Immigrant health, our health

Who seeks care and for what reasons at a nurse-led walk-in center in an immigrant-dense area-A quantitative survey

OBJECTIVE

To describe who seeks care and for what reasons at a nurse-led primary healthcare walk-in center in an immigrant-dense area. Studies evaluating the use of nurse-led walk-in centers in primary healthcare, emphasizing migrants, are limited. Due to language difficulties and a healthcare system based on telephone consultations, access to care is limited/problematic for the care seeker and the healthcare provider. The center aims to provide migrants and Swedish-born persons equal access to primary healthcare. Care was integrated into a healthcare center with a multi-professional environment, offering Arabic and Somali interpreters.

DESIGN

Cross-sectional descriptive registry study.

SAMPLE

All consecutive patients visiting during 1-month.

RESULTS

Most individuals (70%) seeking care at the nurse-led walk-in center were non-European migrants from Syria, Iraq and Somalia, but Swedish-born persons (30%) also consulted the clinic. Women, middle-aged, and lower-educated patients dominated. Reasons for seeking care included different kinds of pain, ear/nose/throat issues, and skin problems. Migrants prioritized non-specific pain and dizziness/headaches, while Swedes sought help primarily for upper respiratory tract infections. About 25% of the migrants needed interpreters, mostly females.

CONCLUSION

The nurse-led walk-in center provides accessible care in a multi-professional team, if needed, serving migrants and Swedish-born persons, promoting equal healthcare for all.

Spatial clustering and temporal trend analysis of international migrants diagnosed with tuberculosis in Brazil

Background

Tuberculosis (TB) in migrants is of concern to health authorities worldwide and is even more critical in Brazil, considering the country´s size and long land borders. The aim of the study was to identify critical areas in Brazil for migrants diagnosed with TB and to describe the temporal trend in this phenomenon in recent years.

Methods

This is an ecological study that used spatial analysis and time series analysis. As the study population, all cases of migrants diagnosed with TB from 2014 to 2019 were included, and Brazilian municipalities were considered as the unit of ecological analysis. The Getis-Ord Gi* technique was applied to identify critical areas, and based on the identified clusters, seasonal-trend decomposition based on loess (STL) and Prais-Winsten autoregression were used, respectively, to trace and classify temporal trend in the analyzed series. In addition, several municipal socioeconomic indicators were selected to verify the association between the identified clusters and social vulnerability.

Results

2,471 TB cases were reported in migrants. Gi* analysis showed that areas with spatial association with TB in immigrants coincide with critical areas for TB in the general population (coast of the Southeast and North regions). Four TB clusters were identified in immigrants in the states of Amazonas, Roraima, São Paulo, and Rio de Janeiro, with an upward trend in most of these clusters. The temporal trend in TB in immigrants was classified as increasing in Brazil (+ 60.66% per year [95% CI: 27.21–91.85]) and in the clusters in the states of Amazonas, Roraima, and Rio de Janeiro (+1.01, +2.15, and + 2.90% per year, respectively). The cluster in the state of São Paulo was the only one classified as stationary. The descriptive data on the municipalities belonging to the clusters showed evidence of the association between TB incidence and conditions of social vulnerability.

Conclusions

The study revealed the critical situation of TB among migrants in the country. Based on the findings, health authorities might focus on actions in regions identified, stablishing an intensive monitoring and following up, ensuring that these cases concluded their treatment and avoiding that they could spread the disease to the other regions or scenarios. The population of migrants are very dynamic, therefore strategies for following up them across Brazil are really urgent to manage the tuberculosis among international migrants in an efficient and proper way.

Evaluation of a healthcare walk-in centre in an immigrant-dense area from the perspective of Swedish-born patients

AIM

This study evaluates a healthcare walk-in centre in an immigrant-dense area from the perspective of Swedish-born patients.

BACKGROUND

The studied healthcare centre started a walk-in centre to increase healthcare accessibility for immigrants. This form of care is not primarily for Swedish-born patients although everyone is welcome. For this reason, it is important to evaluate the walk-in centre from different perspectives: the healthcare workers, the immigrant patients, and in this study focusing on the Swedish-born patients.

METHOD

This qualitative exploratory study used content analysis to analyse data collected from semi-structured interviews. Semi-structured interviews were held with 12 purposively sampled Swedish-born patients visiting a healthcare centre in Sweden.

FINDINGS

Most informants characterised the care they received as professional and timely and noted that accessibility was the main reason they sought care at the walk-in centre. In addition, they noted that being able to seek care on the day they want creates a feeling of security. However, Swedish-born informants seemed to prefer a traditional healthcare centre, although they viewed the walk-in centre as legitimate because everyone has access to it.

CONCLUSION

As the walk-in centre was perceived as having good accessibility, participants experienced that they could easily receive help for minor health problems. However, they also identified several ways the walk-in centre could be improved. For example, some participants preferred to remain outside while awaiting their turn to see a healthcare provider and wanted immigrant patients to leave their relatives at home when possible to minimise the risk of spreading infection. In addition, some participants thought a triage system could be implemented so that more severe cases could advance more quickly in the queue. The homogeneous sample of informants raises questions about whether this healthcare model is indeed accessible to everyone.

Placental weight in first generation migrant mothers in Germany. Do the length of stay, acculturation or migrant status play a role?

INTRODUCTION

Migration status affects perinatal outcomes. A small placenta is associated with placental dysfunction and poor outcomes. Placental weight and perinatal outcomes are influenced by migrant status, the length of stay and the level of acculturation in the host country. Our aim was to compare placental weight in first generation immigrants to native non-immigrants in a teaching hospital in Berlin. The influence of migrant status, the length of stay and the level of acculturation on placental weight was also ascertained.

METHODS

At the Charité University Hospital in Berlin Germany between January 2011 and January 2012, 1373 non-migrant and 1243 first generation migrants were included. Data collection was by means of a standardized questionnaire. The level of acculturation was based on the Frankfurter Acculturation Questionnaire (Frankfurter Akkulturationsfragebogen-FRAKK). Demographic parameters such as age, maternal weight, country of origin, parity, anemia, diabetes, hypertension, smoking and neonatal outcomes including neonatal weight, placental weight were measured.

RESULTS

We found no difference in mean placenta weight when comparing first generation women with a migration background to women of the native population (608 g vs 597 g, p-value 0.41). There was also no difference in placental weight when assessed by the length of stay and degree of acculturation in the host country.

DISCUSSION

While first generation migrant women have increased perinatal complications, there is no influence of migrant status, length of stay and the degree of acculturation on placenta weight. Pregnancy outcomes maybe be more dependent on factors such as the access to adequate maternal care.

Barriers and Facilitators to Cervical Screening among Migrant Women of African Origin: A Qualitative Study in Finland

Globally, cervical cancer constitutes a substantial public health concern. Evidence recommends regular cervical cancer screening (CCS) for early detection of "precancerous lesions."Understanding the factors influencing screening participation among various groups is imperative for improving screening protocols and coverage. This study aimed to explore barriers and facilitators to CCS participation in women of Nigerian, Ghanaian, Cameroonian, and Kenyan origin in Finland. We utilized a qualitative design and conducted eight focus group discussions (FGDs) in English, with women aged 27-45 years (n = 30). The FGDs were tape-recorded, transcribed verbatim, and analyzed utilizing the inductive content analysis approach. The main barriers to CCS participation included limited language proficiency, lack of screening awareness, misunderstanding of screening's purpose, and miscomprehension of the CCS results. Facilitators were free-of-charge screening, reproductive health services utilization, and women's understanding of CCS's importance for early detection of cervical cancer. In conclusion, among women, the main barriers to CCS participation were language difficulties and lack of screening information. Enhancing screening participation amongst these migrant populations would benefit from appropriate information about the CCS. Those women with limited language skills and not utilizing reproductive health services need more attention from healthcare authorities about screening importance. Culturally tailored screening intervention programs might also be helpful.

Health-Related Disparities among Migrant Children at School Entry in Germany. How does the Definition of Migration Status Matter?

Background: Migration background is known to be an important risk factor for a number of medical outcomes. Still, relatively little is known about the epidemiologic relevance of different definitions of migration status. Methods: Data from 5250 school entry examinations spanning three consecutive years (2015-2017) were gathered from the Public Health Department in Halle, Germany. Data were stratified according to six different migration statuses and evaluated for differences in health service utilization and developmental outcomes. Results: Compared to non-migrant children, migrant children have a lower utilization of preventative services, and higher frequencies of developmental delays. Children with first-generation migration background consistently show results worse than all others, while children with one-sided second-generation migration background show results similar to those of their non-migrant peers. These findings are not substantially altered by adjustment for social status. Conclusions: Children with first-generation migration background should receive special attention in school entry examinations, since they constitute a group with consistently higher health risks compared to other groups of preschoolers.

Register-based study concerning the problematic situation of using interpreting service in a region in Sweden

BACKGROUND

Due to increasing international migration, Sweden has become a multicultural and multilingual society, with about 19% of the population born abroad, which imposes high demands on the healthcare sector and interpreting services. The aim was to investigate problems in the use of interpreters as recorded by healthcare staff and the interpreter service in a region in Sweden.

METHODS

Cross-sectional register-based study. The study focused on a geographically well-defined region in Sweden including (a) specialized care at three hospitals; (b) local healthcare, including out-patient clinics at hospital and emergency healthcare and primary healthcare; and (c) dental care. The study was based on 726 existing incident reports on the interpreting service and information from the interpreter agency from 2012 and the first quarter of 2016 during a period of a massive influx of refugees.

RESULTS

The highest number of adverse advents was reported in local healthcare and mainly concerned the absence of an interpreter at the appointed time. Non-authorized in-person interpreters performed most interpretation assignments and Arabic was the most requested language.

CONCLUSIONS

This study highlights the significance of good cooperation between healthcare and the interpreter service in order to guarantee safe and high-quality healthcare for patients in need of interpreters to be able to communicate in healthcare.

Medical care for migrant children in Europe: a practical recommendation for first and follow-up appointments

Between 2015 and 2017, an estimated 200,000 to 400,000 children were seeking asylum each year in EU/EEA countries. As access to high-quality health care is important, we collected and compared current recommendations across Europe for a consensus recommendation on medical care for migrant (asylum-seeking and refugee) children. Existing recommendations were collected from published literature and identified through national representatives from paediatric societies of 31 EU/EEA countries through the European Academy of Paediatrics (EAP). Recommendations were systematically extracted and collected in a database. Those mentioned in at least one recommendation were evaluated for inclusion, and evidence on recommendations was specifically identified in literature searches focused on recent evidence from Europe. For eight EU/EEA countries, a national recommendation was identified. Growth and development, vision and hearing impairment, skin and dental problems, immunisations, anaemia, micronutrient deficiency, helminths, hepatitis B and C, human immunodeficiency virus, malaria, schistosomiasis, syphilis, tuberculosis, mental health disorder and sexual health were most frequently mentioned and therefore selected for inclusion in the recommendation.Conclusion: The current document includes general recommendations on ethical standards, use of interpreters and specific recommendations for prevention or early detection of communicable and non-communicable diseases. It may serve as a tool to ensure the fundamental right that migrant children in Europe receive a comprehensive, patient-centred health care.

Study protocol: Worldwide comparison of vitamin D status of immigrants from different ethnic origins and native-born populations-a systematic review and meta-analysis

BACKGROUND

A growing body of literature indicates that, worldwide, immigrants experience health deterioration after their arrival into their adopted country, and moreover, they have lower vitamin D compared to the native-born population. We plan to review if the levels of vitamin D are comparable between different ethnic groups in different regions of the world with those of native-born populations and to identify the possible associations between vitamin D deficiency and disease status among immigrants.

METHODS/DESIGN

A systematic review and meta-analysis will be conducted following the methods of the Cochrane handbook for systematic reviews. A literature search was performed to identify studies on immigrants and vitamin D. The primary outcome is vitamin D levels, and the secondary outcome is any vitamin D deficiency-related disease. Study design and participant characteristics will be extracted, including ethnicity, country of birth and/or origin, and the host country. Descriptive and meta-analytic summaries of the outcomes will be derived. Distiller-SR and RevMan will be used respectively for data management and meta-analysis.

DISCUSSION

This systematic review may partially help clarify vitamin D-related health deterioration in migrants; moreover, to develop a global guideline that specifies sub-populations, in which the evidence and vitamin D-related recommendations might differ from the overall immigrant population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086729.

Severe disseminated tuberculosis in HIV-negative refugees

In high-income countries, the presentation of tuberculosis is changing, primarily because of migration, and understanding the specific health needs of susceptible populations is becoming increasingly important. Although disseminated tuberculosis is well documented in HIV-positive patients, the disease is poorly described and less expected in HIV-negative individuals. In this Grand Round, we report eight HIV-negative refugees, who presented with extensively disseminated tuberculosis. We discuss the multifactorial causes, such as deprivations during long journeys, precarious living conditions, and the experience of violence, which might add to nutritional factors and chronic disorders, eventually resulting in a state of predisposition to immune deficiency. We also show that disseminated tuberculosis is often difficult to diagnose when pulmonary symptoms are absent. Communication difficulties between refugees and health-care workers are another major hurdle, and every effort should be made to get a valid patient history. This medical history is crucial to guide imaging and other diagnostic procedures to establish a definite diagnosis, which should be confirmed by a positive tuberculosis culture. Because many of these patients are at risk for multidrug-resistant tuberculosis, drug susceptibility testing is imperative to guide therapy. In the absence of treatment guidelines for this entity, clinicians can determine treatment duration according to recommendations provided for extrapulmonary tuberculosis and affected organs. Paradoxical expansion of tuberculous lesions during therapy should be treated with corticosteroids. In many cases, treatment duration must be individualised and might even exceed 12 months.

The definition of immigrant status matters: impact of nationality, country of origin, and length of stay in host country on mortality estimates

BACKGROUND

Mortality is a robust indicator of health and offers valuable insight into the health of immigrants. However, mortality estimates can vary significantly depending on the manner in which immigrant status is defined. Here, we assess the impact of nationality, country of origin, and length of stay in the host country on mortality estimates in an immigrant population in Aragón, Spain.

METHODS

Cross-sectional retrospective study of all adult subjects from the EpiChron Cohort in 2011 (n = 1,102,544), of whom 146,100 were foreign-born (i.e., according to place of birth) and 127,213 were non-nationals (i.e., according to nationality). Directly standardized death proportions between years 2012-2015 were calculated, taking into account the age distribution of the European population in 2013. Binary logistic regression was used to compare the four-year probability of death.

RESULTS

The age- and sex-standardized number of deaths per 1000 subjects were 45.1 (95%CI 44.7-45.2) for the Spanish-born population, 29.3 (95%CI 26.7-32.1) for the foreign-born population, and 18.4 (95%CI 15.6-21.6) for non-Spanish nationals. Compared with the Spanish-born population, the age- and sex-adjusted likelihood of dying was equally reduced in the foreign-born and non-national populations (OR 0.6; 95%CI 0.5-0.7) when the length of stay was less than 10 years. No significant differences in mortality estimates were detected when the length of stay was over 10 years.

CONCLUSIONS

Mortality estimates in immigrant populations were lower than those of the native Spanish population, regardless of the criteria applied. However, the proportion of deaths was lower when immigrant status was defined using nationality instead of country of birth. Age- and sex-standardized death proportions tended to increase with increased length of stay in the host country.

Healthcare staff's evaluation of a walk-in centre at a healthcare centre in an immigrant-dense area

AIMS AND OBJECTIVES

To evaluate a walk-in centre at a healthcare centre in an immigrant-dense area where a high proportion of the patients have limited language ability in Swedish, from the perspective of healthcare personnel.

BACKGROUND

Increased global migration results in higher vulnerability in migrants, with the risk of increased morbidity and mortality. Migrants' health often deteriorates, which can be attributed to an increased level of stress and adaptation to a new lifestyle. Therefore, immigrants are at higher risk of being affected by, for example, cardiovascular diseases and diabetes. This requires access to good health care.

DESIGN

A qualitative exploratory study was conducted, using semi-structured interviews. Content analysis was used in the analysis process.

METHODS

Semi-structured interviews were held with 15 purposively sampled doctors and nurses, working at a healthcare centre in Sweden. Data were collected during autumn 2017. The study was performed in accordance with COREQ.

RESULTS

Working at the walk-in centre involved caring for everything from basic to advanced health problems and meant a high pace that required stress-resistant personnel. The walk-in centre was described as both promoting and threatening patient safety. The personnel had several ideas on how to develop the walk-in centre.

CONCLUSIONS

A walk-in centre can be seen as a necessity related to issues of ensuring patient safety and delivering care for everyone in an immigrant-dense area. However, it cannot be the only form of care offered, as it seems not be adapted to certain groups, such as people with disabilities and the elderly.

RELEVANCE TO CLINICAL PRACTICE

The findings emphasise that a walk-in centre is a way to increase accessibility for the entire population and offer equal care for all, even if it involves challenges that need to be addressed.

Migration and health: A retrospective study about the prevalence of HBV, HIV, HCV, tuberculosis and syphilis infections amongst newly arrived migrants screened at the Infectious Diseases Unit of Modena, Italy

INTRODUCTION

Aim of the study is to evaluate the prevalence of HBV, HIV, HCV, tuberculosis and syphilis infection among immigrants assigned to the immigrant centre of the province of Modena.

METHODS

At the time of arrival all immigrant were tested for: HBsAg, HBsAb, HBcAb, Ag p24/HIVAb, HCVAb, RPR, TPPA, Mantoux test (>10mm diameter of induration was considered to be positive), Chest X-rays. In case of positive samples, second level tests were performed (HbeAg, HBeAb, HDVAb, and baseline management and treatment of the infection detected).

RESULTS

A total of 304 immigrant people were enrolled in the study. HBsAg positivity was 12.2%, HCVAb 3.3%, HIVAb 1.6%, TPPA+RPR positivity in the 0.7%; 10.2% had a positive Mantoux test; 5.6% had Chest X-rays positive for signs of infection and 6 patients had an active tuberculosis. 83.8% HBsAg were HBeAb positive/HBeAg negative. HDVAb resulted positive in 1 patient (2.7%). Previous HBV infection was detected in 28.6% of cases, isolated HBcAb in 2.3%; 5.6% of patients resulted to be positive to HbsAb alone (probable vaccinated).

CONCLUSION

Our study confirms the high prevalence of HBsAg positivity and latent tuberculosis among immigrants, underlying the importance of screening for infections in this special population.

Social Hazards as Manifested Workplace Discrimination and Health (Vietnamese and Ukrainian Female and Male Migrants in Czechia)

Social hazards as one of the dimensions of workplace discrimination are a potential social determinant of health inequalities. The aim of this study was to investigate relations between self-reported health and social hazard characteristics (defined as—discrimination as such, violence or threat of violence, time pressure or work overload and risk of accident) among Vietnamese and Ukrainian migrants (males and females) in Czechia by age, education level and marital status. This study is based on data from a survey of 669 immigrants in Czechia in 2013. Logistic regression analysis indicates that the given independent variables (given social hazards and socio-demographic characteristics), as predictors of a quality of self-reported health are more important for immigrant females than for males, irrespective of citizenship, albeit only for some of them and to differing extents. We found out that being exposed to the selected social hazards in the workplace leads to worsening self-rated health, especially for females. On the other hand, there was no statistically significant relationship found between poor self-rated health and discrimination as such. Reality calls for more research and, consequently, better policies and practices in the field of health inequalities.

Cancer risk in different generations of Middle Eastern immigrants to California, 1988-2013

The objective of this study is to compare cancer risk among different generations of Middle Eastern immigrants (ME) and non-Hispanic whites (NHW) in California between 1988 and 2013. We used data from the California Cancer Registry to identify invasive primary incident cancer cases in three population groups: (i) first-generation ME immigrants, (ii) second- or subsequent-generations ME immigrants, and (iii) NHW. Proportional incidence ratio (PIR) was used to compare cancer risk of the 15 selected most common cancers in the 3 population groups taking into consideration time since immigration for first-generation ME immigrants. First generation ME immigrants were more likely to be at increased risk of stomach (PIR= 3.13) and hepatobiliary (PIR = 2.27) cancers in females and thyroid (PIR = 2.19) and stomach (PIR = 2.13) cancers in males in comparison with NHW. Second- or subsequent-generations ME immigrants were at increased risk of thyroid cancer (PIR = 1.43 in females and 2.00 in males) in comparison with NHW, and malignant melanoma cancer (PIR = 4.53 in females and 4.61 in males) in comparison with first-generation ME immigrants. The risk levels of breast, thyroid and bladder cancers in ME first generation were significantly higher compared to NHW regardless of time spent in the United States suggesting the role of genetic predisposition, and/or cultural characteristics associated with these cancers. The results suggest that differences in cancer risk between ME first-generation immigrants and NHW change in second or subsequent generations, approaching the risk level of NHW and indicating the impact of acculturation in this immigrant population.

Migration to middle-income countries and tuberculosis-global policies for global economies

Background

International migration to middle-income countries is increasing and its health consequences, in particular increasing transmission rates of tuberculosis (TB), deserve consideration. Migration and TB are a matter of concern in high-income countries and targeted screening of migrants for active and latent TB infection is a main strategy to manage risk and minimize transmission. In this paper, we discuss some aspects of TB control and migration in the context of middle-income countries, together with the prospect of responding with equitable and comprehensive policies.

Main body

TB rates in middle-income countries remain disproportionally high among the poorest and most vulnerable groups in large cities where most migrant populations are concentrated. Policies that tackle migrant TB in high-income countries may be inadequate for middle-income countries because of their different socio-economic and cultural scenarios. Strategies to control TB in these settings must take into account the characteristics of middle-income countries and the complexity of TB as a disease of poverty. Intersectoral policies of social protection such as cash-transfer programs help reducing poverty and improving health in vulnerable populations. We address the development of new approaches to improve well-established strategies including contact tracing and active and latent TB screening as an ‘add on’ to the existing health care guidelines of conditional cash transfer programs. In addition, we discuss how it might improve health and welfare among both poor migrants and locally-born populations. Authorities from middle-income countries should recognise that migrants are a vulnerable social group and promote cooperation efforts between sending and receiving countries for mitigation of poverty and prevention of disease in this group.

Conclusions

Middle-income countries have long sent migrants overseas. However, the influx of large migrant populations into their societies is relatively new and a growing phenomenon and it is time to set comprehensive goals to improve health among these communities. Conditional cash transfer policies with TB screening and strengthening of DOTS are some strategies that deserve attention. Reduction of social and health inequality among migrants should be incorporated into concerted actions to meet TB control targets.

Drawing on healthcare professionals’ ethnicity: lessons learned from a Danish community pharmacy intervention for ethnic minorities

Aims: To present and discuss implementation experiences regarding the involvement of community pharmacists with ethnic minority backgrounds in a medication review intervention for ethnic minority poly-pharmacy patients in Denmark. Methods: Data sources include 1) reflection notes from an introductory seminar with pharmacists and the cross-disciplinary research team and 2) five individual interviews and one focus group interview with pharmacists. Data were thematically coded and synthesised to identify underlying rationales and challenges encountered when involving professionals with ethnic minority backgrounds in interventions for ethnic minorities. Results: Informants perceived the need for interventions targeted at ethnic minority poly-pharmacy patients, and highlighted the potential of involving professionals with diverse ethnic backgrounds in such interventions. However, implementation created challenges, because the professional identity of the pharmacists reduced their options for serving as peers with the same ethnic background. Furthermore, issues related to organisational difficulties and overcoming language barriers in the intervention impacted on the potential of involving professionals with ethnic minority backgrounds. Conclusions: Involving healthcare professionals with ethnic minority backgrounds in encounters with ethnic minorities holds potential for the adaptation of services to ethnically diverse populations, thus improving access to and quality of care. However, it is important to ensure sufficient personal and organisational support and to acknowledge the delicate balance between simultaneously serving as a peer and as a professional.

A systematic review of the use of health services by immigrants and native populations

Background

Changes in migration patterns that have occurred in recent decades, both quantitative, with an increase in the number of immigrants, and qualitative, due to different causes of migration (work, family reunification, asylum seekers and refugees) require constant u pdating of the analysis of how immigrants access health services. Understanding of the existence of changes in use patterns is necessary to adapt health services to the new socio-demographic reality. The aim of this study is to describe the scientific evidence that assess the differences in the use of health services between immigrant and native populations.

Methods

A systematic review of the electronic database MEDLINE (PubMed) was conducted with a search of studies published between June 2013 and February 2016 that addressed the use of health services and compared immigrants with native populations. MeSH terms and key words comprised Health Services Needs and Demands/Accessibility/Disparities/Emigrants and Immigrants/Native/Ethnic Groups. The electronic search was supplemented by a manual search of grey literature. The following information was extracted from each publication: context of the study (place and year), characteristics of the included population (definition of immigrants and their sub-groups), methodological domains (design of the study, source of information, statistical analysis, variables of health care use assessed, measures of need, socio-economic indicators) and main results.

Results

Thirty-six publications were included, 28 from Europe and 8 from other countries. Twenty-four papers analysed the use of primary care, 17 the use of specialist services (including hospitalizations or emergency care), 18 considered several levels of care and 11 assessed mental health services. The characteristics of immigrants included country of origin, legal status, reasons for migration, length of stay, different generations and socio-demographic variables and need. In general, use of health services by the immigrants was less than or equal to the native population, although some differences between immigrants were also identified.

Conclusions

This review has identified that immigrants show a general tendency towards a lower use of health services than native populations and that there are significant differences within immigrant sub-groups in terms of their patterns of utilization. Further studies should include information categorizing and evaluating the diversity within the immigrant population.

Middle Eastern Conflicts: Implications for Refugee Health in the European Union and Middle Eastern Host Countries

Until very recently, health care in conflict settings was based on a model developed in the second half of the twentieth century. Things have changed, and present civil wars, such as those that are currently taking place in the Middle East, do not address the complexity of the ongoing armed conflicts in countries such as Syria, Iraq, and Afghanistan. These conflicts have caused a significant increase in the number of refugees in the region, as well as in Europe. Hundreds of thousands of refugees succeed in settling in mid- and north-European countries, and their health issues are becoming of great importance. Refugees in Europe in the twenty-first century do not suffer so much from infectious diseases but more from noninfectious chronic diseases such as diabetes, cardiac disease, and cancer. These facts profoundly alter the demographics and disease burden of hostility-derived migrants. Thus, host European countries face situations they have never faced before. Hence, new approaches and strategies are urgently needed to cope with this new situation. The efforts to absorb refugees of different traditions and cultural backgrounds often cause increasing ethnic and religious tensions, which frequently escort the emergence of social violence. To date, little attention has been paid to the overall load of distress being experienced, especially among the first-generation refugees. The current ongoing hostilities in the Middle East induce a long-term health impact on people expelled from their homes, communities, traditions, and cultural environment. The realization of collective suffering forces communities and governmental health agencies to develop new programs that include social determinants to overcome the severe cultural gaps of the newcomers in their new European host countries.

Is the Swedish FRAX model appropriate for Swedish immigrants?

The incidence of hip fracture in Sweden is substantially lower in immigrants than in the population born in Sweden. Thus, the use of a FRAX® model in immigrants overestimates the risk of fracture, and the use of country of origin-specific models may be more appropriate.

INTRODUCTION

Age-specific fracture and mortality rates vary between countries so that FRAX tools are country-specific. In the case of immigrants, it is not known whether the model for the original or the new country is most appropriate. The aim of this study was to compare the incidence of hip fractures in foreign-born and Swedish-born individuals residing in Sweden.

METHODS

We studied the incidence of hip fracture in all men and women aged 50 years or more in Sweden between 1987 and 2002. The population comprised 2.8 million Swedish-born and 270,000 foreign-born individuals.

RESULTS

Incident hip fractures occurred in 239,842 Swedish-born and 12,563 foreign-born individuals. The hip fracture incidence rose with age for both groups and was higher for women than men amongst both Swedish-born and foreign-born individuals. The hip fracture incidence for the Swedish-born cohort was approximately twice that of immigrants. For example, at the age of 70 years, the annual hip fracture incidence (per 100,000) was 450 (95 % CI 446-454) for a Swedish-born woman and 239 (95 % CI 223-257) for a foreign-born woman at the time of immigration. The hip fracture incidence rose slowly with time from immigration (0.6 % per annum, 95 % CI 0.5-0.8 %) but remained significantly lower than for Swedish-born individuals even after 40 years of residence.

CONCLUSIONS

The incidence of hip fracture in Sweden is substantially lower in immigrants than in the population native to Sweden. Although there was a small rise in age- and sex-specific incidence after immigration, the incidence remained markedly lower than that observed in Swedish-born individuals. Thus, the use of a FRAX model for Sweden will overestimate the risk of fracture for foreign-born individuals living in Sweden.