Use of health care services among Syrian refugees migrating to Norway: a prospective longitudinal study

Including highly educated migrants in academia to improve their health-protocol for a pilot intervention

Introduction

Norway's healthcare system needs a diversified work force to meet societal demands for improved cultural competence. However, many migrants in Norway who were educated as health professions in their home countries are not practicing these professions. This may negatively affect their physical and mental health and hinder their personal social integration. Though good health is often seen as a precondition for work, relevant working activities can also improve health. However, including health professionals with foreign education in academic institutions prior to receiving necessary accreditation is a complex task. This study will pilot an intervention aiming to improve health through meaningful integration of these professionals in academic environments.

Materials and methods

This paper is a protocol for a non-randomized pilot intervention study targeting migrants who are waiting for their health education accreditation in Norway. To test the benefits of meaningful activity on health and explore possibilities for implementing such activity, we have designed a six-month long intervention consisting of including nurses, doctors, and other highly educated migrants with healthcare backgrounds between 20 and 67 years of age, into health-related working tasks, at two higher education institutions in Bergen, Norway. The intervention will be tailored according to the participant's expertise. This hybrid type 2 pilot protocol paper will present how feasibility, fidelity, dose received (satisfaction), and dose of exposure (participation), will be assessed and whether the intervention is experienced as beneficial for the participants' health as primary outcome utilizing both quantitative and qualitative methods.

Conclusion

We present a complex, personalized intervention that has the potential for large scale implementation in the future. By thoroughly presenting our designed intervention and assessment methods, this protocol will add to the study's transparency and facilitate replicability and comparison with future studies. This study will be of benefit to the migrants themselves, policy makers, government agencies and academia at large as it can point to a unique and sustainable way of speeding up the integration of highly educated migrants in their respective fields in a new host country.

Chronic pain and use of painkillers, healthcare services and long-term impairment among Syrian refugees: a cross-sectional study

BACKGROUND

The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway.

METHODS

This cross-sectional study is based on survey data collected from 353 quota refugees in 2018-19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience.

RESULTS

Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0-4.7)), moderate (1.8 (1.1-2.8)), strong (1.7 (1.1-2.6)), and prescription painkillers; mild (4.6 (2.2-9.5)), moderate (5.6 (3.2-10.0)), strong (6.7 (3.9-11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2-3.5), 3.9 (2.1-7.0) and 2.4 (1.3-4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6-13.49)), moderate (6.7 (4.3-10.5)) and strong (6.6 (4.3-10.4)).

CONCLUSION

Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Oral Health-Related Quality of Life among Refugees: A Questionnaire-Based Study

OBJECTIVES

The issue of oral health problems among refugees, not only during their journey but also once they arrive at their destination, is a current one. This study aimed to evaluate the oral health-related quality of life (OHRQoL) of refugees, with the intention of highlighting a potential need for improved education and easier access to dental care.

MATERIALS AND METHODS

A questionnaire based on the Oral Health Impact Profile (OHIP-14) was distributed via hyperlink on social media, targeting individuals with a refugee background to collect data on their OHRQoL.

RESULTS

A total of 401 participants completed the questionnaire. The median OHIP score for all participants was 8 (IQR 2-17) out of a maximum of 56, with 0 representing the best possible OHRQoL. The median OHIP score was 6 (IQR 2-16) for male and 8 (IQR 2-18) for female participants.

CONCLUSIONS

A comparison of the OHIP score from this study with reference values from non-refugee populations shows an elevated score and, thus, a lower oral quality of life.

CLINICAL RELEVANCE

The findings of this study indicate a clear need for enhanced access to dental care for refugees, coupled with an educational initiative aimed at fostering an appreciation of the importance of daily dental hygiene.

A Scoping Review of Instruments Used in Measuring Social Support among Refugees in Resettlement

This study aimed to systematically review current research on the application of existing social support scales in research with refugees in resettlement, assess their quality, and identify gaps in measurement to enhance research and practice. A scoping review was conducted on the extant literature published until March 2023. A team of researchers conducted search, sorting, and data extraction processes following best practices for scale development and validation. Of the 1185 studies collected from the search process, 41 articles were retained in the final analysis, from which 17 distinct social support instruments used in research with resettled refugees were identified. An assessment of all 17 instruments showed the presence of one or more limitations associated with construct, criterion, convergent, and/or discriminant validity. Test of reliability was assessed in all studies, with a range of 0.80 to 0.90. Our findings show that most of the research evaluating social support among resettled refugees is conducted without measurement instruments adequately validated in the resettlement context. This analysis highlights the need for rigorously developed social support scales that reflect the lived experiences, needs, and priorities of resettled refugees.

Quality of Life and Psychometric Characteristics of Syrian Refugee Physicians Who Migrated to Turkey: A Cross-Sectional Study

Background

The concept of migration comes with various problems, affecting the quality of life and psychological state of immigrants. This study aimed to investigate the quality of life and depression and anxiety states of physicians who immigrated to Turkey after the civil war that started in Syria in 2011.

Methods

In this cross-sectional study, a sociodemographic questionnaire form, the short version of the World Health Organization's quality of life assessment tool (WHOQOL-BREF), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) were applied to Syrian doctors who received integration training to work in refugee health centers established for immigrants in Turkey.

Results

A total of 570 participants were included in the study. The median scores of WHOQOL-BREF domains of the participants were 75 for DOM1 (min: 25, max: 100, IQR: 18), 69 for DOM2 (min: 6, max: 100, IQR: 25), 69 for DOM3 (min: 0, max: 100, IQR: 19), and 63 for DOM4 (min: 0, max: 94, IQR: 19). The median BDI score of the participants was 7 (min: 0, max: 41, IQR: 8), and the median BAI score was 5 (min: 0, max: 50, IQR: 8). Having primary care experience, having knowledge about the Turkish healthcare system, believing that they can adapt to work in refugee health centers, and not having a plan to return to their country were found to be associated with a higher score in at least one of the WHOQOL-BREF subdomains. Planning to turn back their country was significantly associated with higher BAI scores.

Conclusions

The overall quality of life of most refugee physicians in Turkey was high, and the BDI and BAI scores were also below the threshold values. Further qualitative studies that allow in-depth analyses may reveal underlying factors for this situation.

Neurologic Care of Forcibly Displaced Persons: Emerging Issues in Neurology

There is a growing number of forcibly displaced persons (FDPs) worldwide. With more than 100 million people forcibly displaced today, there is an urgent mandate to understand the neurologic care needs of this population and how neurologists and other health care workers can most effectively provide that care. In this Emerging Issues in Neurology article, we attempt to (1) define the scope of the problem of providing neurologic care to FDPs, (2) highlight commonly encountered clinical challenges related to neurologic care of FDPs, and (3) provide useful clinical information for neurologists and other clinicians who deliver care to FDPs with neurologic needs. We address the terminology of forcible displacement and how terms may differ across a person's migration journey. Common challenges encountered by FDPs with neurologic needs across settings include loss of support systems, loss of personal health information, language barriers and differing expression of symptoms, differing belief systems, epidemiologic patterns of disease unfamiliar to the clinician, and patients' fear and perceived risks of engaging with health systems. Practical approaches are shared for clinicians who encounter an FDP with a neurologic presentation. Finally, the article discusses many unmet neurologic needs of FDPs, which require significant investment. These include addressing lapses in neurologic care during displacement and understanding the effects of forcible displacement on people with chronic neurologic conditions. Future research and educational resources should focus on improving epidemiologic intelligence for neurologic conditions across geographies, developing curricula for optimizing the neurologic care of FDPs, and evaluating the most appropriate and effective uses of health technologies in humanitarian settings.

Health service behaviors of migrants: A conceptual framework

Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.

Coordination and Perceived Support for Return to Work: A Cross-Sectional Study among Patients in Swedish Healthcare

Background: Receiving support from a return-to-work (RTW) coordinator (RTWC) may be beneficial for people on long-term sick leave. The aim of this study was to investigate whether the number of contacts with an RTWC and their involvement in designing rehabilitation plans for the patients were associated with perceiving support for RTW, emotional response to the RTWC, and healthcare utilization. Methods: In this cross-sectional study, 274 patients who had recently been in contact with an RTWC in Swedish primary or psychiatric care answered questions regarding their interaction with an RTWC, perceived support for RTW, and emotional response to the RTWC. Results: Having more contact with an RTWC was associated with perceiving more support in the RTW process (adjusted OR 4.14, 95% CI 1.49–11.47). RTWC involvement in designing a rehabilitation plan for the patient was associated with perceiving more support in the RTW process from an RTWC and having a more positive emotional response to the RTWC. Conclusions: From the patient’s perspective, this study indicates that the involvement of an RTWC and receiving a rehabilitation plan that an RTWC has helped to design might be perceived as important in the RTW process.

The road to equitable healthcare: A conceptual model developed from a qualitative study of Syrian refugees in Norway

BACKGROUND

Refugees in high-income countries face barriers to healthcare access even when they have the same rights and entitlements as the host population. Disadvantages in healthcare access contribute to differences in health outcomes and impact acculturation. This study explores perceived changes in health status and experiences with the Norwegian healthcare system of Syrian refugees living in Norway, using a trajectory perspective.

METHODS

We conducted 15 semi-structured interviews in April 2020 among purposefully recruited adult refugees from Syria resettled in Norway. Interviews were carried out in Arabic and analysed with Systematic Text Condensation using NVivo software. We used Lévesque's access model and Edberg's migration trajectory perspective as theoretical frameworks. A conceptual model was developed - The Migrant Sensitive Access Model - that highlights the factors contributing to a positive versus negative healthcare journey.

RESULTS

Findings were summarized under three main themes: changes in health and well-being, expectations, and trust. Perceived changes in health status and attributed causes for change were related to the resettlement phase, gender, and were highly informed by pre-migration and migration experiences. The users' perception of the caregiver, communication, and time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver.

CONCLUSION

Syrian refugees in Norway appreciate the Norwegian healthcare system but are impeded in their access to care. Many of the barriers can be bridged during the doctor-patient interaction with a diversity sensitive caregiver. The model we propose gives a comprehensive overview of key areas determining the healthcare experience of this population. The results of this study can be useful to policymakers and healthcare providers when addressing disparities in healthcare access for forced migrants.