Population-based assessment of health, healthcare utilisation, and specific needs of Syrian migrants in Germany: what is the best sampling method?

Prevalence and risk factors of food insecurity among Syrian refugees in Türkiye

BACKGROUND

Although Türkiye (Turkey) hosts the largest number of Syrian refugees, studies on food insecurity are limited. This study examined the prevalence and risk factors of food insecurity among Syrian refugees living in Istanbul, which has the highest number of refugees in Türkiye.

METHODS

A cross-sectional survey was conducted among Syrian refugees in Istanbul between September 2021 and March 2022. The main income earners of 103 households were interviewed by a research dietitian, with the assistance of an Arabic speaking interpreter through hour-long face-to-face. Data on sociodemographic characteristics (age, gender, nationality, marital status, educational status, the family income, the major source of family income, and the number of family members living in the household etc.) and household food insecurity status were collected. Household food insecurity status was assessed with the eighteen-item Household Food Security Survey Module.

RESULTS

The household food insecurity rate was 90.3%, and those of adults and children were 88.4% and 84.8%, respectively. It was observed that family income level was significantly associated with food insecurity. A one-unit increase in monthly income increased food security by 0.02 times (p < 0.001). The number of employed refugees in the food security group was higher than that in the food insecurity group (p = 0.018). A significant difference was found in the rate of occupation type of the major income earner between the groups (p = 0.046).

CONCLUSIONS

High rates of food insecurity, particularly severe food insecurity, were found among Syrian refugees living in Istanbul. While more research is warranted to explore the root causes and efficacy of the current support system, it requires the immediate attention of policymakers at the national and international levels to implement effective policies and interventions.

Using Respondent-Driven Sampling (RDS) to Identify the Healthcare Needs among Women of Reproductive Age Who Migrated from Venezuela to Brazil, 2018-2021

In 2021, an RDS survey was conducted among Venezuelan migrant women of reproductive age who migrated to two Brazilian cities (Manaus and Boa Vista) from 2018 to 2021. To start the RDS recruitment, we chose seeds non-randomly in both cities. The study variables were age, educational level, self-rated health, pregnancy, migratory status and use of health services. We estimated the prevalence, confidence intervals and homophily effects by variable category. We used a multivariate logistic regression model to identify the main factors associated with healthcare use. A total of 761 women were recruited in Manaus and 1268 in Boa Vista. Manaus showed more irregular migrants than Boa Vista. The main reasons for using health services were as follows: illness, disease prevention and prenatal care. The logistic regression model showed the use of health services was associated with educational level and healthcare needs but not with migratory status. The social inclusion of Venezuelan migrants is extremely relevant, although many challenges must be overcome. The strategy of the Brazilian Federal Government for providing humanitarian assistance to Venezuelan migrants should be expanded to include and facilitate their integration into labor markets, access to healthcare and education, benefiting both migrants and the Brazilian people by reducing social inequality.

[Health Literacy of People with Former Soviet Union and Turkish Migration Background in Germany]

AIM

So far, there are hardly any data on the health literacy of persons with a migration background in Germany. The aim of the article was to analyse the health literacy of this population group - particularly persons who originate in Turkey and the former Soviet Union (FSU).

METHODOLOGY

In summer 2020, face-to-face interviews with 525 persons with FSU and 512 persons with Turkish migration background above the age of 18 were carried out across Germany. The interviews were conducted in German, Russian or Turkish. Health literacy was assessed using the internationally developed HLS19-Q47 instrument. Bivariate and multivariate analyses were carried out for each immigration group separately considering demographic, socioeconomic, linguistic and migration-specific variables.

RESULTS

Overall, around half of the respondents had low health literacy, with no differences between the immigration groups. In both groups, low educational levels, socioeconomic disadvantages, limited German literacy skills, older age, multiple chronic illnesses and personal experience of immigration were linked with lower health literacy. In multivariate analyses, associations between health literacy and literacy skills, social status, financial deprivation, and chronic illness remained; however, after adjustment, no significant difference persisted by immigration generation.

CONCLUSION

While a significant proportion of persons with Turkish or FSU migration background in Germany have difficulty dealing with health information, compared with existing studies, they do not have a lower health literacy than the population without a migration background. People with a migration background are therefore not to be regarded as vulnerable to low health literacy in general. Particularly socioeconomically disadvantaged subgroups display low health literacy. Interventions should therefore target these subgroups specifically and consider their living conditions. In addition, people with low literacy skills and German proficiency have greater difficulties in processing health information. This highlights the need for multilingual information, but also for multimedia materials in plain language. Structural measures are necessary for a health-literate health system and for reducing health inequalities.

Design and implementation of a web-based, respondent-driven sampling solution

BACKGROUND

Respondent-driven sampling (RDS) refers both to a chain-referral sampling method and an analytical model for analysing sampled data. Web-based respondent-driven sampling (webRDS) uses internet-based recruitment coupled with an electronic survey to carry out RDS studies; there is currently no commercially available webRDS solution. We designed and developed a webRDS solution to support a research study aimed at estimating conflict-attributable mortality in Yemen. Our webRDS solution is composed of an existing survey platform (i.e. ODK) and a bespoke RDS system. The RDS system is designed to administer and manage an RDS survey cascade and includes: (1) an application programming interface, (2) a study participant client, and (3) an administrator interface. We report here on the design of the webRDS solution and its implementation.

RESULTS

We consulted members of the Yemeni diaspora throughout the development of the solution. Technical obstacles were largely the result of: WhatsApp's policies on bulk messaging and automated messaging behaviour, the inherent constraints of SMS messaging, and SMS filtering behaviour. Language support was straight-forward yet time consuming. Survey uptake was lower than expected. Factors which may have impacted uptake include: our use of consumable survey links, low interest amongst the diaspora population, lack of material incentives, and the length and subject matter of the survey itself. The SMS/WhatsApp messaging integration was relatively complex and limited the information we could send potential participants.

CONCLUSION

Despite lower-than expected survey uptake we believe our webRDS solution provides efficient and flexible means to survey a globally diverse population.

Access to Healthcare Services among Thai Immigrants in Japan: A Study of the Areas Surrounding Tokyo

Numerous undocumented and uninsured foreigners living in Japan have faced barriers when trying to obtain appropriate healthcare services, which have occasionally led to issues with unpaid medical bills to medical institutions. Although information on health and socioeconomic status is essential to tackle such issues, relevant data has been unavailable due to difficulties in contacting this population. This study involved a cross-sectional survey using questionnaires concerning the general demographic characteristics, socioeconomic status, health profiles, information access, and knowledge/attitude/practice of health insurance of Thai nationals living in Japan. The study participants included Thai nationals who lived in Tokyo and the surrounding prefectures. The survey was conducted mainly at public religious events from September 2022 to December 2022. Overall, the questionnaires were obtained from 84 participants, though 67 participants were included in the final analysis after excluding missing variables. There were participants with unspecified visa status (32.8%) and uninsured status (40.3%). Among them, 86.4% expressed positive attitudes towards health insurance. However, multivariate multivariable regression analyses revealed the low insurance practice status among the unspecified visa group (aOR, 0.02; 95% CI, 0.00-0.13). Overall, the results reveal limited access to healthcare services in subgroups of Thai immigrants in Japan.

Differences in health literacy domains among migrants and their descendants in Germany

Background

Health literacy (HL) is considered to be an important precondition for health. HL research often identifies migrants as vulnerable for low HL. However, in-depth data on HL among migrants especially in its domains of health care, disease prevention and health promotion and its determinants are still scarce.

Objective

The aim of this study was therefore to analyse the current status of HL among migrants and their descendants from Turkey and from the former Soviet Union (FSU) in Germany and factors associated with it. This has not been studied using large-scale data and bilingual interviews. We differentiate between dimensions of HL, namely the domains of health care, disease prevention and health promotion which goes beyond many previous studies. In addition, we explore new mechanisms by testing the explanatory power of self-efficacy and interethnic contacts for migrants' HL.

Methods

The study includes 825 first- and second-generation adult migrants from two of the largest immigration groups in Germany, from Turkey and FSU, who were interviewed face-to-face in German, Turkish or Russian in late summer 2020. HL was measured using the HLS19-Q47 instrument. Age, gender, educational level, social status and financial deprivation, chronic illness, health-related literacy skills, self-efficacy, interethnic contacts, migration generation, duration of stay and region of origin were considered as possible determinants. Ordinary least square regressions were estimated.

Results

The average general HL score was 65.5. HL in health promotion and disease prevention was lower than in health care. Low financial deprivation, health-related literacy skills, and self-efficacy were positively correlated with each HL domain. Educational level, social status, age, gender, duration of stay and interethnic contacts were positively correlated with HL in some domains. Region of origin was only correlated with the domain of disease prevention until interethnic contact was accounted for.

Conclusion

Our study contributes to the existing knowledge by analyzing different domains of HL and testing its correlations with self-efficacy and interethnic contact among migrants. We reveal that migrants cannot generally be considered as vulnerable for low HL, as oftentimes outlined. There is a need for interventions e.g. to enhance the understanding of health information among subgroups with lower HL.

HIV Surveillance and Research for Migrant Populations: Protocol Integrating Respondent-Driven Sampling, Case Finding, and Medicolegal Services for Venezuelans Living in Colombia

BACKGROUND

Epidemiologic research among migrant populations is limited by logistical, methodological, and ethical challenges, but it is necessary for informing public health and humanitarian programming.

OBJECTIVE

We describe a methodology to estimate HIV prevalence among Venezuelan migrants in Colombia.

METHODS

Respondent-driven sampling, a nonprobability sampling method, was selected for attributes of reaching highly networked populations without sampling frames and analytic methods that permit estimation of population parameters. Respondent-driven sampling was modified to permit electronic referral of peers via SMS text messaging and WhatsApp. Participants complete sociobehavioral surveys and rapid HIV and syphilis screening tests with confirmatory testing. HIV treatment is not available for migrants who have entered Colombia through irregular pathways; thus, medicolegal services integrated into posttest counseling provide staff lawyers and legal assistance to participants diagnosed with HIV or syphilis for sustained access to treatment through the national health system. Case finding is integrated into respondent-driven sampling to allow partner referral. This study is implemented by a local community-based organization providing HIV support services and related legal services for Venezuelans in Colombia.

RESULTS

Data collection was launched in 4 cities in July and August 2021. As of November 2021, 3105 of the target 6100 participants were enrolled, with enrollment expected to end by February/March 2022.

CONCLUSIONS

Tailored methods that combine community-led efforts with innovations in sampling and linkage to care can aid in advancing health research for migrant and displaced populations. Worldwide trends in displacement and migration underscore the value of improved methods for translation to humanitarian and public health programming.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36026.

Challenges and lessons learned in mental health research among refugees: a community-based study in Turkey

BACKGROUND

Turkey hosts nearly four million refugees and 99% live in urban areas. Research in urban settings pose different challenges and opportunities than research in refugee camps. In this article, we aimed to share the challenges and experiences we encountered in a mixed-methods study to assess mental health problems and barriers to accessing mental health care among refugees in urban areas of Turkey.

DISCUSSION

In our case, the main challenges in conducting research with refugees were collecting data from a highly traumatized population, difficulties with contacting undocumented asylum seekers including trust issues and the fear of deportation, the risk of secondary traumatization among data collectors, and the bureaucracy during study approval processes. Targeting a representative sample was not feasible, because of the lack of publicly available demographic data on a district level, presence of undocumented asylum seekers and high mobility among the refugees. Although respondents with significant psychological symptoms were routinely referred to available mental health services, we were able to do less for unregistered refugees with problems in accessing health care. Language/alphabet differences and differing dialects of Arabic posed another challenge in both translation and administration of the scales. Based on cultural characteristics, a gender-balanced team was used and the interviewers were gender-matched whenever needed. Also, the research team had to work after work hours and during weekends to be able to interview male refugees, since most refugee men were at work during working hours and most days of the week.

CONCLUSIONS

The research team's experience showed that refugee population characteristics including level of trauma, language, culture, gender, legal status, and urban setting characteristics including places of living, mobility, availability of publicly available demographic data, and outreach-related barriers lead to different challenges and ethical responsibilities of researchers and affect the research costs in terms of time, human resources and finance. Even in a host country with geographical, religious and cultural proximity to the refugees, profound challenges exist in conducting mental health research in urban settings. Learning from previous experience and collaborating with local researchers and institutions are vital for better public health research and practice outcomes.

A review of reported network degree and recruitment characteristics in respondent driven sampling implications for applied researchers and methodologists

OBJECTIVE

Respondent driven sampling (RDS) is an important tool for measuring disease prevalence in populations with no sampling frame. We aim to describe key properties of these samples to guide those using this method and to inform methodological research.

METHODS

In 2019, authors who published respondent driven sampling studies were contacted with a request to share reported degree and network information. Of 59 author groups identified, 15 (25%) agreed to share data, representing 53 distinct study samples containing 36,547 participants across 12 countries and several target populations including migrants, sex workers and men who have sex with men. Distribution of reported network degree was described for each sample and characteristics of recruitment chains, and their relationship to coupons, were reported.

RESULTS

Reported network degree is severely skewed and is best represented by a log normal distribution. For participants connected to more than 15 other people, reported degree is imprecise and frequently rounded to the nearest five or ten. Our results indicate that many samples contain highly connected individuals, who may be connected to at least 1000 other people.

CONCLUSION

Because very large reported degrees are common; we caution against treating these reports as outliers. The imprecise and skewed distribution of the reported degree should be incorporated into future RDS methodological studies to better capture real-world performance. Previous results indicating poor performance of regression estimators using RDS weights may be widely generalizable. Fewer recruitment coupons may be associated with longer recruitment chains.

Applications and Recruitment Performance of Web-Based Respondent-Driven Sampling: Scoping Review

Background

Web-based respondent-driven sampling is a novel sampling method for the recruitment of participants for generating population estimates, studying social network characteristics, and delivering health interventions. However, the application, barriers and facilitators, and recruitment performance of web-based respondent-driven sampling have not yet been systematically investigated.

Objective

Our objectives were to provide an overview of published research using web-based respondent-driven sampling and to investigate factors related to the recruitment performance of web-based respondent-driven sampling.

Methods

We conducted a scoping review on web-based respondent-driven sampling studies published between 2000 and 2019. We used the process evaluation of complex interventions framework to gain insights into how web-based respondent-driven sampling was implemented, what mechanisms of impact drove recruitment, what the role of context was in the study, and how these components together influenced the recruitment performance of web-based respondent-driven sampling.

Results

We included 18 studies from 8 countries (high- and low-middle income countries), in which web-based respondent-driven sampling was used for making population estimates (n=12), studying social network characteristics (n=3), and delivering health-related interventions (n=3). Studies used web-based respondent-driven sampling to recruit between 19 and 3448 participants from a variety of target populations. Studies differed greatly in the number of seeds recruited, the proportion of successfully recruiting participants, the number of recruitment waves, the type of incentives offered to participants, and the duration of data collection. Studies that recruited relatively more seeds, through online platforms, and with less rigorous selection procedures reported relatively low percentages of successfully recruiting seeds. Studies that did not offer at least one guaranteed material incentive reported relatively fewer waves and lower percentages of successfully recruiting participants. The time of data collection was shortest in studies with university students.

Conclusions

Web-based respondent-driven sampling can be successfully applied to recruit individuals for making population estimates, studying social network characteristics, and delivering health interventions. In general, seed and peer recruitment may be enhanced by rigorously selecting and motivating seeds, offering at least one guaranteed material incentive, and facilitating adequate recruitment options regarding the target population’s online connectedness and communication behavior. Potential trade-offs should be taken into account when implementing web-based respondent-driven sampling, such as having less opportunities to implement rigorous seed selection procedures when recruiting many seeds, as well as issues around online rather than physical participation, such as the risk of cheaters participating repeatedly.

Protocol of a population-based prospective COVID-19 cohort study Munich, Germany (KoCo19)

BACKGROUND

Due to the SARS-CoV-2 pandemic, public health interventions have been introduced globally in order to prevent the spread of the virus and avoid the overload of health care systems, especially for the most severely affected patients. Scientific studies to date have focused primarily on describing the clinical course of patients, identifying treatment options and developing vaccines. In Germany, as in many other regions, current tests for SARS-CoV2 are not conducted on a representative basis and in a longitudinal design. Furthermore, knowledge about the immune status of the population is lacking. Nonetheless, these data are needed to understand the dynamics of the pandemic and hence to appropriately design and evaluate interventions. For this purpose, we recently started a prospective population-based cohort in Munich, Germany, with the aim to develop a better understanding of the state and dynamics of the pandemic.

METHODS

In 100 out of 755 randomly selected constituencies, 3000 Munich households are identified via random route and offered enrollment into the study. All household members are asked to complete a baseline questionnaire and subjects ≥14 years of age are asked to provide a venous blood sample of ≤3 ml for the determination of SARS-CoV-2 IgG/IgA status. The residual plasma and the blood pellet are preserved for later genetic and molecular biological investigations. For twelve months, each household member is asked to keep a diary of daily symptoms, whereabouts and contacts via WebApp. If symptoms suggestive for COVID-19 are reported, family members, including children < 14 years, are offered a pharyngeal swab taken at the Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, for molecular testing for SARS-CoV-2. In case of severe symptoms, participants will be transferred to a Munich hospital. For one year, the study teams re-visits the households for blood sampling every six weeks.

DISCUSSION

With the planned study we will establish a reliable epidemiological tool to improve the understanding of the spread of SARS-CoV-2 and to better assess the effectiveness of public health measures as well as their socio-economic effects. This will support policy makers in managing the epidemic based on scientific evidence.