[Perinatal mortality among asylum seekers in the Netherlands seven times higher than in Dutch women]. / Zeven keer zo hoge perinatale sterfte bij vluchtelingen.

In this commentary we discuss the findings of the study by Verschuuren et al. on pregnancy outcomes in asylum seekers centres in the North of the Netherlands. Although alarming, the findings do not surprise us. A lack of continuity in care, language barriers and limited understanding of the healthcare system are just some of the factors shown to result in substandard care that we see regularly in our daily practice. Our main recommendations for healthcare practitioners are to: a) work with professional interpreters; b) maintain an active attitude in inquiring whether an asylum seeker is pregnant; and c) ensure effective collaboration between social and healthcare services. Additionally, we advise healthcare practitioners to: a) actively work on building a relationship of trust with their patients; b) plea for the minimisation of relocations and c) urge researchers to study mortality, morbidity and effectiveness of care around pregnancy and childbirth in the three refugee groups.

Strategies to reach and motivate migrant communities at high risk for TB to participate in a latent tuberculosis infection screening program: a community-engaged, mixed methods study among Eritreans.

BACKGROUND: In the Netherlands, migrant populations with a high tuberculosis (TB) incidence are an important target group for TB prevention. However, there is a lack of insight in effective community-engaged strategies to reach and motivate these migrants to participate in latent TB infection (LTBI) screening and treatment programs. METHODS: In cocreation with Eritrean key figures and TB staff, we designed and executed six strategies to reach and motivate Eritrean communities to participate in LTBI programs, in five regions in the Netherlands. We registered participation in LTBI education and screening, and LTBI treatment uptake and completion. We used semi-structured group and individual interviews with Eritrean participants, key figures, and TB staff to identify facilitators and barriers. RESULTS: Uptake of LTBI education (13-75%) and consequent screening (10-124%) varied between strategies. LTBI screening uptake > 100% resulted from educated participants motivating others to participate in screening. Two strategies, using face-to-face promotion and targeting smaller groups, were the most successful. The program resulted in high LTBI treatment initiation and completion (both 97%). Reported program barriers included: competing priorities in the target group, perceived good health, poor risk perception, and scepticism towards the program purpose. TB staff perceived the program as useful but demanding in terms of human resources. CONCLUSIONS: Eritrean migrant communities can be successfully reached and motivated for LTBI screening and treatment programs, when sufficient (human) resources are in place and community members, well-connected to and trusted by the community, are engaged in the design and execution of the program.

Latent tuberculosis screening and treatment among asylum seekers: a mixed-methods study.

INTRODUCTION: Evidence on conditions for implementation of latent tuberculosis infection (LTBI) screening and treatment among asylum seekers is needed to inform tuberculosis (TB) control policies. We used mixed-methods to evaluate the implementation of an LTBI screening and treatment programme among asylum seekers in the Netherlands. METHODS: We offered voluntary LTBI screening to asylum seekers aged ≥12 years living in asylum seeker centres from countries with a TB incidence >200 per 10 000 population. We calculated LTBI screening and treatment cascade coverage, and assessed associated factors with Poisson regression using robust variance estimators. We interviewed TB care staff (seven group interviews) and Eritrean clients (21 group and 21 individual interviews) to identify programme enhancers and barriers. RESULTS: We screened 719 (63% of 1136) clients for LTBI. LTBI was diagnosed among 178 (25%) clients; 149 (84%) initiated LTBI treatment, of whom 129 (87%) completed treatment. In-person TB and LTBI education, the use of professional interpreters, and collaboration with partner organisations were enhancers for LTBI screening uptake. Demand-driven LTBI treatment support by TB nurses enhanced treatment completion. Factors complicating LTBI screening and treatment were having to travel to public health services, language barriers and moving from asylum seeker centres to the community during treatment. CONCLUSION: LTBI screening and treatment of asylum seekers is feasible and effective when high quality of care is provided, including culture-sensitive TB education throughout the care cascade. Additionally, collaboration with partner organisations, such as agencies responsible for reception and support of asylum seekers, should be in place.

Maternal and perinatal outcomes of asylum seekers and undocumented migrants in Europe: a systematic review.

BACKGROUND: Asylum seekers (AS) and undocumented migrants (UM) are at risk of adverse pregnancy outcomes due to adverse health determinants and compromised maternal healthcare access and service quality. Considering recent migratory patterns and the absence of a robust overview, a systematic review was conducted on maternal and perinatal outcomes in AS and UM in Europe. METHODS: Systematic literature searches were performed in MEDLINE and EMBASE (until 1 May 2017), complemented by a grey literature search (until 1 June 2017). Primary research articles reporting on any maternal or perinatal outcome, published between 2007 and 2017 in English/Dutch were eligible for inclusion. Review protocols were registered on Prospero: CRD42017062375 and CRD42017062477. Due to heterogeneity in study populations and outcomes, results were synthesized narratively. RESULTS: Of 4652 peer-reviewed articles and 145 grey literature sources screened, 11 were included from 4 European countries. Several studies reported adverse outcomes including higher maternal mortality (AS), severe acute maternal morbidity (AS), preterm birth (UM) and low birthweight (UM). Risk of bias was generally acceptable, although the limited number and quality of some studies preclude definite conclusions. CONCLUSION: Limited evidence is available on pregnancy outcomes in AS and UM in Europe. The adverse outcomes reported imply that removing barriers to high-quality maternal care should be a priority. More research focussing on migrant subpopulations, considering potential risk factors such as ethnicity and legal status, is needed to guide policy and optimize care.

What can we learn from unaccompanied refugee adolescents' perspectives on mental health care in exile?

Unaccompanied refugee adolescents who have fled war and persecution often have poor mental health. Yet, little is known about their own perspectives on what can relieve their mental health problems. The aim was to explore unaccompanied refugee adolescents' perspectives on healing and the mental healthcare offered to them when resettled. The study was based on methodical triangulation of participant observation in a Danish municipal institution for unaccompanied refugee minors, semi-structured individual interviews with experts, social workers and male refugee minors and a focus group interview with refugee minors. Results show that the refugee adolescents associated traditional conversational therapy with discussing negative and stigmatising aspects of their past and carrying risks of re-traumatisation. Instead, alternative activities were proposed, through which resources could be accumulated and they could be met without stereotype.Conclusion: To enhance the complex mental health needs of unaccompanied minors' mental healthcare, the perspective of the refugee adolescents should be taken into account. This calls for a holistic approach to mental healthcare in their daily lives, where they are met in a non-stigmatising manner in which their unique capabilities are the main focus. Moreover, a trusting relationship constitutes the fundament to support good mental health among refugee adolescents. What is Known: • Unaccompanied refugee adolescents are at risk of poor mental health outcomes, e.g., depression, anxiety, PTSD and psychosocial stress. • Stigma, lack of social support, stressful life events and lack of intercultural competency among mental health professionals are barriers to good mental health. What is New: • There is a need for informal and tailored health promotion initiatives in the refugee adolescents' everyday lives. • To treat the refugee adolescents as equal human beings through curiosity and receptiveness to their resources is important in order to build trust and address stigma.

How Do Countries' Health Information Systems Perform in Assessing Asylum Seekers' Health Situation? Developing a Health Information Assessment Tool on Asylum Seekers (HIATUS) and Piloting It in Two European Countries.

Background: Accurate data on the health status, health behaviour and access to health care of asylum seekers is essential, but such data is lacking in many European countries. We hence aimed to: (a) develop and pilot-test an instrument that can be used to compare and benchmark the country health information systems (HIS) with respect to the ability to assess the health status and health care situation of asylum seekers and (b) present the results of that pilot for The Netherlands (NL) and Germany (DE). Materials and Methods: Reviewing and adapting existing tools, we developed a Health Information Assessment Tool on Asylum Seekers (HIATUS) with 50 items to assess HIS performance across three dimensions: (1) availability and detail of data across potential data sources; (2) HIS resources and monitoring capacity; (3) general coverage and timeliness of publications on selected indicators. We piloted HIATUS by applying the tool to the HIS in DE and NL. Two raters per country independently assessed the performance of country HIS and the inter-rater reliability was analysed by Pearson's rho and the intra-class correlation (ICC). We then applied a consensus-based group rating to obtain the final ratings which were transformed into a weighted summary score (range: 0-97). We assessed HIS performance by calculating total and domain-specific HIATUS scores by country as well as absolute and relative gaps in scores within and between countries. Results: In the independent rating, Pearson's rho was 0.14 (NL) and 0.30 (DE), the ICC yielded an estimated reliability of 0.29 (NL) and 0.83 (DE) respectively. In the final consensus-based rating, the total HIATUS score was 47 in NL and 15 in DE, translating into a relative gap in HIS capacity of 52% (NL) and 85% (DE) respectively. Shortfalls in HIS capacity in both countries relate to the areas of HIS coordination, planning and policies, and to limited coverage of specific indicators such as self-reported health, mental health, socio-economic status and health behaviour. The relative gap in the HIATUS component "data sources and availability" was much higher in Germany (92%) than in NL (28%). Conclusions: The standardised tool (HIATUS) proved useful for assessment of country HIS performance in two countries by consensus-based rating. HIATUS revealed substantial limitations in HIS capacity to assess the health situation of asylum seekers in both countries. The tool allowed for between-country comparisons, revealing that capacities were lower in DE relative to NL. Monitoring and benchmarking gaps in HIS capacity in further European countries can help to strengthen HIS in the future.

High HIV Prevalence among Asylum Seekers Who Gave Birth in the Netherlands: A Nationwide Study Based on Antenatal HIV Tests.

OBJECTIVES: Asylum seekers are considered to be a particularly vulnerable group with respect to HIV. Data on the HIV prevalence among asylum seekers, however, are scarce. The aim of this study is to map the HIV prevalence among asylum seekers who gave birth in The Netherlands. METHODS: We used a nationwide electronic medical records database from the community health services for asylum seekers (MOA). The study population consisted of 4,854 women and girls who delivered in asylum reception between 2000 and 2008. A unique electronic health data base was used and case allocation was based on ICPC-codes. RESULTS: The number of women and girls that was HIV positive during their last pregnancy was 80, of which 79 originated from sub-Saharan Africa. The prevalence for women from this region of origin (3.4%) was high compared to women from all other regions of origin (0.04%; OR = 90.2; 95%CI 12.5-648.8). The highest HIV prevalence rates were found for women from Rwanda (17.0%) and Cameroon (13.2%). HIV prevalence rates were higher among women who arrived in reception without partner (OR = 1.82; 95%CI 0.75-4.44) and unaccompanied minors (OR = 2.59; 95%CI 0.79-8.49), compared to women who arrived in reception with partner. CONCLUSIONS: We conclude that, among asylum-seeking women from sub-Saharan Africa giving birth in The Netherlands, the HIV prevalence is high compared to the host population. For women from other regions of origin, the prevalence is at the same level as in the host population. The high HIV prevalence underlines the importance of preventive interventions and voluntary HIV testing for sub-Saharan African asylum seekers as from shortly after arrival.

Frequent relocations between asylum-seeker centres are associated with mental distress in asylum-seeking children: a longitudinal medical record study.

BACKGROUND: There are concerns about negative effects of relocations between asylum-seeker centres on the mental health of asylum-seeking children. However, empirical evidence comes from cross-sectional studies only. In this longitudinal medical record study, we aimed to assess: (i) whether relocations during the asylum process are associated with the incidence of newly recorded mental distress in asylum-seeking children; and (ii) whether this association is stronger among vulnerable children. METHODS: Data were extracted from the electronic medical records database of the Community Health Services for Asylum Seekers in The Netherlands (study period: 1 January 2000-31 December 2008). Included were 8047 children aged 4 to 17 years. Case attribution was done using International Classification of Primary Care codes for mental, behavioural or psychosocial problems. The association between annual relocation rate and incidence of mental distress was measured using relative risks (RR) estimated with multivariate Cox regression models. RESULTS: A high annual relocation rate (>1 relocation/year) was associated with increased incidence of mental distress [RR = 2.70; 95% confidence interval (CI) 2.30-3.17]. The relative risk associated with a high annual relocation rate was larger in children who had experienced violence (RR = 3.87; 95% CI 2.79-5.37) and in children whose mothers had been diagnosed with post-traumatic stress disorder or depression (RR = 3.40; 95% CI 2.50-4.63). CONCLUSIONS: The risk of mental distress was greater in asylum-seeking children who had undergone a high annual relocation rate. This risk increase was stronger in vulnerable children. These findings contribute to the appeal for policies that minimize the relocation of asylum seekers.

Relationship between post-traumatic stress disorder and diabetes among 105,180 asylum seekers in the Netherlands.

BACKGROUND: Several reports have demonstrated a relationship between post-traumatic stress disorder (PTSD) and type 2 diabetes (T2DM) mainly in combat veterans. The relationship between PTSD and T2DM has not been evaluated among vulnerable migrant populations. The main objective of this study was therefore to assess the relationship between PTSD and T2DM among asylum seekers in the Netherlands. METHODS: Analysis of a national electronic database of the Dutch Community Health Services for Asylum seekers aged≥18 years (N=105,180). RESULTS: Asylum seekers with PTSD had a higher prevalence of T2DM compared with those without PTSD. The age-adjusted prevalence ratios (APR) were 1.40 (95% CI, 1.12-1.76) in men and 1.22 (95% CI, 0.95-1.56) in women compared with individuals without PTSD, respectively. There was an interaction between PTSD and comorbid depression (P<0.05) in men and women, indicating that the effect of PTSD and comorbid depression on T2DM differed. When the analyses were stratified by depression status, among non-depressed group, individuals with PTSD had a higher prevalence of T2DM compared with those without PTSD [APR=1.47 (95% CI, 1.15-1.87) in men and APR=1.27 (95% CI, 0.97-1.66) in women]. Among the depressed individuals, however, there was no association between PTSD and T2DM [APR=0.87 (95% CI, 0.43-1.76) in men, and APR=1.00, (95% CI, 0.54-1.83) in women]. CONCLUSION: The findings suggest that history of PTSD is related to high levels of T2DM among asylum seekers independent of comorbid depression. Clinicians and policy makers need to take PTSD into account when assessing and treating diabetes among vulnerable migrant populations.

Suicide death and hospital-treated suicidal behaviour in asylum seekers in the Netherlands: a national registry-based study.

BACKGROUND: Several suicide and suicidal behaviour risk factors are highly prevalent in asylum seekers, but there is little insight into the suicide death rate and the suicidal behaviour incidence in this population. The main objective of this study is to assess the burden of suicide and hospital-treated non-fatal suicidal behaviour in asylum seekers in the Netherlands and to identify factors that could guide prevention. METHODS: We obtained data on cases of suicide and suicidal behaviour from all asylum seeker reception centres in the Netherlands (period 2002-2007, age 15+). The suicide death rates in this population and in subgroups by sex, age and region of origin were compared with the rate in the Dutch population; the rates of hospital-treated suicidal behaviour were compared with that in the population of The Hague using indirect age group standardization. RESULTS: The study included 35 suicide deaths and 290 cases of hospital-treated suicidal behaviour. The suicide death rate and the incidence of hospital-treated suicidal behaviour differed between subgroups by sex and region of origin. For male asylum seekers, the suicide death rate was higher than that of the Dutch population (N = 32; RR = 2.0, 95%CI 1.37-2.83). No difference was found between suicide mortality in female asylum seekers and in the female general population of the Netherlands (N = 3; RR = 0.73; 95%CI 0.15-2.07). The incidence of hospital-treated suicidal behaviour was high in comparison with the population of The Hague for males and females from Europe and the Middle East/South West Asia, and low for males and females from Africa. Health professionals knew about mental health problems prior to the suicidal behaviour for 80% of the hospital-treated suicidal behaviour cases in asylum seekers. CONCLUSIONS: In this study the suicide death rate was higher in male asylum seekers than in males in the reference population. The incidence of hospital-treated suicidal behaviour was higher in several subgroups of asylum seekers than that in the reference population. We conclude that measures to prevent suicide and suicidal behaviour among asylum seekers in the Netherlands are indicated.

[Obstetric outcomes and expressed health needs of pregnant asylum seekers: a literature survey]. / Zwangerschapsuitkomsten en zorgbehoeften bij asielzoeksters: een literatuuroverzicht.

OBJECTIVE: To analyse whether specific attention is needed for the improvement of health for pregnant asylum seekers by producing an overview of obstetric outcomes, risk factors and expressed health needs of asylum seekers in the Netherlands and other Western host countries. DESIGN: Literature study. METHOD: A search was performed in Medline, Embase and PsycInfo for empirical studies about pregnancy and delivery specifically among asylum seekers in Western host countries and published since 1995. Picarta and the authors' literature collections were used to find Dutch studies. Google was used to find grey literature. RESULTS: Published empirical studies on pregnancy outcome indicators specific for asylum seekers were scarce and limited to the Netherlands. The studies found revealed an increased risk of perinatal and maternal mortality and severe maternal morbidity. These studies, however, were based on small numbers of cases. Qualitative studies revealed that pregnant asylum seekers expressed the following needs: a) information about pregnancy and about healthcare in the host country, b) healthcare professionals who pay attention to their problems and c) mothers' groups for social contacts and information exchange. CONCLUSION: Specific attention must be paid to improving the care for pregnant asylum seekers, since the limited number of studies suggest that asylum seekers are at increased risk of perinatal mortality, maternal mortality and severe maternal morbidity. More studies are needed into risk factors and quality of care for pregnant asylum seekers. The publications studied contain recommendations for an improved matching of the care with the needs expressed. The recommendations concern provision of information, cultural competencies of care providers, identification of risk factors, health networks approach, continuity of care and organising mother's groups.

Cultural competence among nurse practitioners working with asylum seekers.

Asylum seekers often have complex medical needs. Little is known about the cultural competences health care providers should have in their contact with asylum seekers in order to meet their needs. Cultural competence is generally defined as a combination of knowledge about certain cultural groups, as well as attitudes towards and skills for dealing with cultural diversity. Given asylum seekers' specific care needs, it may be asked whether this set of general competences is adequate for the medical contact with asylum seekers. We explored the cultural competences that nurse practitioners working with asylum seekers thought were important. A purposive sample of 89 nurse practitioners in the Netherlands completed a questionnaire. In addition, six group interviews with nurse practitioners were also conducted. A framework analysis was used to analyse the data of the questionnaires and the interviews. From the analysis, several specific competences emerged, which were required for the medical contact with asylum seekers: knowledge of the political situation in the country of origin; knowledge with regard to diseases common in the country of origin; knowledge of the effects of refugeehood on health; awareness of the juridical context in the host country; ability to deal with asylum seekers' traumatic experiences; and skills to explain the host country's health care system. Apart from these cultural competences specific for the situation of asylum seekers, general cultural competences were also seen as important, such as the ability to use interpretation services. We conclude that insight into these cultural competences may help to develop related education and training for health care providers working with asylum seekers.