Nurse education about forced migrants with diverse sexual orientations, gender identities, and gender expressions: An exploratory focus group study

BACKGROUND

In many countries, forced migrants can seek asylum based on persecution and danger related to self-identifying as having diverse sexual orientations, gender identities, and gender expressions; herein defined as lesbian, gay, bisexual, transgender, queer, or other non-heterosexual orientations, non-cisgender identities, gender expressions and/or reproductive development considered beyond cultural, societal or physiological norms. Nurse education has a significant role in promoting cultural competence among future health professionals.

OBJECTIVES

To explore the experiences and views regarding education about forced migrants with diverse sexual orientations, gender identities, and gender expressions, among students and lecturers in nurse education.

DESIGN

Explorative qualitative study with focus group discussions.

SETTINGS

Swedish nursing programs.

PARTICIPANTS

Final-year nursing students and lecturers (n = 25 participants) at nursing programs were recruited with convenience and snowball sampling.

METHODS

Semi-structured digital focus group discussions (n = 9) were audio recorded and transcribed verbatim. Data were analyzed with inductive qualitative content analysis.

RESULTS

Promoting a broader understanding regarding societal structures and preparing students to provide culturally sensitive care were considered as essential components in nurse education. Challenges and problems involved a need for increased awareness, the associated topics and target populations seldom being addressed, and a need for improvements within clinical placements. Participants suggested the utilization of external resources, presented a range of different specific learning activities that would promote in-depth understanding, and articulated a need for overarching decisions and guidelines regarding mandatory inclusion in nurse education.

CONCLUSIONS

Students and lecturers describe several challenges and problems that need to be addressed in regard to forced migration, sexual health, and inclusion health. There seems to be a need for utilization of external competence in learning activities as well as establishing clearer guidelines, which may increase the quality of education and better prepare future nurses to support patients with diverse backgrounds and identities.

Inequality by design: The politics behind forced migrants' access to healthcare

When a system comes under strain, the persons most likely to suffer from the repercussions are those at and beyond its margins, as the age-old rule 'Help yourself before helping others' typically guides crisis management within the system. Similar behavioural patterns on the side of policy-makers have left a distinct mark on the healthcare rights of forced migrants in the context and aftermath of the so-called 'migration crisis' of 2015-2016, as this article demonstrates. Following the crisis, this group of persons, who are traditionally situated at the margins of society already, have been pushed further outside social and healthcare systems through increasingly restrictive incorporation policies across Europe. By analysing recent legislative reforms in four countries (Germany, Italy, Sweden, and the UK) which stood out in various ways during the crisis, this article sheds light on the increasing politicisation and polarisation of the intersection of incorporation and healthcare. It shows that the crisis induced similar responses of legal adaptation in countries with fundamentally different healthcare and incorporation systems, and analyses the dynamics behind such processes of change. The article thereby contributes to a better understanding of healthcare legislation as a reflection of political opposition to or acceptance (if not fuelling) of societal inequalities.

"Better than having no evaluation done": a pilot project to conduct remote asylum evaluations for clients in a migrant encampment in Mexico

Background

Asylum evaluations are highly specialized medico-legal encounters to collect physical or mental health evidence for use in immigration proceedings. Although the field of asylum medicine is growing, access to these evaluations is still inadequate, particularly for those in United States immigration detention or other forms of custody, such as under the U.S. Migrant Protection Protocols or “Remain in Mexico” policy. Given advances in telehealth in recent years and growing evidence of similar outcomes with in-person management, it seems prudent to examine whether remote modalities may also be effective for conducting mental health asylum evaluations in hard-to-reach populations.

Methods

We analyzed the responses of 12 U.S. clinicians who conducted 25 cross-border remote mental health evaluations with clients in Mexico prior to the COVID-19 pandemic, and completed a post-evaluation survey regarding their impressions and experiences of the remote encounter. Data were coded through a process of thematic analysis.

Results

The average evaluation time was 2.3 h, slightly shorter than might be expected from an in-person encounter. Five themes emerged from the coding process: rapport building, achieving overall goal, comparison of in-person vs. remote, technical issues, and coordination. Clinicians encountered a number of challenges including technical difficulties and a decreased ability to establish rapport. Nearly uniformly, however, clinicians noted that despite difficulties, they were able achieve the goals of the evaluation, including rapport building and diagnosis.

Conclusion

Remote evaluations appear to achieve their intended goal and may be useful in expanding legal options for hard-to-reach asylum seekers.

Everyday life experiences and mental health among conflict-affected forced migrants: A meta-analysis

BACKGROUND

There are a growing number of forced migrants worldwide. Early detection of poor adjustment and interventions to facilitate positive adaptation within these communities is a critical global public health priority. A growing literature points to challenges within the post-migration context as key determents of poor mental health.

AIMS

The current meta-analysis evaluated the association between daily stressors and poor mental health among these populations.

METHOD

A systematic search in PsycINFO, PubMed, and Web of Science identified relevant studies from inception until the end of 2018. Effect sizes (correlation coefficients) were pooled using Fisher's Z transformation and reported with 95% confidence intervals. Moderator and mediator analyses were conducted. The protocol is available in PROSPERO [CRD42018081207].

RESULTS

Analysis of 59 eligible studies (n = 17,763) revealed that daily stressors were associated with higher psychiatric symptoms (Zr=0.126-0.199, 95% CI=0.084-0.168, 0.151-0.247, p<0.001) and general distress (Zr=0.542, 95% CI=0.332-0.752, p<0.001). Stronger effect sizes were observed for mixed daily stressors relative to subjective, interpersonal, and material daily stressors, and for general distress relative to posttraumatic stress symptoms and general well-being. Effect sizes were also stronger for children and adolescents relative to adults. Daily stressors fully mediated the associations of prior trauma with post-migration anxiety, depressive, and post-traumatic stress disorder symptoms.

CONCLUSIONS

This meta-analysis provides a synthesis of existing research on the role of unfavorable everyday life experiences and their associations with poor mental health among conflict-affected forced migrants. Routine assessment and intervention to reduce daily stressors can prevent and reduce psychiatric morbidity in these populations.

Acculturation and mental health among adult forced migrants: a meta-narrative systematic review protocol

BACKGROUND

The global refugee crisis has become central to health and policy debates. There is a growing need to investigate how acculturation impacts mental health among asylum seekers and refugees. Many forced migrants have an increased risk of experiencing negative mental health outcomes, but this review will only assess the current literature on acculturation and mental health among adults. Research questions include the following: (1) How is acculturation conceptualised? (2) What are the most salient mental health outcomes? (3) How are acculturation and mental health measured and related? and (4) How do macrostructural factors affect the relationship between mental health and acculturation?

METHODS

We will use a meta-narrative approach to synthesise the breadth of acculturation and mental health literature from various research traditions. This review will include empirical studies measuring variations of acculturation and mental health among adult forced migrants from low- and middle-income countries residing in high-income countries. Studies will be retrieved from the following academic databases: MEDLINE, Embase, PsycINFO, Global Health, ProQuest Social Science and Web of Science. Additional studies will be collected from King's College London's online library databases and e-resources, and reference lists of eligible studies. Studies from database inception and written in English will be included. All full-text papers will undergo quality appraisal using the Mixed Methods Appraisal Tool (MMAT). Extracted data will be analysed using a conceptual framework analysis to construct overarching narratives and a framework that will describe the relationship between acculturation and mental health.

DISCUSSION

A meta-narrative systematic review provides a flexible and systematic approach to synthesising the heterogeneous literature on acculturation and mental health. This review will guide the development of a conceptual framework to aid future research on acculturation among adult forced migrants. As high-income countries seek to integrate forced migrants into society and improve their access to vital resources, this review has the potential to transform policies and practices that influence migrant mental health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018089148.

Forced migrants involved in setting the agenda and designing research to reduce impacts of complex emergencies: combining Swarm with patient and public involvement

PLAIN ENGLISH SUMMARY

The UK's National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response was asked to undertake research on how to reduce the impact of complex national/international emergencies on public health. How to focus the research and decide on priority topics was challenging, given the nature of complex events. Using a type of structured brain-storming, the researchers identified the ongoing UK, European and international migration crisis as both complex and worthy of deeper research. To further focus the research, two representatives of forced migrant communities were invited to join the project team as patient and public (PPI) representatives. They attended regular project meetings, insightfully contributed to and advised on practical aspects of potential research areas. The representatives identified cultural obstacles and community needs and helped choose the final research study design, which was to interview forced migrants about their strategies to build emotional resilience and prevent mental illness. The representatives also helped design recruitment documents, and undertake recruitment and interviewer training.

BACKGROUND

Many events with wide-ranging negative health impacts are notable for complexity: lack of predictability, non-linear feedback mechanisms and unexpected consequences. A multi-disciplinary research team was tasked with reducing the public health impacts from complex events, but without a pre-specified topic area or research design. This report describes using patient and public involvement within an adaptable but structured development process to set research objectives and aspects of implementation.

METHODS

An agile adaptive development approach, sometimes described as swarm, was used to identify possible research areas. Swarm is meant to quickly identify strengths and weaknesses of any candidate project, to accelerate early failure before resources are invested. When aspects of the European migration crisis were identified as a potential priority topic area, two representatives of forced migrant communities were recruited to explore possible research ideas. These representatives helped set the specific research objectives and advised on aspects of implementation, still within the swarm framework for project development.

RESULTS

Over ten months, many research ideas were considered by the collaborative working group in a series of six group meetings, supplemented by email contact in between. Up to four possible research ideas were scrutinised at any one meeting, with a focus on identifying practical or desirable aspects of each proposed project. Interest settled on a study to solicit original data about successful strategies that forced migrants use to adapt to life in the UK, with an emphasis on successfully promoting resilience and minimizing emotional distress. "Success in resettlement" was identified to be a more novel theme than "barriers to adaption" research. A success approach encourages participation when individuals may find discussion of mental illness stigmatising. The patient representatives helped with design of patient-facing and interview training materials, interviewer training (mock interviews), and aspects of the recruitment.

CONCLUSION

Using patient and public involvement (PPI) within an early failure development approach that itself arises from theory on complex adaptive systems, we successfully implemented a dynamic development process to determine research topic and study design. The PPI representatives were closely involved in setting research objectives and aspects of implementation.

Social factors ameliorate psychiatric disorders in community-based asylum seekers independent of visa status

The impact of industrialised host nations' deterrent immigration policies on the mental health of forced migrants has not been well characterised. The present study investigated the impact of Australia's refugee determination process (RDP) on psychiatric morbidity in community-based asylum-seekers (AS) and refugees. Psychiatric morbidity was predicted to be greater in AS than refugees, and to persist or increase as a function of time in the RDP. The effect on mental health of demographic and socio-political factors such as health cover and work rights were also investigated. Psychiatric morbidity was measured prospectively on five mental health indices at baseline (T1, n=131) and an average of 15.7 months later (T2, n=56). Psychiatric morbidity in AS significantly decreased between time points such that it was no longer greater than that of refugees at T2. Caseness of PTSD and demoralisation reduced in AS who gained protection; however, those who maintained asylum-seeker status at T2 also had a significant reduction in PTS and depression symptom severity. Reduced PTS and demoralisation symptoms were associated with securing work rights and health cover. Living in the community with work rights and access to health cover significantly improves psychiatric symptoms in forced migrants irrespective of their protection status.

The lower quality of preventive care among forced migrants in a country with universal healthcare coverage

OBJECTIVE

To assess the association between socio-demographic factors and the quality of preventive care and chronic care of cardiovascular (CV) risk factors in a country with universal health care coverage.

METHODS

Our retrospective cohort assessed a random sample of 966 patients aged 50-80years followed over 2years (2005-2006) in 4 Swiss university primary care settings (Basel/Geneva/Lausanne/Zürich). We used RAND's Quality Assessment Tools indicators and examined recommended preventive care among different socio-demographic subgroups.

RESULTS

Overall patients received 69.6% of recommended preventive care. Preventive care indicators were more likely to be met among men (72.8% vs. 65.4%; p<0.001), younger patients (from 71.0% at 50-59years to 66.7% at 70-80years, p for trend=0.03) and Swiss patients (71.1% vs. 62.7% in forced migrants; p=0.001). This latter difference remained in multivariate analysis adjusted for gender, age, civil status and occupation (OR 0.68; 95% CI 0.54-0.86). Forced migrants had lower scores for physical examination and breast and colon cancer screening (all p≤0.02). No major differences were seen for chronic care of CV risk factors.

CONCLUSION

Despite universal healthcare coverage, forced migrants receive less preventive care than Swiss patients in university primary care settings. Greater attention should be paid to forced migrants for preventive care.