Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca

Burden of Disease in Refugee Patients with Diabetes on the Island of Lesvos-The Experience of a Frontline General Hospital

Diabetes mellitus is a non-communicable disease which poses a great burden on refugee populations, who are confronted with limited access to healthcare services and disruption of pre-existing pharmacological treatment.

AIMS

We sought to evaluate the degree of hyperglycaemia in refugees with known or recently diagnosed diabetes, to assess cardiovascular comorbidities and diabetes complications, to review and provide available therapeutic options, and to compare, if possible, the situation in Lesvos with other locations hosting refugee populations, thus raising our awareness towards barriers to accessing healthcare and managing diabetes in these vulnerable populations and to propose follow-up strategies.

METHODS

We retrospectively studied 69 refugee patients (68% of Afghan origin, 64% female) with diabetes mellitus (81% with type 2 diabetes), who were referred to the diabetes outpatient clinics of the General Hospital of Mytilene, Lesvos, Greece, between June 2019 and December 2020. Age, Body Mass Index, diabetes duration, glycaemic control (HbA1c and random glucose), blood pressure, estimated renal function, lipid profile, diabetes complications and current medication were documented at presentation and during subsequent visits.

RESULTS

For all patients with type 1 diabetes and type 2 diabetes, age at presentation was 17.7 and 48.1 years, BMI 19.6 kg/m2 and 28.9 kg/m2 and HbA1c 9.6% and 8.7%, respectively (all medians). One-third (29%) of patients with type 2 diabetes presented either with interrupted or with no previous pharmacological treatment. Insulin was administered to only 21% of refugees with poorly controlled type 2 diabetes. Only half of the patients (48%) with hypertension were taking antihypertensive medication and one-sixth (17%) were taking lipid-lowering medication. Forty-two per cent (42%) of patients were lost to follow-up.

CONCLUSIONS

Our results showed that a significant portion of refugees with diabetes have either no treatment at all or have had their treatment discontinued, that insulin is still underutilised and that a significant portion of patients are lost to follow-up. It is essential to enhance our ability to identify refugees who may be at risk of developing diabetes or experiencing complications related to the disease. Additionally, it is important to expand access to crucial treatment and monitoring services. By improving our policies for managing non-communicable diseases, we can better support the health and well-being of these vulnerable populations. Furthermore, it is vital to recognize that Greece cannot bear the burden of the refugee crisis alone; international support and collaboration are necessary to address these challenges effectively.

Psychological adaptation among health care workers who work with trauma-exposed refugees in Greece

Greek health care workers (HCWs) working with refugee and asylum-seeker populations may be at risk of trauma exposure and related distress. The current study sought to further understand the factors that may promote or hinder psychological adaptation among HCWs working with trauma-exposed refugee populations in Greece. Participants were HCWs (N = 20) who completed semistructured interviews. Thematic analysis procedures identified three main themes: vicarious traumatization, (b) mismatch of expectations, and (c) difficulty coping. Our study findings highlight the need to provide adequate training, supervision, and mental health support for HCWs to prevent mental health issues in this population. Additional studies are necessary to understand the long-term consequences of working with refugee populations and explore ways to assist HCWs with self-care.

Scenarios for Assessing Leadership Behaviors of Mid-level Managers in the Greek National Health System Through the Lens of Servant Leadership Theory: A Pilot Study in the Hospital Cluster of North Attica

This study aimed to develop a scenario-based questionnaire for evaluating medium-level leadership behaviors within the Greek National Healthcare System (NHS), drawing upon the principles of servant leadership theory. Data for this pilot study were collected in the first quarter of 2019, using a sample of 33 (22.9% of all medium-level managerial positions) medium-level managers from the Greek NHS hospital cluster located in North Attica. To assess managerial behaviors, an ordinal scale was employed, revealing non-normal data distributions. Consequently, our analysis involved presenting descriptive statistics, utilizing non-parametric tests to explore distinctions in managerial behaviors, and conducting thematic analysis of responses to open-ended questions, with frequencies and relative frequencies of each theme meticulously recorded. Overall, our findings indicate that, in most cases, managers exhibited positive behaviors toward their employees, regardless of whether the outcomes were positive, negative, or unknown. Positive behaviors towards the administration were comparatively rare. Significant differences were observed, highlighting that managers were more inclined to exhibit positive behaviors when the outcome was known, particularly in scenarios involving employee management. Within each scenario, behavioral patterns varied, with managers demonstrating a propensity to take credit for employee success in positive outcomes but distancing themselves from negative outcomes when reporting to the administration. Furthermore, the survey responses underscored the prevalence of positive attitudes regarding accountability and stewardship, with stewardship showing a positive correlation with scenario-based behaviors. Finally, our study brought to light several challenges in the management of the Greek NHS, including the absence of comprehensive managerial evaluation, the lack of meritocracy, regulatory deficiencies, and a shortage of leadership skills among current managers. These findings emphasize the importance of scenario-based assessments for Greek hospital managers, as they can help connect managerial behaviors to stewardship, accountability, and skills, ultimately contributing to the enhancement of leadership within the Greek NHS.

Prevalence of COVID-19 vaccine acceptance among migrant and refugee groups: A systematic review and meta-analysis

Objectives

Understanding COVID-19 vaccine hesitancy among migrant and refugee groups is critical for achieving vaccine equity. Therefore, we aimed to estimate the prevalence of COVID-19 vaccine acceptance among migrant and refugee populations.

Methods

A systematic review (PROSPERO: CRD42022333337) was conducted (December 2019-July 2022) using PubMed, Scopus, Web of Science, ProQuest and Google Scholar.

Results

Nineteen studies from 12 countries were included. The pooled estimated prevalence of COVID-19 vaccine willingness among migrant and refugee groups was 70% (19 studies, 95% CI: 62.3-77.4%, I2: 99.19%, τ2: 0.03). Female and male participants did not differ significantly with each other (p = 0.64). Although no individual variable contributed statistically significantly in multivariable meta-regression analysis, the multivariable model that considered methodological quality, mean age of participants, participant group and country of origin explained 67% of variance.

Discussion

Proportions of migrant/refugee groups receiving COVID-19 vaccinations approximated those observed among general populations. Additional studies are needed to examine factors relating to vaccine willingness to identify the most significant factors that may be targeted in interventions.

Prevalence of Malnutrition among Syrian Refugee Children from Lebanon

Today, the situation of Syrian refugees is one of the world's worst humanitarian crises. To estimate the prevalence of malnutrition among pediatric populations of Syrian refugees, 176 Syrian refugee children, with stays of more than two years at three refugee camps (Zalhé, Deddeh, and Kfar Jouz) or from the town of Yohmor, Lebanon were authorized by their parents to participate in this study. The children were anthropometrically evaluated and height-for-age Z-score (HAZ), weight-for-age Z-score (WAZ), and weight-for-height (WHZ) Z-scores were obtained and compared with WHO standards. Furthermore, mid-upper arm circumference (MUAC) was analyzed for screening children 6-59 months old. According to the anthropometric measures, no child met the criteria for chronic, global, acute malnutrition (CGAM), severe acute malnutrition (SAM), or moderate acute malnutrition (MAM). In the total sample, 49.4% of participants were moderately thin, with girls presenting a higher prevalence of thinness than that of boys. Thus, the absence of high rates of malnutrition was verified despite the magnitude of the Syrian refugee's problem. The data provided by this study identify the need to carry out further research to assess anthropometric growth and nutritional status among long-staying refugee children in order to prevent any health issues that may arise in the future.

Exploring the Influence of Social Capital on HIV Prevention with Migrants from the Democratic Republic of Congo (DRC) Living in Durban, South Africa

Background: Research shows a growing attentiveness to the role of social and environmental influences on HIV risk behaviours. Moreover, the understanding of HIV risk behaviours has moved from an earlier consideration of individual risk, to ecological models, with the understanding that behaviours are rooted in the economic, environmental and social structure. Aim: To explore how social capital, specifically on a social bonding level, operates as a risk or protective factor for the spread of HIV among French-speaking migrants from the Democratic Republic of Congo (DRC), living in Durban, South Africa. Methods: A qualitative approach using a case study design was used to conduct the study. Data were collected through focus group discussions and individual in-depth interviews from a purposive sample of French-speaking migrants from DRC, living in Durban, South Africa. Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal's Human and Social Science Research Ethics' Committee. Data were analysed thematically using Creswell's steps of data analysis. Results: This study found that social capital can act as both a protective factor in certain circumstances, and a risk factor in others. Trust, norms, reciprocity and social networks are complex elements in the refugee community and are influenced by a myriad of factors including the past and present stressors that are prevalent within this community. Conclusions: The findings confirm the complexity of issues related to HIV prevention which necessitate policy and practice interventions to mitigate consequences that may result from the higher risks of HIV transmission in this community.

Access to Healthcare Services and Essential Medicines in GREEK Migrant Camps: an Online Cross-Sectional Study

During the last years, Greece has become the entry point of a high number of migrants and asylum seekers. The aim of this study was to assess the access to selected fields of primary healthcare, to emergency medical care, secondary healthcare and essential medicines among populations living in reception, temporary accommodation, and detention centres (migrant camps) in Greece. An online cross-sectional survey was conducted based on a self-administered questionnaire. Participants included indviduals working or volunteering in migrant camps in Greece. 64 individuals participated in this study. The most common health problem among people residing in migrant camps was mental health conditions. The access to each field of primary healthcare was assessed as minimum to non-existent by most of the participants. 47.2% assessed the access to emergency medical care as minimum/non-satisfactory, while 60.8% assessed the access to secondary healthcare as minimum to non-existent. Most participants assessed the access to all the medicines categories as minimum or moderate. Access to both primary and secondary health was given a lower grade in the East-Aegean islands compared to the mainland. Major health inequalities among populations residing in Greek migrant camps were highlighted in this study. A change in the current migration policies of Greece and the European Union is urgently needed.

Journey Effects? Waiting Periods in European Transit Countries and Subsequent Economic Integration of Refugees in Switzerland

Refugees face difficult journeys to receiving countries. These journeys often include waiting periods in transit countries, as refugees plan and collect resources for the next leg of transit. Sociological theories of waiting suggest that longer sojourns in transit countries may hamper subsequent economic integration in receiving countries. However, studying the effect of journey duration on refugee economic integration is difficult due to data constraints and endogeneity issues. In this article, I leverage a natural experiment. For refugees who entered Switzerland through the European Refugee Relocation Program in 2016 and 2017, waiting periods for relocation from Greece and Italy varied quasi-randomly from three to 17 months. My analysis shows that longer waiting periods in European transit countries did not reduce subsequent labor market participation. However, female refugees who waited longer worked less after arrival than male refugees who had comparable waits. This gap is partially driven by a positive effect of wait times on labor market participation among male refugees. These conditional results have implications for understandings of asylum-seeker integration, the gendered risks and opportunities that arise during refugee journeys, and migration policy making.

Reasons for referral and referral compliance among Congolese and Burundian refugees living in Tanzania: a community-based, cross-sectional survey

OBJECTIVES

In order to prevent overburdening of higher levels of care, national healthcare systems rely on processes of referral, including for refugee populations which number 26 million globally. The goal of this study is to use data from a population-based household survey to describe patterns of referral services among a population of Congolese and Burundian refugees living in Tanzania.

DESIGN

Cross-sectional survey using cluster randomised sampling.

SETTING

Nyarugusu refugee camp, Kigoma, Tanzania.

PARTICIPANTS

153 refugees.

PRIMARY OUTCOME

Referral compliance.

SECONDARY OUTCOMES

Proportion of referrals that were surgical; proportion of referrals requiring diagnostic imaging.

RESULTS

Out of 153 individuals who had been told they needed a referral, 96 (62.7%) had gone to the referral hospital. Of the 57 who had not gone, 36 (63%) reported they were still waiting to go and had waited over a month. Of the participants who had been referred (n=96), almost half of the participants reported they were referred for a surgical problem (n=43, 45%) and the majority received radiological testing at an outside hospital (n=72, 75%). Congolese refugees more frequently had physically completed their referral compared with Burundians (Congolese: n=68, 76.4% vs Burundian: n=28, 43.8%, p<0.001). In terms of intracamp referral networks, most refugees reported being referred to the hospital or clinic by a community health worker (n=133, 86.9%).

CONCLUSION

To our knowledge, this is the first community-based study on patterns of referral healthcare among refugees in Tanzania and sub-Saharan Africa. Our findings suggest patients were referred for surgical problems and for imaging, however not all referrals were completed in a timely fashion. Future research should attempt to build prospective referral registries that allow for better tracking of patients and examination of waiting times.

Using an IT-Based Algorithm for Health Promotion in Temporary Settlements to Improve Migrant and Refugee Health

The application of the electronic algorithm developed by the Mig-Healthcare project was pilot tested in a sample of migrants and refugees in 2 Reception and Identification Centres (RICs), temporary settlements, in Greece using portable devices. The questions relate to health literacy issues, to mental health, to vaccination history, to lifestyle habits such as smoking, alcohol intake, diet, to the presence of diseases such as heart disease or diabetes, to the use of prevention services and to dental care. A total of 82 adults, 50 women and 32 men, participated. Data analysis showed that 67.1% (55) of the respondents had difficulty in understanding medical information and 57.3% (47) did not know where to seek medical help for a specific health problem. Four main areas of health problems were identified and further action is required: (A) mental health concerns, (B) vaccinations, (C) obesity, and (D) dental hygiene. Direct linkage with the "Roadmap and Toolbox" section of the project's website gave the respondents access to many sources and tools, while through the use of the interactive map, specific referral points of healthcare delivery in their area were identified. IT-based intervention in migrant and refugee populations in Greece are effective in increasing health literacy levels and identifying areas for health promotion interventions in these groups. Through linkage with the project's database, access to healthcare provision points and action to seek appropriate healthcare when necessary are encouraged. Given the attenuated vulnerability profile of people living in temporary settlements, this algorithm can be easily used in primary care settings to improve migrant and refugee health.

The genes road: impact of migration on newborn screening and health amid the COVID-19 pandemic in the Eastern Mediterranean region

Nearly two-thirds of migrants residing in camps in Europe are women and children. Many of these children, being born on the way without essential newborns screening, are at some point admitted to pediatric wards in asylum countries. With hospitals overwhelmed with COVID-19 cases, taking appropriate care of newborns becomes a considerable burden. In this frame, prevention, in the form of adequate newborn screening, emerges as a better and more feasible strategy than healing.

A cross-sectional survey of sociodemographic characteristics, primary care health needs and living conditions of asylum-seekers living in a Greek reception centre

Background

In 2019, a migrant camp on the Greek island of Samos designed for 650 people was home to a growing population of over 5500. We aimed to quantitatively describe living conditions and health needs in the camp.

Methods

A questionnaire was designed with reference to international humanitarian standards, following a consultative process with the asylum-seeker population. Domains assessed included demographics, living conditions, safety/vulnerability, and health. The questionnaire was piloted and then conducted in June 2019 on a sample of asylum seekers.

Results

Five hundred participants, predominantly from Afghanistan and the Democratic Republic of Congo (DRC). Of these, 79.4% lived in tents. Respondents cared for a total of 570 children; 20.6% of women were pregnant, 35.4% had experienced violence, 83% psychological distress, 71% skin disease, 66% diarrhoea and vomiting, and 64% respiratory disease. Accommodation, sanitation, and nutrition fell below internationally recognised standards, and poor access to water was significantly associated (p < 0.001) with respiratory disease, diarrhoea and vomiting, skin disease ,and psychological distress.

Conclusions

Living conditions in the Samos camp fall below basic humanitarian standards and are associated with poor health status. Further research is imperative to analyse and monitor the diverse, varying needs of asylum-seekers and inform policies to improve conditions.

Mental health consequences of long-term stays in refugee camps: preliminary evidence from Moria

Background

Ever since the implementation of the EU-Turkey deal, most refugees that enter Greece via sea are confined to the island on which they arrive until their asylum claims are adjudicated, where they generally reside in camps. Some of these camps have detention-like characteristics and dire living conditions, such as Moria camp on the island of Lesbos, Greece. Aid-organizations have stated that the situation in camp Moria deteriorates the mental health of its inhabitants and there is qualitative evidence to support this. This study explores the quantitative relationship between the incidence of acute mental health crises and the length of stay in the camp.

Methods

A cross-sectional study was conducted using routinely collected data on 856 consultations of 634 different patients during 90 nights at an emergency clinic in Moria camp. Logistic regression analysis was used to explore whether the length of stay in the camp was predictive of the occurrence of an acute mental health crisis.

Results

Of the 634 patients, the majority were men (59·3%), the average age was 23·2 years [0–71], and 24·3% was < 18 years. 25·5% (n = 218) of consultations were related to mental health problems; 17·0% (n = 37) of these met the study’s case definition of an acute mental health crisis. Such crises were positively associated with the length of stay in the camp (p = 0·011); the odds ratio of a mental health crisis increases with 1·03 for every 10% increase in days of residence in the camp. This is notable when considering the average length of stay in the camp is 71 days.

Conclusion

This study offers quantitative support for the notion that the adverse conditions in Moria camp deteriorate the mental health of its inhabitants as suggested in qualitative research. Although this study does not provide evidence of causality, it is likely that the poor and unsafe living conditions, challenging refugee determination procedures, and a lack of mental health services in the camp are significant contributing factors. We urgently call for Europe’s policymakers to honour the ‘51 Geneva refugee convention and terminate the neglectful situation on the Greek archipelago.

Vaccine hesitancy in migrant communities: a rapid review of latest evidence

By refusing or delaying vaccination, vaccine hesitant individuals and communities undermine the prevention, and ultimately, elimination of communicable diseases against which safe and effective vaccines are available. We reviewed recent evidence of vaccine hesitancy within migrant communities in the context of increased human mobility and widespread anti-immigrant sentiment and manifest xenophobia. Among many immigrant parents and families, vaccine hesitancy is largely associated with fears and misinformation about vaccine harms, limited knowledge of both preventable diseases and vaccines, distrust of host countries' health systems and their attendant intentions, language barriers, and perceived incompatibility between vaccine uptake and migrants' religion. Hesitancy toward measles, influenza, and human papillomavirus vaccines are most discernible, and main migrant populations involved include Somalis and Poles.

A retrospective review of specialist referrals for refugees into Greece's health system: A humanitarian organization's perspective

AIM

Refugee arrivals to Europe have numbered more than one million since 2015 with the majority arriving through Greece. The healthcare needs of refugees have placed strains on Greece's healthcare system which has already been affected by its ongoing economic crisis. At the peak of arrivals during 2016, primary healthcare was primarily provided by humanitarian organizations with specialist referrals into the Greek healthcare system. There is little published literature on the type and impacts of specialist referrals for refugees in Greece. The aim of this retrospective review is to identify the type and impacts of specialist referrals for refugees into Greece's health system.

METHODS

This retrospective study reviewed the number and type of specialty referrals from one humanitarian organization providing primary healthcare for refugees in Greece. All consultations during an 8-month period (December 1, 2016-July 31, 2017) were reviewed.

RESULTS

Of 4168 consultations, 42% were patients aged 17 years or younger, 52% were male, and 90% were Syrian. Two hundred and thirty-three patients (11%) required a specialist referral; 25% were for dental (provided by another humanitarian organization), 10% each for obstetrics and gynecology and pediatrics, and 8% for ophthalmology. Respiratory complaints were most frequently seen, and these were more predominant in the winter months. Pediatric consultations varied according to month, likely due to population movements.

CONCLUSION

Dentistry was noted to be a gap in humanitarian response programming and accounted for the greatest need for specialist input with referrals for women and children accounting for a large proportion of referrals.

Maternity care for refugees living in Greek refugee camps: What are the challenges to provision?

BACKGROUND

Over a two-year period between 2015 and 2016, unprecedented numbers of people arrived in Greece fleeing conflict, persecution, and poverty. With new arrivals every day, there is a significant unmet need for health care provision, posing a challenge to the Greek Healthcare System. For pregnant refugees, a known vulnerable group, this has resulted in a complex partnership of shared maternity care between humanitarian organizations, the Greek national health care system, and European multi-state initiatives. Our aim was to understand the challenges to providing maternity care services in Greek refugee camps as perceived by health care providers.

METHODS

A qualitative study comprising observation and semi-structured interviews with health care providers working with pregnant refugees was conducted in five refugee camps in May 2017. Interviews were transcribed and analyzed with thematic coding.

RESULTS

Twenty-one health care providers were interviewed and field notes taken from observational study of services in five refugee camps. Health care providers describe difficult cross-cultural communication to be their biggest challenge to caring for pregnant refugee women. The limited availability of female only safe spaces is also identified as a barrier. Lastly, the overburdened Greek public health system limits their ability to provide care.

CONCLUSIONS

Our research supports other literature describing difficult communication and the overburdened Greek health system as significant health care barriers for pregnant refugees in Greece. There is limited literature examining the role of "safe space," and further research is needed. Stakeholders providing maternity care to refugees should look to tackle these key issues as they seek to provide care to this population.

Fighting with the Lernean Hydra: Greek Humanitarian Crisis Enters Worst-Case Scenario. Comment on: Joseph, L.; Ismail, S.A.; Gunst, M.; Jarman, K.; Prior, D.; Harris, M.; Abbara, A. A Qualitative Research Study Which Explores Humanitarian Stakeholders' Views on Healthcare Access for Refugees in Greece. Int. J. Environ. Res. Public Health 2020, 17, 6972

Liz Joseph and collaborators shed light upon the real challenges of securing health during the Greek humanitarian crisis from the point of view of the key stakeholders in healthcare access, reflecting the need to reform a range of different contexts and types of humanitarian response [...].

Care providers' views on burden of psychosomatic symptoms of IS-traumatized female refugees participating in a Humanitarian Admission Program in Germany: A qualitative analysis

BACKGROUND

Traumatized refugees often suffer from diverse psychosomatic symptoms. Female Yazidi refugees from Northern Iraq who survived attacks of the so-called "Islamic State" were brought to Germany to receive special medical and psychotherapeutic treatment in a unique worldwide humanitarian admission program (HAP). Here, we report on their psychosomatic symptoms and helpful strategies from the perspective of care providers.

METHODS

Care providers (N = 84) in this HAP were interviewed in an individual setting as well as in focus groups to gather information about the HAP beneficiaries' psychosomatic symptoms. Data analysis followed Qualitative Content Analysis by Mayring.

RESULTS

The care providers reported five main psychological burdens of the Yazidis: 1) insecurity regarding loss, 2) worries about family members, 3) ambivalence about staying in Germany or returning to Iraq, 4) life between two worlds and 5) re-actualization of the traumatic experiences. The predominant psychological symptoms the care providers noticed were fear, depressive symptoms, feelings of guilt, and sleep and eating disorders. Regarding somatic symptoms, the care providers mainly received complaints about pain in the head, back, chest and stomach. Helpful strategies for providing adequate health care were care providers' cooperating with physicians, precise documentation of beneficiaries' symptoms, and additional support in directing the beneficiaries through the health care system. Regarding psychotherapy, interpreters help to overcome language barriers, onsite psychotherapy, flexible therapy appointments, psychoeducational methods, time for stabilization, and support in coping with daily life aspects. In the care providers' experience, psychotherapists have to build a relationship of trust. After grief therapy, a trauma-specific therapy in a culturally adapted way is possible.

CONCLUSION

The HAP is a unique model health care program to offer highly traumatized refugees medical and psychological help. Care providers reported on several (psycho-)somatic symptoms of the traumatized women. The strategies the HAP care providers perceived as helpful can be recommended for similar projects in the future.

A Qualitative Research Study Which Explores Humanitarian Stakeholders' Views on Healthcare Access for Refugees in Greece

Introduction: As of January 2020, 115,600 refugees remain in Greece; most are Afghani, Iraqi or Syrian nationals. This qualitative research study explores the views of key stakeholders providing healthcare for refugees in Greece between 2015 and 2018. The focus was on identifying key barriers and facilitators to healthcare access for refugees in Greece. Methods: 16 interviewees from humanitarian and international organisations operating in Greece were identified through purposive and snowball sampling. Semi-structured interviews were conducted between March and April 2018. Data were analysed using the Framework Method. Results: Key themes affecting healthcare access included the influence of socio-cultural factors (healthcare expectations, language, gender) and the ability of the Greek health system to respond to existing and evolving demands; these included Greece's ongoing economic crisis, human resource shortages, weak primary healthcare system, legal barriers and logistics. The evolution of the humanitarian response from emergency to sustained changes to EU funding, coordination and comprehensiveness of services affected healthcare access for refugees. Conclusion: The most noted barriers cited by humanitarian stakeholders to healthcare access for refugees in Greece were socio-cultural and language differences between refugees and healthcare providers and poor coordination among stakeholders. Policies and interventions which address these could improve healthcare access for refugees in Greece with coordination led by the EU.

Determinants of Refugee and Migrant Health Status in 10 European Countries: The Mig-HealthCare Project

In this study, we collect and synthesize information on the health status of the refugee/migrant population in ten European countries in order to map refugee/migrant health needs. With this information, we identify areas of intervention and healthcare system strengthening to provide the basis for future health planning and effective healthcare provision to migrants, asylum-seekers and refugees in the European Union (EU). Methods: 1407 migrants in ten European Union countries (consortium members of the Mig-HealthCare project) were surveyed on general health, mental health, and specific diseases using an interviewer-administered questionnaire. Descriptive statistics and multivariable linear regression analyses were conducted to investigate the risk factors on general quality of life for migrants and refugees in the EU. Results: Mean age was 31.9 (±11.05) years and 889 (63.1%) participants were males. The majority came from Syria, Afghanistan, Iraq, Nigeria, and Iran. Having a mental health disorder or a chronic disease such as a heart or respiratory disease was associated with worse general health. On the other hand, having permission to stay in the country of interview and being interviewed in the country of final destination was associated with better general health. Access to health care services was fragmented or unavailable for some interviewees because of linguistic, cultural, or administrative barriers. Conclusions: The management of chronic diseases and mental health conditions in European migrants and refugees is a key priority for health service provision. Further efforts should be made to guarantee healthcare access for migrant and refugee populations.

Health-related publications on people living in fragile states in the alert zone: a bibliometric analysis

Background

Fragile states pose a global challenge. Assessing health research activity on people living in these states can help identify neglected health domains in fragile settings. The objective of the current study was to assess and describe health research activity on people living in fragile states in the alert zone.

Method

A bibliometric method was applied using SciVerse Scopus. Research articles published on people in fragile states in the alert zone were retrieved and analyzed. The Fragile State Index (FSI) score was used for selection of states in the alert zone. The analysis was limited to 1 year; 2018.

Results

The search query found 2299 research articles giving an average of 2 research articles per one million population per year in the selected fragile states. The number of research articles per one million population was not significantly correlated (p = 0.053; r = − 0.349) with FSI scores. However, it was significantly correlated with the extent of international research collaboration (p < 0.01, r = 065). Research on communicable diseases was the largest research domain (763 articles; 33.2%) followed by maternal/women’s health (430 articles; 18.7%), non-communicable diseases (291 articles; 12.7%), health system/policy (271 articles; 11.8%) and psychosocial and mental health (89; 3.9%). There were three research themes in the research domain of infectious diseases: HIV/AIDS; water-borne infectious diseases; and miscellaneous infectious diseases such as tuberculosis and malaria. The top ten cited articles were mainly on infectious diseases, particularly on malaria and Lassa fever. Of all the retrieved documents, 727 (31.6%) research articles appeared in national/regional journals while the remaining appeared in international journals. The World Health organization was the most active funding organization for research on fragile states. Top ten active institutions were mainly based in fragile states with the lowest FSI score, specifically Ethiopia, Uganda, Nigeria, and Pakistan.

Conclusion

Research on fragile states was relatively low. Research on mental health and health system/policy should be encouraged. Collaboration and funding might help academic institutions in fragile states to make health problems in these countries more visible.

Distal determinants of mental health conditions (MHC) for asylum-seeking children in Greece: A health system enhancement study

Mental health conditions (MHC) of asylum-seeking children in Greece are dire, but still recovering from the financial crisis, Greece cannot afford the cost of mental health treatments. We were motivated to understand the root causes of these mental health problems to explore the possibilities for prevention. We developed our inferences in four ways: (1) secondary analyses of thirty-nine semi-structured informational interviews conducted with national and international aid organizations and healthcare providers; (2) secondary analyses of nine interviews with asylum seekers; (3) direct observation during six refugee camp visits from June 1 to July 28, 2017; and (4) a literature review to develop a diagnostic tree of causal outcomes. Results revealed eight proximal causes: chronic stress, trauma, at-risk population without protection and assistance, the large number of vulnerable groups, feeling of insecurity, feeling of lacking control, a lack of autonomy, and feeling helpless and hopeless. We identified sixty-nine distal determinants of adverse MHC beneath the proximal causes. Too numerous and too diverse to treat effecvively with limited resources, these root causes of MHC were thematically grouped into: laws and regulations, capacity and resources, accountability and standards, prioritization, bias and stigma, and displacement. Using a common health systems framework, we developed strategic policy approaches to target the root causes, which could prevent ill-health while saving time and resources.

Systemic Solutions for Addressing Non-Communicable Diseases in Low- and Middle-Income Countries

Non-communicable diseases (NCDs) have been on the rise in low- and middle-income countries (LMICs) over the last few decades and represent a significant healthcare concern. Over 85% of "premature" deaths worldwide due to NCDs occur in the LMICs. NCDs are an economic burden on these countries, increasing their healthcare expenditure. However, targeting NCDs in LMICs is challenging due to evolving health systems and an emphasis on acute illness. The major issues include limitations with universal health coverage, regulations, funding, distribution and availability of the healthcare workforce, and availability of health data. Experts from across the health sector in LMICs formed a Think Tank to understand and examine the issues, and to offer potential opportunities that may address the rising burden of NCDs in these countries. This review presents the evidence and posits pragmatic solutions to combat NCDs.

Stillbirth in Greece during the years of economic crisis: a population-based study

The recent economic crisis has been linked with declines in population health. Evidence on the impact of the crisis on stillbirth rates is scarce. The aim of this study was to assess trends of stillbirth rates in Greece during the pre-crisis (2004-2008) and crisis period (2009-2015) and explore risk factors. Nationwide data (n = 1,276,816 births; 5023 stillbirths) were used to assess rates and trends through Poisson and joinpoint regressions. Multivariable Poisson regressions by nationality were fitted. The overall annual stillbirth rate was 3.9/1000 births with higher rates among non-Greeks (5.0/1000) than Greeks (3.7/1000). Non-significant decreasing trends were noted for Greeks (- 0.5%, 95% confidence interval [CI] - 1.4, 0.4%) versus non-significant increasing trends in non-Greeks (1.4%, 95% CI - 0.5, 3.3%). After adjusting for possible confounders, the relative stillbirth risk (RR) increased during the crisis versus the pre-crisis period (RR_Greeks 1.61, 95% CI 1.50, 1.74; RR_non-Greeks 1.92, 95% CI 1.64, 2.26). Multiplicity, birth order, birth size, maternal education, marital status, and parental age were risk factors.Conclusions: Bidirectional stillbirth trends were observed among Greeks and non-Greeks, whereas the RR increased by 2-fold during the crisis. Persisting disparities require tailored employment of preventive measures ensuring optimal quality of the child's and maternal health.What is Known:• Stillbirth rate is a key population health indicator reflecting economic development and health care services within a population.• The recent economic crisis has been linked with declines in population health.What is New:• Economic crisis, ethnic minorities, and several modifiable factors seem to be significant determinants of stillbirth risk.

Enhanced Public Interest in Response to the Refugee and Healthcare Crises in Greece

Background: The Greek National Health System (NHS) has been profoundly affected by the synergy of the economic and refugee crises. We aimed at evaluating the public interest regarding refugee and healthcare issues in Greece. Methods: Google Trends was employed to normalize traffic data on a scale from 0 to 100, presented as monthly relative search volume (RSV) for the search term queries: "refugees", "health", "diseases", "hospital", and "economic crisis" in Greece, from the period 2008 to 2020. Cross-country comparisons in selected European countries were made. Results: The analysis of RSV data showed an upward trend for the keyword "refugee", in Greece, in the last five years, with two remarkable peaks from 2015 to 2016 and from 2019 to the present. Interest regarding refugees was more prevalent in the Aegean islands compared to the mainland. The mass influx of refugees has been linked to disease-related concerns. The search terms "hospital" and "health" have been the most popular and constantly quested topics since the beginning of the economic crisis in Greece, in 2009. Similar trends existed across Europe. Conclusion: There is an urgent need for effective public awareness of current politico-ethical and social-economic conditions. The patterns of public interest can formulate public policy.

Disparities of infant and neonatal mortality trends in Greece during the years of economic crisis by ethnicity, place of residence and human development index: a nationwide population study

OBJECTIVE

To study trends of infant mortality rate (IMR) and neonatal mortality rate in Greece during the period 2004-2016 and explore the role of sociodemographic factors in the years of crisis.

DESIGN

Nationwide individual data for live births and infant (0-11 months) deaths provided by the Hellenic Statistical Authority were examined using Poisson, joinpoint regression and interrupted time series (ITS) analyses.

SETTING

Greece.

PARTICIPANTS

All infant deaths (n=4862) over the 13-year period, of which 87.2% were born to Greek mothers, and respective live births.

MAIN OUTCOME MEASURES

Evolution of IMR (0-364 days), early (<7 days) neonatal mortality rate (ENMR), late (7-27 days) neonatal mortality rate (LNMR) and post neonatal (28-364 days) mortality rate (PNMR) trends, by maternal nationality, place of residence and Human Development Index (HDI).

RESULTS

By Poisson regression, overall, during the study period, among infants of Greek mothers, IMR and PNMR declined significantly (-0.9%; 95% CI -1.7% to -0.1% and -1.6%; -3.0% to -0.2% annually, respectively), although differentially by place of residence (IMRurban: -2.1%; -2.9% to -1.3%, IMRrural: +10.6%; 7.6% to 13.6%). By contrast, among infants of non-Greek mothers, the low starting IMR/ENMR/LNMR/PNMR increased significantly (max ENMR:+12.5%; 8.6% to 16.5%) leading to a non-significant time-trend pattern overall in Greece. The inverse associations of HDI with IMR, ENMR and PNMR were restricted to Greek mothers' infants. Joinpoint regression analyses among Greek mothers' infants indicated non-significant increasing trends of IMR and ENMR following the crisis (+9.3%, 2012-2016, p=0.07 and +10.2%, 2011-2016, p=0.06, respectively). By contrast, the high (+17.1%; 8.1% to 26.9%, p=0.002) IMR increases among non-Greek infants were restricted to 2004-2011 and equalised to those of Greek mothers' infants thereafter. ITS analyses in preset years (2008, 2010, 2012) identified significantly increasing trends in IMR, LNMR and PNMR after 2012, and in ENMR after 2010, among Greek mothers' infants.

CONCLUSIONS

HDI and rural residence were significantly associated with IMR. The strongly decreasing IMR trends among Greek-mothers' infants were stagnated after a lag time of ~4 years of crisis approximating the previously sharply increasing trends among non-Greeks.

A Crisis of Humanitarianism: Refugees at the Gates of Europe

Having initially welcomed more than a million refugees and forced migrants into Europe between 2015 and 2016, the European Union’s (EU’s) policy has shifted toward externalising migration control to Turkey and Northern Africa. This goes against the spirit of international conventions aiming to protect vulnerable populations, yet there is widespread indifference toward those who remain stranded in Italy, Greece and bordering Mediterranean countries. Yet there are tens of thousands living in overcrowded reception facilities that have, in effect, turned into long-term detention centres with poor health and safety for those awaiting resettlement or asylum decisions. Disregard for humanitarian principles is predicated on radical inequality between lives that are worth living and protecting, and unworthy deaths that are unseen and unmarked by grieving. However, migration is on the rise due to natural and man-made disasters, and is becoming a global issue that concerns us all. We must therefore deal with it through collective political action that recognises refugees’ and forced migrants’ right to protection and ensures access to the health services they require.

Health and health needs of migrants in detention in Greece: shedding light to an unknown reality

Background

Population movements have been increasing over the past years in Europe due to socioeconomic factors, global turbulence and conflicts, especially in the area of Middle East. The presence of migrant populations in Europe challenges health systems due to increased requirements for health care provision. However, to date there is limited published data on the burden of disease among this population (in Greece and elsewhere). Our objective was to record burden of disease of undocumented migrants hosted in a Detention Center and therefore generate data for migrant and public health planning.

Methods

Epidemiological data have been collected for 4756 male migrants hosted in a Detention Center from mid 2013 to mid 2015. Of them, 1427 have used health services in the Center, which maintained a detailed record of their medical history and tests.

Results

The majority of the study population was aged between 18 and 40 years old. Among those who used health services, most suffered from respiratory (45.6%) and digestive (30.1%) diseases. Injury, poisoning and other external causes accounted for 19.6% of service use, diseases of the skin and subcutaneous tissue for 18.7%, and factors affecting health status and contact with health services for 16.7%. Prevalence of communicable diseases was 15.9% amongst migrants randomly tested.

Conclusion

Systematic screening and monitoring of diseases and use of health services by migrants in detention centers allows for an evidence based understanding of the burden of disease related to these populations and the investment required to effectively manage it, thus providing critical input to appropriate health planning. Surveillance for communicable diseases amongst migrants in detention centers would also allow for a true picture of the impact of their presence on public health indicators and help address related prejudices and stigma.