Utilisation of dental services by refugees in Germany: Results of the population-based RESPOND survey

Background

The utilisation of outpatient dental services is an important indicator for monitoring healthcare provision in Germany. In the general population, the 12-month prevalence of dental service utilization is 82.2 %. For refugees, this indicator has hardly been measured, although studies suggest an objectively high need for dental care.

Methodology

As part of the population-based cross-sectional RESPOND study (2018), self-reported health and healthcare, including the use of dental services, was assessed in three representative, random samples of refugees residing in reception and shared accommodation centres in Baden-Württemberg and Berlin.

Results

The indicator was available for 68.8 % (594) of the 863 surveyed refugees. Overall, 38.2 % of the respondents stated that they had utilised dental services in the previous 12 months, whereas 41.4 % had never used any dental care in Germany.

Conclusions

The utilisation of dental services among refugees is very low compared to the level of utilisation in the general population. It reflects a discrepancy between access and needs.

Context, health and migration: a systematic review of natural experiments

Background

Migration health research pays little attention to the places into which people migrate. Studies on health effects of contextual factors are often limited because of the ability of individuals to self-select their environment, but natural experiments may allow for the causal effect of contexts to be examined. The objective was to synthesise the evidence on contextual health effects from natural experiments among migrant groups.

Methods

We performed a systematic review of natural experiments among migrant populations in PubMed/MEDLINE, The Cochrane Library, Web of Science, CINAHL and Google Scholar for literature published until 13 October 2022. 5870 articles were screened in duplicate using the following inclusion criteria: quantitative natural experiment design, migrant population, context factor as treatment variable and health or healthcare outcome variable. Synthesis without meta-analysis was performed following quality appraisal using the EPHPP tool for quantitative studies and data extraction (PROSPERO: CRD42020169236).

Findings

The 46 included articles provide evidence for negative effects of neighbourhood disadvantage on physical health and mortality, while finding mixed effects on mental health. Articles comparing migrants with those that stayed behind demonstrate detrimental effects of migration and adverse post-migratory contexts on physical health and mortality, while demonstrating favourable effects for mental and child health. Natural experiments of policy environments indicate the negative impacts of restrictive migration and social policies on healthcare utilization, mental health and mortality, as well as the positive health effects when restrictions are lifted.

Interpretation

Natural experiments complement observational studies and provide robust evidence to advocate for more inclusive migration, health and social policies as well as neighbourhood improvement programmes. In order to strengthen the methodological approach, future research utilising natural experiments should be more explicit in the mechanisms underlying the experiment and provide details on potential causal mechanisms for the observed effects.

Funding

German Science Foundation (FOR: 2928/GZ: BO5233/1-1).

Contextual effects on health: systematic review of studies using natural experiments among migrants

Background

Many studies on contextual health effects suffer from compositional bias and selective migration into neighbourhoods. Longitudinal natural experiments have the potential to overcome these limitations, and there are several opportunities for this research design in the migration context. We aimed to synthesize evidence from natural experiments among migrants studying the effect of contextual factors on health and healthcare.

Methods

Peer-reviewed literature in English or German was systematically searched in four major databases in December 2021. Following systematic abstract- and fulltext-screening, 32 studies were included for analysis. Evidence on contextual impacts on physical and mental health, mortality, and healthcare was narratively synthesized and quality appraisal conducted.

Results

We found four types of contextual health effects: factors of the place of residence in receiving countries (n = 6), migration-context interactions (n = 10), policy environments (n = 15) and cultural factors (n = 1). Results show the negative impacts of post-migratory contexts on physical health and mortality and the favourable impacts on child health. Impacts on mental health are mixed. Analyses of policy contexts indicate the negative impacts of restrictive migration and social policies on healthcare utilization, mental health and mortality as well as the positive effects when restrictions are lifted.

Conclusions

Natural experiments can serve as powerful tools in disentangling the effect of context on health and reducing bias through self-selection. Results demonstrate the negative impacts for health which lie at the nexus of migration and neighbourhood disadvantage. At the same time, studies uncover the potential of health, welfare and visa programs to counteract such disadvantages and create healthy post-migratory contexts. With careful consideration of causal pathways, results from migration contexts can serve as a magnifying glass for effects of context in other population groups.

Key messages

• Natural experiments can serve as powerful tools in disentangling the effect of context on health and reduce bias through self-selection.

• Results show the negative impacts for health that lie at the nexus of migration and neighborhood disadvantage, as well as the potential of inclusionary policies to counteract them.

COVID-19 among migrants, refugees, and IDPs: a synthesis of the global empirical literature

Background

The COVID-19 syndemic reveals social and health inequalities, putting marginalized groups such as migrants at greater risk. Yet health systems fail to routinely monitor the health of migrants, refugees, and internally displaced persons. Our systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 infection risk, transmission, outcome of disease and risk of severe course of disease among migrant populations. It further aims to compile extant evidence on COVID-19 vaccination coverage among these groups, and on the effects of pandemic control measures on their health.

Methods

Following PRISMA guidelines, we registered a review protocol, searched 14 scientific databases and 4 pre-print servers using the WHO database of global literature on COVID-19, and hand-searched relevant websites for grey literature. The search period covers the time from 12/2019 to 11/30/2021. Articles in English, German and Spanish and all study designs were included.

Results

A total of 6966 references were identified for title and abstract screening. 518 records were screened in full-text, out of which 204 articles were included so far (conflict solving at full-text stage and data extraction are ongoing). Our review presents a broad landscape of different study designs, migrant populations and COVID-19 outcomes. Based on previous work, we expect to find a higher risk of infection in migrants and their disproportionate share among COVID-19 cases, and consolidate the (mental) health impacts of pandemic control measures. Our preliminary findings indicate a vast knowledge gap on vaccination coverage among migrant groups.

Conclusions

Two years into the syndemic, this review summarizes the global empirical evidence on the impact of the COVID-19 syndemic on migrant populations. With health systems often lacking related data, the review provides an important evidence base for the consideration of migrants in future pandemic preparedness policies.

Key messages

• The systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 among diverse migrant populations globally.

• Knowledge on vaccination coverage in migrants remains patchy.

From Research into Practice: Converting Epidemiological Data into Relevant Information for Planning of Regional Health Services for Refugees in Germany

Health data of refugees and asylum seekers (ASR) is not routinely collected in Germany. Based on health data of ASR collected in 2018 in regional accommodation centres, we developed a dashboard to estimate regional burden of disease in Baden-Wuerttemberg, Germany. We aimed to find out how scientific data can support actors involved in healthcare planning for ASR in Germany and, within this scope, to explore how healthcare planning is conducted in this context. We conducted 12 qualitative semi-structured interviews including a usability test for a health data dashboard with regional decision-makers. Results showed that healthcare planning processes for ASR in Germany involve a complex set of actors in both long- and short-term decision-making. Data gained from representative surveys can support long-term decision-making and thus support the resilience of the health system, but it must balance the need for simple data presentation with transparent communication of potentially complex methods.

SARS-CoV-2 attack rate in reception and accommodation centres for asylum seekers during the first wave: systematic review of outbreak media reports in Germany

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Sars-CoV-2 attack rate in asylum reception centers in Germany during the first wave was 13%.

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Mass quarantine was imposed in 75% of outbreaks, but was associated with higher attack rate.

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Recommended standards of isolation of infected persons not always implemented.

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Protective measures for vulnerable individuals reported for minority of outbreaks.

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Implementation of adequate infection control measures is required despite vaccine availability.

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Mass quarantine should be avoided.

Objectives

Despite concerns about the impact of the severe acute respiratory syndrome corona virus (SARS-CoV-2) in refugee camps, data on attack rates and effectiveness of containment measures are lacking. We aimed to (1) quantify the attack rate of SARS-CoV-2 during outbreaks in reception and accommodation centres in Germany during the first pandemic wave, (2) assess differences in the attack rate based on containment measures, and (3) provide an overview of testing strategies, communication, conflicts, and protection measures for refugees with special needs.

Methods

Systematic web-based review of outbreak media reports (until June 2020) on confirmed SARS-CoV-2 cases in reception centres for asylum seekers in Germany using the google search engine. Reports were screened for pre-defined inclusion criteria and complemented by snowball searches. Data on facility name, location, confirmed cases, containment measures, communication, protection strategies, and conflicts was extracted for each outbreak and reporting date. Evidence synthesis: meta-analysis and negative binomial regression.

Findings

We identified 337 media reports on 101 SARS-CoV-2 outbreaks in 99 reception and accommodation centres in Germany. The pooled SARS-CoV-2 attack rate was 13.1% (95% confidence interval, CI: 9.8–16.7). Outbreak sites implementing mass quarantine (n = 76) showed higher rates (15.7; 95% CI: 11.6–20.2) compared to sites using conventional strategies (6.6; 95% CI: 3.1–11.2), yielding a rate ratio of 0.44 (95% CI: 0.27–0.72) adjusted for testing strategies, type and size of accommodation. Conflicts occurred in at least 11.8% of all outbreaks. Few sites reported specific measures to protect refugees with special needs.

Conclusion

Mass quarantine is associated with higher attack rates, and appears to be a counter-productive containment measure in overcrowded camps, but further research with individual-level data is required to rule out residual confounding. Despite available vaccines, reception centres and refugee camps should follow the available guidelines on COVID-19 response and refrain from mass quarantine if physical distancing cannot be guaranteed.

Housing and health: An empirical framework for refugee reception centres

Background

Housing is a key social determinant of health. Newly arriving asylum seekers and refugees (ASR) in Germany are assigned to reception centres (RC), comprising large, shared facilities in remote locations. Our aim was to explore how housing affects health from the perspective of ASR in order to develop an empirical framework for further research.

Methods

We conducted a secondary analysis of 47 qualitative interviews with ASR living in German RC and developed a multidimensional framework containing the effects of housing characteristics on health in this setting. An initial coding scheme with five dimensions was developed from the literature: material aspects, meaningful aspects, housing as an expression of socioeconomic status, community, and immediate environment. Using thematic analysis, sub-codes were generated inductively, resulting in the final framework.

Results

Important material aspects included building structure, basic amenities, sharing of living space and food provision. Among these, room sharing and food provision were particularly relevant for participants. Meaningful dimensions important for health included autonomy, privacy, safety and stability, which were limited in RC due to missing door locks, room sharing, restrictions of movement and frequent transfers between centres. Based on participants' statements, the community was divided into “outside” and “inside” the RC, which, unlike the “outside” community, have collective and organisational characteristics. We subsumed statements about distances to services and amenities into immediate environment. However, participants reported that short distances did not always guarantee access.

Conclusions

We identified important interdependent dimensions of housing which affect health and well-being among ASR and consolidated them into an empirical framework which can serve as a basis for further research, including the future development of measurement instruments to assess effects of housing on ASR health.

Key messages

ASR narratives show that housing dimensions with importance for health in reception centres have specific characteristics and are interdependent. We developed a framework which can be used for further research on the effects of housing on ASR health in this setting, including the construction of quantitative measurement instruments.

SARS-CoV-2 among migrants and forcibly displaced populations: A rapid systematic review

The economic and health consequences of the COVID-19 pandemic pose a particular threat to vulnerable groups, such as migrants, particularly forcibly displaced populations. The aim of this review is (i) to synthesize the evidence on risk of infection and transmission among migrants, refugees, asylum seekers and internally displaced populations, and (ii) the effect of lockdown measures on these populations. We searched MEDLINE and WOS, preprint servers, and pertinent websites between 1st December 2019 and 26th June 2020. The included studies showed a high heterogeneity in study design, population, outcome and quality. The incidence risk of SARS-CoV-2 varied from 0•12% to 2•08% in non-outbreak settings and from 5•64% to 21•15% in outbreak settings. Migrants showed a lower hospitalization rate compared to non-migrants. Negative impacts on mental health due to lockdown measures were found across respective studies. However, findings show a tenuous and heterogeneous data situation, showing the need for more robust and comparative study designs.

Monitoring the health and healthcare provision for refugees in collective accommodation centres: Results of the population-based survey RESPOND

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.