Effect of area-level socioeconomic deprivation on mental and physical health: A longitudinal natural experiment among refugees in Germany.

Existing studies on contextual health effects struggle to account for compositional bias, limiting causal interpretation. We use refugee dispersal in Germany as a natural experiment to study the effect of area-level socioeconomic deprivation on mental and physical health, while considering the potential mediating role of neighbourhood characteristics. Refugees subject to dispersal (n = 1466) are selected from a nation-wide longitudinal refugee study (IAB-SOEP-BAMF Panel; 2016-2018). Multi-level linear regression models, adjusted for age, sex, education, country of origin, federal state, asylum status and length of residence in Germany, are fitted to the change in mental and physical health subscales of the SF-12 depending on quintiles (Q1 - Q5) of commune-level socioeconomic deprivation (German Index of Socioeconomic Deprivation, GISD). This is followed by sensitivity analyses and mediation analyses for housing, social cohesion, proportion of non-citizens in the neighbourhood, access to green space, population density and primary care physician density. Residency in districts with moderate-high deprivation (Q4) has a negative impact on physical health (coef.: -2.2, 95%CI: -4.1;-0.2) compared to lowest deprivation (Q1). Moderate-high deprivation (Q4) has a positive impact on mental health, but the effect is statistically insignificant (coef.: 1.6, 95%CI: -0.7; 3.9). Comparisons with other deprivation quintiles are statistically insignificant. Sensitivity analyses confirm results of the final models, while no mediating factors show a substantial impact on the observed relationship. The results point to gaps in health and social service provision for refugees living in the most deprived regions, but further research is required to understand the precise mechanisms behind the observed relationships. Further research using longer timeframes and larger sample sizes are required to confirm results.

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.

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

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

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).

Type of Refugee Accommodation and Health of Residents: A Cross-Sectional, Population-Based Cluster Analysis in South-West Germany.

Objectives: Few studies have assessed whether refugees' health is associated with accommodation characteristics. We aimed to devise a typology of refugee accommodation based on variables on the accommodation and its physical context before assessing its association with health in multivariate analyses. Methods: We performed a cluster analysis based on a hierarchal, agglomerative clustering algorithm using Euclidean Distance and Ward's method. We analysed accommodation clusters based on number of inhabitants, degree of housing deterioration, urbanity of location (urban/rural distinction), and remoteness (walking distance to shops, medical or administrative services). In total, we analysed health and accommodation data of 412 refugees and asylum seekers from 58 different accommodation facilities in the federal state of Baden-Württemberg in the south-west of Germany. Results: Accommodations with a moderate occupation, lowest levels of deterioration, and a central urban location showed the best health outcomes in terms of subjective general health status, depression, and generalized anxiety disorder (GAD). Associations were strongest for GAD and weakest for depression. Conclusion: Our findings inform policymakers on layout and location of refugee collective accommodation centres.

Ensuring cross-cultural data comparability by means of anchoring vignettes in heterogeneous refugee samples.

BACKGROUND: Configural, metric, and scalar measurement invariance have been indicators of bias-free statistical cross-group comparisons, although they are difficult to verify in the data. Low comparability of translated questionnaires or the different understanding of response formats by respondents might lead to rejection of measurement invariance and point to comparability bias in multi-language surveys. Anchoring vignettes have been proposed as a method to control for the different understanding of response categories by respondents (the latter is referred to as differential item functioning related to response categories or rating scales: RC-DIF). We evaluate the question whether the cross-cultural comparability of data can be assured by means of anchoring vignettes or by considering socio-demographic heterogeneity as an alternative approach. METHODS: We used the Health System Responsiveness (HSR) questionnaire and collected survey data in English (n = 183) and Arabic (n = 121) in a random sample of refugees in the third largest German federal state. We conducted multiple-group Confirmatory Factor Analyses (MGCFA) to analyse measurement invariance and compared the results when 1) using rescaled data on the basis of anchoring vignettes (non-parametric approach), 2) including information on RC-DIF from the analyses with anchoring vignettes as covariates (parametric approach) and 3) including socio-demographic covariates. RESULTS: For the HSR, every level of measurement invariance between the Arabic and English languages was rejected. Implementing rescaling or modelling on the basis of anchoring vignettes provided superior results over the initial MGCFA analysis, since configural, metric and - for ordered categorical analyses-scalar invariance could not be rejected. A consideration of socio-demographic variables did not show such an improvement. CONCLUSIONS: Surveys may consider anchoring vignettes as a method to assess cross-cultural comparability of data, whereas socio-demographic variables cannot be used to improve data comparability as a standalone method. More research on the efficient implementation of anchoring vignettes and further development of methods to incorporate them when modelling measurement invariance is needed.

[Early crisis response to the COVID-19 pandemic in collective accommodation facilities for refugees : Analysis of cross-actor working arrangements from the perspective of the reception authorities in Germany]. / Krisenreaktion zu Beginn der COVID-19-Pandemie in Sammelunterkünften für Geflüchtete : Analyse der akteursübergreifenden Zusammenarbeit aus Perspektive der Aufnahmebehörden in Deutschland.

BACKGROUND: Refugees in collective accommodation facilities are at increased risk of COVID-19-infections due to high occupancy density and shared spaces. It is unclear which (organisational) actors the reception authorities were working with in their crisis response and how. The aim of this paper is to examine the working arrangements between reception authorities and other actors involved in accommodation and (health) care during the first wave of the COVID-19 pandemic and to derive recommendations for future crisis responses. METHODS: The analysis was based on qualitative interviews with representatives responsible for the reception and accommodation of refugees (N = 46) conducted from May to July 2020. Cross-actor networks were visualised, and a qualitative analysis of the data material was carried out using the framework method. RESULTS: The reception authorities worked with a multitude of other (organisational) actors. Health authorities, social workers and security personnel were mentioned most frequently. The crisis response was found to be highly heterogeneous due to its dependence on the commitment, knowledge and attitude of the individuals and organisations involved. In the absence of a coordinating actor, there may also be delays due to a "wait-and-see" attitude of the actors involved. CONCLUSION: Crisis response in collective accommodation facilities for refugees would benefit from a clear allocation of the coordinating role to an appropriate actor. Instead of improvised ad hoc solutions, sustainable improvements in terms of transformative resilience are needed to reduce structural vulnerabilities.

The Southern Ocean mixed layer and its boundary fluxes: fine-scale observational progress and future research priorities.

Interactions between the upper ocean and air-ice-ocean fluxes in the Southern Ocean play a critical role in global climate by impacting the overturning circulation and oceanic heat and carbon uptake. Remote and challenging conditions have led to sparse observational coverage, while ongoing field programmes often fail to collect sufficient information in the right place or at the time-space scales required to constrain the variability occurring in the coupled ocean-atmosphere system. Only within the last 10 years have we been able to directly observe and assess the role of the fine-scale ocean and rapidly evolving atmospheric marine boundary layer on the upper limb of the Southern Ocean's overturning circulation. This review summarizes advances in mechanistic understanding, arising in part from observational programmes using autonomous platforms, of the fine-scale processes (1-100 km, hours-seasons) influencing the Southern Ocean mixed layer and its variability. We also review progress in observing the ocean interior connections and the coupled interactions between the ocean, atmosphere and cryosphere that moderate air-sea fluxes of heat and carbon. Most examples provided are for the ice-free Southern Ocean, while major challenges remain for observing the ice-covered ocean. We attempt to elucidate contemporary research gaps and ongoing/future efforts needed to address them. This article is part of a discussion meeting issue 'Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities'.

Between Care and Coercion: Asylum Seekers' Experiences With COVID-19 Containment and Mitigation Measures in German Reception Centres.

Objectives: COVID-19 containment and mitigation measures have been criticised for amplifying pre-existing individual and structural vulnerabilities among asylum seekers. We qualitatively explored their experiences with and attitudes towards pandemic measures to inform people-centred responses in future health emergencies. Methods: We interviewed eleven asylum seekers in a German reception centre (July-December 2020). The semi-structured interviews were recorded, transcribed, and analysed thematically with an inductive-deductive approach. Results: Quarantine was experienced as burdensome by participants. Shortcomings in social support, everyday necessities, information, hygiene, and daily activities exacerbated the strains of quarantine. Interviewees held different opinions about the usefulness and appropriateness of the various containment and mitigation measures. These opinions differed by individual risk perception and the measures' comprehensibility and compatibility with personal needs. Power asymmetries related to the asylum system furthermore impacted on preventive behaviour. Conclusion: Quarantine can amplify mental health burdens and power asymmetries and can therefore constitute a considerable stressor for asylum seekers. Provision of diversity-sensitive information, daily necessities, and accessible psychosocial support is required to counteract adverse psychosocial impacts of pandemic measures and safeguard wellbeing in this population.

Local political climate and spill-over effects on refugee and migrant health: a conceptual framework and call to advance the evidence.

The health of refugees and migrants is determined by a wide range of factors. Among these, the local political climate in the postmigration phase is an important determinant which operates at interpersonal and institutional levels. We present a conceptual framework to advance theory, measurement and empirical evidence related to the small-area factors which shape and determine the local political climate, as these may translate into variations in health outcomes among refugees, migrants and other marginalised population groups. Using the example of Germany, we present evidence of small-area variation in factors defining political climates, and present and discuss potential pathways from local political climates to health outcomes. We show that anti-immigrant and antirefugee violence is a Europe-wide phenomenon and elaborate how resilience of individuals, communities, and the health system may function as moderator of the effects of the local political climate on health outcomes. Building on a pragmatic review of international evidence on spill-over effects identified in other racialised groups, we present a conceptual framework which incorporates direct effects as well as 'spill-over' effects on mental health with the aim to spark further academic discussion and guide empirical analysis on the topic. After presenting and discussing methodological challenges, we call for collective efforts to build coalitions between social sciences, conflict and violence studies, political science, data science, social psychologists and epidemiology to advance theory, measurement, and analysis of health effects of local political climates.

Conceptualising difference: a qualitative study of physicians' views on healthcare encounters with asylum seekers.

OBJECTIVES: In many high-income countries, structural, legal, social and political barriers to adequate healthcare interfere with the ability of health professionals to respond to the healthcare needs of a fluctuating and superdiverse population of asylum seekers. However, the relationship between individual, interpersonal and structural factors is not well understood. We explore the views and experiences of physicians working with asylum seekers in Germany and aim to identify how these may impact the provision of medical care. METHODS: A secondary analysis of 16 semistructured interviews conducted in two qualitative studies was performed. These explored the delivery of medical care to asylum seekers in Germany. In order to examine physicians' views towards their work with asylum seekers, we analysed evaluative judgements on interpersonal relationships, workplace factors, the external environment, the physician's own self and individual medical conduct. Analysis was conducted by identifying cross-cutting themes through thematic analysis and mapping these onto a framework matrix. RESULTS: Physicians perceive the provision of medical care to asylum seekers as 'different'. This 'difference' is conceptualised at three levels: patients' perceived cultural attributes, the workplace or contextual level. Evaluative judgements on patients perceived as 'other' and the difference of the space of care provision were found to impede appropriate care, while physicians emphasising contextual factors reported more responsive medical practices. CONCLUSIONS: Concepts of difference at patient level resemble processes of 'othering' asylum seekers as a 'different patient group', while differences in rules, norms and practices in settings of medical care to asylum seekers create heterotopic spaces. Both appear to endanger the doctor-patient relationship and responsiveness of care, while an understanding of differences attributed to context seemed to foster a more caring approach. Training in contextual competence, sufficient physical and human resources and encouraging support between physicians working with asylum-seeking patients could counteract these processes.

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.

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

BACKGROUND: Research on health and healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness, as non-medical quality of care, in the narratives of ASR patients recently arrived in Germany. METHODS: 31 ASR with existing medical conditions were recruited in six refugee reception centres and three psychosocial centres. Semi-structured, qualitative interviews were conducted which reconstructed their patient journey after arrival in Germany. Interviews were recorded, transcribed verbatim and evaluated using thematic analysis. RESULTS: The experiences of participants throughout the patient journey provided a rich and varied description of the responsiveness of health services. Some dimensions of responsiveness, including respectful treatment, clear communication and trust, resurfaced throughout the narratives. These factors were prominent reasons for positive evaluations of the health system, and negative experiences were reported in their absence. Other dimensions, including cleanliness of facilities, autonomy of decision-making and choice of provider were raised seldomly. Positive experiences in Germany were often set in contrast to negative experiences in the participants' countries of origin or during transit. Furthermore, many participants evaluated their experience with healthcare services in terms of the perceived technical quality of medical care rather than with reference to responsiveness. CONCLUSION: This qualitative study among ASR analysed patient experiences to better understand responsiveness of care for this population. While our results show high overall satisfaction with health services in Germany, using the lens of responsiveness allowed us to identify particular policy areas where care can be strengthened further. These include in particular the expansion of high-quality interpreting services, provision of professional training to increase the competency of healthcare staff in caring for a diverse patient population, as well as an alignment between healthcare and asylum processes to promote continuity of care.

Comparable worth of life for all? Conducting and disseminating health economic evaluations for refugees in Germany.

Comparative health economic evaluation is based on premise of being able to compare the worth of a year of life lived in full quality across different patients, population groups, settings and interventions. Given the rising numbers of forcibly displaced people, the nexus of economics, migration and health has emerged as a central theme in recent conceptual and empirical approaches. However, some of the assumptions made in conventional economic approaches do not hold true in the decision-making context of migration and the health of forcibly displaced populations. Using the experience of conducting and disseminating economic analyses to support decision-making on health screening policies for refugees in Germany, we show that in particular the assumptions of individual utility with no positive externalities, equity-blind utilitarian ethical stances and stable budgets are challenged. The further development of methods to address these challenges are required to support decision-makers in this contentious and politically fraught context and continue to make choices and decisions transparent.

Using independent cross-sectional survey data to predict post-migration health trajectories among refugees by estimating transition probabilities and their variances.

Health research is often concerned with the transition of health conditions and their relation with given exposures, therefore requiring longitudinal data. However, such data is not always available and resource-intensive to collect. Our aim is to use a pseudo-panel of independent cross-sectional data (e.g., data of T0$T_0$ and T1$T_1$ ) to extrapolate and approximate longitudinal health trajectories ( T0$T_0$ - T1$T_1$ ). Methods will be illustrated by examples of studying contextual effects on health among refugees by calculating transition probabilities with associated variances. The data consist of two cross-sectional health surveys among randomly selected refugee samples in reception ( T0$T_0$ ) and accommodation centers ( T1$T_1$ ) located in Germany's third-largest federal state. Self-reported measures of physical and mental health, health-related quality of life, health care access, and unmet medical needs of 560 refugees were collected. Missing data were imputed by multiple imputation. For each imputed data set, transition probabilities were calculated based on (i) probabilistic discrete event systems with Moore-Penrose generalized inverse matrix method (PDES-MP) and (ii) propensity score matching (PSM). By application of sampling approaches, exploiting the fact that status membership is multinomially distributed, results of both methods were pooled by Rubin's Rule, accounting for within and between-imputation variance. Most of the analyzed estimates of the transition probabilities and their variances are comparable between both methods. However, it seems that they handle sparse cells differently: either assigning an average value for the transition probability for all states with high certainty (i) or assigning a more extreme value for the transition probability with large variance estimate (ii).

Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states.

BACKGROUND: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). METHODS: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. RESULTS: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. CONCLUSION: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Inequalities in health system responsiveness among asylum seekers and refugees: A population-based, cross-sectional study in Germany.

Global migration has sparked renewed interest in Universal Health Coverage in high-income countries. However, quality of care has received little attention. This study uses the concept of responsiveness to study quality of care for asylum seekers and refugees (ASR) in Germany and identify inequalities among this group. We report results from a population-based, cross-sectional health monitoring survey in Germany's third-largest federal state using random sampling methods. Established instruments were used to measure responsiveness, health status and socio-demographic factors. Data were weighted and adjusted logistic regression models applied to identify inequalities related to health status, structural and socio-demographic factors. N = 344 survey participants were included in the analysis (response rate 39.2%). Combined responsiveness was 77% (95%CI: 68%; 83%) but varied between domains. Responsiveness was poor for individuals with symptoms of anxiety (OR 0.35, 95%CI 0.13,0.99), longstanding illness (OR:0.42, 95%CI:0.17,1.06) and diminished health-related quality of life (OR:0.24, 95%CI:0.06,0.95). Individuals from Southern Asia (OR: 0.24, 95%CI: 0.07,0.86) and young participants (OR:0.31, 95%CI:0.12,0.82) also reported less responsive care. Unique patterns of explanatory factors were identified within each responsiveness domain. We found important differences in responsiveness related to health, socio-demographic and structural factors, both in combined responsiveness and in individual domains. Inequalities related to health status factors are particularly concerning given the potential implications for equity of access. Future research should explore responsiveness for different sectors, include individuals who have not utilised healthcare and allow for the adjustment of differential expectations of care between population groups.

Association between psychosocial functioning, health status and healthcare access of asylum seekers and refugee children: a population-based cross-sectional study in a German federal state.

BACKGROUND: The mental health condition and healthcare needs of asylum seeking and refugee (ASR) children may go unrecognized if barriers to healthcare access exist accompanied by exclusive focus on somatic illness. We analysed the relationship between psychosocial functioning, health status and healthcare access of ASR children. METHODS: During 2018, 560 ASR adults in 58 collective accommodations in Germany's 3rd largest federal state were randomly sampled and assessed. The parent-reported Strengths and Difficulties Questionnaire (SDQ) was used to assess child psychosocial functioning. SDQ dimensions (Emotional, Conduct, Peer, Hyperactivity, Prosocial, Total) were compared by demographics (sex, age, region of origin, time since arrival, subjective social status), health status (long-lasting illness, physical limitation, pain) and healthcare access (utilization: paediatrician, specialist, dentist, psychologist, hospital/emergency department, prescribed medicines; and unmet needs: for paediatrician/specialist, reduced spending to cover healthcare cost). Age and sex-adjusted odds ratios (AOR, 95%CI-Confidence Intervals) for scoring in borderline/abnormal ranges in SDQ dimensions were estimated through logistic regression depending on children' health status and healthcare access. RESULTS: We analysed parents' answers pertaining to 90 children aged 1-17 years old, 57% of which were girls and 58% with (Eastern or Western) Asian nationality. Scoring in the borderline/abnormal range of the SDQ Total Difficulties score was associated with feeling bodily pain (compared to no pain, AOR, 95%CI = 3.14, 1.21-8.10) and with an unmet need for a specialist during the previous year (4.57, 1.09-19.16). Borderline/abnormal SDQ Emotional scores were positively associated with a long-lasting illness (5.25, 1.57-17.55), physical limitation (4.28, 1.49-12.27) and bodily pain (3.00, 1.10-8.22), and negatively associated with visiting a paediatrician (0.23, 0.07-0.78), specialist (0.16, 0.04-0.69), and the emergency department (0.27, 0.08-0.96). CONCLUSION: Poor psychosocial functioning among ASR children is associated with somatic problems, unmet medical needs, and lower healthcare utilisation. Somatic clinical encounters with ASR should include children' mental health symptomatology assessment, especially in those with worst physical health conditions.

[COVID-19 in collective accommodation centres for refugees: assessment of pandemic control measures and priorities from the perspective of authorities]. / COVID-19 in Sammelunterkünften für Geflüchtete: Analyse von Pandemiemaßnahmen und prioritäre Bedarfe aus behördlicher Sicht.

BACKGROUND: The containment of the COVID-19 pandemic in collective accommodation centres is crucial to maintain the physical and mental health of refugees. It is unclear what measures have been taken by authorities in this setting to reduce the risk of infection, minimise stressors for refugees during the pandemic and communicate containment measures. OBJECTIVES: Assessment of measures that have been taken to prevent and contain SARS-CoV­2 in collective accommodation for refugees and identification of support required by authorities. METHODS: Qualitative interview study with 48 representatives responsible for the reception and accommodation of refugees. Individual interviews were transcribed verbatim and evaluated using framework analysis. RESULTS: We found substantial heterogeneity of measures taken to prevent infection, inform refugees, maintain social and health services, test for SARS-CoV­2 and quarantine positive cases. Effective intersectoral cooperation proved to be particularly important for coordination and implementation of measures. Need for support was expressed with regard to the improvement of infrastructure, opportunities to work with language interpreters and stronger involvement of local health experts. CONCLUSION: Amidst multiple actors and the complexity of structures and processes, the admission authorities have been taking on essential responsibilities related to infection control on an ad hoc basis, without being sufficiently positioned to do so. In order to further contain the pandemic, a strengthening of centralised, setting-specific recommendations and information as well as their translation through the pro-active involvement of the public health authorities at the local level are essential.

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

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