Improving the information base regarding the health of people with a migration background.Project description and initial findings from IMIRA

Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems.

Funding

No specific funding received.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

GEDA Fokus was an interview survey among people with Croatian, Italian, Polish, Syrian, or Turkish citizenship living in Germany aged 18 - 79 years, with a targeted sample size of 1,200 participants per group. The gross sample of 33,436 people was drawn out of the residents' registration offices of 99 German municipalities based on citizenship. Sequentially, multiple modes of administration were offered. The questionnaire was available for self-administration (online and paper-based); in bigger municipalities, personal or phone interviews were possible later on. Study documents and the questionnaire were bilingual, in German and the respective translation language depending on the citizenship. Data collection took place from November 2021 until May 2022.

RESULTS

Overall, 6,038 respondents participated in the survey, 49.4% were female. The median age was 39 years, and the median duration of residence in Germany was 10 years, with 19.7% of the sample being born in Germany. The overall response rate was 18.4% (AAPOR response rate 1) and was 6.8% higher in the municipalities where personal interviews were offered (19.3% vs. 12.5%). Overall, 78.2% administered the questionnaire on their own, while 21.9% took part in a personal interview. A total of 41.9% answered the questionnaire in German language only, 16.7% exclusively used the translation, and 41.4% used both languages in the bilingual version of the questionnaire.

CONCLUSIONS

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

CLINICALTRIAL

Investigating people's attitudes towards participating in longitudinal health research: an intersectionality-informed perspective

BACKGROUND

Increasing evidence suggests that participation proportions in longitudinal health research vary according to sex/gender, age, social class, or migration status. Intersectionality scholarship purports that such social categories cannot be understood in isolation and makes visible the co-dependent nature of the social determinants of health and illness. This paper uses an intersectionality-informed approach in order to expand the understanding of why people participate in health research, and the impact of intersecting social structures and experiences on these attitudes.

METHODS

A sample of 80 respondents who had previously either accepted or declined an invitation to participate in the German National Cohort (NAKO) participated in our interview study. Interviews were semi-structured and contained both narrative elements and more structured probes. Data analysis proceeded in two steps: first, the entire data set was analysed thematically (separately for participants and non-participants); second, key themes were compared across self-reported sex/gender, age group and migration status to identify differences and commonalities.

RESULTS

Respondents' attitudes towards study participation can be categorised into four themes: wanting to make a contribution, seeking personalised health information, excitement and feeling chosen, and seeking social recognition. Besides citing logistical challenges, non-participants narrated adverse experiences with or attitudes towards science and the healthcare system that deterred them from participating. A range of social experiences and cultural value systems shaped such attitudes; in particular, this includes the cultural authority of science as an arbiter of social questions, transgressing social categories and experiences of marginalisation. Care responsibilities, predominantly borne by female respondents, also impacted upon the decision to take part in NAKO.

DISCUSSION

Our findings suggest that for participants, health research constitutes a site of distinction in the sense of making a difference and being distinct or distinguishable, whereas non-participants inhabited an orientation towards science that reflected their subjective marginalisation through science. No clear relationship can thereby be presumed between social location and a particular attitude towards study participation; rather, such attitudes transgress and challenge categorical boundaries. This challenges the understanding of particular populations as more or less disadvantaged, or as more or less inclined to participate in health research.

Protagonist der Sozialepidemiologie: Laudatio zu Ehren von PD Dr. PH Thomas Lampert – Träger der Salomon-Neumann-Medaille 2022

The Salomon Neumann Medal of the German Society for Social Medicine and Prevention (DGSMP) honours individuals and institutions who have made special contributions to preventive and social medicine. In 2022, the medal was awarded to PD Dr. Thomas Lampert, Robert Koch Institute, who has been a strong advocate for reporting on health inequalities in Germany for many years. His extensive work provides a precise cartography of the social determinants of health in Germany after the turn of the millennium.

Investigating associated factors of primary and specialist health care utilization among people with selected nationalities: results of a multilingual survey in two German federal states

BACKGROUND

Approximately every fourth person in Germany has a migration background. Health research on the use of primary and specialist health care in this group is still scarce. Few studies have suggested a difference in the use of primary and specialist health care among people with a migration background. Potential resources and barriers to health care access should be investigated as they are critical to health equity. This study investigates associated sociodemographic, migration-sensitive, and health-related factors of primary and specialist health care utilization among people with a migration background as defined by nationality.

METHODS

Analyses are based on data from a feasibility study of the project "Improving Health Monitoring in Migrant Populations" (IMIRA), conducted by the Robert Koch Institute. The sample (n = 1055) included persons with Croatian, Polish, Romanian, Syrian, and Turkish nationalities living in the federal states of Berlin and Brandenburg, Germany. Descriptive and bivariate analyses as well as multiple binary logistic regression analyses were carried out to assess sociodemographic (sex, age, socioeconomic position), health-related (self-rated health), and migration-sensitive factors (duration of residence in Germany, residence status, German language proficiency) associated with the use of primary and specialist health care services in the past 12 months.

RESULTS

Of the total study population, 79.62% visited a general practitioner and 59.53% a specialized physician in the past 12 months. Participants who were female sex, aged 65 and older, and with moderate/poor/very poor self-rated health had higher odds of visiting a general practitioner and a specialized physician, with the strongest impact from self-rated health. After controlling for sociodemographic and health-related factors, duration of residence in Germany and residence status were associated with primary but not with specialist health care utilization.

CONCLUSIONS

Our results suggest that migration-sensitive characteristics, such as duration of residence, should be considered in a differentiated manner in health services research to gain detailed insights into health care utilization and its potential barriers among the heterogenous group of people with a migration background. Further research needs to be done to evaluate how to get people into contact with a general practitioner.

Pictorial Assessment of Health-Related Quality of Life. Development and Pre-Test of the PictoQOL Questionnaire

The aim of the present study was to develop a pictorial questionnaire for the assessment of health-related quality of life (PictoQOL) and to examine its content validity and usability across three exemplary population groups of different origin residing in Germany (non-migrants, Turkish migrants and Arabic-speaking migrants). A mixed-methods design combining qualitative and quantitative methods was used, comprising 6 focus group discussions with a total of 17 participants, 37 cognitive interviews and a quantitative pretest with 15 individuals. The PictoQOL consists of a pictorial representation of a total of 15 different situations. Using a visual Likert scale, respondents indicate how much each situation applies to them. Some representations proved to be culturally sensitive and were adapted. Respondents found the use of an additional graphic layer in the form of symbols in addition to pictures helpful for interpretation. The PictoQOL is considered to allow a more accessible assessment and better comparability of HRQOL across different population groups regardless of their literacy level. It is therefore considered to be superior to existing instruments for routine use in health research and practice. Future studies need to examine its convergent and factorial validity.

Prevalence of Hepatitis B, C, and D in Germany: Results From a Scoping Review

Background: One of the five strategic directions in the World Health Organization global health sector strategy on viral hepatitis 2016-2021 is to generate strong strategic information for focused action to understand the viral hepatitis epidemic and focus the response. Knowledge of national prevalence is a cornerstone of strategic information. Germany is considered to be a low prevalence country for viral hepatitis B, C, and D, however the prevalence is likely to be higher among at-risk groups. Methods: The aim of this work was to give a detailed overview of the prevalence of viral hepatitis B (HBsAg, anti-HBc), C (anti-HCV, HCV RNA), and D (anti-HDV, HDV RNA) in different population groups in Germany. Therefore, we analyzed the results of a comprehensive literature search on various aspects of the epidemiological situation of hepatitis B, C, and D in Germany. Eligible publications including information on hepatitis B, C, and D prevalence were extracted from the overall spreadsheet table and summarized and analyzed based on virus and different population groups. A quality appraisal was performed using a checklist developed by Hoy et al. to assess risk of bias in prevalence studies. Results: Overall, 51 publications were identified through the literature search. The overall prevalence of HBsAg in the general (and proxy) population ranged from 0.3 to 1.6%. Among at-risk groups, including clinical populations and health care workers, the HBsAg prevalence ranged from 0.2% (among rheumatic patients) to 4.5% among HIV positive patients. The overall prevalence of anti-HCV in the general (and proxy) population ranged from 0.2 to 1.9%. Among at-risk groups, including clinical populations and health care workers, the anti-HCV prevalence ranged from 0.04% (among health care workers) to 68.0% among people who inject drugs. Conclusions: The hepatitis B and C prevalence in the general population in Germany is low. Prevalence is high to very high among at-risk populations, however for some groups evidence was incomplete or missing completely. To reach the elimination goals in Germany and implement a targeted response, more research among at-risk groups is needed.

The health of children and adolescents with a migration background in Germany - Results of the cross-sectional KiGGS Wave 2 study

Over a third (36.5%) of young people living in Germany have a migration background. Based on the data of the second follow-up to the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017), the health situation of 11- to 17-year-olds with and without a migration background is described using selected indicators. In order to account for the diversity among children and adolescents with a migration background, the health indicators used in this study are stratified by migration background but also by additional migration-related characteristics. In addition, the results from the various subgroups are also stratified by sociodemographic characteristics. No differences in self-assessed general health or the outpatient utilisation of paediatric and general medical services were identified between 11- to 17-year-olds with and without a migration background. However, migration-related differences were identified in health behaviour: whereas children and adolescents with a one- or two-sided migration background are more frequently overweight (including obesity), they consume risky amounts of alcohol less often than those of the same age without a migration background. Finally, the outcomes of the indicators also vary according to migration-related and sociodemographic characteristics.

Concepts for migration-sensitive health monitoring

According to microcensus data, nearly one quarter of the German population has a migration background. This means that either themselves or at least one parent was born without German citizenship. Based on the currently available data and due to the underrepresentation of specific population groups, representative findings on the health of the total population residing in Germany are only possible to a limited degree. Against this backdrop, the Robert Koch Institute initiated the Improving Health Monitoring in Migrant Populations (IMIRA) project. The project aims to establish a migration-sensitive health monitoring system and to better represent people with a migration background in health surveys conducted by the Robert Koch Institute. In this context it is crucial to review and further develop relevant migration-sensitive concepts and appropriate surveying instruments. To achieve this, the concepts of acculturation, discrimination, religion and subjective social status were selected. This article theoretically embeds these concepts. Furthermore, we describe their application in epidemiology as well as provide a proposal on how to measure and operationalise these concepts. Moreover, recommendations for action are provided regarding the potential application of these concepts in health monitoring at the Robert Koch Institute.

Health reporting on people with a migration background - Selection and definition of (core) indicators

As part of the project Improving Health Monitoring in Migrant Populations (IMIRA), a (core) set of indicators was developed to describe the health of people with a migration background. This work was underpinned by research into and assessment of relevant data sources in the field of migration and health. Initially, four fields of action were identified together with a number of associated topics and potential indicators for each of the area's individual topics. The choice of core indicators was based on (1) a systematic comparison of widely accepted indicator systems, (2) an assessment of public health relevance, (3) comprehensibility and (4) informative value, as well as (5) the availability of (largely) representative data that could properly account for the diversity of the migrant population. The (core) indicator set was finalised using an internal and external indicator development process that involved an interdisciplinary expert panel. This resulted in the selection of 25 core indicators; 41 additional indicators were documented as part of an 'extended' indicator set. The (core) set of indicators is to be continually developed in line with the work being undertaken to improve the integration of people with a migration background in the health monitoring conducted at the Robert Koch Institute. In the future, the indicator set is to be incorporated into an overall concept to regular, migration-related health reporting.