[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

Posttraumatic stress among refugees: The moderating effect of perceived social support

Objective

Social support has been associated with the mental health of refugees. However, little is known about the characteristics and effects of social support in this group. The aim of this study was to investigate the protective role of social support, specifically through the perceived opportunity to confide in someone. We hypothesized that the opportunity to confide would have a moderating influence on the dose-effect relationship between trauma exposure and PTSD symptoms.

Methods

Clinical face-to-face interviews were conducted with 65 adult refugees who were living in the north-east of North Rhine-Westphalia. Interpreters (Arabic, Farsi, Kurmancî) were present if necessary. Interviews included a detailed assessment of traumatic event types, PTSD symptoms (assessed via the PTSD Checklist for DSM-5 (PCL-5)), and social support experienced by the participants.

Results

The multiple hierarchical regression analysis revealed a significant moderation of the perceived opportunity to confide on the association of number of traumatic event types reported and PTSD symptomatology. For refugees with limited trauma exposure, opportunity to confide was associated with lower PTSD symptoms. Most confidants were located within the countries of reception, while contacts in the home countries were less often identified as protective.

Conclusions

Social support, in particular the opportunity to confide, seems to act as a buffering factor up to a certain number of experienced traumatic event types. Specialized interventions may be necessary for people with a high trauma load and / or high symptom level.

Special needs of refugees with substance use disorders from conflict-affected countries: a comparison with German-born individuals

BACKGROUND

Refugees seem to be at enhanced risk for substance use disorders. At the same time, they have less access to services and their health needs remain poorly understood. This study aims to evaluate the specific needs of refugees as compared to German-born individuals seeking help for substance use disorders.

METHODS

We conducted an observational case-control study using all treatment episodes in outpatient addiction facilities in three German federal states during the year 2020. A total of 719 refugee clients were matched to 713 German-born individuals using propensity score matching. We compared potential needs related to features of substance use as well as different psychosocial areas.

RESULTS

The final sample of refugees was composed of n = 384 (26.8%) cases from Afghanistan, n = 214 (14.9%) from Syria and n = 121 (8.4%) from Iraq. Clients consulted mostly due to cannabis use (44.8%) or opioid use (20.1%). Intravenous use of drugs and needle sharing was significantly lower in refugees (p < 0.05). A higher proportion of refugees than Germans lived in provisional housing, were unemployed or in charge of minor children (p < 0.05). Mental and physical comorbidities were significantly higher in refugees (p < 0.05). They were also more likely to have been victims of violence and less likely to present violent behaviors.

CONCLUSION

Refugees with substance use disorders differ regarding a spectrum of psychosocial issues from German-born individuals. This highlights the need to link addiction treatment with other parts of the health care and psychosocial support systems to provide adequate care for this group.

Experiences and concerns of pregnant refugee women from Nigeria seeking for asylum in Germany - A qualitative analysis

PROBLEM

Insights into and data of the experiences of pregnant women seeking asylum in Germany are largely lacking.

BACKGROUND

Due to multiple stress factors, pregnant refugees are considered a vulnerable group. Gender-specific causes of flight, traumatic experiences during flight, and numerous stressors in the respective host country have a decisive impact on the health of women and affect pregnancy and childbirth.

AIM

This study aims to assess the perspectives and needs of pregnant refugee women from Nigeria, that are residing in an initial reception center in Germany.

METHODS

Experiences and concerns of N = 20 pregnant refugee women from Nigeria relating to pregnancy and impending childbirth were assessed in semi-structured interviews, conducted by three psychologists in English.

FINDINGS

Findings emphasize the need for continuous medical and psychotherapeutic care due to the multiple stressors and the partial lack of social support, especially for single women. The participants described their concerns particularly related to their personal and their family's health, as well as their impending birth, their optimistic attitude about the parenting experience, and confidence in medical care in Germany. Their wishes were predominantly related to items necessary for the care of their children, information about the pregnancy and birth process as well as for their integration. Utilization of resources and positive activities were indicative of adapting coping styles and resilience factors of pregnant refugee women.

CONCLUSION

This study highlights the importance of the context-sensitive medical and psychotherapeutic care to adequately support the women during pregnancy and around childbirth. Furthermore, the study demonstrates the necessity of counteracting the negative effects of experiences on their health and that of their children.

[Global Change in Psychotherapy: Influences of Current Social Change on Mental Health and Therapy]

Global change affects both individual life situations and social coexistence in a variety of ways. However, the effects of social events on mental illness and psychotherapy are only recorded and included in psychotherapy research in individual areas. The aim of this study is to explore current problems and concerns of patients in Germany on the basis of practical experience reports, to collect possible social causes and to bundle considerations for therapeutic treatment. To this end, psychotherapists (n=10) and psychotherapy patients (n=12) were interviewed in qualitative interviews and these were analyzed using grounded theory. After evaluating the collected perspectives, five main effects of current social events and the consequences of globalization were identified. From the perspectives of psychotherapists and patients, these include increasing anxiety about the future, decreasing social inclusion, increased questions about goals and identity as a concern for psychotherapy, increased psychological stress as a result of political divide and an increased demand for diversity-sensitive psychotherapy. In addition to expanding the scope of action, therapeutic approaches primarily include providing contact, guidance, orientation, emotional support and bonding experiences. The inclusion of knowledge from psychotherapists and patients as well as findings from social science can be helpful for identifying current problems and developing new therapeutic approaches or bundling, linking, and effectively using existing ones.

Healthcare provision for displaced people in transit: Analyses of routinely collected data from INTERSOS clinics at the Ukrainian border with Moldova and Poland

Background

The Russian military invasion of Ukraine has sparked Europe's largest forced displacement since World War II, bringing about significant health vulnerabilities for migrants and refugees. European health information systems lack comprehensive data coverage, especially in underrepresented migration stages like transit. This study aims to address this gap by analyzing data from INTERSOS clinics at the Moldovan and Polish borders with Ukraine to identify the common health conditions prompting people to seek healthcare services during transit.

Methods

From 6th March to 31st May 2022, this cross-sectional study observed migrants and refugees receiving INTERSOS services at two mobile clinics in Moldova, and a facility in Poland. We analyzed data by age, sex, nationality, and reported disease frequencies and care provided.

Results

This study used routinely collected data from 1756 patients. The majority of the adult population seeking healthcare were females (76.5 %), 26.1 % were children and 18.7 % were older individuals. Noncommunicable diseases (NCDs) were the primary reason for seeking healthcare at these clinics, with 23.3 % of the study population being diagnosed with at least one chronic disease, and 3.4 % of people having multimorbidity. Mental and behavioural disorders were diagnosed in 12.6 % of the population, and somatoform disorders and related stress (F40-F48) in 10.8 %.

Discussion

Our study indicates the diversity of forcibly displaced populations and the corresponding diversity of their healthcare needs. In the shadow of a forced displacement crises triggered by the conflict in Ukraine, there is an urgent need to give more attention to subgroups of the population that are often neglected in humanitarian crises. These include older adults, females, and ethnic minorities. Additional attention should also be given to NCDs and sexual and reproductive health (SRH) care needs, especially given the high numbers of older adults and females in this population. Early medical support, psychological first aid and interventions in transit centers that promote survivor resilience and recovery are required.

Conclusion

Our findings shed light on the healthcare needs of forcibly displaced populations during transit, a stage often overlooked in migration health research. They underscore the diverse healthcare needs of forcibly displaced populations, emphasizing the necessity for humanitarian aid programs to acknowledge and address this diversity. Accessing data on displaced populations' healthcare needs in transit can help the preparing and planning of healthcare services for these populations in host or destination countries. Ensuring objective anonymization and preventing patient re-identification are essential, particularly in safeguarding refugee privacy and data protection to avoid the misuse of their data.

Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening

Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.

Seasonal patterns of communicable disease incidence and antibiotic prescribing in Moria refugee camp, Greece

BACKGROUND

Infectious diseases remain a major risk for refugees living in camps. Limited research has been undertaken into the burden and impact of infections in the current refugee crisis around the Mediterranean.This analysis examines the frequency and incidence rates of common infections, and use of antibiotics at a healthcare facility inside Moria refugee camp on the island of Lesvos, Greece, during the winter and summer seasons of 2019.

METHODS

This is a retrospective analysis of routinely, prospectively collected service data from the main acute healthcare facility inside Moria camp.

RESULTS

Of a total of 9601 consultations, 25.16% were for infections (winter: 31.53%, summer: 19.45%). Respiratory, skin and gastrointestinal infections were the most frequent, with incidence rates up to 3.5 times, 50 times and twice as high as those in Western Europe, respectively. Antibiotic prescribing was high (27.7% of all respiratory infections) with high use of broad-spectrum antibiotics (40.2%), raising concerns about induction of antimicrobial resistance.

CONCLUSIONS

The burden of infectious diseases in refugee camps remains high throughout all seasons. Antimicrobial stewardship programmes should be adapted to refugee camp settings to prevent the development of unnecessary antimicrobial resistance. Improving living conditions and access to healthcare in refugee camps is likely to reduce infection rates and antimicrobial resistance among refugees.

Exploring contextual effects of post-migration housing environment on mental health of asylum seekers and refugees: A cross-sectional, population-based, multi-level analysis in a German federal state

Asylum seekers and refugees (ASR) in Germany are dispersed quasi-randomly to state-provided, collective accommodation centres. We aimed to analyse contextual effects of post-migration housing environment on their mental health. We drew a balanced random sample of 54 from 1 938 accommodation centres with 70 634 ASR in Germany's 3rd largest federal state. Individual-level data on depression and anxiety as well as sociodemographic- and asylum-related covariates, were collected and linked to contextual geo-referenced data on housing environment ('Small-area Housing Environment Deterioration' index, number of residents, remoteness, urbanity, and German Index of Multiple Deprivation). We fitted two-level random-intercept models to exploratively estimate adjusted contextual effects. Of 411 surveyed participants, 45.53% and 44.83%, respectively, reported symptoms of depression or anxiety. 52.8% lived in centres with highest deterioration, 46.2% in centres with > = 50 residents, 76.9% in urban, and 56% in deprived districts. 7.4% of centres were remote. We found statistically significant clustering in reporting anxiety on the level of accommodation centres. The model resulted in an intraclass correlation of 0.16 which translated into a median odds ratio of 2.10 for the accommodation-level effects. No significant clustering was found for symptoms of depression. The highest degree of deterioration, large accommodation size, remoteness, and district urbanity showed higher, but statistically not significant, odds for reporting anxiety or depression. District deprivation demonstrated higher odds for anxiety and lower odds for depression yet remained statistically insignificant for both. Evidence for contextual effects of housing environment on mental health of ASR could not be established but residual confounding by length of stay in the accommodation centre cannot be ruled out. Confirmatory analyses with prior power calculations are needed to complement these exploratory estimates.

The burden of substance use and (mental) distress among asylum seekers: a cross sectional study

Background

Asylum seekers are a particularly vulnerable population due to a wide range of external stressors. Traumatic events and difficult social/economic prospects can lead to an elevated susceptibility for substance use disorders. The aim of the present study was to determine whether asylum seekers suffering from mental or physical distress present higher levels of substance use disorder (SUD) in a state reception center in Germany and whether there are identifiable risk or protective factors.

Methods

We performed a hierarchical logistic regression on data of N = 238 people who had applied for asylum in Germany to analyze the SUD variance explanation by (1) sociodemographic, (2) flight-specific, and (3) psychometric (ERQ, SOC-9 L, SCL-K9) variables. On level (4), we included the location of data collection (walk-in clinic or accommodation,) as an indicator of individual's need for a psychologist's or General practitioner's help in order to assess for the participant's (mental) distress.

Results

Low educational level, lower sense of coherence, and mental distress (location of data collection in the psychosocial or general medical outpatient clinic) were associated with SUD. Those suffering from SUD seemed to be less aware of external stressors as SUD was also associated with low levels of reported post-migratory stress.

Discussion

The association of SUD with psychological distress and lower education reaffirms the concept that some vulnerable groups are at a higher risk for substance-related difficulties. Strengthening the sense of coherence with targeted interventions might enable at-risk groups to cope better with forthcoming burdens and help with abstaining from current or future consumption.

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

[Experiences of people with refugee backgrounds in utilising healthcare in Germany-findings from a qualitative study]

BACKGROUND

Refugees and asylum seekers face a variety of legal, structural, administrative, cultural and linguistic barriers in accessing healthcare. However, there is currently a lack of available data on the health needs of refugees and asylum seekers. In particular, their subjective experience in accessing healthcare has not been considered sufficiently.

AIM OF THE STUDY

This paper explores the subjective experiences of refugees and asylum seekers in accessing and using healthcare. Strategies for dealing with potential challenges are presented.

METHODS

The recruitment of interview partners was based on a quantitative cross-sectional study collected as part of a study on the health of refugees (FlüGe health study). Persons who agreed to be contacted again were contacted by telephone. A heterogeneous sub-sample (n = 18) with regard to age, gender, nationality, health status and utilisation behaviour was interviewed using interpreter-supported problem-centred interviews. Data were analysed using a deductive-inductive approach.

RESULTS AND DISCUSSION

The migration-insensitive healthcare for refugees and asylum seekers is characterised by language barriers, disorientation, experiences of rejection, mistreatment and structural barriers. Experiences of foreignness in the healthcare system can lead to delayed care seeking or underusage of healthcare systems. At the same time, individual strategies by refugees, asylum seekers and healthcare providers are used in order to meet these challenges.

Patient-centredness in primary care walk-in clinics for refugees in Hamburg

BACKGROUND

The huge increase of refugees to Germany caused a great challenge to the health system. We aimed to examine the level of patient-centredness in medical consultations with refugee patients, aided by video interpreters in primary care walk-in clinics (PCWC) in Hamburg.

METHODS

Videotaped consultations (N = 92) of 83 patients from 2017 to 2018 were analysed. Two raters used the Measure of Patient-Centered Communication (MPCC) and the International Classification of primary care (ICPC-2). MPCC scores with regard to patients' reason for seeking medical care and the procedures taken were explored using variance analyses adjusted for age, gender, and the duration of the consultation. The duration was further explored by Pearson correlations.

RESULTS

Patient-centredness of all consultations on average was 64% (95% CI 60-67) according to MPCC, with health-related issues affecting the results. The highest level of patient-centredness was achieved in psychological health issues with 79% (65-94), the lowest in respiratory ones with 55% (49-61). Longer consultations resulted in higher MPCC scores.

CONCLUSIONS

The level of patient-centredness varied in the addressed health issues as well as in the duration of the consultation. Despite the variation, video interpreting in consultations supports a solid patient-centredness.

PRACTICE IMPLICATIONS

We recommend the use of remote video interpreting services for outpatient healthcare to support patient-centred communication and to fill the gap of underrepresentation of qualified interpreters on site, regarding a high diversity of spoken languages.

German Health Update Fokus (GEDA Fokus) among Residents with Croatian, Italian, Polish, Syrian, or Turkish Citizenship in Germany: Protocol for a Multilingual Mixed-Mode Interview Survey

BACKGROUND

Germany has a long history of migration. In 2020, more than 1 person in every 4 people had a statistically defined, so-called migration background in Germany, meaning that the person or at least one of their parents was born with a citizenship other than German citizenship. People with a history of migration are not represented proportionately to the population within public health monitoring at the Robert Koch Institute, thus impeding differentiated analyses of migration and health. To develop strategies for improving the inclusion of people with a history of migration in health surveys, we conducted a feasibility study in 2018. The lessons learned were implemented in the health interview survey German Health Update (Gesundheit in Deutschland aktuell [GEDA]) Fokus, which was conducted among people with selected citizenships representing the major migrant groups in Germany.

OBJECTIVE

GEDA Fokus aimed to collect comprehensive data on the health status and social, migration-related, and structural factors among people with selected citizenships to enable differentiated explanations of the associations between migration-related aspects and their impact on migrant health.

METHODS

GEDA Fokus is an interview survey among people with Croatian, Italian, Polish, Syrian, or Turkish citizenship living in Germany aged 18-79 years, with a targeted sample size of 1200 participants per group. The gross sample of 33,436 people was drawn from the residents' registration offices of 99 German municipalities based on citizenship. Sequentially, multiple modes of administration were offered. The questionnaire was available for self-administration (web-based and paper-based); in larger municipalities, personal or phone interviews were possible later on. Study documents and the questionnaire were bilingual-in German and the respective translation language depending on the citizenship. Data were collected from November 2021 to May 2022.

RESULTS

Overall, 6038 respondents participated in the survey, of whom 2983 (49.4%) were female. The median age was 39 years; the median duration of residence in Germany was 10 years, with 19.69% (1189/6038) of the sample being born in Germany. The overall response rate was 18.4% (American Association for Public Opinion Research [AAPOR] response rate 1) and was 6.8% higher in the municipalities where personal interviews were offered (19.3% vs 12.5%). Overall, 78.12% (4717/6038) of the participants self-administered the questionnaire, whereas 21.88% (1321/6038) took part in personal interviews. In total, 41.85% (2527/6038) of the participants answered the questionnaire in the German language only, 16.69% (1008/6038) exclusively used the translation.

CONCLUSIONS

Offering different modes of administration, as well as multiple study languages, enabled us to recruit a heterogeneous sample of people with a history of migration. The data collected will allow differentiated analyses of the role and interplay of migration-related and social determinants of health and their impact on the health status of people with selected citizenships.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43503.

The patient journey of newly arrived asylum seekers and responsiveness of care: A qualitative study in Germany

Background

Research on health and healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness, as non-medical quality of care, in the narratives of ASR patients recently arrived in Germany.

Methods

31 ASR with existing medical conditions were recruited in six refugee reception centres and three psychosocial centres. Semi-structured, qualitative interviews were conducted which reconstructed their patient journey after arrival in Germany. Interviews were recorded, transcribed verbatim and evaluated using thematic analysis.

Results

The experiences of participants throughout the patient journey provided a rich and varied description of the responsiveness of health services. Some dimensions of responsiveness, including respectful treatment, clear communication and trust, resurfaced throughout the narratives. These factors were prominent reasons for positive evaluations of the health system, and negative experiences were reported in their absence. Other dimensions, including cleanliness of facilities, autonomy of decision-making and choice of provider were raised seldomly. Positive experiences in Germany were often set in contrast to negative experiences in the participants’ countries of origin or during transit. Furthermore, many participants evaluated their experience with healthcare services in terms of the perceived technical quality of medical care rather than with reference to responsiveness.

Conclusion

This qualitative study among ASR analysed patient experiences to better understand responsiveness of care for this population. While our results show high overall satisfaction with health services in Germany, using the lens of responsiveness allowed us to identify particular policy areas where care can be strengthened further. These include in particular the expansion of high-quality interpreting services, provision of professional training to increase the competency of healthcare staff in caring for a diverse patient population, as well as an alignment between healthcare and asylum processes to promote continuity of care.

[Mental Health Screening of Syrian Refugees in Germany: The Refugee Health Screener]

Mental Health Screening of Syrian Refugees in Germany: The Refugee Health Screener Objectives: This study investigated the psychometric properties of the time-efficient Refugee Health Screener (RHS-13 and RHS-15) for assessing mental disorders among Syrian refugees in Germany. Methods: The RHS-15 was compared with benchmark screeners on psychological distress such as depression, anxiety, somatisation and post-traumatic stress symptoms and its diagnostic quality was assessed using appropriate methods (e. g. ROC-analyses). Results: Participants were 116 Syrian refugees (age: M = 37), 69 % of them men. The RHS-13 screened 57 % and the RHS-15 screened 66 % of participants as positive for psychological distress. Both RHS versions had very good reliability and validity and reliably identified clinically relevant psychological problems related to depression, anxiety, somatisation or PTSD. The RHS-13 proved to be more economical and slightly more valid. Conclusions: Consistent with previous findings, our results suggest that the RHS is an efficient and valid screening tool for common mental health disorders among Syrian refugees in Germany.

The Impact of an Insecure Asylum Status on Mental Health of Adult Refugees in Germany

Background

Forcibly displaced people have a higher chance of developing post-traumatic stress disorder (PTSD) compared to people who have not experienced displacement. In addition to potentially traumatic events due to war, persecution, and flight, post-migration living stressors are an important influencing factor. Among these, an insecure asylum status is one of the main stressors with which forcibly displaced people must cope. The aim of this study was to investigate the additive effect of an insecure asylum status on PTSD symptomatology in refugees, over and above the influence of other pre- and peri-migration factors, in particular potentially traumatic event types reported and duration of stay in Germany.

Method

Two overlapping convenience samples of 177 and 65 adult refugees that were assessed at different timepoints were interviewed by means of face-to-face interviews. Interviews were conducted in either Arabic, Farsi, Kurmancî, English, or German with the assistance of interpreters where necessary. Besides residence status and potentially traumatic events experienced, mental distress was assessed via the Refugee Health Screener-15 (RHS-15; Study A) and the PTSD Checklist for DSM-5 (PCL-5; Study B).

Results

In both samples, an insecure asylum status explained a significant additional amount of variance of PTSD symptomatology, on top of traumatic events experienced and time since arrival in Germany.

Conclusion

Results suggest that refugees with an insecure asylum status are at higher risk for experiencing increased PTSD symptomatology. Policy changes of asylum procedure in receiving countries could have a positive impact on refugees' mental health.

Cross-sectional survey to describe medicine use among Syrian asylum seekers and refugees in a German federal state: looking beyond infectious diseases

OBJECTIVES

The aim of our study was to describe medicine use and document self-reported diseases or conditions for which medicines were used among Syrian asylum seekers and refugees (AS&Rs) in the German state of North Rhine-Westphalia (NRW). We examined in this study differences in the use of medicines among different age and sex groups of the study participants.

SETTING

Fifteen different refugee shared accommodation centres in the greater Cologne area, a community centre with a language school and consultation office, and other places frequented by the Syrian community.

PARTICIPANTS

Syrian AS&Rs registered in NRW and residing in the city of Cologne or surrounding areas.

PRIMARY OUTCOME MEASURES

The prevalence of using at least one medicine in the 7 days preceding data collection, and the use of prescribed medicines and self-medication.

RESULTS

Of the 1641 Syrian AS&Rs who took part in our study, the overall 7-day prevalence of medicine use was 34.9%. Among adults, headache and hypertension were the most common indications that led to medicine use. By dose, hypertension (954 doses) and diabetes (595 doses) were the first and second most frequent indication. Among children, fever and cough were the most common indication; ibuprofen and hederae helicis folium preparations were the most used medicines. Low prevalence was found of medicine use for the treatment of either infectious diseases or mental disorders.

CONCLUSION

Among the Syrian AS&Rs in NRW who participated in the study, non-communicable diseases (NCDs) were common presumed causes of use of medication among adults. We encourage future studies to pay more attention to NCDs medicine use among AS&Rs. Researchers should also consider reaching AS&Rs who live in private housing and not limit studies only to newly arrived AS&Rs who live in shared accommodation centres.

[Occupational Participation of Syrian Refugees with Posttraumatic Stress in Germany]

OBJECTIVE

Description of employment situation and search for determinants of employment depending on symptom severity in refugees with posttraumatic stress.

METHODS

Standardized interviews with 133 Syrian refugees (18 to 65 years) living in Germany with posttraumatic stress symptoms and exploratory data analysis.

RESULTS

27.1 % of the participants were employed; including 13.9 % women and 86.1 % men (p = 0.001). Links between mental health and employment can be shown (posttraumatic stress p = 0.039, depressiveness p = 0.020, somatisation p = 0.026). With regard to social support and type of trauma, as well as residence status and duration of residence, there were no differences between refugees with and without employment.

CONCLUSION

The current analysis on the employment situation of a circumscribed group of Syrian refugees focuses on the importance of psychological symptom burden.

Mental health service utilization and perceived barriers to treatment among adult refugees in Germany

Background: Prevalence rates of posttraumatic stress disorder and depression are high among refugees in Germany. However, knowledge on subjective as well as objective need for psychotherapy and utilization of psychotherapeutic treatment is scarce. Both structural and personal barriers regarding utilization of mental health services must be addressed in order to increase treatment efficiency. Objective: The aim of this study was to determine the objective as well as the perceived need for treatment, the utilization of mental health care among refugees in the past 12 months, and the perceived barriers to treatment. Method: By means of face-to-face interviews, an unselected convenience sample of 177 adult refugees were interviewed in either Arabic, Farsi, Kurmancî, English, or German. The general sample was reached through social workers. In addition to the Refugee Health Screener-15 (RHS-15), utilization of psychotherapeutic and psychiatric care as well as the subjective needs and barriers to treatment were assessed. Results: According to the RHS-15 54.8% of participants (n = 97) suffered from relevant mental health problems. However, although 28 (28.9%) of the 97 participants who scored above the RHS-15 cut-off perceived a need for therapy, none of them had received psychotherapy as recommended by the German S3 Guidelines. Missing information about mental health and language difficulties were the most frequently cited barriers to mental health services. Conclusions: Psychologically distressed refugees do not receive sufficient treatment. The reduction of barriers to treatment as well as extension of mental health services to lower thresholds should be considered in the future.

Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study

BACKGROUND

Previous studies have already proven high rates of common mental disorders in Syrian refugees. Nevertheless, little is known about the patterns of somatic distress among this refugee population. For this reason, we aimed to examine the prevalence, co-occurrence, and risk factors of somatic distress among Syrian refugees in Germany.

METHODS

This study analyzes the second measurement point (N = 116) of a prospective register-based survey among 200 adult Syrian refugees with residence permission in Germany. The survey consisted of information on sociodemographic and migration-specific characteristics, health care utilization, traumatic life events, acculturative stress (Barcelona Immigration Stress Scale (BISS); subscales: perceived discrimination, intercultural contact stress, homesickness, and general psychosocial stress), and self-reported outcomes of somatic distress (Patient Health Questionnaire (PHQ-15)), depression (PHQ-9), generalized anxiety disorder (GAD-7), and post-traumatic symptoms (Essen Trauma Inventory (ETI)).

RESULTS

Almost half of the respondents (49.1%) were identified as being at risk of somatic distress (PHQ-15 score ≥ 6), and even 24.1% being bothered by moderate-to-severe levels of somatic distress (PHQ-15 score ≥ 10). The most robust associations with somatic distress were found for female gender, the amount of health care utilization, multiple trauma exposures, general psychosocial stress, and self-reported depression and anxiety symptoms. High comorbidities with somatic distress were shown for all of the common mental disorders studied.

CONCLUSIONS

The presented study reveals a significant risk of somatic distress among this displaced population and highlights implications for policy and health care providers.

Prevalence of depressive symptoms and symptoms of post-traumatic stress disorder among newly arrived refugees and asylum seekers in Germany: systematic review and meta-analysis

BACKGROUND

In total numbers, Germany has faced the largest number of refugees and asylum seekers (RAS) in Europe in the past decade. Although a considerable proportion have experienced traumatic and stressful life events, there is no systematic review to date examining the prevalence of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms in RAS in Germany.

AIMS

To calculate the prevalence of depressive symptoms and PTSD symptoms in the general population of RAS living in Germany after the year 2000 and explore the impact of study- and participant-related characteristics on prevalence estimates.

METHOD

We systematically searched PubMed, CINAHL, PsycINFO, PSYNDEX, Academic Search Complete, Science Direct and Web of Science from January 2000 to May 2020 to identify articles reporting prevalence of depressive symptoms and PTSD in RAS in Germany (PROSPERO registration number: CRD42020182796).

RESULTS

In total, 31 different surveys met inclusion criteria with 20 surveys reporting prevalence estimates of depressive symptoms and 25 surveys symptoms of PTSD. Based on screening tools, the pooled prevalence estimate of PTSD symptoms was 29.9% (95% CI 20.8-38.7%) and of depressive symptoms 39.8% (95% CI 29.8-50.1%). Heterogeneity was large within and between subgroups. In multivariate meta-regressions on depressive symptoms, heterogeneity was largely explained by survey period, length of field period and study quality.

CONCLUSIONS

Prevalence rates of depressive symptoms and PTSD symptoms in RAS are notably large. They exceed the prevalence in the general German population. As a result of high heterogeneity, however, pooled prevalence rates should be interpreted with caution.

A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany

Background: Since the onset of the 2015 European refugee crisis, ~4. 46 million people have sought asylum in the European Union, with Germany logging the largest share of all asylum applications. In addition to the severe adversities before and during flight, the process of settling into a new environment involves stressors that affect psychological well-being and mental health. The aim of this systematic review was to examine contextual factors during post-migration that influence the mental health and well-being of asylum seekers and refugees (ASRs) in Germany. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases for English and German studies published between 2015 and 2020 with index keywords. Results: From a total of 303 articles, 156 duplicates were removed and, after title review, another 87 were excluded for not meeting the inclusion criteria. After assessing the abstracts of the remaining 60 articles, 39 were excluded. Full texts of 21 articles were assessed for eligibility and after excluding 8 articles, 13 articles were included in the review. The results demonstrate high rates of psychological distress among ASRs in Germany and the significant influence of contextual factors on their mental health and psychological well-being. The risk factors for poor mental health include an uncertain asylum status, living in shared asylum accommodations, separation from the nuclear family, lack of German language skills, integration issues and discrimination, while employment is a protective factor. Conclusion: Asylum seekers and refugees have high prevalence rates of psychological distress directly influenced by contextual factors in Germany. Based on these findings, policy makers are strongly recommended to apply preventive strategies to reduce mental health problems of ASRs in Germany.

Health and medical care for refugees: design and evaluation of a multidisciplinary clinical elective for medical students

Objective: Caring for refugee patients places special demands on health professionals. To date, medical students in Germany have rarely been systematically prepared for these challenges. This article reports on the development, conceptualisation, implementation, evaluation, and relevance of a multidisciplinary elective for medical students in the clinical study phase. Methodology: The course content was developed based on a needs-assessment among medical students and in cooperation with medical colleagues working in the field of refugee care. The course consisted of a seminar with medical, legal, administrative and socio-cultural learning content as well as a field placement in the medical outpatient clinic of the local reception centre for asylum seekers, which was accompanied by a systematic reflection process. The evaluation concept contained qualitative and quantitative elements. Results: 123 students completed the elective over six semesters (summer 2016 through to winter 2018). It was continuously evaluated and further developed. The students reported learning progress mainly in the following areas: Legal foundations of the asylum procedure and health care entitlements for asylum seekers; multi-perspectivity through multidisciplinarity as well as professional, ethical, interpersonal, and political insights gained through the practical experience. Summary: To prepare students for the complex challenges to be faced in medical care for refugees, a structured, multidisciplinary teaching programme, which combines theory, practice and reflection helps to foster insights into the many facets of this field of activity. The questions students brought to the seminar, the course contents and evaluation results are intended to inspire the design and implementation of similar courses at other universities.

Measuring deterioration of small-area housing environment: Construction of a multi-dimensional assessment index and validation in shared refugee accommodation

Housing is an important health determinant, in particular for asylum seekers and refugees (ASR) living in state-provided accommodation and struggling for residential autonomy. However, few validated objective measurement tools exist to measure housing quality in the sense of the deterioration of the housing environment. We aimed to construct and validate an instrument to enable resource-efficient monitoring of and health research on such housing quality. After considering existing theoretical frameworks on housing effects on health, we constructed an easily applicable tool measuring the degree of “Small-area Housing Environment Deterioration” (SHED), based on the “Broken Windows” - index. In a validation study, we tested SHED index's objectivity and reliability, measuring inter-/intra-rater reliability and internal consistency and discussed its strengths and limitations by means of cognitive testing. We ran a field-test as part of a population-based, cross-sectional refugee health survey in a random sample of 58 shared accommodation centers across 44 districts of the German federal state of Baden-Wuerttemberg, enabling us to test index applicability and convergence with ASR's satisfaction with their living place. The new SHED index provides a validated and field-tested measure of deterioration of small-area housing environment with substantial reliability. Serving both researchers and policy-makers, SHED offers an easily applicable index to support epidemiological analyses on housing as a contextual and social determinant of health as well as evidence-informed decision making in questions of housing policies.

•

Deterioration of housing may affect physical and mental health.

•

Validated, practicable measurement tools for deterioration do not currently exist.

•

We constructed an index to assess deterioration of small-area housing environment.

•

Validation study showed high inter/intra-rater reliability and internal consistency.

•

Cognitive interviews and field testing in refugee centers demonstrated applicability.

[The effect of postmigration stressors on the prevalence of depressive symptoms among refugees in Germany. Analysis of the IAB-BAMF-SOEP Survey 2016]

BACKGROUND

International studies prove the high burden of mental illnesses among refugees. Postmigration stressors in the country of refuge may affect the mental health and result in depression.

OBJECTIVES

The study examines whether postmigration stressors are associated with the prevalence of depressive symptoms among adult refugees in Germany.

METHODS

Secondary data analysis based on cross-sectional data of the IAB-BAMF-SOEP Survey of Refugees 2016 (N = 4465) that is representative for Germany. Depressive symptoms were measured using the Patient Health Questionnaire‑2 (PHQ-2). Unadjusted and adjusted odds ratios (ORs) and confidence intervals (CIs) were calculated with binary logistic regression models to examine associations between depression and sociodemographic, postmigration, and psychosocial factors.

RESULTS

Depressive symptoms show 19.4% of the surveyed refugees. Almost all selected postmigration stressors are significantly associated with depression after adjustment for sociodemographic and psychosocial factors. Unemployment (aOR = 1.48 [1.04-2.12]), loneliness (aOR = 1.14 [1.10-1.18]), and a rejected or undecided asylum application (aOR = 1.34 [1.06-1.70]) increase the odds of depressive symptoms, whereas asylum interviews (aOR = 0.71 [0.56-0.91]) and higher housing satisfaction (aOR = 0.94 [0.91-0.98]) lower the odds of depression.

CONCLUSIONS

Postmigration stress is associated with the occurrence of depressive symptoms. Sociopolitical interventions considering stressful and protective factors of the postmigration phase can reduce the burden of mental disorders in refugee populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study

Background

Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings.

Objective

This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany.

Methods

From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone.

Results

At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations.

Conclusions

The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.

[Guarantee of illness assistance for people seeking asylum: Two-tiered medical system in Germany?]

Hintergrund

Es gibt im Bereich des Asylbewerberleistungsgesetzes (AsylbLG) zwei Möglichkeiten der Leistungsgewährung mit praktischer Relevanz für die Gesundheitsversorgung (abhängig von der Voraufenthaltszeit): die Grundleistungen und die Leistungen in besonderen Fällen analog zum Sozialgesetzbuch (SGB) XII.

Methodik

Die Sekundärdatenanalyse untersucht das Leistungsgeschehen im Krankheitsfall bei den Leistungsempfängern nach dem AsylbLG beim Forschungsdatenzentrum der Statistischen Ämter des Bundes und der Länder. Dem untersuchten Personenkreis wurde noch keine Flüchtlingseigenschaft bzw. Asylberechtigung zuerkannt.

Ergebnisse

Zum Stichtag 31.12.2018 bezogen 423.201 Personen in Deutschland Leistungen nach dem AsylbLG. Davon war gut ein Drittel Frauen. Das Durchschnittsalter betrug 24 Jahre. Über die Hälfte stammte aus Asien. Über ein Drittel aller Leistungsempfänger befand sich in ambulanter (33,5 %) oder stationärer Behandlung (1,3 %). Zwischen den Bundesländern variierten die Leistungen zur Hilfe bei Krankheit sowie die gesundheitsbezogenen Pro-Kopf-Bruttoausgaben sehr stark. Die Gewährung von Leistungen bei Krankheit war in Aufnahmeeinrichtungen relativ gering. Mit Gesundheitskarte war die Inanspruchnahme stationärer Behandlung generell höher.

Die gesundheitsbezogene Regelversorgung mit Hilfen in besonderen Fällen (§2 AsylbLG analog SGB XII) erreichte einen größeren Anteil an leistungsberechtigten Menschen mit 42,7 % am Jahresende als die Minimalversorgung nach §3 AsylbLG mit 29,0 %. Sie verursachte trotzdem im Vergleich weniger Bruttoausgaben.

Schlussfolgerung

Es wird empfohlen, §2 AsylbLG schon bei einer Voraufenthaltszeit ab 3 Monaten anzuwenden, um frühzeitiger die Hilfen analog Kap. 5–9 SGB XII gewähren zu können. Eine flächendeckende Einführung der Gesundheitskarte würde den Zugang verbessern.

Episodes of care in a primary care walk-in clinic at a refugee camp in Germany - a retrospective data analysis

BACKGROUND

From 2015 to 2016 Germany faced an influx of 1.16 million asylum seekers. In the state of Hamburg Primary Care walk-in clinics (PCWC) were commissioned at refugee camps because the high number of residents (57,000 individuals) could not be provided with access to regular healthcare services. Our study aims were (1) to describe the utilization of a PCWC by camp residents, (2) to compare episodes of continuous care with shorter care episodes and (3) to analyse which diagnoses predict episodes of continuous care in this setting.

METHODS

A retrospective longitudinal observational study was conducted by reviewing all anonymized electronic medical records of a PCWC that operated from 4th November 2015 to 22nd July 2016 at a refugee camp in Hamburg. Episodes of care (EOC) were extracted based on the international classification of primary care-2nd edition (ICPC-2). Outcome parameters were episode duration, principal diagnoses, and medical procedures.

RESULTS

We analysed 5547 consultations of 1467 patients and extracted 4006 EOC. Mean patient age was 22.7 ± 14.8 years, 37.3% were female. Most common diagnoses were infections (44.7%), non-communicable diseases (22.2%), non-definitive diagnoses describing symptoms (22.0%), and injuries (5.7%). Most patients (52.4%) had only single encounters, whereas 19.8% had at least one EOC with a duration of ≥ 28 days (defined as continuous care). Several procedures were more prevalent in EOC with continuous care: Blood tests (5.2 times higher), administrative procedures (4.3), imaging (3.1) and referrals to secondary care providers (3.0). Twenty prevalent ICPC-2-diagnosis groups were associated with continuous care. The strongest associations were endocrine/metabolic system and nutritional disorders (hazard ratio 5.538, p < 0.001), dermatitis/atopic eczema (4.279, p < 0.001) and psychological disorders (4.056, p < 0.001).

CONCLUSION

A wide spectrum of acute and chronic health conditions could be treated at a GP-led PCWC with few referrals or use of medical resources. But we also observed episodes of continuous care with more use of medical resources and referrals. Therefore, we conclude that principles of primary care like continuity of care, coordination of care and management of symptomatic complaints could complement future healthcare concepts for refugee camps.

Supporting migrants and refugees with posttraumatic stress disorder: development, pilot implementation, and pilot evaluation of a continuing interprofessional education for healthcare providers

BACKGROUND

Refugees and migrants face an increased risk of developing posttraumatic stress disorder (PTSD). Adequate care can be insufficient due to language barriers, cultural differences, and knowledge deficits of health service providers. Therefore, professional associations requested that healthcare providers to be educated to provide culturally sensitive care. An evidence-based educational intervention in the form of a continuing interprofessional education (CIPE) for healthcare providers on the topic of PTSD in migrants and refugees was developed, pilot-implemented, and evaluated according to the first two levels of the Kirkpatrick evaluation model (reaction and learning).

METHODS

The development of a curriculum for the CIPE intervention was based on a narrative literature review. Its content was validated by experts (N = 17) in an online survey and analyzed using both the Content Validity Index and a thematic analysis. The evaluation of the CIPE intervention was performed by conducting a pilot study with a quasi-experimental single group, using a pre-posttest design. In total, there were 39 participants distributed among three pilot courses. We collected and analyzed data on satisfaction, knowledge, and feasibility.

RESULTS

The curriculum for a half-day course, consisting of 8 modules, showed almost excellent content validity (S-CVI = 0.92). In the pilot-implementation phase, participants were "very satisfied" with the pilot courses and a positive effect on their knowledge was detected. No correlation between satisfaction and knowledge gain was found.

CONCLUSIONS

The CIPE intervention can be considered feasible and seems promising in its effects on satisfaction and knowledge. The insights gained in this study can be used to adapt and optimize the educational intervention, whereby the feedback from course attendees is particularly useful. Future studies need to further examine the effects in larger samples and more robust study designs.

Refugee health in Europe: mapping review of research literature (2015–2019)

Purpose

The purpose of this paper is to map research literature on all aspects of refugee health in Europe (2015–2019): by research domain, study design, targeted population, type of setting, host country, journal title. This will help to identify recent research trends in the field, provide policymakers with useful source of information and help researches to target important gaps in evidence.

Design/methodology/approach

WHO (with other international agencies) has developed strategic documents and produced technical guidance, which formulate priority issues of refugee health in Europe. These documents state the need for relevant information and research data to support effective decision-making at all levels of health care systems. Although recent bibliometric analysis of global migration health research (2000–2016) concluded that 25.4% of retrieved documents were about refugees and asylum seekers, still there remain critical gaps in the knowledge base on a wide range of determinants of health service delivery and access for refugees and asylum seekers in the WHO European Region. Mapping review design was chosen as it maps and categorizes existing literature from which to commission further reviews and/or primary research by identifying gaps in research literature. Search strategy was developed and searches were executed in six databases: PubMed Medline; Scopus; ProQuest (Thesis and Dissertations); Cochrane Library; BASE; eLibrary (Russian journal articles).

Findings

Mapping review revealed that although research in some domains of refugee health was growing (mental health, infectious diseases, access to health care), there are still gaps in evidence in many important aspects: maternal and reproductive health, NCD, nutrition and economic evaluations. Most of 1,291 retrieved studies used observational or quasi-experimental design (75%), while very few were experimental studies (1.8%). Secondary research constituted a significant portion of retrieved publications: systematic reviews and meta-analysis – 8%, other reviews with systematic approach – 16%.

Originality/value

Detailed mapping of research by a combination of setting, population and research domains and comparison of results with those from previous decades and with planned trials and systematic reviews.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe

BACKGROUND

Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance.

METHODS

A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential.

RESULTS

Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration.

CONCLUSIONS

The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

Predictors of asylum seekers' mental health course in the early stages of resettlement: Results of a longitudinal study

OBJECTIVE

Asylum seekers who have experienced persecution, war and torture show high prevalence rates of stress-related mental disorders. After arrival in the host country, the early stages of resettlement seem to be a particularly vulnerable phase characterized by social instability. This longitudinal study aimed to explore predictors of the asylum seekers' course of mental health during the transition phase from a state registration and reception center to municipal shelters.

METHODS

We used hierarchical regression analysis to assess the symptom course of posttraumatic stress disorder (PTSD), depression, anxiety and panic disorders as well as well-being in n = 84 asylum seekers. The follow-up assessment took place three to five months after baseline assessment. The following blocks of possible predictors were included in the statistical models: (1) sociodemographic variables, (2) cultural background related variables, (3) psychometric measures of emotion regulation and sense of coherence and (4) time range to follow-up.

RESULTS

Language proficiency, origin, religion and gender were stronger predictors of the asylum seekers' mental health course in the early stages of resettlement than emotion regulation and sense of coherence.

CONCLUSIONS

Sociodemographic and cultural background related variables, like language proficiency have a high psychosocial relevance for asylum seekers in the early phase of the asylum process. Therefore, language courses should be implemented progressively. Psychotherapy for asylum seekers should always be performed with awareness for cultural specific perspectives and acculturative adjustment processes.

Psychological burden, stressors and resources of social workers working with women and children who suffered extreme violence by the 'Islamic state': A mixed method study

OBJECTIVE

This explorative study aimed to determine the extent of psychological burden in social workers working with traumatized refugees. In addition, distressing and helpful factors determining the psychosocial burden were to be identified and described.

METHODS

Cross-sectional, mixed method design using quantitative and qualitative methods. The quantitative part included the Perceived Stress Questionnaire (PSQ) and items to assess specific factors of the working-context. The qualitative part is based on 5 focus groupdiscussions and 16 individual interviews. Evaluation was carried out using qualitative content analysis (QCA) including cross-analysis along the subscales of the PSQ to organise the qualitative material.

RESULTS

N = 54 social workers completed the questionnaire. High scores were found for all subscales of the PSQ. The distressing factor rated the highest was need of interpreters to communicate (M = 5.1, SD = 1.71), the helpful factor rated the highest was communication skills (M = 6.35, SD = 0.73). In the QCA, aspects of distressing and helpful factors were identified and further detailed.

CONCLUSION

According to the here presented study results, the psychological burdens of social workers working with refugees seem to be high. The impact of distressing factors such as working with interpreters and exposure to trauma content or PTSD symptoms might be reduced by offering specific education and supervision. The individual extent of psychological burden should be considered and (re-)evaluated on a regular basis as secondary prevention. Helpful factors like self-care, teamwork, networking and cooperation are evident and should be supported by implementing professional and psychological support.

Stress on local and international psychotherapists in the crisis region of Iraq

BACKGROUND

Local and international Psychotherapists working with war survivors are confronted with a whole variety of burdens. The close contact to their clients and the conversations about terror, flight and genocides, they are frequently subject to vicarious traumatization resulting from these events and reveal a risk of developing secondary traumatization.

METHODS

We interviewed 54 local psychotherapists and 28 psychotherapists originating from abroad who were treating survivors of ISIS terror in refugee camps organised by non-government organisations (NGOs).

RESULTS

The results show that local and non-local psychotherapists who work in a context of humanitarian crises reveal a risk of developing secondary traumatization. The results of this present study would also indicate that the secondary traumatization depends both on individual characteristics such as bonding styles and personal experiences and also on the ambient characteristics such as the degree of traumatization of the patients.

CONCLUSION

The study revealed that the local and non-local psychotherapists had a range of different pressure factors and helpful resources which indicated that better caring/support, supervision and organization are needed to enable psychotherapists to perform more effectively in war regions from the point of view of preventive healthcare.

Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the "Islamic State" (IS)

BACKGROUND

Refugees with a history of war or sexual violence often experience somatic symptoms along with mental disorders. After being held in captivity by the so-called "Islamic State" (IS), 1100 especially vulnerable Yazidi women and children (around 400 women) received special medical and psychological support. We report on their (psycho-) somatic complaints and concepts of illness.

METHODS

Female refugees (N = 116) were surveyed regarding their somatic complaints and concepts of illness. The Impact of Event Scale-Revised (IES-R) and self-developed questionnaire items with ratings on a five-point Likert scale from 0 ("not at all") to 4 ("extremely") were used. Subgroup analyses and a multiple linear regression model were computed.

RESULTS

Pain (M = 2.43, SD = 1.70) is the main somatic complaint with a moderate rated severity, followed by feelings of suffocation (M = 2.37, SD = 1.53), and movement disorders (M = 1.62, SD = 1.70). In a linear regression model, pain explains variance (R² = 0.325) in the refugees' self-reported health-related wellbeing. Somatic symptoms are mainly attributed to psychological causes, followed by physical (e.g., physical origin of symptoms), religious, and supernatural causes. Women with pain symptoms attributed their symptoms more to physical causes (M = 1.90, SD = 1.78) than did women without pain symptoms (M = 1.07, SD = 1.59).

CONCLUSION

Female Yazidi refugees being kept in IS captivity mainly suffer from pain, which is attributed to an explanatory psychological model. The study results show the specific psychosomatic and psychotherapeutic needs and demands for specifically tailored psychotherapy.

Predictors of Asylum Seekers' Health Care Utilization in the Early Phase of Resettlement

BACKGROUND

Asylum seekers display high prevalence rates of posttraumatic stress disorder, depression, anxiety, and panic disorder due to pre-, peri-, and post-migration stressors. In contrast to the high mental health burden, health care utilization among asylum seekers in the early phase of resettlement is low. However, the early stages after migration are a particularly vulnerable phase in which psychosocial support measures are needed to prevent mental disorders from becoming chronic.

OBJECTIVE

To identify predictors of asylum seekers' health care utilization in the early stages of resettlement.

METHODS

Using hierarchical logistic regression analysis, the variance explanation of the (1) general utilization of health care services as well as the individual utilization of (2) outpatient psychiatrists, (3) counselling centers, and (4) general practitioners was analyzed in n = 65 asylum seekers. A structured interview on health care utilization took place between three to five months after assessment of possible predictors. We defined the following three groups of predictors a) the sociodemographic variables gender, age, number of children, religion, language proficiency, b) the psychological variables sense of coherence and emotion regulation as well as c) the asylum seekers' psychiatric diagnoses.

RESULTS

Individual sociodemographic factors, such as gender, age, and number of children as well as the emotion regulation strategy of expressive suppression and sense of coherence were shown to be predictive for the utilization of health care services among asylum seekers.

CONCLUSIONS

Low-threshold, culture-sensitive treatment offers for asylum seekers should be established in the early phase after migration. General practitioners should be a central hub for further referrals to disorder-specific treatments.

Effects of introducing a walk-in clinic on ambulatory care sensitive hospitalisations among asylum seekers in Germany: a single-centre pre-post intervention study using medical records

OBJECTIVE

Measuring the effect of introducing a walk-in clinic on ambulatory care sensitive (ACS) hospitalisations among asylum seekers in a large state reception- and registration centre.

DESIGN AND SETTING

Pre-post intervention study using anonymous account data from a university hospital functioning as referral facility for a state reception- and registration centre in the third largest German federal state.

PARTICIPANTS

We included all asylum seekers residing in the reception centre and admitted to the referral hospital between 2015 to 2017.

INTERVENTIONS

Establishment of an interdisciplinary walk-in clinic in the reception centre (02/2016).

MAIN OUTCOME MEASURES

International lists for ACS conditions for both adults and children were adapted and used to calculate the prevalence of ACS conditions among the population (primary outcome measure). The impact of the intervention on the outcome was analysed using a segmented Poisson regression to calculate incidence-rate ratios with respective 95% CIs, adjusted for age, sex and admission.

RESULTS

The prevalence of ACS hospitalisations changed over time, as did the effect of age, sex and quarter of admission. Introducing the walk-in clinic reduced the prevalence of ACS hospitalisations among asylum seekers compared with the period before establishment of the clinic (incidence-rate ratios (IRR)=0.80 (0.65 to 1.00), p=0.054), but the effect was attenuated after adjustment for time trends. The average difference in prevalence of ACS hospitalisations compared with the period before establishment of the clinic, corrected for pre-existing time trends, age and sex of asylum seekers was IRR=1.03 ((0.69 to 1.55), p=0.876).

CONCLUSIONS

A walk-in clinic in reception centres may be effective to reduce ACS hospitalisations, but our study could not prove evidence for a measurable effect after full adjustment for time trends. Further research, ideally with parallel control groups, is required to establish evidence for the effectiveness of walk-in clinics in reception centres on reducing ACS hospitalisations.

„Da muss sich jemand anders kümmern“ – Die medizinische Versorgung von Asylsuchenden als Herausforderung für eine bio-psycho-soziale Medizin

Ziel der Studie Die Medizin wird verschiedentlich dafür kritisiert, die biologischen Facetten von Gesundheit und Krankheit gegenüber gesellschaftlichen Einflüssen zu privilegieren. Gegen diesen Vorwurf hat sich in den letzten Jahrzehnten ein medizintheoretischer Ansatz etabliert, der ein bio-psycho-soziales Krankheitskonzept vertritt. Dieser Artikel nutzt ethnografische Perspektiven auf die medizinische Versorgung von Asylsuchenden, um zu untersuchen, inwiefern die Prinzipien der bio-psycho-sozialen Medizin in Bezug auf die wissenschaftlich fundierte Berücksichtigung gesellschaftlicher Einflüsse auf die Gesundheit und Krankheit dieser Patientengruppe verwirklicht werden.

Methoden Dabei findet ein ethnografisches Methodenrepertoire mit narrativen Interviews, Leitfadeninterviews und teilnehmender Beobachtung Anwendung.

Ergebnisse Anhand des Umgangs mit den rechtlichen Rahmenbedingungen der medizinischen Versorgung von Asylsuchenden und mit Sprachinkongruenz wird gezeigt, dass es Ärzt/-innen regelmäßig nicht gelingt, die gesundheitsbezogene Lebenswelt dieser Patientengruppe adäquat und wissenschaftlichen Standards entsprechend in Diagnostik und Therapie zu berücksichtigen. Stattdessen rekurrieren sie im klinischen Alltag häufig auf improvisierte Lösungsansätze oder verschieben die Verantwortung auf andere, oft unbenannte Akteure.

Schlussfolgerung Sozialwissenschaftliche Ansätze, v. a. aus der Medizinanthropologie, könnten diese zu Versorgungsdefiziten führenden Schwierigkeiten beheben und sollten daher vermehrt in die ärztliche Aus- und Weiterbildung integriert werden. Dadurch könnten zudem theoretische und methodische Lücken geschlossen werden, die möglicherweise auch in der Versorgung anderer Patientengruppen bedeutsam sind.

[Health and primary care surveillance among asylum seekers in reception centres in Germany: concept, development, and implementation]

BACKGROUND

Reliable data on health and primary care among asylum seekers in reception centres are not routinely available, but required to plan needs-based healthcare services.

OBJECTIVES

To present the concept, development, and implementation of a routine surveillance system in reception centres for asylum seekers.

METHODS

In the scope of the project PRICARE, medical records in reception centres were standardized and digitized, and continuous surveillance was enabled by means of suitable IT infrastructure. The core elements of the surveillance system were developed in three project phases using an iterative and participative design.

FUNDING

Federal Ministry of Health (Grant no. 2516FSB415).

RESULTS

Forming the basis for the surveillance, the electronic health record Refugee Care Manager® (RefCare®) was developed and gradually implemented in 13 reception centres in three federal states. For implementing the tool in daily care routines, IT infrastructure was implemented in all sites and a legally required data protection concept was established. An indicator set was developed and agreed upon for the surveillance, comprising a total of 64 indicators in four domains: morbidity, processes of care, quality of care, and syndromic alerts.

CONCLUSIONS

For the first time in Germany, a harmonized infrastructure spanning federal states was implemented in healthcare settings ensuring medical documentation and surveillance of health and healthcare of asylum seekers in conformity with data protection requirements. The surveillance is feasible; the long-term benefits of routine surveillance and research within the network will be assessed in the future.

Motives, experiences and psychological strain in medical students engaged in refugee care in a reception center- a mixed-methods approach

BACKGROUND

The UN Refugee Agency has reported that an increasing number of people are being forcibly displaced worldwide. Despite this, global health issues, especially initiatives focusing on physical and psychological conditions of refugees, are still rarely considered in medical curricula. Furthermore, there is little evidence regarding the experiences and possible related psychological strain of medical students who work with refugees. Therefore, the present study aimed to investigate motivations, learning achievements and experiences, as well as psychological strain and possible protective factors, in medical students volunteering in a reception center for refugees.

METHODS

In this prospective study using a mixed-methods approach, we applied (1) qualitative content analysis of semi-standardized interviews in a pre-post design in a subsample of n = 16 students. The aims were to analyze (1a) the students' motivations and experiences in the reception center, and (1b) the students' perceived learning achievement. We further administered (2) psychometric questionnaires using a cross-sectional approach to n = 62 students in order to examine (2a) the students' psychological strain, in terms of secondary traumatization, depression, anxiety and health-related quality of life, and (2b) possible protective factors such as attachment style and sense of coherence.

RESULTS

The content analysis of the students' interviews revealed three main categories before the assignment and four main categories subsequently, displaying a broad variety of perspectives. Quantitative analysis identified that 3.2% of the students showed moderate secondary traumatization, and a correlation emerged between the number of shifts and symptom severity of secondary traumatization. The students displayed significantly reduced scores for depression and anxiety, when compared to a sample of first-year medical students. Sense of coherence was identified as a protective factor concerning secondary traumatization.

CONCLUSION

A rather small proportion of the medical students working in the reception center displayed explicit symptoms of psychological strain in terms of secondary traumatic stress. Due to their assignments, students were able to improve their cultural awareness, which they reported to be highly relevant for their future occupation. In view of increasing globalization, theoretical and practical courses on issues of flight and global health might therefore be implemented as an obligatory part of medical curricula.

Prevalence of post-traumatic stress disorder, depression and somatisation in recently arrived refugees in Germany: an epidemiological study

AIMS

Despite recent worldwide migratory movements, there are only a few studies available that report robust epidemiological data on the mental health in recent refugee populations. In the present study, post-traumatic stress disorder (PTSD), depression and somatisation were assessed using an epidemiological approach in refugees who have recently arrived in Germany from different countries.

METHODS

The study was conducted in a reception facility for asylum-seekers in Leipzig, Germany. A total of 1316 adult individuals arrived at the facility during the survey period (May 2017-June 2018), 569 of whom took part in the study (N = 67 pilot study and N = 502 study sample; response rate 43.2%). The questionnaire (11 different languages) included sociodemographic and flight-related questions as well as standardised instruments for assessing PTSD (PCL-5), depression (PHQ-9) and somatisation (SSS-8). Unweighted and weighted prevalence rates of PTSD, depression and somatisation were presented stratified by sex and age groups.

RESULTS

According to established cut-off scores, 49.7% of the respondents screened positive for at least one of the mental disorders investigated, with 31% suffering from somatisation, 21.7% from depression and 34.9% from PTSD; prevalence rates of major depression, other depressive syndromes and PTSD were calculated according to the DSM-5, which indicated rates of 10.3, 17.6 and 28.2%, respectively.

CONCLUSIONS

The findings underline the dramatic mental health burden present among refugees and provide important information for health care planning. They also provide important information for health care systems and political authorities in receiving countries and strongly indicate the necessity of establishing early psychosocial support for refugees suffering from psychological distress.

[Migration and health in Germany-available data sources]

BACKGROUND

Migration background plays an important role in analyses of health inequalities in Germany. The heterogeneity of people with and without migration background requires a differentiated recording of migration-related characteristics. The latest overview of representative data sources from the Health Reporting (GBE) that included information on migration background was compiled in 2008.

AIM

The aim of this article is to describe existing data sources reporting the health situation of people with and without a migration background.

MATERIALS AND METHODS

Starting from the websites and publications of owners of GBE data, representative studies and routine data sources were identified. All sources that consider at least one migration-related characteristic were included. For all included studies, migration-related characteristics, information on the social situation, and health-related indicators were collected.

RESULTS

A total of 46 data sources (including 19 routine data sources and 27 studies) were included. The most common indicators of the migration background are nationality (n = 36) and the country of birth (n = 29). Health-related indicators cover a wide range of issues.

DISCUSSION

Routine data sources continue to collect little information on the migration background (usually only nationality) and thus constrain migration-differentiated analyses of the health situation. Survey data allow for more nuanced analysis. However, the actual analysis possibilities and content knowledge of the respective data sources were not the subject of this article.

Asylum seekers' mental health and treatment utilization in a three months follow-up study after transfer from a state registration-and reception-center in Germany

Even though asylum seekers show a high prevalence of trauma-related disorders and comorbid psychological stress symptoms, little is known about how their mental health develops during the asylum process and what options of care are provided. We aimed to investigate the mental health and treatment utilization of asylum seekers after they were transferred from a state registration- and reception-center to municipal shelters in Germany. N = 228 asylum seekers with on-going asylum procedure were recruited in the psychosocial walk-in clinic located in a state registration- and reception-center. We firstly captured symptoms of posttraumatic stress, depression, anxiety disorders, quality of life, as well as alcohol or drug abuse. Subsequently we performed a follow-up after three months to evaluate a potential shift in symptoms and determining rates of access to treatment. In the pre-post psychometric assessment, there were statistically significant changes in depression (PHQ-2), panic (PHQ-PD) and psychosocial well-being scores (WHO-5). However, all these scores still remained within a clinical relevant range, respectively. Traumatic stress (PC-PTSD-5) and general anxiety scores (GAD-2) did not change significantly. Although N = 44 (66%) of the interviewed patients had been referred to psychotherapy initially, none (0%) of them had received outpatient psychotherapeutic treatment after three months. Our results emphasize a strong need for low-threshold, cultural adapted psychotherapeutic treatment for asylum seekers.

Stabilizing Techniques and Guided Imagery for Traumatized Male Refugees in a German State Registration and Reception Center: A Qualitative Study on a Psychotherapeutic Group Intervention

Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.

Quality of health care for refugees - a systematic review

OBJECTIVE

The aim of this systematic review was to identify quality indicators (QI) developed for health care for refugees.

METHODS

We conducted a systematic review of international QI databases such as the Agency for Health care Research and Quality in addition to a systematic search in PubMed, Cochrane library and Web of Science, using the terms "refugee" and "quality indicator", complemented by a search in reference lists and grey literature. All papers which included QIs for refugees, especially for health care were included. In a first step all existing QIs were screened for their relevance to refugees. In a second step, all health care QIs were extracted. In a final step, these health care QIs were classified into process, structure and outcome indicators.

RESULTS

Of 474 papers, 23 were selected for a full-text review. Of these 23 publications, 6 contained 115 QIs for health and health care for refugees. The main health care topics identified were reproductive health, health care service and health status.

CONCLUSIONS

Most indicators were indicators for outcome and structure quality, the smallest group were process indicators. Within the area of refugee health care, most QIs that have been found were QIs regarding reproductive health. QI databases do not yet include indicators specifically related to refugees.

Medical Clerkship in a State Registration and Reception Center for Forced Migrants in Germany: Students' Experiences, Teachable Moments, and Psychological Burden

Aspects of global health are becoming increasingly relevant for doctors of future generations. However, medical curricula rarely include courses which focus on global health or forced migration. Furthermore, it remains unclear whether students are at risk to develop psychological strain, after being confronted with highly burdened or even traumatized asylum seekers. This is a prospective study using a mixed-methods approach. We included n = 22 medical students performing a medical clerkship in a state registration and reception center for refugees. By applying (1) qualitative interviews, (2) reflective diaries, and (3) psychometric questionnaires, we examined the students’ experiences, teachable moments, and potential psychological burdens. In the interviews, the students emphasized the importance of cultural sensitivity during their clerkship. However, they also reported cognitive changes concerning their views of themselves and the world in general; this could indicate vicarious traumatization. The reflective diaries displayed high learning achievements. According to the psychometric questionnaires, the assignment in the reception center had not caused any significant psychological strain for the students. By completing their medical clerkship in a reception center, students were able to improve their medical, organizational, and interactional knowledge and skills. Furthermore, they reported that they had broadened their personal and cultural horizons.

"If you can, change this system" -Pregnant asylum seekers' perceptions on social determinants and material circumstances affecting their health whilst living in state-provided accommodation in Germany - a prospective, qualitative case study

Background

Pregnant women and new mothers seeking asylum are highly vulnerable and have special needs, yet there is dearth of research related to this group in Germany. This paper reports on material circumstances and behavioural factors as social determinants of asylum seekers’ health during pregnancy and early motherhood. The study aim was to gain in-depth insights into these women’s experiences and perceived needs with a focus on material circumstances whilst living in state-provided accommodation in one federal state in Southern Germany.

Methods

A qualitative, prospective approach was taken with individual semi-structured interviews of participants during pregnancy and up to the six-week postnatal assessment, aiming at interviewing each woman twice during pregnancy and once after giving birth. Two female interviewers performed interviews assisted by female professional interpreters on the telephone. Interviews were recorded digitally and transcribed verbatim. An inductive approach was taken to perform content analysis of interview material.

Results

21 interviews were performed with nine women seeking asylum in pregnancy and early motherhood. Content analysis of women’s perceived health-related needs revealed significant health challenges due to considerable constraints in two major themes each with associated categories: a) material circumstances and b) behavioural factors. Participants’ experiences of living conditions included significant challenges in terms of housing and neighbourhood quality e.g. poor hygiene standards with fear of disease and restless sleep due to threats of violence. Consumption potential was severely limited because of a minimal living allowance. Food was a major preoccupation for all participants. Catering services in state-provided accommodation were perceived as unsatisfactory and neglecting religious practices. Institutional food provided adequate calorific intake but participants reported loss of appetite due to bland food, limited variety, little choice and unfamiliar tastes. Self-catering was prohibited further exacerbating this problem.

Conclusions

Pregnant asylum seekers and new mothers living in state-provided accommodation experienced major restrictions related to material circumstances in this study. Key results identified housing and neighbourhood quality, consumption potential and nutrition as social determinants of health which women perceived to adversely affect their health, especially during pregnancy and early motherhood.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6481-2) contains supplementary material, which is available to authorized users.