Assessing the contribution of migration related policies to equity in access to healthcare in European countries. A multilevel analysis

Access to good healthcare and the conditions for good health is one of the central dimensions of immigrant integration. National health policies play a major role in equipping residents with the necessary entitlements to accessible and acceptable healthcare services. Rarely analysed so far is the contribution of migration-related health policies to equity in access to healthcare between immigrants and the general population. To address this gap, this study analysed whether the extent to which migration is considered within national health policies moderates the association between immigration status and subjectively perceived unmet medical need in Europe. Using data from the 2019 European Union Statistics on Income and Living Conditions (EU-SILC) survey in combination with the Migration Integration Policy Index (MIPEX) a multilevel analysis was carried out assessing the cross-level interaction between immigration status and MIPEX scores controlling for individual-level factors such as age, gender, education and employment status. While our results showed that immigrants are more likely to report unmet medical need than the general population (adjusted Odds Ratio (aOR) = 1.32; 95% confidence interval (CI) 1.22-1.43), the cross-level interaction indicated increased relative inequality in unmet medical need between immigrants and the general population in countries with high MIPEX scores compared to countries with low MIPEX scores (aOR = 1.39, 95% CI: 1.18-1.63). The main reason for this increase of inequality on the relative scale was the overall lower prevalence of unmet medical need in countries with high MIPEX scores. In conclusion, our findings indicate that even in countries with relatively migration-friendly health policies inequalities in access to healthcare between immigrants and the general population persist.

Family reunion policy for resettled refugees: Governance, challenges and impacts

The past decade has seen renewed efforts to establish resettlement as a durable solution for refugees, both as a protection tool and a mechanism to equitably distribute them among countries. Although the right to a family life is widely recognised as a fundamental human right, whether refugees can arrive with their family or be reunited with family once resettled varies across receiving countries. Little is known about family reunion policies in countries leading the resettlement efforts, and about the impact of these policies on the lives and experiences of resettled refugees. This paper addresses this gap though a systematic scoping review of academic and policy literature on family reunion policies for resettlement refugees, and on the impact of such policy on their lives. Based on a review of 42 papers published between 2010 and 2021, we outline the policies implemented in different receiving countries to enable resettled refugees to reunite with family, documenting at the same time the challenges refugees face in the process, as well as the impact of policy on their experiences. The findings evidence a tension between the refugees' own understanding of family and definitions of family in policy in receiving countries, which often results in family separation or reconfiguration. Additionally, high costs and other administrative barriers, as well as long waiting times associated with family reunification, lead to delayed or denied reunion, having detrimental effects on resettled refugees' well-being in the present and on their future prospects.

Forced Migration, Sexual and Gender-based Violence and Integration: Effects, Risks and Protective Factors

This paper is the first to use empirical evidence to directly examine the relationship between sexual and gender-based violence (SGBV) and multi-dimensional processes of integration of forced migrant SGBV survivors. While it is acknowledged that forced migrants are subjected to a continuum of violence, including SGBV, during the refugee journey, little is known about the long-term impact of SGBV and how it might be mitigated. Our paper, drawing on empirical evidence from 255 interviews with migrants and stakeholders in Australia, the UK, Sweden and Turkey, documented in detail the complex interactions between SGBV and integration using the Indicators of Integration framework. By bringing together the literature on the continuum of violence, SGBV and the Indicators of Integration framework, we identify, on the one hand, the impact of SGBV on integration, and, on the other, how the indicators framework can be used to identify protective and risk factors for forced migrant survivors.

Structural and Symbolic Violence Exacerbates the Risks and Consequences of Sexual and Gender-Based Violence for Forced Migrant Women

While much attention is focused on rape as a weapon of war, evidence shows that forced migrant women and girls face increased risks of Sexual and Gender-Based Violence (SGBV) both during and following forced displacement. In this paper, we argue that gendered forms of structural and symbolic violence enable and compound the harms caused by interpersonal SGBV against forced migrant women and girls. These forms of violence are encountered in multiple contexts, including conflict and post-conflict settings, countries of refuge, and following resettlement. This paper illustrates the consequences of resultant cumulative harms for individuals and communities, and highlights the importance of considering these multiple, intersecting harms for policy and practice.

"We are Forgotten": Forced Migration, Sexual and Gender-Based Violence, and Coronavirus Disease-2019

Adopting a structural violence approach, this article explores, with survivors and practitioners, how early coronavirus disease-2019 pandemic conditions affected forced migrant sexual and gender-based violence survivors’ lives. Introducing a new analytical framework combining violent abandonment, slow violence, and violent uncertainty, we show how interacting forms of structural violence exacerbated by pandemic conditions intensified existing inequalities. Abandonment of survivors by the state increased precarity, making everyday survival more difficult, and intensified prepandemic slow violence, while increased uncertainty heightened survivors’ psychological distress. Structural violence experienced during the pandemic can be conceptualized as part of the continuum of violence against forced migrants, which generates gendered harm.

The violence of uncertainty: Empirical evidence on how asylum waiting time undermines refugee health

The idea of violent uncertainty was first introduced in the New England Journal of Medicine (Grace et al., 2018) making claims about the deleterious impacts of insecure immigration status on the health of migrants. Policies of uncertainty are said to directly and indirectly create harm by impacting on individual's health via detention and public degradation and undermining healthcare services. We offer original empirical evidence indicating an association with uncertainty, in the form of asylum waiting times, on refugees' self-reported health. We devise four hypotheses that: long waiting time for asylum decisions increases likelihood of self-reported health problems and the effect persists overtime, that female refugees report higher levels of health problems resulting from uncertainty and religion moderates the association between health and uncertainty. We use data from the UK longitudinal Survey of New Refugees wherein all new refugees were sent a baseline survey immediately after receiving refugee status and then follow-up surveys 21 months later. The findings show longer asylum waiting time is associated with poor health. Female refugees were more likely to report poor emotional and physical health. The negative effect of asylum waiting time on emotional health persists 21 months post settlement and is worse for women. The hypothesisabout the ameliorating effect of religion is only partially supported. Our findings supports existing theory and qualitative studies about the deleterious effects of using policies of waiting-related uncertainty for managing migration. Given the wide use of such policies in the Global North, our work is suggestive of likely generalisability. Thus, countries with large refugee populations might want to consider our findings when developing asylum policy which minimises impact on refugee health.

A systematic review exploring palliative care for families who are forced migrants

AIMS

To explore the palliative care experiences of forced migrant children, families, and healthcare professionals (HCPs) highlighting successes, challenges, and associated practice implications.

DESIGN

Systematic literature review.

DATA SOURCES

The following search engines were searched from 2008 - 2018: Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health, MEDLINE, Embase, ProQuest, Scopus, Psycinfo, and Web of Science. Extensive reference and citation checking were also conducted.

REVIEW METHODS

Systematic review followed PRISMA guidelines with prepared PROSPERO registered protocol #CRD42019129200. English language qualitative, quantitative, or mixed methods studies were eligible for inclusion. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Eighteen studies (reported in 20 articles) met the final inclusion criteria. Most focused on challenges to care provision. Thematic analysis following methods proposed by Braun and Clarke was undertaken. Five themes were identified: (a) divergence of beliefs and expectations; (b) communication; (c) navigating healthcare systems; (d) burdens and coping strategies; and (e) training and knowledge. A compassionate, collaborative approach with mutual respect crossed themes and was linked to high-quality care.

CONCLUSION

Forced migrant families have multiple needs including physical and emotional support and help in navigating complex systems. Professional interpreters can ease communication barriers when resourced appropriately. Individualized care is crucial to addressing the intricate mosaic of culture such families present. A cultural sensitivity/insensitivity framework is presented that may help guide future interactions and priorities for those working in children's palliative care.

IMPACT

This systematic review explored the international experiences of palliative care for forced migrant families. The findings highlight the plight of families who experience multiple traumas and increased levels of grief and loss through their migration experiences and when caring for a child with a life-limiting condition. This research has potential to have an impact on professionals working with culturally diverse families in all palliative care settings.

Superdiversity, migration and use of internet-based health information - results of a cross-sectional survey conducted in 4 European countries

BACKGROUND

Studies of factors associated with the use of Internet-based health information generally focus on general, rather than migrant populations. This study looked into the reasons why Internet-based health information is used and the effects of migration-related factors, other socio-demographic characteristics and health-related factors on the tendency to consult the Internet.

METHODS

In a cross-sectional survey conducted in eight superdiverse neighbourhoods - two each in Birmingham, United Kingdom; Bremen, Germany; Lisbon, Portugal and Uppsala, Sweden - participants were presented with six scenarios and asked to indicate the resources they most relied on when addressing a health concern from a given list. The scenarios included establishing the underlying causes of a health concern and seeking information about prescription drugs, treatments and services available as part of the public healthcare system. The list of resources included the public healthcare system, alternative medicine, family and friends, and the Internet. Frequencies for which the Internet was consulted for each different scenario were calculated and compared across the participating cities. The association between consulting Internet-based health information and migration-related factors, and further socio-demographic characteristics as well as health-related factors such as self-reported health and health literacy was assessed using multivariable logistic regressions.

RESULTS

Of the 2570 participants from all four cities who were included in the analyses, 47% had a migrant background and 35% originated from non-EU countries. About a third reported relying on Internet-based health information for at least one of the given scenarios. The two most frequently chosen scenarios were to find out about other possible treatments and prescription drugs. Generally, using Internet-based health information was negatively associated with being a first generation migrant (OR 0.65; 95% CI 0.46-0.93), having poor local language competency (OR 0.25; 95% CI 0.14-0.45), older age (≥60 years, OR 0.21; 95% CI 0.15-0.31), low education (OR 0.35; 95% CI 0.24-0.50) and positively associated with low trust in physicians (OR 2.13; 95% CI 1.47-3.10).

CONCLUSION

Our findings indicate the need to consider migration background and language competency when promoting the provision of healthcare services via the Internet so that information and services are widely accessible.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

Healthcare bricolage in Europe's superdiverse neighbourhoods: a mixed methods study

BACKGROUND

Studies of the relationship between diverse populations, healthcare access and health outcomes have been dominated by approaches focusing on ethno-national groups or specific healthcare sectors. Healthcare bricolage conceptualises the processes by which individuals use multiple resources to address health concerns. It is relevant in superdiverse neighbourhoods with complex populations. This paper is original in its application of mixed methods to examine the extent to which, and the reasons why, individuals engage in healthcare bricolage.

METHODS

The study utilized a parallel sequential methodology. Eight superdiverse neighbourhoods were selected, two in each of Bremen, Birmingham, Lisbon and Uppsala. Ethnographic research scoping the nature of each healthcare ecosystem was followed by 160 interviews (20 each neighbourhood) with a maximum variation sample of residents undertaken October 2015 to December 2016. Interviewees were asked to recall a health concern and describe actions taken to attempt resolution. Data was coded with a MAXQDA codebook checked for inter-coder reliability. Interview findings enabled identification of five types of bricolage, the nature of healthcare resources utilised and the factors which influenced residents' tactics. Results were used to design a household survey using new questions and validated epidemiological instruments implemented January to October 2017. Respondents were identified using random address files and interviewed in person or by telephone. Multinomal logistic regressions were used to estimate the effect of changing the values of determinants on the probability of observing an outcome.

RESULTS

Age, gender, level of education, migration background and extent of functional limitation were associated with bricolage tactics. Individuals demonstrating high levels of agency were more likely than those with low levels to engage in bricolage. Residents with high levels of trust in physicians were less likely to bricolage than those with lower levels of trust. Levels of health literacy showed no significant effects.

CONCLUSIONS

The nature and severity of health concern, trust in physicians and agency shaped residents' bricolage tactics. The concept of bricolage enabled us to make visible the actions and resources utilised around public healthcare systems that would otherwise remain outwith healthcare access research. Actions were frequently undertaken via networks offering insights into healthcare-seeking behaviour.

Access to healthcare in superdiverse neighbourhoods

To date little attention has been focused on how the differing features of 'superdiverse' neighbourhoods shape residents' access to healthcare services. Through utilising a cross-national mixed-methods approach, the paper highlights how defining features of superdiverse neighbourhoods - 'newness', 'novelty' and 'diversity' - influence a number of neighbourhood 'domains' and 'rules of access' that regulate access to healthcare. Issues of uncertainty, affordability, compliance, transnationalism and the diversity of community and local sociability are identified as being particularly significant, but which may vary in importance according to the nationality, ethnicity and / or religion of particular individuals.

Experiences of primary care professionals providing healthcare to recently arrived migrants: a qualitative study

OBJECTIVES

The main objectives of the study were to explore the experiences of primary care professionals providing care to recent migrants in a superdiverse city and to elicit barriers and facilitators to meeting migrants' care needs. This paper focuses on a strong emergent theme: participants' descriptions and understandings of creating a fit between patients and practices.

DESIGN

An exploratory, qualitative study based on the thematic analysis of semistructured interviews.

SETTING AND PARTICIPANTS

A purposive sample of 10 practices. We interviewed 6 general practitioners, 5 nurses and 6 administrative staff; those based at the same practice opted to be interviewed together. 10 interviewees were from an ethnic minority background; some discussed their own experiences of migration.

RESULTS

Creating a fit between patients and practice was complex and could be problematic. Some participants defined this in a positive way (reaching out, creating rapport) while others also focused on ways in which patients did not fit in, for example, different expectations or lack of medical records. A small but vocal minority put the responsibility to fit in on to migrant patients. Some participants believed that practice staff and patients sharing a language could contribute to achieving a fit but others outlined the disadvantages of over-reliance on language concordance. A clearly articulated, team-based strategy to create bridges between practice and patients was often seen as preferable.

CONCLUSIONS

Although participants agreed that a fit between patients and practice was desirable, some aimed to adapt to the needs of recently arrived migrants, while others thought that it was the responsibility of migrants to adapt to practice needs; a few viewed migrant patients as a burden to the system. Practices wishing to improve fit might consider developing strategies such as introducing link workers and other 'bridging' people; however, they could also aim to foster a general stance of openness to diversity.

Migrant maternity in an era of superdiversity: New migrants' access to, and experience of, antenatal care in the West Midlands, UK

Rapid increase in the scale, speed and spread of immigration over the past two decades has led to an increase in complexity of populations termed superdiversity. Concerns have been expressed about impacts of the pressure that superdiversity is said to place upon maternity services. High migrant fertility and infant and maternal mortality rates have long been observed in diverse areas with inadequate antenatal monitoring seen as a major causal factor in migrants' maternity outcomes. Using qualitative data from a study of new migrants' access to maternity services in the UK's West Midlands region, with some of the highest infant and maternal mortality rates in Europe, this paper looks at the reasons migrants' access to antenatal care is poor. The paper finds that contrary to earlier studies which pointed to a lack of priority placed on such care by migrants, a combination of structural, legal and institutional barriers prevent migrant women accessing effective antenatal care.

Understanding healthcare practices in superdiverse neighbourhoods and developing the concept of welfare bricolage: Protocol of a cross-national mixed-methods study

Background

Diversity in Europe has both increased and become more complex posing challenges to both national and local welfare state regimes. Evidence indicates specific barriers for migrant, faith and minority ethnic groups when accessing healthcare. However, previous studies of health in diverse cities in European countries have mainly adopted an ethno-national focus. Taking into account the new complexity of diversity within cities, a deeper and multi-faceted understanding of everyday health practices in superdiverse contexts is needed to support appropriate healthcare provision.

Methods/Design

This protocol describes a mixed method study investigating how residents in superdiverse neighbourhoods access healthcare. The study will include participant observation and qualitative interviewing as well as a standardised health survey and will be carried out in eight superdiverse neighbourhoods – with varying deprivations levels and trajectories of change – in four European countries (Germany, Portugal, Sweden and UK). In each neighbourhood, trained polylingual community researchers together with university researchers will map formal and informal provision and infrastructures supportive to health and healthcare. In-depth interviews with residents and healthcare providers in each country will investigate local health-supportive practices. Thematic analysis will be used to identify different types of help-seeking behaviours and support structures across neighbourhoods and countries. Using categories identified from analyses of interview material, a health survey will be set up investigating determinants of access to healthcare. Complex models, such as structural equation modelling, will be applied to analyse commonalities and differences between population groups, neighbourhoods and countries.

Discussion

This study offers the potential to contribute to a deeper understanding of how residents in superdiverse neighbourhoods deal with health and healthcare in everyday practices. The findings will inform governmental authorities, formal and informal healthcare providers how to further refine health services and how to achieve equitable access in diverse population groups.

Migration and maternity in the age of superdiversity

The UK has entered an era of superdiversity with our communities being more diverse than ever before. Migration has contributed to rising birth rates, and poor birth outcomes have been increasingly associated with ethnicity, often in areas with high concentrations of migrants. This article sets out the findings of a study looking at the maternity needs and experiences of migrant women and professionals living in the West Midlands. The study found that migrant women tended to book late or drop out of the maternity system due to a range of barriers including lack of understanding of the system, lack of information, poor language skills and poverty. Migrant women often had negative birth experiences and did not receive the follow on care they needed. Professionals recognised many of the problems migrant women experienced but lacked the time and resources to meet needs. The article concludes by recognising that additional training and time are needed to help professionals to address those needs and signposts the reader to good practice.

A comparison of water turnover in older people in community and institutional settings

BACKGROUND

Maintaining water balance is essential for health, but environmental factors, pathology and the ageing process can adversely affect water homeostasis.

OBJECTIVE

This study examined the relationship between physical dependency and daily water turnover rate in an older population.

DESIGN

Daily water turnover (DWT) was estimated, using deuterium oxide ((2)H(2)O) as a tracer for water, over two separate 7-day periods in summer and winter in two older populations. The independent group (N = 22) lived in their own homes and were self-caring. The dependent group (N = 15) lived in institutional care, and were more physically dependent. None of the subjects had significant mental impairment. Total body water (TBW) and DWT were estimated from the equilibration concentration of ingested (2)H(2)O and its subsequent elimination rate.

RESULTS

The independent group had a median (range) age of 75(69-88) y, a mean Barthel Index (BI) of 19.8, and a mean Abbreviated Mental Test (AMT) score of 9.8. The dependent group were older (83(72-93) y), with a mean BI of 13 and a mean AMT of 9.3. Average median (range) DWT in the independent group was similar in summer (2.2(1.3-3.6) l.d(-1)) and winter (2.1(1.4-3.6) l.d(-1)), but faster than in the dependent group (1.5(0.9-2.9) and 1.6(1.0-2.8) l.d(-1), respectively) during the same two periods. Median urine output in the independent group was similar in summer (1.7(0.8-3.3) l.d(-1)) and winter (1.7(0.9-3.2) l.d(-1)), but greater than in the dependent group (1.1(0.6-2.7) and 0.9(0.5-1.6) l.d(-1), respectively).

CONCLUSION

These results show that the water turnover rate of many older people is low, and that intake may be affected especially in those with physical disability.

First Report of Botryosphaeria rhodina Causing Shoot Blight of Pistachio in California

In the summers of 2000 and 2001, shoot blight was observed in pistachios (Pistacia vera L.) grown in Kern County, California. Black, necrotic lesions developed at the base of shoots originating from contaminated or partially infected buds. Infection moved upward resulting in a progressive wilting and blighting of leaves. Leaf blades on infected shoots withered, and petioles became necrotic. Symptoms have been considered characteristic of infection by Botryosphaeria dothidea (Moug.:Fr.) Ces. & de Not., but this pathogen causes panicle and shoot blight of pistachio (1). However, there were no symptoms of any fruit panicle infections on trees we observed. Isolations on acidified potato dextrose agar from the base of blighted shoots in both years revealed a fast-growing fungus producing pycnidia which was identified as the anamorph Lasiodiplodia theobromae (Pat.) Griffon & Maubl. of B. rhodina Berk. & Curt. Arx. Identification of the pathogen was based on characteristic dark brown, oval pycnidiospores with striations on the surface of the spore along the long axis. Pathogenicity tests were performed on 12 Kerman pistachio trees grown at Kearney Agricultural Center, in Parlier, CA, using three isolates recovered from pistachios grown in two locations. Six to 16 current season shoots of pistachio trees (1 to 2 shoots per tree) were wounded with a 5-mm-diameter cork borer, and a mycelial plug of 5-day-old cultures of B. rhodina was inserted in each wound. Shoots were wrapped with Parafilm to prevent desiccation of inoculum. Six other shoots (one per tree) were inoculated similarly with mycelial agar plugs of a pistachio isolate of B. dothidea and served as positive controls, while six similar shoots were inoculated with only agar plugs and served as negative controls. Wilting of lower leaves in the majority of inoculated shoots started within 4 days for B. rhodina and 7 days for B. dothidea. Depending on the isolate of B. rhodina, 1 to 5 shoots and 50 to 80% of leaves were blighted within 7 days after inoculation. All inoculated shoots were left on the trees until 3 to 4 months after inoculation, pruned and assessed again. For inoculations done in September 2001, 33 to 71% of shoots were blighted, and the rest had cankers ranging from 22.5 to 28 mm long and 13.5 to 23.5 mm wide. A majority (67 to 100%) of shoots had pycnidia of the pathogen present. For inoculations done in October 2001, none of the shoots was blighted, but cankers ranged from 5 to 55.4 mm long and 6 to 22 mm wide and 33.3 to 100% developed pycnidia. B. rhodina was isolated from all inoculated shoots but not from negative controls or those inoculated with B. dothidea. Inoculations of shoots with B. dothidea produced similar symptoms as those of B. rhodina. Shoots that served as negative controls did not develop symptoms. Because panicle and shoot blight of pistachio caused by B. dothidea has developed to epidemic levels in commercial pistachio orchards and is of concern to the pistachio industry in California, it would be of interest to monitor how much shoot blight caused by B. rhodina would eventually develop over the years in commercial pistachio orchards. A survey was initiated in 2002 to determine how widespread B. rhodina is in California pistachios. To our knowledge, this is the first report worldwide of B. rhodina causing shoot blight of pistachio. Reference: (1) T. Michailides. Panicle and shoot blight. Page 68 in: Compendium of Nut Crop Diseases in Temperate Zones. B. L. Teviotdale, T. J. Michailides, and J. W. Pscheidt, eds. American Phytopathological Society, St. Paul, MN 2002.