surveillance systems' performance regarding timeliness, data quality, and simplicity from 2005 to 2014 and at assessing the effect of the amendment on timeliness of AHB surveillance.

STUDY DESIGN

This study is a trend analysis of surveillance data.

METHODS

Aspects of simplicity versus complexity of the surveillance system were assessed by describing data flow, levels of reporting, and data management procedures. Data quality, in terms of data completeness, was evaluated by quantitative indicators, and timeliness was measured in days between different levels of the surveillance system, notification delay, and reporting delay. Trends over time in data quality were analyzed by logistic regression, while negative binomial regression was used to test for trend over time regarding mean notification and reporting delay.

RESULTS

Between January 2005 and December 2014, a total of 22,549 AHB infections were reported at the national level. The data flow of the German AHB surveillance system showed structural characteristics of a complex system. Over the 10-year period, completeness of reporting sex, age, probable route of transmission, and hepatitis B virus (HBV) vaccination were 99%, 100%, 25%, and 73%, respectively. However, data quality decreased over the evaluation period. Although notification delay improved over time (incident rate ratio [IRR] = 0.95, 95% confidence interval [CI] = 0.95-0.96; P < 0.05), reporting delay improved only since the amendment (IRR = 0.76, 95% CI = 0.70-0.82; P < 0.05). In total, mean notification and reporting delay were 3.0 days and 14.3 days, respectively.

CONCLUSIONS

The German AHB surveillance system is operating in a timely manner. Although timeliness improved over the evaluation period and the amendment to the Protection against Infection Act succeeded in reducing reporting time, data quality in terms of completeness of information decreased considerably. As improved data completeness is required to adequately design prevention activities, reasons for this decrease should further be explored.

Effects of introducing a walk-in clinic on ambulatory care sensitive hospitalisations among asylum seekers in Germany: a single-centre pre-post intervention study using medical records

OBJECTIVE

Measuring the effect of introducing a walk-in clinic on ambulatory care sensitive (ACS) hospitalisations among asylum seekers in a large state reception- and registration centre.

DESIGN AND SETTING

Pre-post intervention study using anonymous account data from a university hospital functioning as referral facility for a state reception- and registration centre in the third largest German federal state.

PARTICIPANTS

We included all asylum seekers residing in the reception centre and admitted to the referral hospital between 2015 to 2017.

INTERVENTIONS

Establishment of an interdisciplinary walk-in clinic in the reception centre (02/2016).

MAIN OUTCOME MEASURES

International lists for ACS conditions for both adults and children were adapted and used to calculate the prevalence of ACS conditions among the population (primary outcome measure). The impact of the intervention on the outcome was analysed using a segmented Poisson regression to calculate incidence-rate ratios with respective 95% CIs, adjusted for age, sex and admission.

RESULTS

The prevalence of ACS hospitalisations changed over time, as did the effect of age, sex and quarter of admission. Introducing the walk-in clinic reduced the prevalence of ACS hospitalisations among asylum seekers compared with the period before establishment of the clinic (incidence-rate ratios (IRR)=0.80 (0.65 to 1.00), p=0.054), but the effect was attenuated after adjustment for time trends. The average difference in prevalence of ACS hospitalisations compared with the period before establishment of the clinic, corrected for pre-existing time trends, age and sex of asylum seekers was IRR=1.03 ((0.69 to 1.55), p=0.876).

CONCLUSIONS

A walk-in clinic in reception centres may be effective to reduce ACS hospitalisations, but our study could not prove evidence for a measurable effect after full adjustment for time trends. Further research, ideally with parallel control groups, is required to establish evidence for the effectiveness of walk-in clinics in reception centres on reducing ACS hospitalisations.

[Health and primary care surveillance among asylum seekers in reception centres in Germany: concept, development, and implementation]

BACKGROUND

Reliable data on health and primary care among asylum seekers in reception centres are not routinely available, but required to plan needs-based healthcare services.

OBJECTIVES

To present the concept, development, and implementation of a routine surveillance system in reception centres for asylum seekers.

METHODS

In the scope of the project PRICARE, medical records in reception centres were standardized and digitized, and continuous surveillance was enabled by means of suitable IT infrastructure. The core elements of the surveillance system were developed in three project phases using an iterative and participative design.

FUNDING

Federal Ministry of Health (Grant no. 2516FSB415).

RESULTS

Forming the basis for the surveillance, the electronic health record Refugee Care Manager® (RefCare®) was developed and gradually implemented in 13 reception centres in three federal states. For implementing the tool in daily care routines, IT infrastructure was implemented in all sites and a legally required data protection concept was established. An indicator set was developed and agreed upon for the surveillance, comprising a total of 64 indicators in four domains: morbidity, processes of care, quality of care, and syndromic alerts.

CONCLUSIONS

For the first time in Germany, a harmonized infrastructure spanning federal states was implemented in healthcare settings ensuring medical documentation and surveillance of health and healthcare of asylum seekers in conformity with data protection requirements. The surveillance is feasible; the long-term benefits of routine surveillance and research within the network will be assessed in the future.

Motives, experiences and psychological strain in medical students engaged in refugee care in a reception center- a mixed-methods approach

BACKGROUND

The UN Refugee Agency has reported that an increasing number of people are being forcibly displaced worldwide. Despite this, global health issues, especially initiatives focusing on physical and psychological conditions of refugees, are still rarely considered in medical curricula. Furthermore, there is little evidence regarding the experiences and possible related psychological strain of medical students who work with refugees. Therefore, the present study aimed to investigate motivations, learning achievements and experiences, as well as psychological strain and possible protective factors, in medical students volunteering in a reception center for refugees.

METHODS

In this prospective study using a mixed-methods approach, we applied (1) qualitative content analysis of semi-standardized interviews in a pre-post design in a subsample of n = 16 students. The aims were to analyze (1a) the students' motivations and experiences in the reception center, and (1b) the students' perceived learning achievement. We further administered (2) psychometric questionnaires using a cross-sectional approach to n = 62 students in order to examine (2a) the students' psychological strain, in terms of secondary traumatization, depression, anxiety and health-related quality of life, and (2b) possible protective factors such as attachment style and sense of coherence.

RESULTS

The content analysis of the students' interviews revealed three main categories before the assignment and four main categories subsequently, displaying a broad variety of perspectives. Quantitative analysis identified that 3.2% of the students showed moderate secondary traumatization, and a correlation emerged between the number of shifts and symptom severity of secondary traumatization. The students displayed significantly reduced scores for depression and anxiety, when compared to a sample of first-year medical students. Sense of coherence was identified as a protective factor concerning secondary traumatization.

CONCLUSION

A rather small proportion of the medical students working in the reception center displayed explicit symptoms of psychological strain in terms of secondary traumatic stress. Due to their assignments, students were able to improve their cultural awareness, which they reported to be highly relevant for their future occupation. In view of increasing globalization, theoretical and practical courses on issues of flight and global health might therefore be implemented as an obligatory part of medical curricula.

Asylum seekers' mental health and treatment utilization in a three months follow-up study after transfer from a state registration-and reception-center in Germany

Even though asylum seekers show a high prevalence of trauma-related disorders and comorbid psychological stress symptoms, little is known about how their mental health develops during the asylum process and what options of care are provided. We aimed to investigate the mental health and treatment utilization of asylum seekers after they were transferred from a state registration- and reception-center to municipal shelters in Germany. N = 228 asylum seekers with on-going asylum procedure were recruited in the psychosocial walk-in clinic located in a state registration- and reception-center. We firstly captured symptoms of posttraumatic stress, depression, anxiety disorders, quality of life, as well as alcohol or drug abuse. Subsequently we performed a follow-up after three months to evaluate a potential shift in symptoms and determining rates of access to treatment. In the pre-post psychometric assessment, there were statistically significant changes in depression (PHQ-2), panic (PHQ-PD) and psychosocial well-being scores (WHO-5). However, all these scores still remained within a clinical relevant range, respectively. Traumatic stress (PC-PTSD-5) and general anxiety scores (GAD-2) did not change significantly. Although N = 44 (66%) of the interviewed patients had been referred to psychotherapy initially, none (0%) of them had received outpatient psychotherapeutic treatment after three months. Our results emphasize a strong need for low-threshold, cultural adapted psychotherapeutic treatment for asylum seekers.

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015

BACKGROUND

Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of screening yield.

METHODS

We combined individual data of 119,037 asylum seekers screened for TB in Germany (2002-2015) with TB estimates of the World Health Organization (WHO) (1990-2014) for their 81 countries of origin. Adjusted rate ratios (aRR) and 95% credible intervals (CrI) of the observed yield of screening were calculated in Bayesian Poisson regression models by categories of WHO-estimated TB incidence. We assessed changes in sensitivity depending on screening thresholds, used WHO TB estimates as prior information to predict TB in asylum seekers, and modelled country-specific probabilities of numbers needed to screen (NNS) conditional on different screening thresholds.

RESULTS

The overall yield was 82 per 100,000 and the annual yield ranged from 44.1 to 279.7 per 100,000. Country-specific yields ranged from 10 (95%- CrI: 1-47) to 683 (95%-CrI: 306-1336) per 100,000 in Iraqi and Somali asylum seekers, respectively. The observed yield was higher in asylum seekers from countries with a WHO-estimated TB incidence > 50 relative to those from countries ≤50 per 100,000 (aRR: 4.17, 95%-CrI: 2.86-6.59). Introducing a threshold in the range of a WHO-estimated TB incidence of 50 and 100 per 100,000 resulted in the lowest "loss" in sensitivity. WHO's TB prevalence estimates improved prediction accuracy for eight of the 11 countries, and allowed modelling country-specific probabilities of NNS.

CONCLUSIONS

WHO's TB data can inform the estimation of screening yield and thus be used to improve screening efficiency in asylum seekers. This may help to develop more targeted screening strategies by reducing uncertainty in estimates of expected country-specific yield, and identify thresholds with lowest loss in sensitivity. Further modelling studies are needed which combine clinical, diagnostic and country-specific parameters.

Health of Syrian unaccompanied asylum seeking adolescents (UASA) at first medical examination in Germany in comparison to UASA from other world regions

BACKGROUND

The war in Syria has led to the biggest refugee crisis of our time. Unaccompanied asylum seeking adolescents (UASA) are a particularly vulnerable subgroup of refugees. This study aims to describe the weight status, health behaviour and disease spectrum of Syrian UASA in comparison to UASA from other world regions.

METHODS

The study was conducted as a prospective cross-sectional analysis of health metrics and diagnoses from 346 UASA (78% male; mean age 16 years) between 2011 and 2017. The data was collected in an outpatient clinic for internal and tropical medicine during a systematic medical examination after arrival. Descriptive and bivariate analyses stratified by gender and region/country of origin were performed.

RESULTS

The general health status of the UASA in most cases was good. Compared to other UASA Syrian UASA had the highest underweight prevalence (16.7%) (p = .013) and the second highest smoking prevalence (37.9%) (p < .001). Diseases at first medical examination mostly were infections and diseases of the digestive system, with significant differences between the regions/countries of origin (p < .001; p < .001, respectively). Syrian UASA had a lower prevalence of infections (28%) and a similar prevalence of mental and behavioural problems (10.3%) than the average of all regions/countries of origin (48.6%; 11%, respectively).

CONCLUSION

Tailored screening for diseases as well as for health behaviour immediately after arrival in Germany is needed to reduce the individual burden of disease and to offer targeted preventive measures.