The health needs and access barriers among refugees and asylum-seekers in Malaysia: a qualitative study

Correlates of COVID-19 vaccine uptake among the forcibly displaced: evidence from Libya

BACKGROUND

Vaccine hesitancy and refusal can hinder the control of infectious diseases such as coronavirus disease 2019 (COVID-19). Although forcibly displaced individuals are at high risk of contracting COVID-19, evidence shows that they are less likely to accept the COVID-19 vaccine. Given their predicament, the factors influencing vaccine uptake in the general population might differ vastly from those in displaced populations. Given the limited evidence on vaccine uptake from humanitarian settings, the current study examined the determinants of COVID-19 vaccine uptake among the forcibly displaced in Libya.

METHODS

Data were extracted from the World Bank/United Nations High Commissioner for Refugees (UNHCR) microdata repository. Data were collected between April and July 2021 after the rollout of the first dose of the COVID-19 vaccine in Libya. Percentages, means, and standard deviations were used to quantify the distribution of the sample population. Logistic regression models were employed to identify factors influencing COVID-19 vaccine uptake.

RESULTS

Odds ratios (ORs) with p values are used to present the regression analysis results. The study revealed that people unaffected by COVID-19 were less likely (OR = .71, 95%CI = 0.67-0.89) to accept the vaccine. Similarly, individuals with access to free COVID-19 vaccines were more likely to be vaccinated than those without free vaccines (OR = 38, 95%CI = 0.19-0.28). Finally, the results indicated that individuals were six times more likely to be vaccinated at mass vaccination sites ((OR = 6.31, 95%CI = 5.46- 7.94) and 1.92 times more likely to be vaccinated at local health centers (OR = 1.92, 95%CI = 0.1.72-3.11) than they were at hospitals and distant health facilities.

CONCLUSION

Implementing comprehensive mass vaccination venues, public education initiatives, and awareness campaigns regarding the importance of vaccination can decrease vaccine hesitancy among the forcibly displaced.

Seroprevalence of dengue and chikungunya viruses among urban refugees in Klang Valley, Malaysia

BACKGROUND

Mosquito-borne diseases pose a significant global public health threat, with Malaysia's Klang Valley experiencing numerous outbreaks in densely populated urban areas.

METHODS

This study aimed to estimate the seroprevalence of anti-dengue and anti-chikungunya antibodies among urban refugees in the Klang Valley, Malaysia, and identify associated risk factors.

RESULTS

High seroprevalence of anti-dengue immunoglobulin G (IgG) and IgM (60.0% [confidence interval {CI} 55.39 to 64.48] and 9.2% [CI 6.77 to 12.25], respectively) were observed among refugees >18 years of age (χ22=11.720, p=0.003), Kachin ethnicity (χ28=72.253, p<0.001), without formal education (χ21=3.856, p=0.050), homes near waste disposal sites (χ21=10.378, p=0.001) and refugees who have experienced flooding (χ21=5.460, p=0.019). Meanwhile, the overall seroprevalence of anti-chikungunya IgG and IgM was 9.7% (CI 7.15 to 12.73) and 10.8% (CI 8.09 to 13.93), respectively, with ages 12-18 years (χ22=6.075, p=0.048), Rohingya ethnicity (χ28=31.631, p<0.001) and homes close to waste disposal sites (χ21=3.912, p=0.048) being significant risk factors. Results showed a link to poor environmental living conditions, with an increase in the vector population with higher availability of breeding sites and thus exposure to dengue and chikungunya virus.

CONCLUSIONS

Health education among the community is the key to disease prevention, as there are no specific antiviral drugs for treatment and limited vaccine availability.

Meta-synthesis of mental healthcare-seeking behavior - Perspectives of refugees and asylum seekers

The number of refugees and asylum seekers worldwide is increasing, and these populations often experience significant mental health challenges due to their difficult life experiences. This study aims to explore the perspectives of refugees and asylum seekers regarding their behavior when seeking mental healthcare. We conducted a meta-synthesis of thirteen articles published between January 2000 and January 2023. The study identified four main themes: understanding of mental health, utilization of health services, the role of society, and necessary interventions. Based on our findings, we provided recommendations for healthcare providers, governments, and researchers to improve the mental healthcare-seeking behavior of these populations in the future.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring refugees' health care access in times of COVID-19: a quantitative study in the Lisbon region, Portugal

Background

To address the health needs of refugees, health services must be culturally competent and facilitate this population's access to health care, especially in a context prone to the amplification of social inequities, such as the COVID-19 pandemic. However, few quantitative studies exist in the European Union, and to the extent of our knowledge, there are no published quantitative studies exploring refugees' access to health care during the pandemic in Portugal. The objective of this study is to describe the demographic and socioeconomic characteristics of refugees living in Lisbon and to explore their healthcare access patterns during the COVID-19 pandemic.

Methods

We conducted a cross-sectional, descriptive, and quantitative study from May to November 2022. Using Levesque' s theory on health care access, we designed and applied a 38-item questionnaire through face-to-face interviews with refugees living in Lisbon for at least 12 months, and used descriptive statistics to characterize sociodemographic and healthcare access profiles during the pandemic.

Results

The mean age of the 36 recruited refugees was 35 years (SD = 10.24), the majority were male (56%), married (72%), had at least a secondary education (69%), were unemployed (77.8%), and had a median length of stay in Portugal of 17 months (IQR = 45). All were registered in a primary care center, and 94% used healthcare services during the pandemic. The majority never tested positive for the coronavirus (58%) and one out of the positive was admitted to hospital due to severe COVID-19. A total of 97% received COVID-19 vaccination, of which 69% had an incomplete schedule. A quarter of the participants did not have access to information about COVID-19 in a language they understood, and although 97% needed health care during the pandemic, more than half (63%) did not seek it because of structural and cultural barriers. Half of the respondents had difficulty getting medical advice by phone or email, and 39.4% could not afford a medical examination or treatment. Only 18.2% sought counseling services. A total of 58.8% of the participants felt like healthcare professionals did not always show respect towards their culture, and 64.7% reported that healthcare professionals did not always discuss treatment options with them.

Conclusion

This study's findings highlight the need to endow inclusive communication, cultural competency, and patient involvement in health care, alongside improving the socioeconomic condition of refugees. Identified population characteristics and barriers to health care access by refugees in this study may inform future research on the health care needs of refugees in Portugal and ultimately assist in the devising of strategies to reduce inequalities in health care access.

Intestinal parasitic infections and risk analysis among urban refugees in the Klang Valley, Malaysia

BACKGROUND

Global studies show intestinal parasitic infections (IPIs) have been introduced and spread with refugee inflows from low to high socio-economic countries. However, there is relatively limited information on the prevalence of infections among the community.

METHODS

A 2-year cross-sectional study was conducted to determine the prevalence and associated risk factors for infections among urban refugees in the Klang Valley, Malaysia. A total of 418 faecal samples were collected and examined by microscopy.

RESULTS

Faecal screening revealed moderate levels (32.3%) of infections in the community. Three nematode (Ascaris lumbricoides, Trichuris trichiura and hookworm) and three protozoan species (Entamoeba, Giardia and Cryptosporidium) were recorded, with the highest prevalence being A. lumbricoides (20.6%) followed by T. trichiura (10.3%), while other infections were <5%. Statistical analysis found that young males with less education were more likely to be infected with helminths. Additionally, living near waste disposal sites, the presence of stray animals, eating with bare hands, bare footedness, poor handwashing practices and no anthelmintic treatment constituted significant risk factors for helminth infections. Protozoan infections were linked to drinking tap water or from water dispensers and poor handwashing practices.

CONCLUSIONS

These findings emphasize the importance of health education in addition to introduction of biannual anthelmintic treatment to promote community health and well-being.

Preventive knowledge, attitude, and vaccination challenges for COVID-19 among Myanmar refugees and irregular migrants in Malaysia

Access to vaccinations is crucial for everyone in the fight against the COVID-19 pandemic, regardless of migration or refugee status. This study explored COVID-19 prevention knowledge, attitudes, and vaccination challenges among refugees and irregular migrants from Myanmar in Malaysia. This study employed a descriptive mixed-method approach. Convenience sampling was used to conduct an online survey of 174 participants and two focus groups (N = 14). The majority (51.7 %) were refugees, and 48% were irregular migrant workers. In this study, 90.9% of the participants used social networks and social media chats to obtain information about COVID-19, 84.1% understood and found the vaccination campaign helpful, and 44.2% were aware of it. Although 70% of the participants considered vaccination crucial, 95% said that they would not take it because of fear of arrest and deportation, even though they considered vaccination necessary. Approximately 21.2% of the workers reported that their employers did not provide masks or hand sanitisers. Most of the participants (39.7 %) lived in dormitories provided by their employers. This puts them at a higher risk of infection because of the difficulty in practising social distancing. As part of COVID-19 prevention, the government should grant an amnesty period and work with migrant civil society organisations to administer vaccinations and effective measures for all immigrant populations in Malaysia.

A randomized controlled trial testing the feasibility, acceptability, and preliminary effects of a mental health Screening, Brief Intervention, and Referral to Treatment among refugees in Malaysia

BACKGROUND

Among refugees residing in countries of first asylum, such as Malaysia, high rates of psychological distress call for creative intervention responses.

AIMS

This study examines implementation of a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model promoting emotional well-being and access to services.

METHOD

The one-session intervention was implemented in community settings by refugee facilitators during 2017 to 2020. 140 Participants including Afghan (n = 43), Rohingya (n = 41), and Somali (n = 56) refugees were randomized to receive either the intervention at baseline, or to a waitlist control group. At 30 days post-intervention, all participants completed a post-assessment. Additionally, after completing the intervention, participants provided feedback on SBIRT content and process.

RESULTS

Findings indicate the intervention was feasible to implement. Among the full sample, Refugee Health Screening-15 emotional distress scores reduced significantly among participants in the intervention group when compared to those in the waitlist control group. Examining findings by nationality, only Afghan and Rohingya participants in the intervention condition experienced significant reductions in distress scores compared to their counterparts in the control condition. Examining intervention effects on service access outcomes, only Somali participants in the intervention condition experienced significant increases in service access compared to the control condition.

CONCLUSIONS

Findings indicate the potential value of this SBIRT intervention, warranting further research.

Body mapping for arts-based inquiry in mental health research: a scoping review

Traditional research methods have not yet yielded highly effective long-term mental health treatments and might not reflect diverse lived experiences. Body mapping, which is an arts-based research method, could complement the verbal data of existing approaches through its focus on visual and symbolic processes to understand subjective, embodied experiences related to mental health. We did a scoping review on the use of body mapping in research on mental health experiences and outcomes. We searched Web of Science, PubMed, Scopus, PsycINFO, Embase, Ovid Medline, and Google Scholar to retrieve peer-reviewed articles in English. In 19 articles representing 17 studies, participant numbers for body mapping ranged from three to 48, and some studies exclusively recruited women or children and young people. Study domains included primary mental health experiences and mental health in relation to physical health or social experiences. The benefits of body mapping included its exploration of difficult-to-access emotions and experiences, its focus on strength and resilience, the therapeutic effect, its participatory and collaborative nature, its empowerment and dissemination of participants' voices, and the engagement of children and young people. Body mapping holds promise for research with marginalised groups typically excluded from mental health research.

Health System Response to Refugees' and Migrants' Health in Iran: A Strengths, Weaknesses, Opportunities, and Threats Analysis and Policy Recommendations

Objective: Iran is one of the main hosts of Afghan refugees. This study aims to provide comprehensive evidence to increase Afghan migrants' access to healthcare services in Iran. Methods: To assess the health system's response to Afghan migrants in Iran, we conducted three phases for SWOT analysis, including: 1-developing a review and comprehensive analysis of documents, laws, and, programs, 2-conducting semi-structured interviews with policymakers and experts, and 3-mapping the results through the Levesque's conceptual framework for healthcare access. Results: We evaluated the response of the health system to Afghan migrants' health needs in three domains: 1-Approachability and ability to perceive migrants; 2-Ability to reach, engage, and availability and accommodation and appropriateness; 3-The ability to pay and affordability. For each of the three domains, we identified strengths, weaknesses, opportunities, and threats, complemented with evidence-based suggestions to improve migrants' access to needed healthcare services. Conclusion: Given the rising trend of immigration and deteriorating financial crises, we recommend appropriate strategies for the adoption of specialized focus services, gateway services, and restricted services. Also simplifying financial procedures, and implementing innovative insurance mechanisms are essential.

Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach

INTRODUCTION

Iran is host to one of the world's largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection.

METHODS

This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees.

RESULTS

Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from non-vulnerable refugees.

CONCLUSIONS

A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them.

A Mixed Methods Protocol for Developing Strategies to Improve Access to Health Care Services for Refugees and Asylum Seekers in Gauteng Province, South Africa

Access to healthcare is a fundamental human right for all people, including refugees and asylum seekers. Despite the provision in the Refugee Act of South Africa, which allows refugees to enjoy the same access to health services as the citizens of the Republic, refugees still encounter challenges in accessing such services in Gauteng province. This protocol aims to develop strategies to improve access to health care services for refugees and asylum seekers in Gauteng province, South Africa. The study will be conducted in three phases. An exploratory sequential mixed methods design will be employed in phase 1 of the study; the initial study will be based on a qualitative approach followed by a quantitative approach. Phase 1 (a) of this study will employ a qualitative approach in Gauteng province among conveniently sampled health practitioners as well as purposively sampled refugees and asylum seekers. Interviews will be used to collect data that will be analyzed thematically. Phase 1 (b) will adopt a quantitative approach based on the findings from the initial qualitative study. The ethical principles of informed consent, anonymity, privacy, confidentiality, and avoidance of harm will be adhered to throughout the research process. Phase 1 (c) will be meta-inference and conceptualization. Phase 2 will focus on the development of strategies using strength, weakness, opportunities, and threats analysis and a build, overcome, explore, and minimize model to guide the process. In Phase 3, the Delphi technique will be used to validate the developed strategies. The conclusion and recommendations will be based on the findings of the study.

Prevalence of COVID-19 vaccine acceptance among migrant and refugee groups: A systematic review and meta-analysis

Objectives

Understanding COVID-19 vaccine hesitancy among migrant and refugee groups is critical for achieving vaccine equity. Therefore, we aimed to estimate the prevalence of COVID-19 vaccine acceptance among migrant and refugee populations.

Methods

A systematic review (PROSPERO: CRD42022333337) was conducted (December 2019-July 2022) using PubMed, Scopus, Web of Science, ProQuest and Google Scholar.

Results

Nineteen studies from 12 countries were included. The pooled estimated prevalence of COVID-19 vaccine willingness among migrant and refugee groups was 70% (19 studies, 95% CI: 62.3-77.4%, I2: 99.19%, τ2: 0.03). Female and male participants did not differ significantly with each other (p = 0.64). Although no individual variable contributed statistically significantly in multivariable meta-regression analysis, the multivariable model that considered methodological quality, mean age of participants, participant group and country of origin explained 67% of variance.

Discussion

Proportions of migrant/refugee groups receiving COVID-19 vaccinations approximated those observed among general populations. Additional studies are needed to examine factors relating to vaccine willingness to identify the most significant factors that may be targeted in interventions.

"My young life, finished already?": a qualitative study of embedded social stressors and their effects on mental health of low-wage male migrant workers in Singapore

BACKGROUND

Increasing evidence shows low-wage migrant workers experience a high prevalence of mental health disorders and adverse health outcomes. Significant disparities in health services usage among migrant workers create added vulnerability to health complications. However, much remains unclear about how vulnerabilities are constructed in migrant worker populations. Additionally, no studies in Singapore have attempted to critically examine the degree to which social environment and structures affect the health and wellbeing of migrant workers. Therefore, this study aimed to critically situate the socio-structural factors creating conditions of vulnerability among migrant workers using a social stress perspective.

METHODS

We conducted semi-structured individual and group interviews with migrant workers focused on individual life experiences, community experiences (individual and collective social capital), health (mental and physical health concerns) and stress response behaviours. We used a grounded theory approach to identify sources of stress and stress responses and uncover pathways to social vulnerabilities.

RESULTS

Findings from 21 individual and 2 group interviews revealed that migrant workers were embedded in a cycle of chronic stress driven by structural factors that were mutually reinforced by stressors arising from their social environment. Socio-structural stressors enacted as poor living, working and social conditions resulted in their negative quality-of-life appraisal. Stressors arising from being "foreign" resulted in anticipated stigma, concealment, and healthcare avoidance. These factors synergistically created a persistent mental health burden for migrant workers.

CONCLUSIONS

Findings highlight the need to address the mental health burden placed on migrant workers and create avenues for migrant workers to seek psychosocial support to manage their stressors.

Socio-ecological barriers to access COVID-19 vaccination among Burmese irregular migrant workers in Thailand

Thailand is a migration hub in ASEAN (Association of Southeast Asian Nations), with more than 3.9 million migrant workers, accounting for 10% of the country's workforce. The government of Thailand has moved from a pandemic to an endemic state of living with the SAR-CoV2 virus as a new normal since over half of the population has been vaccinated. There is, however, an estimated 1.3 million irregular migrant workers in Thailand who are not covered by Social Security Schemes (SSS) and are likely to have not been vaccinated. This study examines the socio-ecological barriers to accessing vaccination among Burmese irregular migrant workers in Thailand. Qualitative and quantitative data were collected from NGO (Non-Government Organizations) workers and Burmese irregular migrants through an online survey and in-depth interviews. The study reported that over 90% of Burmese irregular migrants were unvaccinated. The main reasons for the low vaccination rate include exclusion from the vaccine distribution program, high cost of the vaccine, perceived low quality of vaccine, language barriers, lack of vaccine information, private and public discrimination against migrants, fear of being detained and deported, and difficulties in finding time and transportation to go to vaccination centres. The Thai government should employ culturally competent interpreters to disseminate vaccine information and potential side effects to encourage vaccinations in order to prevent further casualties and curb the global health crisis. Moreover, it is imperative that the Thai government provide free vaccines to all immigrants regardless of their status and amnesty from deportation and detention during the vaccination period.

Exploring theory-based behavioral interventions promoting COVID-19 prevention and healthcare-seeking for migrant worker men in Singapore: a qualitative study

Background

The first wave of COVID-19 during April to July 2020 in Singapore largely affected the migrant workers living in residential dormitories. A government taskforce working with dormitory operators, employers and non-government agencies came together to deliver behavioral interventions and health care services for migrant worker as dorms were imposed movement restrictions. To fill the research gap in understanding movement restriction experiences of migrant workers, this research seeks to describe dormitory contexts and explore behavior change related to both prevention of transmission as well as healthcare seeking for COVID-19 among male migrant workers.

Methods

With social constructivism as the foundation for this study, 23 telephone interviews were conducted with Bangladeshi and Indian migrant workers. A theory-informed, data-driven conceptual framework, characterized by the “Four Ss”: Sensitization, Surveillance, Self-preservation, and Segregation was first generated and later used to frame second-stage, more in-depth, thematic analyses. An effective multipronged approach was documented, persuading migrant workers in our case-study to improve hygiene and follow some safe distancing measures, and adhere to help-seeking when symptomatic.

Results

Rapid collective adaptation was demonstrated; it was propped up by effective harnessing of infrastructure and technology. While technology and digital platforms were central to shaping Sensitization for prevention-related behaviors, interpersonal communication, especially peer-sharing, was key to normalizing and accepting healthcare delivery and norms about healthcare seeking. Interpersonal factors particularly supported successful implementation of case-detection Surveillance, stimulating Self-preserving and acceptance of rules, and was found helpful to those Segregated in recovery facilities. In contrast, encouraging prevention-related behaviors relied more heavily on multiple online-platforms, phone-based e-learning/knowledge testing, e-monitoring of behavior, as well as interpersonal exchanges.

Conclusion

Overall, the findings showed that the conception of the Four Ss helped inform intervention strategies. Anchoring these towards optimal use of technology and harnessing of interpersonal communication for prevention and promotion of healthcare seeking in the planning of future Infectious Disease outbreaks in closed institutional settings is recommended.

Hearing Loss Screening, Diagnosis, and Treatment for Refugees and Asylees in an Urban Clinic, 2014-2017

Objectives

First, to determine whether using a single-question subjective hearing screen vs gold standard audiometric evaluation is effective for hearing loss screening in refugees and asylees. Second, to understand the clinical pathways for hearing loss diagnosis and treatment.

Study Design

This is a case series with chart review from January 2014 to December 2017.

Setting

A large urban safety net primary care clinic in San Francisco, California.

Methods

Patients were included who had a medical record and completed single-question subjective hearing screening and audiometric evaluation during refugee health examinations. An overall 349 patients met all inclusion criteria.

Results

Out of 349 patients, 48% were male; the median age was 29.3 years (SD, 15.1). The majority came from Central or South America (n = 148, 42%) and China (n = 79, 23%). Among all patients, 10 (3%) failed the subjective hearing screen, and 18 (5%) failed audiometric evaluation. Of those who failed the subjective hearing screen, 4 (40%) passed audiometric evaluation. Of those who failed the audiometric evaluation, 12 (66%) passed subjective screening, and only 5 (28%) received a diagnostic audiogram, with 4 diagnosed with hearing loss and 1 receiving hearing aids. The sensitivity of the subjective screening question was 33% and the specificity 99% as compared with audiometric evaluation.

Conclusion

Audiometric evaluation is relatively inexpensive and easily administered, while a single subjective question is a poor screening tool. Hearing loss is undertreated in this population. Ensuring appropriate hearing loss screening, diagnosis, and treatment in this population is paramount to improving quality of life.

Migrant Health and COVID-19 Pandemic: A Cross-sectional Study of Characteristics, Clinical Features, and Health Outcome from Iran

BACKGROUND

As the pandemic unfolds, major concerns remain with those in disadvantaged positions who may be disproportionately affected. This paper aimed to present the characteristics of COVID-19 immigrant patients and investigate whether they were disproportionately affected by COVID-19 pandemic.

METHODS

A cross-sectional study was performed using data on 589,146 patients diagnosed with COVID-19 in Iran. Descriptive analyses were used to summarize the study population's characteristics. Chi-squared test and logistic regression model were applied.

RESULTS

After accounting for possible confounding covariates, being an immigrant was significantly associated with increased risk of death due to COVID-19 (OR 1.64, CI 1.568-1.727). When compared to Iranian-born patients, the prevalence of low blood oxygen levels on admission was higher among immigrant patients (53.9% versus 47.7%, P value < 0.001). Moreover, greater proportions of immigrants who were diagnosed with COVID-19 were admitted to an ICU (17% versus 15.8%, P value < 0.001). Patients aged 65 and above were the largest age category in both populations. However, there was a significant difference between the age profiles of patients, with children under the age of eighteen presenting 16% of immigrant patients vs 6.6% of Iranian-born patients (P value < 0.001). In both groups, more men were affected by COVID-19 than women, yet the sex bias was more prominent for migrant patients (P value < 0.001).

CONCLUSION

The evidence from this study revealed that immigrant patients infected with COVID-19 were more likely to suffer from severe health outcome of the disease compared to Iranian-born patients.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey

Background

The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda.

Methods

Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles.

Results

There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups.

Conclusions

Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Systematic review of electronic health records to manage chronic conditions among displaced populations

OBJECTIVES

The objective of this study was to assess the impact of electronic health records (EHRs) on health outcomes and care of displaced people with chronic health conditions and determine barriers and facilitators to EHR implementation in displaced populations.

DESIGN

A systematic review protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, Health Technology Assessment, Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was searched from inception to 12 April 2021.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Inclusion criteria were original research articles, case reports and descriptions of EHR implementation in populations of displaced people, refugees or asylum seekers with related chronic diseases. Grey literature, reviews and research articles unrelated to chronic diseases or the care of refugees or asylum populations were excluded. Studies were assessed for risk of bias using a modified Cochrane, Newcastle-Ottawa and Joanna Briggs Institute tools.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from each study using Covidence. Due to heterogeneity across study design and specific outcomes, a meta-analysis was not possible. An inductive thematic analysis was conducted using NVivo V.12 (QSR International, Melbourne, Australia). An inductive analysis was used in order to uncover patterns and themes in the experiences, general outcomes and perceptions of EHR implementation.

RESULTS

A total of 32 studies across nine countries were included: 14 in refugee camps/settlements and 18 in asylum countries. Our analysis suggested that EHRs improve health outcomes for chronic diseases by increasing provider adherence to guidelines or treatment algorithms, monitoring of disease indicators, patient counselling and patient adherence. In asylum countries, EHRs resource allocation to direct clinical care and public health services, as well as screening efforts. EHR implementation was facilitated by their adaptability and ability to integrate into management systems. However, barriers to EHR development, deployment and data analysis were identified in refugee settings.

CONCLUSION

Our results suggest that well-designed and integrated EHRs can be a powerful tool to improve healthcare systems and chronic disease outcomes in refugee settings. However, attention should be paid to the common barriers and facilitating actions that we have identified such as utilising a user-centred design. By implementing adaptable EHR solutions, health systems can be strengthened, providers better supported and the health of refugees improved.

Access to Health Care for Migrants Along the Mexico-United States Border: Applying a Framework to Assess Barriers to Care in Mexico

Background

Migrants in Mexico are entitled to care at all levels, independently of their migration status. However, previous studies show that access to care is difficult for this population. As the movement of in-transit migrants and asylum seekers has been interrupted at the Mexico-United States border by migration policies such as the “Remain in Mexico” program, and by border closures due to the COVID-19 pandemic, the Mexican health system has the challenge of providing them with health care. Levesque et al.'s framework, according to which access occurs at the interface of health system characteristics and potential users' abilities to interact with it, is a useful theoretical tool to analyze the barriers faced by migrants.

Objective

The objective of this article is to analyze the barriers to access the public Mexican health system, encountered by migrants in cities in Mexican states at the Mexico-United States border during the COVID-19 pandemic.

Methods

Data came from a multiple case study of the response of migrant shelters to health care needs during the COVID-19 pandemic. The study consisted of a non-probability survey of migrants with a recent health need, and interviews with persons working in civil society organizations providing services to migrants, governmental actors involved in the response to migration, and academics with expertise in the subject. We analyzed the quantitative and qualitative results according to Levesque et al.'s framework.

Results

36/189 migrants surveyed had sought health care in a public service. The main limitations to access were in the availability and accommodation dimension (administrative barriers decreasing migrants' ability to reach the system), and the affordability dimension (out-of-pocket costs limiting migrants' ability to pay). Civil society organizations were a major source of social support, helping migrants overcome some of the barriers identified.

Conclusions

While Mexico's health regulations are inclusive of migrants, in practice there are major barriers to access public health services, which might inhibit migrants from seeking those services. In order to comply with its commitment to guarantee the right to health of all persons, the Mexican health authorities should address the implementation gap between an inclusive policy, and the barriers to access that still remain.

Refugee and Asylum Seeker Women's Experiences with Healthcare and Social Environment in Malaysia

The internal conflict in Rakhine State, Myanmar over the last few decades has forced Rohingyas to flee to other countries, including Malaysia. However, the non-recognition of the status of refugees in Malaysia keeps Rohingyas as "people without documents" and without adequate protection, access to healthcare services, education, and employment. Women among these groups face different challenges and are at risk of numerous physical and mental health issues. Thus, this research attempted to understand the experiences of Rohingya women in Malaysia, particularly in accessing public hospitals. Focus group discussions and key-informant interview techniques were used to collect data. The transcripts were then analysed using the thematic analysis method. The research found that Rohingya women experience numerous challenges despite being on safer ground in Malaysia. Their experiences of marriage and domestic violence, access to public hospitals, financial barriers to healthcare services, and the services provided by medical social workers in the country to refugees and asylum seekers are presented. Non-recognition of the status of refugees in the country is one of the primary barriers to the allocation and provision of resources for refugees and asylum seekers. Due to structural barriers, medical social workers are unable to provide their services to this population. This article provides recommendations for social workers in Malaysia on how to overcome these challenges and work more effectively with refugees and asylum seekers.

Psychometrics and measurement invariance: Health Literacy Scale for Vietnamese and Indonesian married immigrants

AIMS

To examine the psychometrics and measurement invariance of the Short-Form Health Literacy 12-item questionnaire (HL-SF12) among Vietnamese and Indonesian married immigrants.

DESIGN

A cross-sectional survey design.

METHODS

In total, 1171 Vietnamese and Indonesian married immigrants were enrolled between September 2019 and December 2019. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to verify the structural validity of the suggested factor structure. The multiple-group CFA (MGCFA) used a series of hierarchical nested-in models as a measurement invariance test which confirmed the adequacy of the model fit at each stage.

RESULTS/FINDINGS

The Kaiser-Meyer-Olkin coefficient was 0.898, and the Bartlett test of sphericity was statistically significant (χ² [66] = 1965.97, p < 0.01). According to a scree plot and Kaiser's criterion for eigenvalues of >1, the EFA explained 61.6% of the total variance and confirmed three theoretically supported factors of health care, disease prevention and health promotion. The 12 items showed factor loadings of >0.4 and four items were in each subscale. The CFA showed adequate structural validity, including a relative chi-squared/degrees of freedom (X² /df) of 2.01, a comparative fit index (CFI) of 0.98 and a root mean square error of approximation (RMSEA) of 0.04 (95% confidence interval [0.03, 0.05]) in married immigrants. For the measurement invariance, a change in the goodness-of-fit measures did not exceed 0.02 for the RMSEA or 0.01 for the CFI. The results indicated Cronbach's α values of 0.87 for the HL-SF12 scale in Vietnamese and Indonesian combined samples (n = 1171). A t-test showed that the HL-SF12 and its three subscales were unable to significantly differentiate between Vietnamese and Indonesian groups (all p > 0.05).

CONCLUSIONS

The HL-SF12 scale showed acceptable theoretically supported structural validity, equivalent measurement invariance and reliable internal consistency among Vietnamese and Indonesian married immigrants. Measurements of immigrants' HL using the HL-SF12 could be integrated into future immigrant health policies.

IMPACT

As the first study of the measurement invariance of the HL-SF12 instrument among immigrants. Related factors of immigrants' HL can be further explored to increase immigrants' health and empowerment.

Developing strategies to address barriers for tuberculosis case finding and retention in care among refugees in slums in Kampala, Uganda: a qualitative study using the COM-B model

Background

Globally, displaced populations face an increased burden of tuberculosis (TB). Uganda is currently hosting unprecedented big numbers of refugees from the East African region. Recent evidence shows increased spread of multi-drug resistant TB (MDR-TB) across East Africa as a result of migrants from Somalia- a high MDR-TB prevalent country, calling for urgent identification and management of cases for the countries in the region. One of the strategies recommended is optimization of diagnosis, treatment and prevention of TB in refugees. This study aimed at exploring the barriers to and facilitators for TB case finding and retention in care among urban slum refugees and suggestions on how to improve. This was to guide the development of interventions to improve TB case finding and retention in care among the said population.

Methods

A cross-sectional study utilizing qualitative methods was conducted among refugees in an urban slum in Kampala City, Uganda. Key informant interviews with health care workers and community leaders and in-depths interviews with refugee TB patients and care takers of TB patients were conducted (30 interviews in total). Interview questions were based on constructs from the COMB-B model (Capability, Opportunity and Motivation Model of Behaviour change). Manual content analysis was performed and identified targeted intervention strategies guided by the related Behavior Change Wheel implementation framework.

Results

Key barriers included; physical capability (availability of and easily accessible private facilities in the community with no capacity to diagnose and treat TB), psychological capability (lack of knowledge about TB among refugees), social opportunity (wide spread TB stigma and language barrier), physical opportunity (poor living conditions, mobility of refugees), reflective motivation (lack of facilitation for health workers), automatic motivation (discrimination and rejection of TB patients). Facilitators were; physical capability (availability of free TB services in the public health facilities), social opportunity (availability of translators). We identified education, incentivization, training, enablement, and restructuring of the service environment as relevant intervention functions with potential to address barriers to and enhance facilitators of TB case finding and retention among refugees in urban slums.

Conclusion

The key barriers to TB control among refugees living urban slums in Kampala- Uganda, included; poor access to health services, limited knowledge about TB, TB stigma, language barrier and lack of facilitation of community health workers. Identified intervention strategies included; education, training, enablement, environmental restructuring and persuasion. The findings could serve as a guide for the design and implementation of interventions for improving the same.

Health Inequalities amongst Refugees and Migrant Workers in the Midst of the COVID-19 Pandemic: a Report of Two Cases

Malaysia hosts a significant number of refugees, asylum-seekers and migrant workers. Healthcare access for these individuals has always proved a challenge: language barriers, financial constraints and mobility restrictions are some of the frequently cited hurdles. The COVID-19 pandemic has exacerbated these existing inequalities, with migrants and refugees bearing the brunt of chronic systemic injustices. Providing equitable healthcare access for all, regardless of their citizenship and social status remains an ethical challenge for healthcare providers, particularly within the framework of a resource-limited healthcare system. Inclusive healthcare and socio-economic policies are necessary to ensure every individual’s equal opportunity to attain good health. The collective experiences of refugees and migrants in the pursuit of healthcare, as highlighted by the two cases described, showcases the importance of equity in healthcare access and the detrimental implications of non-inclusive healthcare and socio-economic policies.

Analysing the impact of migration on HIV/AIDS cases using epidemiological modelling to guide policy makers

In this paper, we present the impact of migration on the spread of HIV and AIDS cases. A simple model for HIV and AIDS that incorporates migration and addresses its contributions to the spread of HIV and AIDS cases was constructed. The model was calibrated to HIV and AIDS incidence data from Malaysia. We explore the use of Markov chain Monte Carlo (MCMC) simulation method to estimate uncertainty in all the unknown parameters incorporated in our proposed model. Among the migrant population, 1.5572e-01 were susceptible to HIV transmission, which constituted 67,801 migrants. A proportion of migrants, 6.3773e-04, were estimated to be HIV infected, constituting 278 migrants. There were 72 (per 10,000) migrants estimated to have had AIDS, representing a proportion of 1.6611e-08. The result suggests that the disease-free steady state was unstable since the estimated basic reproduction number R0 was 2.0906 and 2.3322 for the models without and with migration, respectively. This is not a good indicator from the public health point of view, as the aim is to stabilize the epidemic at the disease-free equilibrium. The advantage of introduction of migration to the simple model validated the true R0 and the transmission rate β associated with HIV and AIDS epidemic disease in Malaysia. It also indicates an approximately 12 percentage points increase in the rate of HIV infection with migration.

Conceptualizing religious asylum: Security, religiosity, and subjective well-being of Christian asylum-seekers in Hong Kong

This article proposes the concept of religious asylum to examine how Christian asylum-seekers utilize religion to cope with their emotional experiences, induced by a sense of insecurity, during prolonged displacement. Drawing from interviews and ethnographic observations of people seeking asylum in Hong Kong, this research determines that asylum-seekers use religion to redefine their positive sense of self beyond their current situation, which is central to the construct of well-being. While religion supports asylum-seekers going through psychosocial distress and suffering, this discussion on religious asylum shows how asylum-seekers utilize the religiously inflected space to make the experience of prolonged displacement meaningful.

Policies and initiatives/programs that promote health and self-care in asylum seekers living in high income countries: a narrative review

Purpose

This paper aims to identify health-care entitlements that exist for asylum seekers with chronic non-communicable disease (CNCD) that promote their health and self-care, and to explore health policies, initiatives and programmes with the potential to foster self-care in this populace.

Design/methodology/approach

Narrative review of literature conducted by searching EMBASE, CINAHL, WEB OF SCIENCE and PSYCINFO databases for articles published from 2010 to 2021. Included articles focussed on policies, programmes or initiatives with the potential to promote health in adult asylum seekers residing in high-income countries. Studies inclusive of other migrant groups such as undocumented migrants and those with mental health conditions were excluded. Eleven studies fitting the inclusion criteria were assessed against the study objectives.

Findings

Free access to health-care services and pharmaceutical products, free access to food banks and supermarket model food banks, English and cooking lessons, community integration training sessions and culturally competent health-care workers were found to promote health and self-care. There is little research on self-care and health promotion in adult asylum seekers with CNCD. CNCDs represent high burden of disease in asylum seekers but have a low priority in reported research.

Originality/value

This narrative review is the first to explicitly focus on asylum seekers in high-income countries with CNCD, excluding mental health conditions, and to explore initiatives, programmes and policies that enhance health promotion to facilitate self-care in this populace.

Prevalence of anti-Leptospira antibodies and associated risk factors in the Malaysian refugee communities

Background

Refugees in Malaysia, who are afflicted by poverty, conflict and poor health, are vulnerable to a range of zoonotic infections in the deprived environmental and social conditions under which they live. Exposure to infections such as leptospirosis, for which rodents are primary hosts, is of particular concern.

Methods

A wellness program was conducted to determine the presence of antibodies against Leptospira (seroprevalence) in 11 refugee community schools and centers in the Klang Valley, Malaysia. A total of 433 samples were assessed for IgG and IgM antibodies against Leptospira, using enzyme-linked immunosorbent assays (ELISA).

Results

Overall Leptospira seroprevalence was 24.7%, with 3.0% being seropositive for anti-Leptospira IgG and 21.7% for anti-Leptospira IgM. Factors significantly associated with overall Leptospira seroprevalence included: age, ethnicity, pet ownership, knowledge of disease and awareness of disease fatality. For IgM seroprevalence, significant risk factors included sex, ethnicity, eating habits with hands, pet ownership, the presence of rats, walking in bare feet and water recreation visits.

Conclusions

These findings highlight the need for improvements in health and well-being among the refugee community through disease awareness programs and provision of healthy behavior programs, particularly in hygiene and sanitation through community engagement activities.

Exploring electronic health records to estimate the extent of catch-up immunisation and factors associated with under-immunisation among refugees and asylum seekers in south east Queensland

BACKGROUND

Australia is one of the leading countries resettling people from refugee-like backgrounds. Catch-up immunisation is a key priority in this cohort. However, few studies have included asylum seekers and the adult age group in their study sample. In addition, Electronic Health Records (EHR) has recently been recognised as a vital tool in big data analysis with the capacity to contribute to informed strategic decision making. As such, the main aim of this study is to explore EHR routinely used in a specialised refugee clinic in South East Queensland to estimate the extent of catch-up immunisation and assess the factors associated with under-immunisation among refugees and asylum seekers.

METHODS

A quantitative study involving a secondary data analysis on a pre-existing dataset was undertaken. Relevant data was extracted from the EHR in the clinic. SPSS was used to perform Statistical data analysis.

RESULTS

The majority of clients originated from Papua New Guinea, followed by Iran and Afghanistan. When assessing the uptake of catch-up immunisations among refugees and asylum seekers, MMR (Measles-Mumps-Rubella), Polio and DTP (Diphtheria-Tetanus-Pertussis) had the highest uptake, while HPV (Human Papilloma Virus), Pneumococcal and Hib (Haemophilus influenza type b) immunisations had the lowest uptake. Binary logistic regression revealed that the younger patients, the refugees (compared to asylum seekers) and those with a longer residential duration in Australia are at a higher risk of being under-immunised.

CONCLUSION

This study indicates that the broader group of immigrants, and in particular refugees and asylum seekers, do not represent a homogenous group in terms of immunisation coverage, and that each cohort should be carefully considered during immunisation interventions and strategies. This will be particularly important during targeted health promotions and future immunisation programs in this cohort.

Associations between dental care approachability and dental attendance among women pregnant with an Indigenous child: a cross-sectional study

Background

Oral health during pregnancy is vital for both mother and child. Indigenous Australians face many barriers in accessing dental care. Service approachability is one of the key domains in accessing health services. There is little empirical evidence of the association between service approachability and dental care attendance or oral health outcome. The aim of this study is to examine the relationship between dental service approachability on dental care attendance and self-reported gum disease among South Australian women pregnant with an Aboriginal child.

Methods

Four hundred and twenty-seven women pregnant with an Aboriginal child completed questionnaires in both metropolitan and regional health settings in South Australia in 2011. Four variables related to approachability of dental services: (1) perception of need; (2) service-related health literacy; (3) oral health beliefs and; (4) trust and expectation of dental service. The association between service approachability-related factors, dental utilisation and self-reported gum disease during pregnancy were assessed using Generalised Poisson regression models, after adjusting for age, remoteness, employment status and education. Estimates were presented as adjusted prevalence ratios (APR).

Results

Most participants (85.8%) reported a need for dental care, had positive oral health beliefs (88.3%) and had expectations towards dental care (86.2%). Dental service utilisation during pregnancy was low (35.7%). Many participants (78.0%) expressed knowing what to do if they needed dental care, while most (39.8%) doubted that dental care would be available the next day. Poor health service literacy was identified as a risk factor for non-optimal dental attendance (APR = 0.86, 95%CI 0.74–0.99). Perceived need for dental care was positively associated with self-reported gum disease (APR = 1.24, 95%CI 1.06–1.45).

Conclusion

Inability to navigate the dental care system was a risk factor for poor dental attendance among South Australian women pregnant with an Aboriginal child. Perceived need for dental care was associated with gum disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01816-5.

Misconceptions about COVID-19 among older Rohingya (forcefully displaced Myanmar nationals) adults in Bangladesh: findings from a cross-sectional study

OBJECTIVES

Due to low health literacy and adverse situation in the camps, there are possibilities of misconceptions related to COVID-19 among the older Rohingya (forcefully displaced Myanmar nationals or FDMNs) adults in Bangladesh. The present research aimed to assess the level of misconceptions and the factors associated with it among the older FDMNs in Bangladesh.

DESIGN

Cross-sectional.

SETTING

A selected Rohingya camp situated in Cox's Bazar, a southeastern district of Bangladesh.

PARTICIPANTS

Information was collected from 416 conveniently selected FDMNs who were aged 60 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was misconceptions related to the spread, prevention and treatment of COVID-19. Information on 14 different locally relevant misconceptions was gathered, each was scored as one, and obtained a cumulative score, ranging from 0 to 14, with a higher score indicating a higher level of misconceptions. A multiple linear regression model explored the factors associated with misconceptions.

RESULTS

The participants had an average of five misconceptions. The most prevalent misconceptions were: everyone should wear personal protective equipment when outside (84.6%) and its prevention by nutritious food (62.5%) and drinking water (59.3%). Other notable misconceptions included the spread of COVID-19 through mosquito bites (42%) and its transmissions only to the non/less religious person (31.4%). In regression analyses, memory or concentration problems, communication frequency with social networks, pre-existing conditions and receiving information from health workers were significantly associated with higher COVID-19 misconceptions. These misconceptions were less likely among those overwhelmed by COVID-19, having COVID-19 diagnosed friends or family members and receiving information from friends and family.

CONCLUSIONS

Overall, we found that misconceptions were prevalent among the older FDMNs in Bangladesh. The associations have important implications for programmes to prevent and manage COVID-19 in these settings. Health workers need to be adequately trained to provide clear communication and counter misconceptions.

Assessing healthcare access using the Levesque's conceptual framework- a scoping review

INTRODUCTION

Countries are working hard to improve access to healthcare through Universal Healthcare Coverage. To genuinely address the problems of healthcare access, we need to recognize all the dimensions and complexities of healthcare access. Levesque's Conceptual Framework of Access to Health introduced in 2013 provides an interesting and comprehensive perspective through the five dimensions of access and the five abilities of the population to access healthcare. The objectives of this paper are to identify and analyze all empirical studies that applied Levesque's conceptual framework for access to healthcare and to explore the experiences and challenges of researchers who used this framework in developing tools for assessing access.

METHODS

A scoping review was conducted by searching through four databases, for studies citing Levesque et al. 2013 to select all empirical studies focusing on healthcare access that applied the framework. An initial 1838 documents underwent title screening, followed by abstract screening, and finally full text screening by two independent reviewers. Authors of studies identified from the scoping review were also interviewed.

RESULTS

There were 31 studies identified on healthcare access using the Levesque framework either a priori, to develop assessment tool/s (11 studies), or a posteriori, to organize and analyze collected data (20 studies). From the tools used, 147 unique questions on healthcare access were collected, 91 of these explored dimensions of access while 56 were about abilities to access. Those that were designed from the patient's perspective were 73%, while 20% were for health providers, and 7% were addressed to both. Interviews from seven out of the 26 authors, showed that while there were some challenges such as instances of categorization difficulty and unequal representation of dimensions and abilities, the overall experience was positive.

CONCLUSION

Levesque's framework has been successfully used in research that explored, assessed, and measured access in various healthcare services and settings. The framework allowed researchers to comprehensively assess the complex and dynamic process of access both in the health systems and the population contexts. There is still potential room for improvement of the framework, particularly the incorporation of time-related elements of access.

Refugees' Opinions about Healthcare Services: A Case of Turkey

Background: Migration is one of the most important social events in human history. In recent years, Turkey hosted a high number of asylum seekers and refugees, primarily because of continuing wars and radical social changes in the Middle East. Methods: Using a random sampling method, Syrian refugees aged 18 and over, who can communicate in Turkish, were reached via personal contact and a total of 714 refugees participated in the study voluntarily. Results: Turkey has mounted with some success and to point out that even though participating refugees in both provinces are young and healthy, almost 50% have bad or worse health status, 61% have chronic diseases, and 55% need regular medication. Participating refugees living in Şanlıurfa stated that ‘Hospitals are very clean and tidy.’ (3.80 ± 0.80). The answers given to the following statements had the highest mean for the participating refugees living in Kilis; ‘Hospitals are clean and tidy.’ (3.22 ± 1.25). Conclusion: Due to financial and human resource deficiencies, there are problems in providing preventive and therapeutic health services, especially to refugees living outside the refugee camps in bad conditions. It is important that refugees are encouraged to apply to family health and community health centers in this context.

A Cross-Sectional Study on Disparities in Unmet Need among Refugees and Asylum Seekers in Thailand in 2019

The health of urban refugees and asylum seekers (URAS) in Thailand has been under-researched compared with other groups of non-Thai populations, especially on the topic of unmet need. The aim of this study is to examine the level of unmet need among URAS in Thailand, focusing on out-patient (OP) and in-patient (IP) care. A cross-sectional study was conducted between October and December 2019. Stratified random sampling was undertaken and a total of 181 participants were included. A bivariate analysis was used to explore the level of unmet need among different URAS groups. Multivariate logistic regression was undertaken to examine the association between potential correlations and unmet need of IP and OP care. The majority of participants were female and aged below 30 years, with a low educational background and poor economic status. Most of them had experienced an illness in the past month before the interview, and some suffered from chronic diseases. The prevalence of both OP and IP unmet needs was more frequent among URAS from Arab countries. Furthermore, being from Arab countries indicated a strong link with OP and IP unmet need. Additionally, having illness over the past six months and chronic diseases were found to be significant determinants of IP unmet need. Our analysis showed that nationality had a strong association with both IP and OP unmet need, especially among those from Arab countries. Therefore, culturally appropriate health services should be considered to promote healthcare access among diverse groups of URAS. Further qualitative studies on barriers to accessing OP and IP care, such as communication, interpretation, and social dimensions, are required.

Climate-related migration and population health: social science-oriented dynamic simulation model

BACKGROUND

Social science models find the ecological impacts of climate change (EICC) contribute to internal migration in developing countries and, less so, international migration. Projections expect massive climate-related migration in this century. Nascent research calls to study health, migration, population, and armed conflict potential together, accounting for EICC and other factors. System science offers a way: develop a dynamic simulation model (DSM). We aim to validate the feasibility and usefulness of a pilot DSM intended to serve as a proof-of-concept and a basis for identifying model extensions to make it less simplified and more realistic.

METHODS

Studies have separately examined essential parts. Our DSM integrates their results and computes composites of health problems (HP), health care (HC), non-EICC environmental health problems (EP), and environmental health services (ES) by origin site and by immigrants and natives in a destination site, and conflict risk and intensity per area. The exogenous variables include composites of EICC, sociopolitical, economic, and other factors. We simulate the model for synthetic input values and conduct sensitivity analyses.

RESULTS

The simulation results refer to generic origin and destination sites anywhere on Earth. The effects' sizes are likely inaccurate from a real-world view, as our input values are synthetic. Their signs and dynamics are plausible, internally consistent, and, like the sizes, respond logically in sensitivity analyses. Climate migration may harm public health in a host area even with perfect HC/ES qualities and full access; and no HP spillovers across groups, conflict, EICC, and EP. Deviations from these conditions may worsen everyone's health. We consider adaptation options.

CONCLUSIONS

This work shows we can start developing DSMs to understand climate migration and public health by examining each case with its own inputs. Validation of our pilot model suggests we can use it as intended. We lay a path to making it more realistic for policy analysis.

Healthcare inequities and barriers to access for homeless individuals: a qualitative study in Barcelona (Spain)

BACKGROUND

In Spain, homeless individuals have lower perceived quality of health than the rest of the population and their life expectancy is 30 years lower than the national average. While the Spanish health system provides universal access and coverage, homeless individuals do not access or use public care enough to maintain their health. The objective of this study is to determine if homeless individuals can access public health services in conditions of equality with the rest of the population, as established in healthcare legislation, and to better understand the causes of observed inequalities or inequities of access.

METHODS

A detailed qualitative study was carried out in the city of Barcelona (Spain) from October 2019 to February 2020. A total of nine open and in-depth interviews were done with homeless individuals along with seven semi-structured interviews with key informants and two focus groups. One group was composed of eight individuals who were living on the street at the time and the other consisted of eight individuals working in healthcare and social assistance.

RESULTS

The participants indicated that homeless individuals tend to only access healthcare services when they are seriously ill or have suffered some kind of injury. Once there, they tend to encounter significant barriers that might be 1) administrative; 2) personal, based on belief that that will be poorly attended, discriminated against, or unable to afford treatment; or 3) medical-professional, when health professionals, who understand the lifestyle of this population and their low follow-through with treatments, tend towards minimalist interventions that lack the dedication they would apply to other groups of patients.

CONCLUSIONS

The conclusions derived from this study convey the infrequent use of health services by homeless individuals for reasons attributable to the population itself, to healthcare workers and to the entire healthcare system. Accordingly, to reduce inequities of access to these services, recommendations to healthcare service providers include adapting facilities to provide more adequate care for this population; increasing sensitivity/awareness among healthcare workers; developing in situ care systems in places where the homeless population is most concentrated; and establishing healthcare collaboration agreements with entities that work with this population.

Reducing health inequities for asylum seekers with chronic non-communicable diseases: Australian context

Asylum seekers are susceptible to chronic non-communicable diseases pre- and post-arrival due to poor living conditions, unhealthy lifestyles and restrictive and poor access to health services. Despite their need for constant and continuous health care access due to poor health, they face healthcare services access restrictions dependent on their visa conditions in Australia. Some visas only allow access to hospital services with restrictions on primary health services access such as GPs and free or discounted pharmaceutical products. In comparison, disadvantaged host populations have access to free/discounted pharmaceutical products and unrestricted access to primary and secondary health care. Ten professionals who constantly engage with asylum seekers in three large asylum seeker centres in Melbourne were interviewed either face-to-face or over the phone. The interviews were essential to understand how health inequities may be addressed for asylum seekers. Interviews were audio-recorded, transcribed verbatim and analysed using a thematic analysis framework. Their recommendations, based mainly on their experience and evaluation of programs, were: (1) cultural competence training; (2) use of interpreters; (3) free access to health services and medications; (4) use of English learning to promote health literacy and community integration; (5) robust chronic non-communicable diseases screening; and (6) health promotion and accessible food programs.

The barriers and facilitators to the telephonic application of the FAST assessment for stroke in a private emergency dispatch centre in South Africa

BACKGROUND

Stroke is one of the leading contributors to morbidity and mortality globally. The incidence of stroke is on the increase in Sub-Saharan countries such as South Africa. As stroke is a time-sensitive condition, emergency medical services (EMS) play an important role in the early recognition of stroke. The telephonic application of the FAST (Face, Arm, Speech, Time) assessment has been suggested to screen patients for stroke, but this is not applied consistently. This study aimed to identify the barriers and facilitators to the telephonic application of the FAST assessment.

METHODS

This retrospective, exploratory study sampled 20 randomly selected emergency calls to a private EMS in South Africa, with suspected stroke. After verbatim self-transcription, data were analysed using inductive content analysis to identify the barriers and facilitators to the application of the FAST assessment. Results were arranged according to themes.

RESULTS

Results indicated that in 15/20 (75%) of the calls, the FAST assessment was successfully applied. Eight barriers under three themes (practical barriers, emotionality, and knowledge and understanding) and three facilitators under one theme (clear communication) were identified. Most notably, language discordance, lack of empathy and caller frustration featured prominently as barriers while caller cooperation and clear instructions were prominent facilitators.

CONCLUSION

With the barriers known, methods to address these may be constructed. Additional training and credentialing for call-takers may be a reasonable first step. These lessons can likely be applied to other telephonic acuity and recognition algorithms.

Developing an evidence assessment framework and appraising the academic literature on migrant health in Malaysia: a scoping review

BACKGROUND

A large number of international migrants in Malaysia face challenges in obtaining good health, the extent of which is still relatively unknown. This study aims to map the existing academic literature on migrant health in Malaysia and to provide an overview of the topical coverage, quality and level of evidence of these scientific studies.

METHODS

A scoping review was conducted using six databases, including Econlit, Embase, Global Health, Medline, PsycINFO and Social Policy and Practice. Studies were eligible for inclusion if they were conducted in Malaysia, peer-reviewed, focused on a health dimension according to the Bay Area Regional Health Inequities Initiative (BARHII) framework, and targeted the vulnerable international migrant population. Data were extracted by using the BARHII framework and a newly developed decision tree to identify the type of study design and corresponding level of evidence. Modified Joanna Briggs Institute checklists were used to assess study quality, and a multiple-correspondence analysis (MCA) was conducted to identify associations between different variables.

RESULTS

67 publications met the selection criteria and were included in the study. The majority (n=41) of studies included foreign workers. Over two-thirds (n=46) focused on disease and injury, and a similar number (n=46) had descriptive designs. The average quality of the papers was low, yet quality differed significantly among them. The MCA showed that high-quality studies were mostly qualitative designs that included refugees and focused on living conditions, while prevalence and analytical cross-sectional studies were mostly of low quality.

CONCLUSION

This study provides an overview of the scientific literature on migrant health in Malaysia published between 1965 and 2019. In general, the quality of these studies is low, and various health dimensions have not been thoroughly researched. Therefore, researchers should address these issues to improve the evidence base to support policy-makers with high-quality evidence for decision-making.

Southeast Asian health system challenges and responses to the 'Andaman Sea refugee crisis': A qualitative study of health-sector perspectives from Indonesia, Malaysia, Myanmar, and Thailand

BACKGROUND

Southeast Asian countries host signficant numbers of forcibly displaced people. This study was conducted to examine how health systems in Southeast Asia have responded to the health system challenges of forced migration and refugee-related health including the health needs of populations affected by forced displacement; the health systems-level barriers and facilitators in addressing these needs; and the implications of existing health policies relating to forcibly displaced and refugee populations. This study aims to fill in the gap in knowledge by analysing how health systems are organised in Southeast Asia to address the health needs of forcibly displaced people.

METHODS AND FINDINGS

We conducted 30 semistructured interviews with health policy-makers, health service providers, and other experts working in the United Nations (n = 6), ministries and public health (n = 5), international (n = 9) and national civil society (n = 7), and academia (n = 3) based in Indonesia (n = 6), Malaysia (n = 10), Myanmar (n = 6), and Thailand (n = 8). Data were analysed thematically using deductive and inductive coding. Interviewees described the cumulative nature of health risks at each migratory phase. Perceived barriers to addressing migrants' cumulative health needs were primarily financial, juridico-political, and sociocultural, whereas key facilitators were many health workers' humanitarian stance and positive national commitment to pursuing universal health coverage (UHC). Across all countries, financial constraints were identified as the main challenges in addressing the comprehensive health needs of refugees and asylum seekers. Participants recommended regional and multisectoral approaches led by national governments, recognising refugee and asylum-seeker contributions, and promoting inclusion and livelihoods. Main study limitations included that we were not able to include migrant voices or those professionals not already interested in migrants.

CONCLUSIONS

To our knowledge, this is one of the first qualitative studies to investigate the health concerns and barriers to access among migrants experiencing forced displacement, particularly refugees and asylum seekers, in Southeast Asia. Findings provide practical new insights with implications for informing policy and practice. Overall, sociopolitical inclusion of forcibly displaced populations remains difficult in these four countries despite their significant contributions to host-country economies.

Refugee women’s well-being, needs and challenges: implications for health policymakers

Background

Refugees face circumstances where their health and well-being are compromised. In this qualitative study, the aim was to understand Syrian refugee women’s needs for care and the predisposing and enabling factors to healthcare access and utilisation.

Methods

Out of 945 Syrian mothers who gave birth in our university hospital between 2014 and 2018, 195 were reached; out of which, 47 women were included. Semi-structured in-depth interviews were conducted and were later analysed using a qualitative content analysis approach. Depression was assessed by the Patient Health Questionnaire-9 at the end of the interview.

Results

Social isolation and maternal depression, language barrier and challenges while navigating the healthcare system emerged as the main themes of the study. Low educational and occupational status of the women, poor social resources, limited Turkish proficiency and unfamiliarity with the host healthcare system were identified as the predisposing factors for poor healthcare services utilisation.

Conclusion

Recommendations include bridging language gaps, improving the navigation of the healthcare system by visual support or in-person interpretation, and psychosocial support. Providing hospital-based language courses to mothers and social integration programs for families will improve the mothers’ well-being and indirectly care of the child.

Exclusion of Migrant Workers from National UHC Systems-Perspectives from HealthServe, a Non-profit Organisation in Singapore

Low-wage migrant workers in Singapore are legally entitled to healthcare provided by their employers and supported by private insurance, separate from the national UHC (universal health coverage) system. In practice, they face multiple barriers to access. In this article, we describe this policy-practice gap from the perspective of HealthServe, a non-profit organisation that assists low-wage migrant workers. We outline the healthcare financing system for migrant workers, describe commonly encountered barriers, and comment on their implications for the global UHC movement’s key ethical concepts of fairness, equity, and solidarity.

Telephonic description of sepsis among callers to an emergency dispatch centre in South Africa

Introduction

Sepsis is an acute, life-threatening condition caused by a dysregulated systemic response to infection. Early medical intervention such as antibiotics and fluid resuscitation can be life-saving. Diagnosis or suspicion of sepsis by an emergency call-taker could potentially improve patient outcome. Therefore, the aim was to determine the keywords used by callers to describe septic patients in South Africa when calling a national private emergency dispatch centre.

Methods

A retrospective review of prehospital patient records was completed to identify patients with sepsis in the prehospital environment. A mixed-methods design was employed in two-sequential phases. The first phase was qualitative. Thirty cases of sepsis were randomly selected, and the original call recording was extracted. These recordings were transcribed verbatim and subjected to content analysis to determine keywords of signs and symptoms telephonically. Once keywords were identified, an additional sample of sepsis cases that met inclusion and exclusion criteria were extracted and listened to. The frequency of each of the keywords was quantified.

Results

Eleven distinct categories were identified. The most prevalent categories that were used to describe sepsis telephonically were: gastrointestinal symptoms (40%), acute altered mental status (35%), weakness of the legs (33%) and malaise (31%). At least one of these four categories of keywords appeared in 86% of all call recordings.

Conclusion

It was found that certain categories appeared in higher frequencies than others so that a pattern could be recognised. Utilising these categories, telephonic recognition algorithms for sepsis could be developed to aid in predicting sepsis over the phone. This would allow for dispatching of the correct level of care immediately and could subsequently have positive effects on patient outcome.

Prevalence of latent tuberculosis among refugee children in Malaysia

Introduction

Tuberculosis remains one of the top 10 major causes of global mortality, imposing social-economic and medical challenges in Malaysia. Refugees sheltered in Malaysia are a high-risk population but basic health checks upon their arrival, including tuberculosis screening, are not practised. This study aimed to identify the prevalence and risk factors of tuberculosis and latent tuberculosis infection (LTBI) among refugee children in Malaysia.

Methods

A cross-sectional study was performed in three refugee schools in the Klang Valley, Malaysia, using tuberculin skin tests or interferon-γ release assays. Participants who tested positive were sent for further examination with chest radiography to confirm the tuberculosis diagnosis.

Results

From April 2018 to April 2019, we screened 430 refugee children with a median age of 13.0 years. Most of the children were born in Myanmar (n=274, 63.7%) and Pakistan (n=60, 14.0%). No children were diagnosed with active tuberculosis but 55 of the children (12.8%) were diagnosed with LTBI. Children with LTBI were generally older (OR 3.01, 95% CI 1.71-5.29; p<0.001) than those without LTBI infection. Sex, history of bacille Calmette-Guérin vaccination and country of birth were not associated with increased risk of LTBI.

Conclusion

The relatively high LTBI burden among refugee children in this study poses an indication of possible LTBI risk among this population nationwide, and thus would be an important group to target for preventive therapy. This provides a unique opportunity for researchers to further examine and implement well-structured preventive strategies in combating the endemic infectious disease in Malaysia.