COVID-19 among migrants, refugees, and IDPs: a synthesis of the global empirical literature

Background

The COVID-19 syndemic reveals social and health inequalities, putting marginalized groups such as migrants at greater risk. Yet health systems fail to routinely monitor the health of migrants, refugees, and internally displaced persons. Our systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 infection risk, transmission, outcome of disease and risk of severe course of disease among migrant populations. It further aims to compile extant evidence on COVID-19 vaccination coverage among these groups, and on the effects of pandemic control measures on their health.

Methods

Following PRISMA guidelines, we registered a review protocol, searched 14 scientific databases and 4 pre-print servers using the WHO database of global literature on COVID-19, and hand-searched relevant websites for grey literature. The search period covers the time from 12/2019 to 11/30/2021. Articles in English, German and Spanish and all study designs were included.

Results

A total of 6966 references were identified for title and abstract screening. 518 records were screened in full-text, out of which 204 articles were included so far (conflict solving at full-text stage and data extraction are ongoing). Our review presents a broad landscape of different study designs, migrant populations and COVID-19 outcomes. Based on previous work, we expect to find a higher risk of infection in migrants and their disproportionate share among COVID-19 cases, and consolidate the (mental) health impacts of pandemic control measures. Our preliminary findings indicate a vast knowledge gap on vaccination coverage among migrant groups.

Conclusions

Two years into the syndemic, this review summarizes the global empirical evidence on the impact of the COVID-19 syndemic on migrant populations. With health systems often lacking related data, the review provides an important evidence base for the consideration of migrants in future pandemic preparedness policies.

Key messages

• The systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 among diverse migrant populations globally.

• Knowledge on vaccination coverage in migrants remains patchy.

How do managers and physicians reconcile between financial and clinical considerations in hospitals?

Background

Hospital managers and physicians may face dilemmas due to their role as dual agents, committed both to their hospitals and their patients. We aim to pinpoint situations where economic and clinical considerations are aligned or conflicting; and to explore how managers and physicians reconcile different considerations in their decision-making in Germany and Israel.

Methods

Qualitative, thematic analysis based on 47 in-depth interviews with managers, ward directors and physicians in five hospitals in Germany and five in Israel.

Results

Economic and clinical considerations are aligned when gaps between hospital payments and costs are small, and economic incentives do not distort clinical considerations or when good medicine avoids complications while saving costs. Dilemmas arise when procedures are underpriced, resulting in financial losses to the hospital, and represent barriers for adoption of new, costly, medical equipment. In many instances, managers and ward directors choose one of the principals (hospital or patient), yet sometimes they develop reconciliation strategies that include: (1) improving coding of activities and diagnoses to assure higher payments; (2) reducing costs per case by choosing cheaper supplies with the same quality, bulk purchasing or reducing unnecessary lengths-of-stay; (3) providing clear treatment guidelines that support decision-making. Hospitals in Germany increase efficiency through specialization, and try to find alternative, less costly, care settings such as rehabilitation facilities. In Israel, hospitals balance the amount of unprofitable cases with many other profitable cases.

Conclusions

While sometimes one principal prevails, agents reconcile economic and clinical considerations. In Germany, a high-expenditure hospital market, there is some flexibility to change the character of hospitals activity, while in Israel, a middle-expenditure market, agents balance activities within the existing framework.

Key messages

Dilemmas exist regardless of the amount of hospitals’ funds. In Germany there is flexibility to change hospitals’ activity, while in Israel agents balance activities within the existing framework.

A first assessment of the electronic health insurance card for asylum seekers in Berlin

Background

Healthcare provision for asylum seekers differs across Germany. Most states use treatment vouchers as proof of eligibility; i.e., asylum seekers must first obtain a voucher from the welfare office to access healthcare. Since 2016 several states have introduced an electronic health insurance card (EHIC) for asylum seekers that enables access to care akin to statutory insurance. The EHIC has reanimated an old debate about asylum seekers’ health benefits. Opponents claim that medical costs will rise if control over healthcare access is eased. Proponents argue that the EHIC reduces costs through the cutback of administrative workloads and improves access to care. Evidence for either position is scarce.

Goal

The study goal was to assess the 2016 EHIC introduction in Berlin to enable evidence-informed decision-making.

Methods

We analyzed claims data that were retrieved from the Berlin Senate Administration and ten semi-structured in-depth interviews with key informants. Interviews were recorded, transcribed and subjected to thematic analysis using ATLAS.ti software. Ethical clearance was obtained.

Results

Our study found an overall positive evaluation of the EHIC. Although the introduction implied extra efforts and total administrative workloads remained unaltered, the EHIC was said to have the following advantages as compared to treatment vouchers: 1) It simplifies certain work processes and 2) allows for unprecedented financial transparency and control. 3) It eases access to care with 4) no increase in medical costs. Finally 5) the EHIC signifies equality and integration for asylum seekers.

Conclusions

In light of our study results the common economic arguments against greater inclusion of asylum seekers into public healthcare systems appear unfounded. On the contrary, the example of the EHIC shows that inclusion can create win-win-situations by improving healthcare access, whilst keeping medical costs constant and advancing financial transparency.

Key messages

In Germany there is a long-standing debate whether easing access to care for asylum seekers will increase health costs. Our case study shows that, on the contrary, the introduction of an electronic health insurance card for asylum seekers can both improve access and have organizational and economic benefits.

Ethics, economics and migration: intersections, synergies and tensions

The presentation will provide food for thought on the relationships between value-based discussions and economic evaluations of healthcare provision for marginalized migrant groups along two different lines of thought. First, while economic analyses are often interpreted as objective and neutral pieces of evidence, it can be argued that every economic model and analysis has its starting point in specific ethical values that are set as basic assumptions. This, in turn, has inevitable impacts on possible results and conclusions. The presentation will use examples to illustrate the value-based foundations of economic analyses in migrant healthcare; and it will propose options for the more explicit reflection of value-based assumptions in economic evaluations. Secondly, the presentation will reflect on existing research on the rationales shaping political decision-making processes in the field of migrant healthcare. In specific, it will examine the concepts of “health-related deservingness” and of “political decisions”, which both postulate that eventually values tip the scales in political decisions on migrant healthcare; and it will discuss the meaning of these concepts for the role of economic evidence in policy-making processes. In doing so, the presentation will relate back to the workshop’s overarching question on how to build synergies and bridges between migration and health research, economic analysis, and policy making to overcome inherent tensions.

Texas Tobacco Prevention Pilot Initiative: processes and effects

The study was designed to examine how intensity of anti-smoking media campaigns and differing types of anti-smoking community-based programs influence young adolescents' tobacco use and related psychosocial variables. Sixth grade students attending 11 middle schools in eight study communities assigned to varying intervention conditions were assessed by a pre-intervention survey conducted in spring 2000. The assessment was followed by summer and fall 2000 media and community interventions that were evaluated by post-intervention data collection taking place with a new cohort of sixth graders in the same 11 schools in late fall 2000. In analyses conducted at the school level, the enhanced school and comprehensive community program conditions outperformed the no intervention program condition to reduce tobacco use and intentions to use tobacco. Combining the intensive or low media campaign with the comprehensive community program was most effective in suppressing positive attitudes toward smoking, while the enhanced school program alone was less effective in influencing attitudes. The most consistent changes, at least short-term, to reduce teen tobacco use, susceptibility to smoking and pro-smoking attitudes were achieved by combining the intensive media campaign with the comprehensive community program condition.

Efficacy and safety of troglitazone in the treatment of lipodystrophy syndromes

BACKGROUND

Troglitazone promotes adipocyte differentiation in vitro and increases insulin sensitivity in vivo. Therefore, troglitazone may have therapeutic benefit in lipoatrophic diabetes.

OBJECTIVE

To determine whether troglitazone ameliorates hyperglycemia and hypertriglyceridemia or increases fat mass in lipoatrophic patients.

DESIGN

Open-labeled prospective study.

SETTING

United States and Canada.

PATIENTS

20 patients with various syndromes associated with lipoatrophy or lipodystrophy.

INTERVENTION

6 months of therapy with troglitazone, 200 to 600 mg/d.

MEASUREMENTS

Levels of hemoglobin A1c triglycerides, free fatty acids, and insulin; respiratory quotient; percentage of body fat; liver volume; and regional fat mass.

RESULTS

In the 13 patients with diabetes who completed 6 months of troglitazone therapy, hemoglobin A1c levels decreased by a mean of 2.8% (95% CI, 1.9% to 3.7%; P < 0.001). In all 19 study patients, fasting triglyceride levels decreased by 2.6 mmol/L (230 mg/dL) (CI, 0.7 to 4.5 mmol/L [62 to 398 mg/dL]; P = 0.019) and free fatty acid levels decreased by 325 micromol/L (CI, 135 to 515 micromol/L; P = 0.035). The respiratory quotient decreased by a mean of 0.12 (CI, 0.08 to 0.16; P < 0.001), suggesting that troglitazone promoted oxidation of fat. Body fat increased by a mean of 2.4 percentage points (CI, 1.3 to 4.5 percentage points; P = 0.044). Magnetic resonance imaging showed an increase in subcutaneous adipose tissue but not in visceral fat. In one patient, the serum alanine aminotransferase level increased eightfold during the 10th months of troglitazone treatment but normalized 3 months after discontinuation of treatment Liver biopsy revealed an eosinophilic infiltrate, suggesting hypersensitivity reaction as a cause of hepatotoxicity.

CONCLUSION

Troglitazone therapy improved metabolic control and increased body fat in patients with lipoatrophic diabetes. The substantial benefits of troglitazone must be balanced against the risk for hepatotoxicity, which can occur relatively late in the treatment course.

Heart Partners: a strategy for promoting effective diffusion of school health promotion programs

Heart Partners uses a straightforward, interpersonal approach to increase acceptance and use of innovations in school health promotion. In accord with the linkage model of innovation diffusion, developers of a new program or technology (i.e., resource system) simply designate and train selected members to be recruiters and allies of individual advocates at the campus-level (i.e., user system). Linkage is supported by supplying advocates and allies with guidelines and materials that encourage ongoing, interactive, interpersonal partnerships to promote effective implementation of the new technology at the school. Empirical assessment of this simple strategy implemented by the Texas Affiliate of the American Heart Association showed a twofold to fourfold increase in actual use and reach of school health promotion packages, with an average reported volunteer time of less than three hours per month.

Drinking patterns of greater Boston adults. Subgroups differences on the QFV index

A survey of the Boston metropolitan area correlated drinking patterns with sex, age, race, marital status and social class; findings were compared with previous studies in Boston, San Francisco and nationwide.

Gouty arthritis in the black race

This review of 65 black-black patients with gout, in contrast to tan or tinted, is presented to emphasize the universal nature of the disease, irrespective of race or geographic region. One case of a female who delivered a living child 4 yr after her initial attack of gout is reported. No case of gout secondary to chronic renal disease, or to a blood dyscrasia, including sickle cell disease, was discovered. Except for the race, aberrant sex distribution and low incidence of urate stones, this series is not unlike a series of white gout patients.