Experiences of Providers and Immigrants/Refugees with Health Care: A Meta-Synthesis of the Latin American Context

INTRODUCTION

The experiences of providers and immigrants/refugees related to healthcare in the Latin American context have not yet been aggregated. This study aimed to synthesize the qualitative evidence on this theme.

METHOD

A systematic review of qualitative evidence with meta-synthesis. After identification, eligible studies were evaluated for methodological quality, and information was systematically analyzed.

RESULTS

The sample comprised 26 articles. The meta-theme shows that the experiences of providers and immigrants/refugees are determined by multilevel factors. In a macro-context, these factors involve the vulnerabilities of immigrants/refugees and the healthcare system/model, and in a closer context, they involve the lack of professional training in cultural skills and communication; language barriers; and prejudice/xenophobia. Within healthcare, the relationship is mostly conflictual, asymmetric, and unable to solve problems, leading to negative repercussions for both.

CONCLUSIONS

Managers involved in developing public policies and providers must consider improving the interrelationship between healthcare services and the migrant population.

The relationship between ethnocentrism and xenophobia level and predictors: A descriptive and correlational study of nurses working in two cities where refugees live intensively in Turkey

Determining the ethnocentrism and xenophobia levels of nurses contributes to nurses' awareness regarding their attitudes on the issue and providing quality care. This descriptive and correlational study aimed to determine the relationship between ethnocentrism and xenophobia levels of nurses working in hospitals located in two different border regions where refugees live intensively in Turkey. The study was conducted with 386 nurses who were working in two different hospitals located in two cities in the south of Turkey. Data were collected using the "Personal Information Form," "Ethnocentrism Scale," and "Xenophobia Scale." About half of the nurses did not want to care for foreign patients. There was a positive and statistically significant relationship between mean scores of the Ethnocentrism Scale and the Xenophobia Scale (p < 0.05). The regression analysis indicated that the level of ethnocentrism explains the level of xenophobia by 9%. Nurses had a high level of xenophobia and moderate ethnocentric attitudes. The level of xenophobia increased as the ethnocentrism level of nurses increased. It is recommended to conduct further studies to determine different predictors of xenophobia among nurses.

Understanding the views of adult migrants around catch-up vaccination for missed routine immunisations to define strategies to improve coverage: A UK in-depth interview study

BACKGROUND

The World Health Organization's (WHO) Immunization Agenda 2030 emphasises ensuring equitable access to vaccination across the life course. This includes placing an emphasis on migrant populations who may have missed key childhood vaccines, doses, and boosters due to disrupted healthcare systems and the migration process, or differing vaccination schedules in home countries. Guidelines exist in the UK for offering catch-up vaccinations to adolscent and adult migrants with incomplete or uncertain vaccination status (including MMR, Td-IPV, MenACWY, HPV), but emerging evidence suggests awareness and implementation in primary care is poor. It is unclear whether patient-level barriers to uptake of catch-up vaccinations also exist. We explored experiences and views around catch-up vaccination among adult migrants from a range of backgrounds, to define strategies for improving catch-up vaccination policy and practice.

METHODS

In-depth semi-structured interviews were carried out in two phases with adult migrant populations (refugees, asylum seekers, undocumented migrants, those with no recourse to public funds) on views and experiences around vaccination, involving a team of peer researchers from specific migrant communities trained through the study. In Phase 1, we conducted remote interviews with migrants resident in the UK for < 10 years, from diverse backgrounds. In Phase 2, we engaged specifically Congolese and Angolan migrants as part of a community-based participatory study. Topic guides were developed iteratively and piloted. Participants were recruited using purposive, opportunistic and snowball sampling methods. Interviews were conducted in English (interpreters offered), Lingala or French and were audio-recorded, transcribed and analysed using a thematic framework approach in NVivo 12.

RESULTS

71 participants (39 in Phase 1, 32 in Phase 2) were interviewed (Mean age 43.6 [SD:12.4] years, 69% female, mean 9.5 [SD:7] years in the UK). Aside from COVID-19 vaccines, most participants reported never having been offered vaccinations or asked about their vaccination history since arriving in the UK as adults. Few participants mentioned being offered specific catch-up vaccines (e.g. MMR/Td-IPV) when attending a healthcare facility on arrival in the UK. Vaccines such as flu vaccines, pregnancy-related or pre-travel vaccination were more commonly mentioned. In general, participants were not aware of adult catch-up vaccination but regarded it positively when it was explained. A few participants expressed concerns about side-effects, risks/inconveniences associated with access (e.g. links to immigration authorities, travel costs), preference for natural remedies, and hesitancy to engage in further vaccination campaigns due to the intensity of COVID-19 vaccination campaigns. Trust was a major factor in vaccination decisions, with distinctions noted within and between groups; some held a healthcare professional's recommendation in high regard, while others were less trusting towards the healthcare system because of negative experiences of the NHS and past experiences of discrimination, injustice and marginalisation by wider authorities.

CONCLUSIONS

The major barrier to adult catch-up vaccination for missed routine immunisations and doses in migrant communities in the UK is the limited opportunities, recommendations or tailored vaccination information presented to migrants by health services. This could be improved with financial incentives for provision of catch-up vaccination in UK primary care, alongside training of healthcare professionals to support catch-up immunisation and raise awareness of existing guidelines. It will also be essential to address root causes of mistrust around vaccination, where it exists among migrants, by working closely with communities to understand their needs and meaningfully involving migrant populations in co-producing tailored information campaigns and culturally relevant interventions to improve coverage.

The prevalence of food insecurity amongst refugees and asylum seekers during, and prior to, their early resettlement period in Australia: A cross-sectional analysis of the 'Building a New Life in Australia' data

With over 100 million humanitarian migrants globally, there is increasing pressure on high-income countries to offer resettlement opportunities. Humanitarian migrants face many challenges during pre-settlement and resettlement. One challenge is food insecurity (FI). The Building a New Life in Australia (BNLA) longitudinal cohort study gathered data from migrating units, that is, a group of humanitarian migrants included on the same visa application (n = 1599). Data were gathered in five annual waves (2013-2018). Data included food security status in four pre-settlement situations and during resettlement. The results of this secondary analysis of BNLA Wave One indicate that FI was highest in refugee camps (71%), followed by bridging visas (30%), community detention (17%), immigration detention (11%), and during early resettlement (9%). During early resettlement, respondents who were male, those from Afghanistan or Iran, and those living in a single person household reported the highest prevalence of FI. An association was found between having spent time on a bridging visa and FI during early resettlement (p < 0.01). This study's results are an important step in understanding the scale of FI and which sub-groups are most vulnerable, so the resources and policies of high-income countries can better meet food security needs during resettlement.

Age assessment in unaccompanied minors: assessing uniformity of protocols across Europe

Age assessment of migrants is crucial, particularly for unaccompanied foreign minors, a population facing legal, social, and humanitarian challenges. Despite existing guidelines, there is no unified protocol in Europe for age assessment.The Forensic Anthropology Society of Europe (FASE) conducted a comprehensive questionnaire to understand age estimation practices in Europe. The questionnaire had sections focusing on the professional background of respondents, annual assessment numbers, requesting parties and reasons, types of examinations conducted (e.g., physical, radiological), followed protocols, age estimation methods, and questions on how age estimates are reported.The questionnaire's findings reveal extensive engagement of the forensic community in age assessment in the living, emphasizing multidisciplinary approaches. However, there seems to be an incomplete appreciation of AGFAD guidelines. Commonalities exist in examination methodologies and imaging tests. However, discrepancies emerged among respondents regarding sexual maturity assessment and reporting assessment results. Given the increasing importance of age assessment, especially for migrant child protection, the study stresses the need for a unified protocol across European countries. This can only be achieved if EU Member States wholeheartedly embrace the fundamental principles outlined in EU Directives and conduct medical age assessments aligned with recognized standards such as the AGFAD guidelines.

Real-time investigation of an influenza A(H3N2) virus outbreak in a refugee community, November 2022

OBJECTIVES

To report epidemiological and virological results of an outbreak investigation of influenza-like illness (ILI) among refugees in Northern Italy.

STUDY DESIGN

Outbreak investigation of ILI cases observed among nearly 100 refugees in Northern Italy unvaccinated for influenza.

METHODS

An epidemiological investigation matched with a differential diagnosis was carried out for each sample collected from ILI cases to identify 10 viral pathogens (SARS-CoV-2, influenza virus type A and B, respiratory syncytial virus, metapneumovirus, parainfluenza viruses, rhinovirus, enterovirus, parechovirus, and adenovirus) by using specific real-time PCR assays according to the Centers for Disease Control and Prevention (CDC) protocols. In cases where the influenza virus type was identified, complete hemagglutinin (HA) gene sequencing and the related phylogenetic analysis were conducted.

RESULTS

The outbreak was caused by influenza A(H3N2): the attack rate was 83.3% in children aged 9-14 years, 84.6% in those aged 15-24 years, and 28.6% in adults ≥25 years. Phylogenetic analyses uncovered that A(H3N2) strains were closely related since they segregated in the same cluster, showing both a high mean nucleotide identity (100%), all belonging to the genetic sub-group 3C.2a1b.2a.2, as those mainly circulating into the general population in the same period.

CONCLUSIONS

The fact that influenza outbreak strains as well as the community strains were genetically related to the seasonal vaccine strain suggests that if an influenza prevention by vaccination strategy had been implemented, a lower attack rate of A(H3N2) and ILI cases might have been achieved.

Knowledge and preventive practices regarding COVID-19 disease among Ukrainian refugees in Poland

Russia's invasion of Ukraine contributed one of the largest migration movements in the 21st century. Refugees may become a source of severe acute respiratory syndrome coronavirus 2 infections for the residents of host countries. The study aim was to assess knowledge and preventive practices regarding coronavirus disease 2019 (COVID-19) among Ukrainian refugees in Poland. The cross-sectional study was conducted between March and April 2022 among Ukrainian refugees registering consecutively in Zielona Góra, Poland. Knowledge and preventive practices were assessed by giving 1 point for each correct answer by anonymous, self-administered questionnaire. The response rate was 96%, 190 participated (mean age 37.8 ± 15.5 years; 57.9% females); 61.6% self-reported their socio-economic status (SES) as high, 38.9% reported high level of education. The mean COVID-19 knowledge score was 3.06 ± 1.95; 19.5% scored >50%. The knowledge level was higher among migrants with high SES (P = .003). The mean preventive practices score was 2.56 ± 1.38; 54.0% scored ≥ 60%. 40.5% declared social distancing, 62.6% followed coughing etiquette, 69.0% home isolate themselves during COVID-19. 57.9% always used masks in public space, however 74.2% wore masks with uncovered nose. Refugees with higher education, high SES and knowledge level had significantly greater preventive practices scores (P = .002; P = .02; P = .03, respectively). The knowledge and preventive practices level was insufficient. Educational campaigns oriented to raising knowledge and prevention behavior skills should be implemented, especially targeting high-risk groups to avoid spread of COVID-19.

The influence of health service interactions and local policies on vaccination decision-making in immigrant women: A multi-site Canadian qualitative study

OBJECTIVES

Research on immigrant and refugee vaccination uptake in Canada shows that immunization decisions vary by vaccine type, location, age and migration status. Despite their diversity, these studies often treat immigrant and refugee populations as a single group relative to other Canadians. In this comparative study, we explored how previous risk communication and immunization experiences influence immunization decisions by immigrant and refugee women from three communities across Canada.

METHODS

Participants included women from the Punjabi immigrant community located in Surrey and Abbotsford, British Columbia (n = 36), the Nigerian immigrant community located in Winnipeg, Manitoba (n = 43), and the Congolese refugee community in Edmonton, Alberta (n = 18). Using focus groups guided by focused ethnography methodology, we sought to understand immunization experiences in Canada and before arrival, and what information sources influenced the immunization decision-making process by the women in the three communities.

RESULTS

Participants had differing past experiences in Canada and before their arrival that influenced how they used information in their vaccination decisions. Clear vaccination communications and dialogue with Canadian health care providers increased trust in Canadian health care and the likelihood of vaccine uptake. By contrast, weak vaccine recommendations and antivaccination information in the community prompted participants to decline future vaccines.

CONCLUSION

Given our participants' different communication preferences and needs, we argue that a one-size-fits-all communication approach is inappropriate for immigrant and refugee populations. Instead, multi-pronged communication strategies are required to reach participants and respond to previous experiences and information that may lead to vaccination hesitancy.

Comparison of perinatal outcome and mode of birth of twin and singleton pregnancies in migrant and refugee populations on the Thai Myanmar border: A population cohort

BACKGROUND

In low- and middle-income countries twin births have a high risk of complications partly due to barriers to accessing hospital care. This study compares pregnancy outcomes, maternal and neonatal morbidity and mortality of twin to singleton pregnancy in refugee and migrant clinics on the Thai Myanmar border.

METHODS

A retrospective review of medical records of all singleton and twin pregnancies delivered or followed at antenatal clinics of the Shoklo Malaria Research Unit from 1986 to 2020, with a known outcome and estimated gestational age. Logistic regression was done to compare the odds of maternal and neonatal outcomes between twin and singleton pregnancies.

RESULTS

Between 1986 and 2020 this unstable and migratory population had a recorded outcome of pregnancy of 28 weeks or more for 597 twin births and 59,005 singleton births. Twinning rate was low and stable (<9 per 1,000) over 30 years. Three-quarters (446/597) of the twin pregnancies and 96% (56,626/59,005) of singletons birthed vaginally. During pregnancy, a significantly higher proportion of twin pregnancies compared to singleton had pre-eclampsia (7.0% versus 1.7%), gestational hypertension (9.9% versus 3.9%) and eclampsia (1.0% versus 0.2%). The stillbirth rate of twin 1 and twin 2 was higher compared to singletons: twin 1 25 per 1,000 (15/595), twin 2 64 per 1,000 (38/595) and singletons 12 per 1,000 (680/58,781). The estimated odds ratio (95% confidence interval (CI)) for stillbirth of twin 1 and twin 2 compared to singletons was 2.2 (95% CI 1.3-3.6) and 5.8 (95% CI 4.1-8.1); and maternal death 2.0 (0.95-11.4), respectively, As expected most perinatal deaths were 28 to <32 week gestation.

CONCLUSION

In this fragile setting where access to hospital care is difficult, three in four twins birthed vaginally. Twin pregnancies have a higher maternal morbidity and perinatal mortality, especially the second twin, compared to singleton pregnancies.

Health care utilisation of asylum seekers and refugees in the South-West of Germany

BACKGROUND

Limited evidence on utilisation of health care by recently arrived asylum seekers and refugees in high-income countries is available. This study aims to describe the implementation of an integrated care facility (ICF) in an initial reception centre and measure the utilisation of care and the influence of operational parameters.

METHODS

In a retrospective cohort study design, using medical records, we followed inhabitants of a reception centre in Germany between 11.10.2015 and 30.05.2018. We assessed frequency of visits and revisits to a newly established integrated care facility (ICF), and the effects of the ICF on visits to the local emergency department (LED) in the regional tertiary hospital using survival analysis and time series regression. We also explore the influence of operational parameters on the different implementation phases; phase 1: provisional clinic with 1-2 hours of physician presence daily, phase 2: implementation of ICF with 2-4 hours of care by a team of doctors and nurses daily, phase 3: routine running of ICF with daily operational hours of 10am-2pm with care provided by an interdisciplinary team of doctors and nurses.

RESULTS

14,419 total medical visits were recorded from 1,883 persons seeking health care in the ICF. The absolute number of visits per day remained similar over the study period (19·9/day), yet the relative number of visits changed from 2·2 to 15 per 100 inhabitants from phase 2 to 3, respectively. Most visits were due to respiratory infections (612/3080, 20%), and trauma and musculoskeletal conditions (441/3080, 14%). The rate of revisits to ICF was 2·9 per person per month (95%CI 2·9-3), more for those older, female, from North Africa and those with a translator present. The ratio of visits to the LED changed from 0·3/100 inhabitants per day to 0·14/100 inhabitants after implementation of the ICF and back to 0·3/100 inhabitants during the routine running.

CONCLUSIONS

Though seasonal variation and referral practices must be considered, a high rate of revisits to the ICF were recorded. While visits to the LED decreased after the implementation of the ICF, visits returned to the pre-ICF levels during the routine running of the ICF. The results show that AS&R require reliable access to health care, yet the needs of specific groups of migrants may be different, especially those with language barriers, minority groups or those from certain regions. As such, care should be migrant sensitive and adapt to the changing needs of the population. Though more research is required to better understand the differing needs of migrants, this study may help to inform guidelines surrounding migrant sensitive standards of care in Germany.

Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings

BACKGROUND

Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC.

METHODS

Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs.

FINDINGS

The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels.

CONCLUSIONS

This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

Predicting intention to vaccinate against COVID-19 in older Syrian refugees in Lebanon: Findings from a multi-wave study

BACKGROUND

COVID-19 vaccine acceptance among refugees in the Arab region remains low. This study aimed to examine the prevalence, reasons and predictors of intention to refuse the COVID-19 vaccine among older Syrian refugees in Lebanon.

METHODS

A nested cross-sectional study within a longitudinal study among older Syrian refugees in Lebanon. The sampling frame was a complete listing of beneficiary households of a humanitarian organization with at least one adult aged 50 years or older. Telephone surveys were completed at months 1 starting September 2020 (wave 1), months 2 (wave 2), months 5 (wave 3), months 6 (wave 4) and months 17 (wave 5) in March 2022. Logistic regression models were used to identify predictors of intention to refuse the COVID-19 vaccine. Models were internally validated using bootstrap methods and the models' calibration and discrimination were presented.

FINDINGS

Of 3167 Syrian refugees, 61.3% intended to receive the COVID-19 vaccine, 31.3% refused, and 7.4% were undecided. Reasons for vaccine refusal were: preference to follow preventive measures (27.4%) and belief that the vaccine is not essential (20.7%). Furthermore, 57.1% of participants registered to take the COVID-19 vaccine in wave 5. Irrespective of vaccination intention, reasons for not registering included: not wanting to receive the vaccine, and being unsure whether to take it. Predictors of intention to refuse the COVID-19 vaccine included: being a female, older age, having elementary education or above, living outside informal tented settlements, perceiving COVID-19 as not severe and vaccines as not safe or effective, and using social media for information on COVID-19. After adjusting for optimization, the final model showed moderate discrimination (C-statistic: 0.651 (95% CI:0.630-0.672)) and good calibration (C-slope: 0.93 (95% CI: 0.823-1.065)).

CONCLUSIONS

This study developed a predictive model for vaccination intention with a moderate discriminative ability and good calibration. Prediction models in humanitarian settings can help identify refugees at higher risk of not intending to receive the COVID-19 vaccine for public health targeting.

Leveraging community advisory boards within travel medicine to help reduce malaria incidence in refugees, immigrants and migrants visiting friends and relatives abroad: reflections from the Minnesota Malaria Community Advisory Board on patient-provider interactions

Refugees, immigrants and migrants often have barriers to travel medicine. Community Advisory Boards (CAB) are a vital but underutilized tool for understanding and meeting healthcare needs and challenges, providing communities with a voice, and finding solutions. The paper discusses a malaria prevention community-based participatory research project informed by a CAB.

Persistent Food Insecurity and Material Hardships: A Latent Class Analysis of Experiences among Venezuelan Refugees and Migrants in Urban Colombia

The causes and conditions of displacement often increase the vulnerability of migrant and refugee populations to food insecurity, alongside other material hardships. We aimed to examine the multidimensional aspects and patterns of food insecurity and other material hardships in a cross-sectional sample of 6221 Venezuelan refugees and migrants in urban Colombia using a latent class analysis. Using multinomial and logistic regression models, we investigated the demographic and migratory experiences associated with identified classes and how class membership is associated with multiple health outcomes among Venezuelan refugees and migrants, respectively. Approximately two thirds of the sample was comprised cisgender women, and the participants had a median age of 32 years (IQR: 26-41). Four heterogeneous classes of food insecurity and material hardships emerged: Class 1-low food insecurity and material hardship; Class 2-high food insecurity and material hardship; Class 3-high income hardship with insufficient food intake; and Class 4-income hardship with food affordability challenges. Class 2 reflected the most severe food insecurity and material hardships and had the highest class membership; Venezuelans with an irregular migration status were almost 1.5 times more likely to belong to this class. Food insecurity and material hardship class membership was independently associated with self-rated health, mental health symptoms, and recent violence victimization and marginally associated with infectious disease outcomes (laboratory-confirmed HIV and/or syphilis infection). Social safety nets, social protection, and other interventions that reduce and prevent material hardships and food insecurity among refugees and migrants, alongside the host community, may improve public health, support development, and reduce healthcare costs. In the long term, regularization and social policies for migrants aimed at enhancing refugees' and migrants' social and economic inclusion may contribute to improving food security in this population.

Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda

BACKGROUND

Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done.

RESULTS

The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences.

CONCLUSIONS

In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

Determinants of self-rated health among highly educated Ukrainian women refugees in Czechia: analysis based on cross-sectional study in 2022

BACKGROUND

Russia's military aggression against Ukraine set in motion a large number of refugees. Considerable amount of them came and stayed in Czechia. Refugees represent special vulnerable individuals often affected by war physically and psychologically. Due to the national regulations not allowing most of Ukrainian men aged 18-60 to leave the country, nowadays Ukrainian forced migration is relatively young and strongly gendered. Evidence suggests the higher probability for searching the safe refuge abroad among Ukrainian women with small children as well as those with relatively higher economic and cultural capital. The aim of this study is to identify the structural features of systemic risks associated with war migration by examining determinants of self-rated health among forcibly displaced highly educated Ukrainian women of productive age residing in Czechia.

METHODS

Data from one wave of the panel survey among Ukrainian refugees in Czechia conducted in September 2022 was used. Determinants of self-rated health including self-reported diseases and healthcare factors, lifestyle, human and social capital, economic factors, and migration characteristics were analysed using binary logistic regression.

RESULTS

About 45% highly educated Ukrainian women refugees in Czechia assessed their health as poor. The poor self-rated health was mostly associated with the number of diseases and depressive symptoms, and by social capital and economic factors. Having four and more diseases (OR = 13.26; 95%-CI: 5.61-31.35), showing some severe depressive symptoms (OR = 7.20; 95%-CI: 3.95-13.13), experiencing difficulties to seek help from others (OR = 2.25; 95%-CI: 1.20-4.23), living alone in a household (OR = 2.67; 95%-CI: 1.37-5.27), having severe material deprivation (OR = 2.70; 95%-CI: 1.35-5.41) and coming originally from the eastern part of Ukraine (OR = 2.96; 95%-CI: 1.34-6.55) increased the chance of these refugees to assess their health as poor.

CONCLUSION

Social and economic determinants such as lack of social contacts for seeking help and material deprivation were found to be crucial for self-rated health and should be tackled via migration policies. Further, qualitative research is needed to better understand the mechanisms behind the factors affecting subjectively assessed health.

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Evaluation of breastfeeding behaviors and complementary feeding practices of Turkish and Syrian refugee mothers

Objectives: The purpose of this study was to compare breastfeeding and related factors (age, level of education, age at first pregnancy, etc.), and complementary feeding practices between Syrian refugee and native Turkish mothers. Material and methods: This descriptive-comparative study examined the nutritional characteristics of infants aged 9 to 60 months whose mothers were Turkish or Syrian refugees who attended Kızıltepe State Hospital between January 2022 and July 2022. Results: 204 mothers (126 Turkish and 78 Syrian) who had a child aged 9-60 months were included. The average age of the mothers was 27.60 ± 5.17 years for Turkish citizens and 28.91 ± 5.62 for Syrian refugees, without significant difference between the two groups (p: 0.091). Postpartum breastfeeding was 91.3% and breastfeeding duration was 12 (0-24) months in Turkish citizens; in Syrian refugees, breastfeeding was 84.6% and average breastfeeding time was 9 (0- 24) months (respectively, breast milk intake p: 0.144, uptake time p: 0.161; no statistical difference). Breastfeeding training was received by 23.8% of Turkish citizens and 5.1% of Syrian refugees; there was a significant difference between the two groups (p: 0.001). Conclusion: In refugee groups, infant and maternal nutrition practices are disrupted. Working in conjunction with local and international organizations and state agencies that give help to refugee groups, the appropriate interventions, initiatives, supports, and awareness-raising activities would strive to improve practices in mother and baby nutrition and narrow gaps.

The crosstalk between subjective fibromyalgia, mental health symptoms and the use of over-the-counter analgesics in female Syrian refugees: a cross-sectional web-based study

Suboptimal fibromyalgia management with over-the-counter analgesics leads to deteriorated outcomes for pain and mental health symptoms especially in low-income countries hosting refugees. To examine the association between the over-the-counter analgesics and the severity of fibromyalgia, depression, anxiety and PTSD symptoms in a cohort of Syrian refugees. This is a cross-sectional study. Fibromyalgia was assessed using the patient self-report survey for the assessment of fibromyalgia. Depression was measured using the Patient Health Questionnaire-9, insomnia severity was measured using the insomnia severity index (ISI-A), and PTSD was assessed using the Davidson trauma scale (DTS)-DSM-IV. Data were analyzed from 291. Among them, 221 (75.9%) reported using acetaminophen, 79 (27.1%) reported using non-steroidal anti-inflammatory drugs (NSAIDs), and 56 (19.2%) reported receiving a prescription for centrally acting medications (CAMs). Fibromyalgia screening was significantly associated with using NSAIDs (OR 3.03, 95% CI 1.58-5.80, p = 0.001). Severe depression was significantly associated with using NSAIDs (OR 2.07, 95% CI 2.18-3.81, p = 0.02) and CAMs (OR 2.74, 95% CI 1.30-5.76, p = 0.008). Severe insomnia was significantly associated with the use of CAMs (OR 3.90, 95% CI 2.04-5.61, p < 0.001). PTSD symptoms were associated with the use of CAMs (β = 8.99, p = 0.001) and NSAIDs (β = 10.39, p < 0.001). Improper analgesics are associated with poor fibromyalgia and mental health outcomes, prompt awareness efforts are required to address this challenge for the refugees and health care providers.

Refugee women's and providers' perceptions of person-centered maternity care: a qualitative study in two refugee camps in Chad

BACKGROUND

Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual's needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings.

METHODS

We conducted a qualitative study to understand Sudanese refugee women's experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers' perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC.

RESULTS

Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected.

CONCLUSIONS

Despite providers' commitment to offering person-centered care and women's generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

Worcester Refugee Assistance Project: An Example of Strengths-Based, Community-Based, Culturally Sensitive Care

Refugee populations are diverse and can present with a variety of unique and complex circumstances. The purpose of this article is to examine an organization that provides care to refugee youth, the ways in which this is accomplished, and a few of the challenges that have been faced. Specifically, the work of this organization will be examined using a Systems of Care philosophy to demonstrate how using these concepts can assist in providing sensitive, high-quality care.

Prevalence of infectious diseases, immunity to vaccine-preventable diseases and chronic medical conditions among Ukrainian refugees in Germany - A cross sectional study from the German Network University Medicine (NUM)

BACKGROUND

Vulnerability to infectious diseases in refugees is dependent on country of origin, flight routes, and conditions. Information on specific medical needs of different groups of refugees is lacking. We assessed the prevalence of infectious diseases, immunity to vaccine-preventable diseases, and chronic medical conditions in children, adolescents, and adult refugees from Ukraine who arrived in Germany in 2022.

METHODS

Using different media, we recruited Ukrainian refugees at 13 sites between 9-12/2022. An antigen test for acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection, serologies for a range of vaccine-preventable diseases, as well as interferon gamma release assays (IGRAs) for tuberculosis (TB), and SARS-CoV-2 were performed. We assessed personal and family history of chronic medical conditions, infectious diseases, vaccination status, and conditions during migration.

RESULTS

Overall, 1793 refugees (1401 adults and 392 children/adolescents) were included. Most participants were females (n = 1307; 72·3%) and from Eastern or Southern Ukraine. TB IGRA was positive in 13% (n = 184) of the adults and in 2% (n = 7) of the children. Serology-based immunological response was insufficient in approximately 21% (360/1793) of the participants for measles, 32% (572/1793) for diphtheria, and 74% (1289/1793) for hepatitis B.

CONCLUSIONS

We show evidence of low serological response to vaccine-preventable infections and increased LTBI prevalence in Ukrainian refugees. These findings should be integrated into guidelines for screening and treatment of infectious diseases in migrants and refugees in Germany and Europe. Furthermore, low immunity for vaccine-preventable diseases in Ukrainians independent of their refugee status, calls for tailor-made communication efforts.

Love thy (Ukrainian) neighbour: Willingness to help refugees depends on their origin and is mediated by perceptions of similarity and threat

Prejudice and discrimination against minorities can be a powerful tool for populistic and reactionary political movements, and it is therefore crucial to study its determinants. The aim of this research is to develop the understanding of a possible mechanism of such discrimination: cultural distance. In a pre-registered survey experiment with a between-subjects design, we draw on the large increase in intra-European refugee migration from Ukraine, to test whether refugees from another ongoing conflict in (culturally distant) Yemen are treated differently than (culturally similar) Ukrainian refugees by British participants (N = 1545). We measured stated willingness to help and to hire refugees. Moreover, the participants were offered the chance to donate their own earnings from survey participation to real charity drives aimed at the respective refugee groups. Thus, we are able to examine both stated and actual helping behaviours that captured both autonomy- and dependency-oriented forms of helping. As expected, participants were more willing to help, hire and donate money to Ukrainian refugees, and these effects were mediated by higher perceived similarity and lower perceived threat from Ukrainians compared with Yemenis.

Empowerment Transformation Training Reduces Rape Among Girls and Young Women in South Sudan and the Kakuma Refugee Camp

PURPOSE

Rape occurs at high rates in South Sudan and Kakuma refugee camps, a region characterized by armed conflict, gender inequity, and economic crisis. To date, we know little about how to prevent rape in this region of the world. As such, the purpose of this study was to examine outcomes of Empowerment Transformation Training (ETT) (an adapted empowerment self-defense program; empowerment self-defense) among female participants in South Sudan and the Kakuma refugee camp.

METHODS

Schools were assigned to the treatment (ETT) condition (n = 7) or control (life skills) condition (n = 9) and used as the unit of analysis given the cluster-randomized design. Female participants anonymously completed a baseline (T1) and 12-month follow-up (T2) paper and pencil survey.

RESULTS

Annual rape victimization rates decreased from 10.7% to 5.5% in the ETT schools (risk ratio [RR] = 0.51); there was no change in the control schools (10.0%-9.0%). Empowerment Transformation Training (ETT) schools had increased confidence at T2 (T1: 42.4%; T2: 75.4%; RR = 1.79) and greater rates of confidence at T2 compared to control schools (54.3%; RR = 1.39). Knowledge of effective self-defense strategies (T2) was greater for ETT schools (47.4%) compared to control schools (30.1%) (RR = 1.57).

DISCUSSION

The ETT program reduced rates of rape, increased confidence, disclosures of rape (among victims), and knowledge of effective self-defense strategies. Empowerment self-defense programs are a critical component to rape prevention across global communities, including those characterized by armed conflict, gender inequity, and economic crisis.

Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review

PURPOSE

The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes.

DESCRIPTION

Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons.

ASSESSMENT

Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001).

CONCLUSION

Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

Mapping a Way to Displaced Persons' Access to Quality Medicines

Reliable, adequate supply of essential items, including quality-assured medicines, is hard to maintain in refugee camps in low- and middle-income countries. Disruption of medicine supply chains delays treatment for displaced persons and drives procurement of poor-quality products, often from unauthorized or unlicensed sellers. This article explains how current strategies and policies disrupt reliable flow of safe medicines to refugee camps and calls on stakeholders to rigorously map medicine supply chains to refugee camps, which would help identify strategies to improve displaced persons' access to quality-assured medicines.

Wellbeing Outcomes and Risk and Protective Factors for Parents with Migrant and Refugee Backgrounds from the Middle East in the First 1000 Days: A Systematic Review

The First 1000 Days (the period from conception to a child's second birthday) is an important developmental period. However, little is known about experiences of parents with refugee and migrant backgrounds during this period. A systematic review was conducted according to PRISMA guidelines. Publications were identified through searches of the Embase, PsycINFO, PubMed, and Scopus databases, critically appraised, and synthesised using thematic analysis. A total of 35 papers met inclusion criteria. Depressive symptomatology was consistently higher than global averages, however maternal depression conceptualisations differed across studies. Several papers reported changes in relationship dynamics as a result of having a baby post-migration. Consistent relationships were found between social and health support and wellbeing. Conceptualisations of wellbeing may differ among migrant families. Limited understanding of health services and relationships with health providers may impede help-seeking. Several research gaps were identified, particularly in relation to the wellbeing of fathers, and of parents of children over 12 months old.

Assisting refugee survivors of torture and trauma: An existential perspective

Consistent exposure to refugee narratives of trauma and torture can profoundly impact trauma therapists. This secondary analysis reanalyzed data from a narrative inquiry investigating the lived experiences of refugee trauma therapists. We aimed to explore emergent concerns through an existential lens to enrich understanding and provide additional insights into the lived experiences of these individuals. Participants in this purposive sample (N = 19) were therapists who had provided interventions to refugees for 2-34 years. Narrative construction, theory-guided data analysis, and memo writing were used to reanalyze data generated by semistructured interviews augmented by photo elicitation. The findings indicate that being forced to reevaluate familiar beliefs consequent to one's professional roles induced intense existential moments, described as "a dark night of the soul," "the paradox of life and death," "uncanny feelings of not being at home," and "a falling." Acknowledging the complexities of the field, an existential framework to assist refugee trauma therapists in metabolizing and living with the professional challenges they encounter instead of focusing on alleviating decontextualized symptoms of distress is recommended. Research to inform requirements of the space to enable refugee trauma therapists to share their concerns and facilitate transitions toward more authentic, nonevasive sense of "being-in-the-world" is suggested.

COVID-19 vaccination roll-out and uptake among refugees and migrants in Greece: a retrospective analysis of national vaccination routine data

OBJECTIVES

Refugees and migrants (R&Ms) exhibited higher risk of COVID-19 infection, and higher mortality rates during the pandemic. Acknowledging these risks, R&Ms early in the pandemic were identified by WHO as a priority vaccination group in need of protection. The aim of this study was to assess the vaccination roll-out and uptake among R&Ms residing in Reception Identification Centers (RICs) and Reception Sites (RSs) in Greece, relative to the general population.

STUDY DESIGN

Nationwide observational study.

METHODS

Retrospective analysis of national vaccination routine data and population census data, collected and triangulated from multiple official/governmental sources. Weekly vaccine roll-out and uptake were calculated for the general Greek population and the R&M population, through the first year of the vaccination programme in Greece (December 2020-December 2021).

RESULTS

Vaccine roll-out among migrants in RICs/RSs started with a 22-week delay, compared to the general population. By the end of the first year of the vaccination programme in Greece in December 2021, the national vaccination uptake among registered R&Ms residing in official reception facilities was 27.3 % for 1st dose and 4.7 % for booster dose; considerably lower compared to the general population (69.5 % uptake for 1st dose, 64.7 % for 2nd dose, and 32.0 % for 3rd dose).

CONCLUSION

Delayed vaccine roll-out and low vaccine uptake among R&Ms in Greece are signs of low prioritisation and implementation failures in the R&M vaccination strategy. In face of future public health threats, lessons should be learned, and vaccine equity should be insured for all socially vulnerable and high-risk population groups.

[Management Of Covid-19 Pandemic In Shelters For Asylum Seekers: Results From A Mixed Methods Study.]

BACKGROUND

Refugees in Germany are often housed in shelters, where their influence on the organization of everyday life is severely limited. During the COVID-19 pandemic, these shelters therefore had a special responsibility to take measures to protect the health of their residents. The aim of this research project was to examine how this task was managed and how the pandemic affected daily life in refugee shelters, with the aim to formulate recommendations for practice.

METHODS

Using a mixed-methods study, the first step was a scoping review of the literature on the management of infectious disease outbreaks in refugee shelters. Building on the findings of the review, management of the pandemic was then explored in an online survey and in interviews with experts and residents of shelters. In a third step, the results of the preceding steps were summarized and discussed with a panel of experts. Recommendations for practice were developed with the expert panel in two discussion rounds two months apart.

RESULTS

The refugee shelters included in the study were inadequately prepared for the pandemic and often did not develop contingency plans until the pandemic was underway. In many cases, the contingency plans included the establishment of crisis teams, but the interests and perspectives of facility residents were generally not represented by these teams. This subsequently led to problems: Pandemic measures were often not communicated in a timely or sufficiently understandable manner, gaps in care resulting from measures were not identified or addressed, and psychosocial stresses associated with the pandemic and quarantine measures were not adequately mitigated.

CONCLUSION

• Refugee shelters should establish mechanisms to integrate residents' interests and perspectives into decision-making processes in a structured manner, regardless of the pandemic.• Depending on the type of shelter, this should be realized through resident involvement in decision-making bodies or other appropriate representation of interests. • Measures introduced during the pandemic that may have a negative impact on the psychosocial situation of residents should be terminated as soon as the epidemic justification for the measures no longer applies.

'I know you like the back of my hand': biometric practices of humanitarian organisations in international aid

Humanitarian organisations are increasingly utilising biometric data. However, we know little about the extent and scope of this practice, as its benefits and risks have attracted all the attention so far. This paper explores the biometric practices of the United Nations Refugee Agency, the United Nations World Food Programme, the International Committee of the Red Cross, Médecins Sans Frontières, and World Vision International. The study analysed relevant documents published over the past two decades and 17 semi-structured interviews with humanitarian workers conducted between June 2021 and June 2022. The findings reveal that humanitarian organisations use diverse types and functions of biometric data for different services, collaborate with many actors, and employ various data protection measures. Ultimately, challenging the straightforward generalisations about the use of such data, the paper argues that variational applications of biometrics in the humanitarian context require case-by-case analysis, as each instance will likely produce a different outcome.

Unaccompanied Children in the Office of Refugee Resettlement Care

Unaccompanied children entering the United States are cared for in a variety of care provider settings across the country while they are in the custody of the Office of Refugee Resettlement (ORR). While in an ORR care provider program, children receive physical and mental health-care services, classroom education, social skills/recreation services, vocational training as appropriate, family unification services, access to legal support, and case management. The Mental and Behavioral Health Services Team was created in 2019 to provide oversight of the mental health of unaccompanied children in ORR care.

'I thought we would be nourished here': The complexity of nutrition/food and its relationship to mental health among Arab immigrants/refugees in Canada: The CAN-HEAL study

Nutritional psychiatry suggests that diet quality impacts one's mental health (MH). The relationship between food/nutrition and MH may be particularly salient for immigrants/refugees who often experience high risk for household food insecurity and MH challenges. An innovative collaborative community-based participatory research and integrated knowledge translation approach was adopted to explore food/nutrition needs as they relate to MH among Arab immigrants/refuges (AIR) in Ontario, Canada. The goal was to co-identify areas that require social change and co-produce applicable knowledge for service improvement. The CAN-HEAL study used a multi-methodological approach, employing qualitative interviews, photovoice and a questionnaire survey. A combination of three sampling approaches (convenience, snowball and purposive) was used to recruit sixty socio-demographically-diverse adult AIR participants. The research was guided by an integrated bio-psycho-socio-cultural framework. Participants reported various socio-economic and structural barriers to nutritious eating. Food quality/safety was a significant concern and source of anxiety among AIR; food mislabeling, the widespread presence of genetically/chemically modified foods and expired/rotten food products were associated with negative MH. Participants experienced an alarming prevalence of food insecurity (65%), which was associated with negative MH. Intersections among age, gender, religion, socio-economic status, parenthood, disability, and place of residence played a considerable role in how nutrition, food security, and dietary intake impacted AIR's MH and caused substantial disparities within the AIR community. The food/nutrition-MH relationship among AIR is multi-faceted, and various psycho-socio-cultural pathways/processes were found to shape MH. Intersectoral collaboration between health and non-health sectors is needed to implement a co-proposed socio-political and community-level action plan to achieve nutrition and health equity for AIR and other similar marginalized groups.

Status of HIV and comorbidities in refugees with HIV from Ukraine

PURPOSE

To describe the clinical characteristics of refugees with HIV from Ukraine that seek continuation of medical care in Germany.

METHODS

Fourty-six refugees with HIV that had left Ukraine between 24 February and 30 December 2022 were examined. Information on patients' history was obtained using a standardized questionnaire for clinical care. Interviews were conducted in Russian during their first clinical presentation.

RESULTS

Fourty-six persons (41 females and 5 males) were included and their mean age was 39.6 (±8.4) years. The mean time since HIV diagnosis was 8.0 (median, IQR 7.15) years and 70.3% of participants currently received tenfofovir-DF, lamividine and dolutegravir. Most refugees had an undetectable HIV viral load and their current mean CD4 T cell count was 702 (SD ± 289) per μL. Serology revealed previous hepatitis B infection in 50.4% without evidence for replication, with undetectable anti-hepatitis B surface antigen in the remaining refugees. Antibodies against hepatitis C were present in 23 refugees (50%), but only 10 patients had been diagnosed with hepatitis C previously. Five refugees had undergone successful antiviral treatment for hepatitis C. Detectable HCV-RNA was evident in nine patients (19.6%). Sixteen (38.6%) refugees had a positive tuberculosis (TB) interferon gamma release assay, and four were on TB treatment for previously diagnosed infection. One had been diagnosed with multidrug-resistant (MDR) TB, two with pre-extensively drug-resistant (pre-XDR) TB and two with XDR TB and were treated with combinations of second-line and novel agents according to WHO guidelines.

CONCLUSIONS

Based on this preliminary analysis of a not fully representative cohort, refugees with HIV from Ukraine were young, mostly healthy females highly adherent to antiretroviral therapy. The rate of transmittable co-infections urges early diagnostic evaluation and treatment.

Comparison of refugee patients with cystic fibrosis and their counterpart children from Turkey during the war

Since the outbreak of the Syrian civil war in 2011, the population of Arab refugees in Turkey has rapidly increased. While cystic fibrosis (CF) is believed to be rare among Arabs, recent studies suggest it is underdiagnosed. This study aims to present the demographic, clinical, and genetic characteristics of CF patients among Arab refugees in Turkey. Additionally, a comparison is made between the findings in the National CF Registry 2021 in Turkey (NCFRT) and the refugee CF patient group. The study included refugee patients between the ages of 0 and 18 years who were diagnosed with CF and received ongoing care at pediatric pulmonology centers from March 2011 to March 2021. The study examined demographic information, age at diagnosis, age of diagnosis of patients through CF newborn screening (NBS), presenting symptoms, CF transmembrane conductance regulator (CFTR) mutation test results, sputum culture results, weight, height, and body mass index (BMI) z score. Their results were compared with the NCFRT results. The study included 14 pediatric pulmonology centers and 87 patients, consisting of 46 (52.9%) boys and 41 (47.1%) girls. All of the patients were Arab refugees, with 80 (92%) being Syrian. All the patients were diagnosed in Turkey. The median age at diagnosis of patients was 22.33 (interquartile range, 1-258) months. The median age of diagnosis of patients through NBS was 4.2 (interquartile range, 1-12) months. The median age of older patients, who were unable to be included in the NBS program, was 32.3 (interquartile range, 3-258) months. Parental consanguinity was observed in 52 (59.7%) patients. The mutation that was most frequently found was F508del, which accounted for 22.2% of the cases. It was present in 20 patients, constituting 32 out of the total 144 alleles. There was a large number of genetic variations. CFTR genotyping could not be conducted for 12 patients. These patients had high sweat tests, and their genetic mutations could not be determined due to a lack of data. Compared to NCFRT, refugee patients were diagnosed later, and long-term follow-up of refugee CF patients had significantly worse nutritional status and pseudomonas colonization.  Conclusion: Although refugee CF patients have equal access to NBS programs and CF medications as well as Turkish patients, the median age at diagnosis of patients, the median age of diagnosis of patients through NBS, their nutritional status, and Pseudomonas colonization were significantly worse than Turkish patients, which may be related to the difficulties of living in another country and poor living conditions. The high genetic heterogeneity and rare mutations detected in the refugee patient group compared to Turkish patients. Well-programmed NBS programs, thorough genetic studies, and the enhancement of living conditions for refugee patients in the countries they relocate to can have several advantages such as early detection and improved prognosis. What is Known: • Children who have chronic diseases are the group that is most affected by wars. • The outcome gets better with early diagnosis and treatment in patients with Cystic Fibrosis (CF). What is New: • Through the implementation of a newborn screening program, which has never been done in Syria previously, refugee patients, the majority of whom are Syrians were diagnosed with cystic fibrosis within a duration of 4 months. • Despite equal access to the newborn screening program and CF medications for both Turkish patients and refugee patients, the challenges of living in a foreign country have an impact on refugees.

Overcoming denominator problems in refugee settings with fragmented electronic records for health and immigration data: a prediction-based approach

BACKGROUND

Epidemiological studies in refugee settings are often challenged by the denominator problem, i.e. lack of population at risk data. We develop an empirical approach to address this problem by assessing relationships between occupancy data in refugee centres, number of refugee patients in walk-in clinics, and diseases of the digestive system.

METHODS

Individual-level patient data from a primary care surveillance system (PriCarenet) was matched with occupancy data retrieved from immigration authorities. The three relationships were analysed using regression models, considering age, sex, and type of centre. Then predictions for the respective data category not available in each of the relationships were made. Twenty-one German on-site health care facilities in state-level registration and reception centres participated in the study, covering the time period from November 2017 to July 2021.

RESULTS

445 observations ("centre-months") for patient data from electronic health records (EHR, 230 mean walk-in clinics visiting refugee patients per month and centre; standard deviation sd: 202) of a total of 47.617 refugee patients were available, 215 for occupancy data (OCC, mean occupancy of 348 residents, sd: 287), 147 for both (matched), leaving 270 observations without occupancy (EHR-unmatched) and 40 without patient data (OCC-unmatched). The incidence of diseases of the digestive system, using patients as denominators in the different sub-data sets were 9.2% (sd: 5.9) in EHR, 8.8% (sd: 5.1) when matched, 9.6% (sd: 6.4) in EHR- and 12% (sd 2.9) in OCC-unmatched. Using the available or predicted occupancy as denominator yielded average incidence estimates (per centre and month) of 4.7% (sd: 3.2) in matched data, 4.8% (sd: 3.3) in EHR- and 7.4% (sd: 2.7) in OCC-unmatched.

CONCLUSIONS

By modelling the ratio between patient and occupancy numbers in refugee centres depending on sex and age, as well as on the total number of patients or occupancy, the denominator problem in health monitoring systems could be mitigated. The approach helped to estimate the missing component of the denominator, and to compare disease frequency across time and refugee centres more accurately using an empirically grounded prediction of disease frequency based on demographic and centre typology. This avoided over-estimation of disease frequency as opposed to the use of patients as denominators.

Design and implementation of an intensive panel survey with refugees and other migrants in need of protection in Costa Rica

Over the last decade, the global population of refugees and other migrants in need of international protection (MNP) has more than doubled. Despite their rapid growth, panel data collection among MNP remains rare, leaving scholars with few data sources to draw on to understand dynamic changes in their social, economic, legal, or health circumstances. With that paucity in mind, we developed and piloted the Encuesta de Refugiados: Experiencias Sociales y Salud (ERESS), a weekly panel survey conducted with MNP living in Costa Rica. To our knowledge, this panel constitutes one of the first weekly surveys with MNP anywhere in the world. Here, we describe the overall study design, sample recruitment and retention, and key descriptive findings. We show that retaining demographically and socioeconomically diverse MNP in intensive panel surveys is possible and that doing so reveals valuable insights into dynamic changes in their incorporation, family dynamics, and health and wellbeing. By offering a summary of our field experiences and central methodological findings, we highlight the potential benefits and challenges of collecting intensive panel data with MNP, as scholars increasingly seek to understand their pre- and post-migration trajectories and relationships between the two.

Barriers and enabling factors for utilizing physical rehabilitation services by Afghan immigrants and refugees with disabilities in Iran: a qualitative study

INTRODUCTION

Individuals with a migrant background often underutilize physical rehabilitation services (PRS) compared to the host population. This disparity is attributed to various barriers, including limited access to information, language barriers, illiteracy, and cultural factors. To improve PRS utilization by Afghan immigrants and refugees in Iran, it is crucial to identify these barriers and enabling factors. In response, this study explored the barriers and enabling factors for utilizing PRS among Afghan immigrants and refugees with disabilities in Iran.

METHODS

This qualitative study was conducted in Iran between January and March 2023. Participants were selected through convenient and snowball sampling. Individual, semi-structured interviews were carried out both in face-to-face and online formats. Data analysis occurred concurrently with data collection, using the directed content analysis approach.

RESULTS

Findings from our research indicate that common barriers to PRS utilization among Afghan immigrants and refugees include insufficient insurance coverage, high service costs, expensive transportation and accommodation, limited knowledge about Iran's health system, inadequate awareness of available supports, restricted access to PRS in remote areas, impatience among PRS providers, fear of arrest and deportation, a lack of trust in modern treatments, stringent immigration rules, high inflation rates limiting the ability to pay for PRS, and limited social support. On the other hand, several enabling factors were identified, such as strengthening insurance coverage, utilizing the capacities of charities and NGOs, providing information about available services, promoting respectful behavior by healthcare providers towards patients, facilitating cultural integration, and increasing immigrants' awareness of available services and eligibility criteria.

CONCLUSION

The barriers and enabling factors uncovered in this study offer valuable insights into the complexities surrounding PRS utilization by Afghan immigrants and refugees with disabilities in Iran. Understanding and addressing these factors is essential for developing targeted interventions and policies that can improve access and utilization, ultimately leading to enhanced health outcomes for this vulnerable population.

Characterizing Mobility and its Association with HIV Outcomes in Refugee Settlements in Uganda

Background

A better understanding of refugee mobility is needed to optimize HIV care in refugee settlements.

Objectives

We aimed to characterize mobility patterns among people living with HIV in refugee settlements in Uganda and evaluate the association between mobility and retention in HIV care.

Methods

Refugees and Ugandan nationals accessing HIV services at seven health centers in refugee settlements across Uganda, with access to a phone, were recruited and followed for six months. Participants received an intake survey and monthly phone surveys on mobility and HIV. Clinic visit and viral suppression data were extracted from clinic registers. Mobility and HIV data were presented descriptively, and an alluvial plot was generated characterizing mobility for participants' most recent trip. Bivariate Poisson regression models were used to describe the associations between long-term mobility (≥1 continuous month away in the past year) and demographic characteristics, retention (≥1 clinic visit/6 months) and long-term mobility, and retention and general mobility (during any follow-up month: ≥2 trips, travel outside the district or further, or spending >1-2 weeks (8-14 nights) away).

Findings

Mobility data were provided by 479 participants. At baseline, 67 participants (14%) were considered long-term mobile. Male sex was associated with an increased probability of long-term mobility (RR 2.02; 95%CI: 1.30-3.14, p < 0.01). In follow-up, 185 participants (60% of respondents) were considered generally mobile. Reasons for travel included obtaining food or supporting farming activities (45% of trips) and work or trade (33% of trips). Retention in HIV care was found for 417 (87%) participants. Long-term mobility was associated with a 14% (RR 0.86; 95%CI: 0.75-0.98) lower likelihood of retention (p = 0.03).

Conclusions

Refugees and Ugandan nationals accessing HIV care in refugee settlements frequently travel to support their survival needs. Mobility is associated with inferior retention and should be considered in interventions to optimize HIV care.

Measles Outbreak in Lebanon: July 2023

After the beginning of the Syrian crisis, increased rates of infectious diseases were reported. Lebanon, a neighboring country with a major socioeconomic crisis, witnessed a measles outbreak since July 2023, with 519 reported suspected cases. Half of the cases were under 5 y of age, most of them were unvaccinated. The mass displacement of refugees from conflict areas in Syria to Lebanon and the low vaccination coverage have made the situation more challenging. Further efforts are required in Lebanon to address identified gaps to prevent or at least better control future outbreaks.

Covid-19 skepticism and public health norms during refugee assistance: does skepticism always lead to poor safety protocol adherence?

BACKGROUND

Skepticism about COVID-19's existence or severity has spread as fast as the disease itself, and in some populations has been shown to undermine protective public health behaviors that can mitigate infection. For populations that are especially vulnerable to COVID spread and severity, such as refugees, COVID skepticism is particularly problematic.

METHODS

We examine data collected from observations of humanitarian services provided to refugees in Lebanon, Türkiye, and Jordan to determine if skepticism is related to adherence to specific health-protective protocols (masking, social distancing, and hand sanitizing), and whether the effects of COVID skepticism are mediated by particular populations of refugees or the country in which those refugees receive assistance.

RESULTS

We found that community skepticism (the frequency of COVID skepticism expressed by others within a service location) is associated with lower adherence to certain protocols and not others. We also found that with certain protocols, the country in which refugees receive services mediates the relationship between community skepticism and protocol adherence, but for other protocols the relationship between skepticism and adherence is independent of either country in which refugees reside or the refugee population being served.

CONCLUSIONS

The existence of skepticism about COVID-19 does not always lead to an unwillingness to take protective measures to avoid infection. The mechanisms underlying the relationship between skepticism and adherence to health-protective protocols vary based on the type of protocol in question. In order to increase protocol adherence, the specific variables predicting adherence to different protocols need to be assessed in order to increase adherence and improve public health during humanitarian services.

Framework for implementing asylum seekers and refugees' health into the undergraduate medical curriculum in the United Kingdom

The Ukrainian conflict and the increasing number of asylum seekers and refugees (AS&Rs) in the United Kingdom have highlighted the critical need for a dedicated AS&R health curriculum in medical undergraduate programmes. This study utilized a mixed-method approach to assess the current state of AS&R curricula worldwide, identify shortcomings in the UK's medical undergraduate curriculum and determine the specific needs of AS&R. A scoping review of literature revealed an absence of comprehensive AS&R health curricula, with many programmes focusing on broader global health issues. Mapping the General Medical Council's (GMC) Outcomes for Graduates to a UK medical school's learning outcomes uncovered misalignments with AS&R health requirements and an online survey of AS&R charities exposed barriers related to accessibility and knowledge. The study's findings emphasize the importance of introducing or reinforcing specific themes in the medical curriculum, such as clarifying terminology and promoting awareness of AS&R organizations. Employing various teaching methods and continuous assessment are vital to evaluate curriculum effectiveness. The development of an AS&R health curriculum is essential to equip future doctors with the necessary skills and knowledge to provide equitable healthcare to this vulnerable population. The study's findings can serve as a basis for curriculum development and implementation in UK medical schools.