Can migration health assessments become a mechanism for global public health good?

Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems.

Funding

No specific funding received.

Management of health information of nepalese labour migrants

INTRODUCTION

The monitoring and improvement of the health of labour migrants (LMs) require sufficient health data to be recorded and managed. In this context, this study was conducted to explore the management of health information of Nepalese labour migrants (NLMs).

METHODS

This is an explorative qualitative study. Stakeholders involved directly or indirectly in maintaining the health profile of NLMs were first mapped, physically visited, and any documents or information were collected. Then, sixteen key informant interviews were conducted among these stakeholders related to labour migrants' health information management and challenges. A checklist extracted information from the interviews, and a thematic analysis was carried out to summarize the challenges.

RESULTS

Government agencies, non-governmental organizations, and government approved private medical centers are involved in generating and maintaining the health data of NLMs. The Foreign Employment Board (FEB) records deaths and disabilities of NLMs while at work abroad and these health records are also maintained in an online portal called Foreign Employment Information Management System (FEIMS) under the Department of Foreign Employment (DoFE). Health assessment of NLMs is a mandatory procedure before departure, which is done through the government-approved pre-departure private medical assessment centers. The health records from these assessment centers are first recorded in paper-based form and then entered into an online electronic form to be stored by the DoFE. The filled-up paper forms are sent to District Health Offices, which further report the data to the Department of Health Services (DoHS), Ministry of Health and Population (MoHP) and associated governmental infectious diseases centers. However, there is no formal health assessment of NLMs upon arrival to Nepal. Key informants raised various issues and concerns in maintaining health records of NLMs, which were grouped into three themes: lack of interest to develop a unified online system; need of competent human resources and equipment; and developing a set of health indicators for migrant health assessment.

CONCLUSION

The FEB and government-approved private assessment centers are the main stakeholders in keeping the health records of outgoing NLMs. The current migrant health record keeping procedure in Nepal is fragmented. The national Health Information Management Systems does not effectively capture and categorize the health record of NLMs. There is a need to effectively link national health information system with premigration health assessment centers; and potentially develop a migrant health information management system by systematically keeping health records electronically with relevant health indicators on departing and arriving NLMs.

Pandemic, Precarity and Health of Migrants in South Asia: Mapping multiple dimensions of precarity and pathways to states of health and well-being

Mobility patterns in South Asia are complex, defined by temporary and circular migration of low waged labourers within and across national borders. They move, live and work in conditions that expose them to numerous hazards and health risks that result in chronic ailments and physical and mental health problems. Yet, public policies and discourses either ignore migrants' health needs or tend to pathologise them, framing them as carriers of diseases. Their structural neglect was exposed by the ongoing pandemic crisis. In this paper, we take stock of the evidence on the health of low-wage migrants in South Asia and examine how their health is linked to their social, political and work lives. The paper derives from a larger body of work on migration and health in South Asia and draws specifically on content analysis and scoping review of literature retrieved through Scopus from 2000 to 2021 on health of low-income migrants. Utilising the lens of precarity and building on previous applications, we identify four dimensions of precarity and examine how these influence health: i) Work-based, concerned with hazardous and disempowering work conditions, ii) Social position-based, pertaining to the social stratification and intersecting oppressions faced by migrants, iii) Status-based, derived from vulnerabilities arising from the mobile and transient nature of their lives and livelihoods, and iv) Governmentality-based, relating to the formal policies and informal procedures of governance that disenfranchise migrants. We illustrate how these collectively produce distinct yet interrelated and interlocking oppressive states of insecurity, disempowerment, dispossession, exclusion, and disposability that define health outcomes, health-seeking pathways, and lock migrants in a continuing cycle of precarity, impoverishment and ill-health.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Healthcare for migrant workers in destination countries: a comparative qualitative study of China and Malaysia

OBJECTIVES

This paper explores policies addressing migrant worker's health and barriers to healthcare access in two middle-income, destination countries in Asia with cross-border migration to Yunnan province, China and international migration to Malaysia.

DESIGN

Qualitative interviews were conducted in Rui Li City and Tenchong County in Yunnan Province, China (n=23) and Kuala Lumpur, Malaysia (n=44), along with review of policy documents. Data were thematically analysed.

PARTICIPANTS

Participants were migrant workers and key stakeholders with expertise in migrant issues including representatives from international organisations, local civil society organisations, government agencies, medical professionals, academia and trade unions.

RESULTS

Migrant health policies at destination countries were predominantly protectionist, concerned with preventing transmission of communicable disease and the excessive burden on health systems. In China, foreign wives were entitled to state-provided maternal health services while female migrant workers had to pay out-of-pocket and often returned to Myanmar for deliveries. In Malaysia, immigration policies prohibit migrant workers from pregnancy, however, women do deliver at healthcare facilities. Mandatory HIV testing was imposed on migrants in both countries, where it was unclear whether and how informed consent was obtained from migrants. Migrants who did not pass mandatory health screenings in Malaysia would runaway rather than be deported and become undocumented in the process. Excessive attention on migrant workers with communicable disease control campaigns in China resulted in inadvertent stigmatisation. Language and financial barriers frustrated access to care in both countries. Reported conditions of overcrowding and inadequate healthcare access at immigration detention centres raise public health concern.

CONCLUSIONS

This study's findings inform suggestions to mainstream the protection of migrant workers' health within national health policies in two middle-income destination countries, to ensure that health systems are responsive to migrants' needs as well as to strengthen bilateral and regional cooperation towards ensuring better migration management.

Tuberculosis in migrants - screening, surveillance and ethics

Tuberculosis (TB) is the leading infectious cause of human mortality and is responsible for nearly 2 million deaths every year. It is often regarded as a 'silent killer' because it predominantly affects the poor and marginalized, and disease outbreaks occur in 'slow motion' compared to Ebola or coronavirus 2 (COVID-19). In low incidence countries, TB is predominantly an imported disease and TB control in migrants is pivotal for countries to progress towards TB elimination in accordance with the World Health Organisations (WHO's) End TB strategy. This review provides a brief overview of the different screening approaches and surveillance processes that are in place in low TB incidence countries. It also includes a detailed discussion of the ethical issues related to TB screening of migrants in these settings and the different interests that need to be balanced. Given recognition that a holistic approach that recognizes and respects basic human rights is required to end TB, the review considers the complexities that require consideration in low-incidence countries that are aiming for TB elimination.

Setting the stage: reviewing current knowledge on the health of New Zealand immigrants-an integrative review

The growth of migrant communities continues to rise globally, creating unique and complex health challenges. Literature on immigrant health in New Zealand (NZ) remains scant. This integrative literature review was conducted drawing on peer-reviewed research articles on immigrant health in NZ published between 2012 and 2018. The objectives were to: (i) provide a critical overview of immigrant health in NZ; (ii) identify general trends in health research conducted in NZ on immigrants; (iii) compare, contrast, and evaluate the quality of the information; (iv) develop a summary of research results and; (v) identify priorities and recommendations for future research. A search yielded more than 130 articles with 28 articles constituting the foundation of the review. This review is timely following the rapid increase in the scale, speed, and spread of immigration and its potential for changing NZ’s national health patterns and priorities. This integrative review led to the four primary conclusions. Firstly, migration in NZ is a gendered phenomenon, as there has been more women and girls arriving as migrants in NZ and being at risk of poor health in comparison with their male counterparts. Secondly, studies on infectious diseases take precedence over other health problems. Thirdly, research methodologies used to collect data may not be relevant to the cultural and traditional customs of the migrant populations. Furthermore, a number of research findings implemented have failed to meet the needs of NZ migrants. Lastly, policy initiatives are inclined more towards supporting health practitioners and lack a migrant centred approach.

What is already known about this topic? Despite NZ becoming more ethnically and linguistically diverse, there is limited literature on the health of migrants living in NZ.

What this paper adds? This integrative literature review provides a critical overview of refugee and migrant health in NZ through reviewing and critiquing the current literature available. This paper identifies research trends, the general health of migrants in NZ, recommendations that could inform future migrant and refugee health research and health policies and initiatives to ensure effective and relevant health service provision to migrants.

Migration and health: a global public health research priority

Background

With 244 million international migrants, and significantly more people moving within their country of birth, there is an urgent need to engage with migration at all levels in order to support progress towards global health and development targets. In response to this, the 2nd Global Consultation on Migration and Health– held in Colombo, Sri Lanka in February 2017 – facilitated discussions concerning the role of research in supporting evidence-informed health responses that engage with migration.

Conclusions

Drawing on discussions with policy makers, research scholars, civil society, and United Nations agencies held in Colombo, we emphasize the urgent need for quality research on international and domestic (in-country) migration and health to support efforts to achieve the Sustainable Development Goals (SDGs). The SDGs aim to ‘leave no-one behind’ irrespective of their legal status. An ethically sound human rights approach to research that involves engagement across multiple disciplines is required. Researchers need to be sensitive when designing and disseminating research findings as data on migration and health may be misused, both at an individual and population level. We emphasize the importance of creating an ‘enabling environment’ for migration and health research at national, regional and global levels, and call for the development of meaningful linkages – such as through research reference groups – to support evidence-informed inter-sectoral policy and priority setting processes.

Global research output in the health of international Arab migrants (1988-2017)

BACKGROUND

In the past few decades Arab countries had witnessed several intra-regional conflicts and civil wars that led to the creation of millions of refugees and migrants. Assessment of research activity is an indicator of national and international efforts to improve the health of those millions of war victims. Therefore, the aim of this study was to analyze published literature in international Arab migrants.

METHODS

Literature in international Arab migrants published during the past three decades (1988-2017) was retrieved using Scopus database. A bibliometric analysis methodology was implemented on the retrieved data. Author keywords were mapped using VOSviewer program.

RESULTS

In total, 1186 documents were retrieved. More than half (658; 55.5%) were published in the last five years (2013-2017). Retrieved documents received an average of 8.6 citations per document and an h-index of 45. The most frequently encountered author keywords were refugees and mental health-related terms. Three countries in the Middle East; Jordan, Lebanon, and Turkey, were among the most active countries. In total, 765 (63.7%) documents were about refugees, 421 (35.5%) were about migrant workers, 30 (2.5%) were about asylum seekers, and 7 (0.6%) were about trafficked and smuggled people. When data were analyzed for the nationality of migrants being investigated, 288 (24.3%) documents were about Syrians, 214 (18.0%) were about Somali, 222 (18.7%) were about Arab or Middle Eastern in general, and 147 (12.4%) were about Palestinians. The American University of Beirut ranked first with 45 (2.4%) publications. The most active journal in publishing research in this field was Journal of Immigrant and Minority Health (35; 3.0%) followed by Journal of Refugee Studies (23, 1.9%), The Lancet (19, 1.6%) and BMC Public Health (16, 1.3%). Publications from Jordan and Lebanon had the highest percentage of international research collaboration.

CONCLUSION

Research in international Arab migrants showed a dramatic increase in the last few years mostly due to the Syrian war. Both mental health and Syrian refugees dominated the literature of international Arab migrants. Research in infectious diseases was relatively low. Research on non-refugee migrants such as workers, trafficked victims, and asylum seekers was also relatively low.

Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe

Migrant health is a critical public health issue, and in many countries attention to this topic has focused on the link between migration and communicable diseases, including tuberculosis (TB). When creating public health policies to address the complex challenges posed by TB and migration, countries should focus these policies on evidence, ethics, and human rights. This paper traces a commonly used migration route from sub-Saharan Africa to Europe, identifying situations at each stage in which human rights and ethical values might be affected in relation to TB care. This illustration provides the basis for discussing TB and migration from the perspective of human rights, with a focus on the right to health. We then highlight three strands of discussion in the ethics and justice literature in an effort to develop more comprehensive ethics of migrant health. These strands include theories of global justice and global health ethics, the creation of 'firewalls' to separate enforcement of immigration law from protection of human rights, and the importance of non-stigmatization to health justice. The paper closes by reflecting briefly on how TB programs can better incorporate human rights and ethical principles and values into public health practice.

Capacity strengthening through pre-migration tuberculosis screening programmes: IRHWG experiences

Effective tuberculosis (TB) prevention and care for migrants requires population health-based approaches that treat the relationship between migration and health as a progressive, interactive process influenced by many variables and addressed as far upstream in the process as possible. By including capacity building in source countries, pre-migration medical screening has the potential to become an integral component of public health promotion, as well as infection and disease prevention, in migrant-receiving nations, while simultaneously increasing capabilities in countries of origin. This article describes the collaborative experiences of five countries (Australia, Canada, New Zealand, United Kingdom and the United States of America, members of the Immigration and Refugee Health Working Group [IRHWG]), with similar pre-migration screening programmes for TB that are mandated. Qualitative examples of capacity building through IRHWG programmes are provided. Combined, the IRHWG member countries screen approximately 2 million persons overseas every year. Large-scale pre-entry screening programmes undertaken by IRHWG countries require building additional capacity for health care providers, radiology facilities and laboratories. This has resulted in significant improvements in laboratory and treatment capacity, providing availability of these facilities for national public health programmes. As long as global health disparities and disease prevalence differentials exist, national public health programmes and policies in migrant-receiving nations will continue to be challenged to manage the diseases prevalent in these migrating populations. National TB programmes and regulatory systems alone will not be able to achieve TB elimination. The management of health issues resulting from population mobility will require integration of national and global health initiatives which, as demonstrated here, can be supported through the capacity-building endeavours of pre-migration screening programmes.

Patterns of abuse amongst Sri Lankan women returning home after working as domestic maids in the Middle East: An exploratory study of medico-legal referrals

OBJECTIVE

Migrant worker abuse is well recognised, but poorly characterised within the scientific literature. This study aimed to explore patterns of abuse amongst Sri Lankan women returning home after working as domestic maids.

METHODS

Sri Lanka has over 2 million of its citizens employed overseas as international labor migrants. A cross-sectional study was conducted on Sri Lankan female domestic maids returning from the Middle East region who were referred for medico-legal opinion.

RESULTS

A total of 20 women were included in the study. Average length of their employment overseas was 14 months. Complaints of physical violence directed mainly through their employers were made by 60% of women. Upon physical examination, two-thirds had evidence of injuries, with a third being subjected to repetitive/systematic violence. Eighty percent suffered some form of psychological trauma. Personal identity papers and travel documents had been confiscated by the employer in 85% of cases, with two thirds indicating they were prevented and/or restricted from leaving their place of work/residence.

CONCLUSIONS

Our study demonstrates that female domestic maid abuse manifests through multiple pathways. Violence against such workers span the full spectrum of physical, financial, verbal, emotional abuse and neglect, as defined by the World Health Organization. Findings from this exploratory study cannot be generalized to the large volume of migrant worker outflows. Further research is needed to determine incidence and define patterns in other migrant worker categories such as low-skilled male workers.

Patients' perception of differences in general practitioners' attitudes toward immigrants compared to the general population: Qualicopc Slovenia

INTRODUCTION

Globally, the number of immigrants is rising every year, so that the number of immigrants worldwide is estimated at 200 million. In Slovenia, immigrants comprise 6.5% of the overall population. Immigrants bring along to a foreign country their cultural differences and these differences can affect immigrants' overall health status and lead to chronic health conditions. The aim of this study was to identify patients' perception of general practitioners' (GPs') attitudes toward immigrants in Slovenia.

METHODS

This study was based on the Qualicopc questionnaire. We used the questions that targeted patients' experience with the appointment at their GP on the day that the study was carried out.

RESULTS

There were no differences in GPs' accessibility based on groups included in our study (p>0.05). Compared to the non-immigrant population, first-generation immigrants answered that their GPs were impolite (p=0.018) and that they did not take enough time for them (p=0.038). In addition, they also experienced more difficulties understanding their GP's instructions (p<0.001). Second-generation immigrants experienced more negative behaviour from GPs, and first-generation immigrants had more difficulties understanding GPs' instructions.

CONCLUSION

There may be some differences in patients' perception of GPs' attitudes towards immigrants in comparison with the general Slovenian population. However, based on the perception of the immigrants that do benefit from the medical care it is not possible to judge the GPs' attitudes towards immigrants as worse compared to their attitude towards the non-immigrant population. Indeed, there may be other reasons why the patients answered the way they did.

Health profiles of foreigners attending primary care clinics in Malaysia

BACKGROUND

The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia.

METHODS

Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care.

RESULTS

Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters.

CONCLUSIONS

More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public clinics suggests a need for improved access to maternal care and pregnancy related care. This has implication on policy and health care provision and access for foreigners and future studies are needed to look into strategies to solve these problems.

Lessons learnt from TB screening in closed immigration centres in Italy

Background

Between June 2012 and December 2013 Médecins Sans Frontières launched a pilot project with the aim of testing a strategy for improving timely diagnosis of active pulmonary TB among migrants hosted in four centres of identification and expulsion (CIE) in Italy.

Methods

This is a descriptive study. For active TB case finding we used an active symptom screening approach among migrants at admission in four CIE's. Here we describe the feasibility and the yield of this programme.

Results

Overall, 3588 migrants were screened, among whom 87 (2.4%) had a positive questionnaire. Out of 30 migrants referred for further investigations, three were diagnosed as having TB, or 0.1% out of 3588 individuals that underwent screening. Twenty-five (29%, 25/87) migrants with positive questionnaires were not referred for further investigation, following the doctors' decision; however, for 32 (37%, 32/87) migrants the diagnostic work-out was not completed. In multivariate analyses, being over 35 years (OR 1.7; 95% CI 1.1–2.6) and being transgender (OR 4.9; 95% CI 2.1–11.7), was associated with a positive questionnaire.

Conclusions

TB screening with symptom screening questionnaires of migrants at admission in closed centres is feasible. However, to improve the yield, follow-up of patients with symptoms or signs suggestive for TB needs to be improved.

From Exceptional to Liminal Subjects: Reconciling Tensions in the Politics of Tuberculosis and Migration

Controlling the movement of potentially infectious bodies has been central to Australian immigration law. Nowhere is this more evident than in relation to tuberculosis (TB), which is named as a ground for refusal of a visa in the Australian context. In this paper, I critically examine the "will to knowledge" that this gives rise to. Drawing on a critical analysis of texts, including interviews with migrants diagnosed with TB and healthcare professionals engaged in their care (n=19), I argue that this focus on border policing, rather than resettlement and the broader social determinants of health that drive current rates of TB, paradoxically renders migrants diagnosed with TB as liminal subjects in the post-arrival phase. This raises ethical issues about who "matters," as well as dilemmas about what constitutes adequate care for the "Other," both of which go to the heart of the political economy of migration.