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.

Management of emotional distress following a myocardial infarction: a qualitative content analysis.

Myocardial infarction (MI) is one of the leading causes of mortality and disability worldwide. Emotional distress, such as anxiety and depression, are common among MI patients. The aim of this study was to investigate emotional reactions following MI and to explore how MI patients self-manage their emotional distress using the perspective of an explanatory behavioural model of depression and anxiety. Written testimonies from 92 MI patients starting an internet-based cognitive behavioural therapy (iCBT) were analysed using qualitative content analysis with a mixed deductive and inductive approach. Six themes were identified. The first three highlight the emotional reactions post-MI: Hypoarousal reactions and low mood; Hyperarousal reactions; and A changed sense of self and outlook on life. The following three themes describe strategies for managing emotional distress: Avoidance of potentially rewarding situations; Avoidance of heart relevant stimuli triggering anxiety; and Engaging in potentially positive activities and acceptance. The MI experience may trigger emotional reactions, with a particular emphasis on heart-focused anxiety, depression and a shift in the perception of one's identity. Patients tend to manage emotional distress through social withdrawal and experiential avoidance which likely maintains the distress. Applying a behavioural model to the management of emotional distress following MI is suited.

Framework for refugee and migrant health research in the WHO European Region.

Migration is a longstanding, growing global phenomenon. As a social determinant of health, migration can lead to health inequities between people on the move and host populations. Thus, it is imperative that there is a coordinated effort to advance migration- and health-related goals. WHO has a specific remit to support evidence-based decision-making in its Member States. As part of that remit, WHO Europe presents this Framework for Refugee and Migrant Health Research in the WHO European Region. It is designed as a starting point for debating and analysing a broad range of options and approaches to help inform a WHO global research agenda on health and migration. This is important because refugee and migrant health research is a complex interdisciplinary field that is expanding in a fast-changing socio-political environment. The Framework is intended for all stakeholders involved: academic, civil society organisations, refugees, migrants, policy-makers, healthcare providers, educators and funders. It is developed by academics in consultation with these stakeholder groups. It reflects on three specific interrelated dynamics in research practice. These are (i) research prioritisation; (ii) study samples and (iii) research design. The Framework offers recommendations to consider for each one of these. It elucidates the value of involving refugees and migrants in research and research agendas and the need to develop an ecosystem that will support and sustain participatory, interdisciplinary, transdisciplinary and inter-sectoral projects.

The social values of newly arrived immigrants in Sweden.

Concerns have been raised that immigrants coming to Europe bring fundamentally different social values, affecting the more liberal receiving societies negatively. However, the topic of immigrants' social values is understudied, and much research studies only one issue at a time, lacking a systematic approach to compare immigrants and native-born across issues. We study the social values of immigrants in Sweden using a large sample of newly arrived immigrants and their opinions on 35 different moral issues. Our results indicate a large heterogeneity across different issues, with, on average, a general tendency towards liberal social values among immigrants. We find that individual characteristics are more important than characteristics of the country of origin in explaining variation of social values between immigrants. Religiosity has the largest effect, with more religious individuals having more conservative stances. Using external data sources, we compare immigrants with native-born regarding both average positions on different issues, and the correlation between issue positions. Compared with the native-born, immigrants have, on average, somewhat more conservative values, but the underlying values structure is the same.

Migration health research in the Nordic countries: Priorities and implications for public health.

The past 50 years have witnessed an increase in immigration to the Nordic countries from and beyond neighbouring countries in Europe. Diversity implies variations and differences in health status and health outcomes both within and across populations. Migrant health research has not been prioritized and health policies and practice, especially long-term national plans, often exclude migrants. In this article, we briefly trace the history, the groups, reasons for migration and the road to migrant health research in Norway, Sweden, Finland and Denmark. We discuss the case for data and research including needs, basis for data collection and the methodological challenges. We provide a brief snapshot of migrant health research, identify current gaps and discuss the implications for research. We recommend a regional Nordic strategy to promote intercountry exchange, sharing and learning. Finally, we reflect on the larger picture, implications for policy and practice that could enable societal conditions to reduce avoidable health inequalities.

Self-perceived cognitive status and cognitive challenges associated with cardiac rehabilitation management: experiences of elderly myocardial infarction patients.

PURPOSE: The study aimed to explore the self-perceived cognitive status and cognitive challenges associated with lifestyle changes in cardiac rehabilitation among elderly myocardial infarction (MI) patients (≥65 years). Further, the study explored coping strategies developed to manage these challenges in the everyday life. METHODS: Nine patients were included in the study. Data were collected by telephone or in person, between 6 and 12 weeks post MI, using semi-structured interviews. Data were analysed inductively, using thematic analysis. RESULTS: Four major themes were identified, highlighting elderly MI patients' experiences of their cognitive status and cardiac rehabilitation management: (1) A change in cognition over time, (2) Situating the MI within a challenging and changing life context, (3) Navigating the hurdles of cardiac rehabilitation, and (4) Being seen within the healthcare system. CONCLUSION: Elderly MI patients are situated in a complex life context, dealing with a transition to retirement, multiple health issues and age-related cognitive decline. In this context, the MI experience is marginalised, and cognitive decline normalized. By adopting individually tailored interventions and improving healthcare provider continuity and accessibility, cognitive challenges associated with cardiac rehabilitation could be easier to overcome.IMPLICATIONS FOR REHABILITATIONSelf-perceived cognitive impairment, in particular regarding memory, seems fairly common among elderly MI patients and should likely be identified prior to hospital discharge in order to optimize the prospects of self-care.There seems to exist an unmet need to implement the practice of individually adapted education and information further, in accordance with current recommendations for elderly cardiac patients.The overall health and cognitive status, social network and the objective living conditions (e.g., distance from service and housing) should be taken into account when planning the patient's cardiac rehabilitation management.Healthcare providers likely need to strengthen the continuity of care and increase its accessibility for elderly MI patients, in particular following the transfer from hospital care to local health centres.

Migrant health and language barriers: Uncovering macro level influences on the implementation of trained interpreters in healthcare settings.

There is a knowledge translation gap between policies promoting equitable access to healthcare and person-centred care, and the use of untrained interpreters in cross-cultural consultations leading to disparities in health outcomes. An 11 member inter-sectoral working group met at four workshops to discuss and agree on levers and barriers to the provision of trained interpreters in healthcare settings in Ireland. The process was informed by Participatory Learning and Action (PLA) research to support inter-stakeholder dialogue and learning. Normalisation Process Theory (NPT) was used as a conceptual framework to analyse levers and barriers. The NPT analysis explored sense-making, engagement and enactment and found challenges with sense-making and engagement in senior level service planners, managers and governmental offices. This had negative impacts on other key actors, including healthcare providers, medical students and interpreters. This also meant that the enactment of interpreted consultations in practice settings was replete with barriers, most notably a lack of resources, training and supportive organisational structures. The emergent action plan focused on improving sense-making and engagement through inter-sectoral awareness raising, designed to stimulate a series of complementary levers for implementation. Combining PLA and NPT provided new insights into macro level influences on implementation work at the level of a national healthcare system. The approaches used in this study are applicable in other fields.

Migrant health research in the Republic of Ireland: a scoping review.

BACKGROUND: Migration to European countries has increased in number and diversity in recent years. Factors such as access to healthcare, language barriers and legal status can impact the health outcomes of migrant groups. However, little is known about the evidence base on the health status of migrants in the Republic of Ireland. Our aim was to scope existing peer-reviewed research on the health of migrants in Ireland and identify any gaps in the evidence. METHODS: We conducted a scoping review of peer-reviewed research on the health of migrants in the Republic of Ireland. Eleven electronic databases were searched for peer-reviewed, empirical articles published between 2001 and 2017. Search terms were adapted from a World Health Organisation review. Findings were analysed using the 2016 World Health Organisation Strategy and Action Plan for Refugee and Migrant Health in the World Health Organisation European region, which outlines nine strategic areas that require collaborative action. RESULTS: Of 9396 articles retrieved, 80 met inclusion criteria, with the majority (81%) published since 2009. More than half of the studies had a quantitative design (65%). Migrants studied came from Eastern Europe, Asia and Africa and included labour migrants, refugees and asylum seekers. Most studies related to two World Health Organisation strategic areas; 4: "achieving public health preparedness and ensuring an effective response", and 5: "strengthening health systems and their resilience". CONCLUSION: There is growing attention to migrant health in Ireland with a balance of qualitative and quantitative research. While much of the identified research is relevant to three of the World Health Organisation strategic areas, there are significant gaps in the other six areas. The study design could be replicated in other countries to examine and inform migrant health research.

Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives.

BACKGROUND: Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance. METHODS: We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed. RESULTS: Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it. CONCLUSIONS: GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public's perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients' expectations.

What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region? Themed issues on migration and health, X

The Health Evidence Network (HEN) is an information service for public health decision-makers in the WHO European Region, in action since 2003 and initiated and coordinated by the WHO Regional Office for Europe under the umbrella of the WHO European Health Information Initiative (a multipartner network coordinating all health information activities in the WHO European Region). HEN supports public health decision-makers to use the best available evidence in their own decisionmaking and aims to ensure links between evidence, health policies and improvements in public health. The HEN synthesis report series provides summaries of what is known about the policy issue, the gaps in the evidence and the areas of debate. Based on the synthesized evidence, HEN proposes policy considerations, not recommendations, for policy-makers to formulate their own recommendations and policies within their national context

What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region?

The recent rapid increases in population movements across borders highlight the importance of reliable data on refugee and migrant health for public health planning. This scoping report examined evidence on the availability and integration of refugee and migrant health data in health information systems in the WHO European Region. Refugee and migrant health data were available in 25 of the Region’s 53 Member States, but differences existed in the availability, data types and main sources of data collection. Except for countries with population registers, the predominant data sources were medical records, disease-specific records and notification data. Data integration was often limited, and health monitoring surveys and data linkage approaches were underused. Policy considerations include harmonizing migrant definitions, promoting the coordination/governance of data collection, performance monitoring for health information systems, promoting cross-country exchange of experiences, exploiting data linkage, expanding existing health surveillance, reducing health-care barriers and strengthening general health information systems.

Experiences and reflections of Somali unaccompanied girls on their first years in Sweden: a follow-up study after two decades.

PURPOSE: Unaccompanied asylum-seeking children (UASC) from Somalia are one of the largest groups of UASC in Europe and Sweden. The current study is a follow-up of a Swedish study conducted in 1999, where unaccompanied asylum-seeking girls (UASG) from Somalia were interviewed. In 2013, UASG from the 1999 study were interviewed again, as adults who have settled and found a new life in Sweden. The purpose of this paper is to explore how these women experienced their transition into the Swedish society. DESIGN/METHODOLOGY/APPROACH: A qualitative research design using semi-structured interviews was adopted for this descriptive study. Thematic analysis was used to analyze the data. FINDINGS: UASG need support from different groups of adults, ranging from the staff at the group homes to community members, including countrymen, to establish a good life in their new country. The UASG need understanding and knowledgeable staff that can support them through the initial period, when they do not have their parents close to them. All actors in the supporter network need more knowledge about the difficulties in war situations. Former UASC can assist newcomers as well as being informants to authorities in a new country. Both parties involved need to be open and willing to learn from each other. RESEARCH LIMITATIONS/IMPLICATIONS: UASG who consider themselves successful in being integrated into the Swedish society were interviewed and, therefore, the study mainly describes aspects that promote integration. ORIGINALITY/VALUE: There are limited follow-up studies on how UASG have experienced their life after almost two decades in the new country.

What constitutes an effective and efficient package of services for the prevention, diagnosis, treatment and care of tuberculosis among refugees and migrants in the WHO European Region?

The WHO European Region has faced high rates of external and internal migration in recent years, with concerns that this is contributing to the burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and TB/HIV coinfection in some countries. This report examines evidence of effective and efficient service packages for the prevention, diagnosis and treatment of TB to inform strategies to address the TB burden in refugee and migrant populations. Significant regional variations were identified in both migration levels and TB burden in refugees and migrants, as well as in approaches to TB control, with low quality of evidence in many cases. While it is unlikely that a single strategy/package will be effective for all situations, the evidence highlights some common approaches that could guide policy-making and service development. TB elimination targets for the Region will not be met unless inequalities in access to screening and treatment for migrants are addressed, alongside efforts to tackle TB globally.

What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region?

The provision of effective health care to linguistically and culturally diverse migrant populations has been identified as a crucial public health issue. This scoping review examines strategies that have been implemented and evaluated to address communication barriers experienced by refugees and migrants in health care settings across the WHO European Region. Four main types of strategy were identified: cultural mediation, interpretation, translation of health information, and guidance and training for health care providers. These have been used to support access to health care, management of specific diseases and promotion of health across a wide variety of health care settings. Intersectoral collaboration was seen as important in the development and implementation of strategies. Policy considerations include the development of national policies and the promotion of intersectoral dialogue to augment the knowledge base and resolve the common issues identified, such as provision of training and confusion regarding the roles of mediators/interpreters, that affect strategy implementation and evaluation.

Detainees, staff, and health care services in immigration detention centres: a descriptive comparison of detention systems in Sweden and in the Benelux countries.

BACKGROUND: Immigration detention has been shown to negatively affect the health and well-being of detainees. The aim of the study was to describe and compare policies and practices that could affect the health and well-being of immigrant detainees in the Benelux countries (Belgium, the Netherlands, and Luxembourg) to those in Sweden. DESIGN: This was a case study. Data were collected in two phases using a questionnaire developed particularly for this study. In the first phase, authorities in the Benelux countries responded to the questionnaire via email. During the second phase, a research team visited detention centres in the Benelux countries to observe and further explore, strengthening findings through triangulation. Data on Swedish detention centres were collected in previous studies. RESULTS: Compared to the Benelux countries, Sweden has limited health care provision available in the detention centres. Swedish detention centres did not have mental health care professionals working at the centres and had fewer restrictions within the centres with regard to access to mobile phone, internet, and various recreational activities. Compared to Sweden, the detention centres in the Benelux countries have more staff categories providing services to the detainees that are provided with relevant and timely on-the-job training. All the countries, except Belgium, provide subsistence allowances to detainees. CONCLUSION: Despite the Common European Asylum System framework, differences exist among the four European Union member states in providing services to immigrant detainees. This study highlights these differences, thereby providing a window on how these diverse approaches may serve as a learning tool for improving services offered to immigrant detainees. In Sweden, the health care available to detainees and training and recruitment of staff should be improved, while the Benelux countries should strive to reduce restrictions within detention centres.

Quality of life among immigrants in Swedish immigration detention centres: a cross-sectional questionnaire study.

BACKGROUND: Detention of immigrants negatively affects their health and well-being. Quality of life (QOL) is a broad concept incorporating the self-evaluation of one's own health and well-being that can provide an understanding of the health and well-being of immigrant detainees. The aim of this study was to estimate QOL among immigrant detainees in Sweden and to assess its relationship with the services provided in detention centres and with the duration of detention. DESIGN: All immigrants in all five existing Swedish detention centres (N=193) were invited to participate in the study (n=127). In this cross-sectional study, QOL was measured using the WHOQOL-BREF questionnaire, which was administered by the first author. The questionnaire contained four additional questions measuring participants' satisfaction with the services provided in detention. Associations between QOL domain scores and service satisfaction scores were assessed using regression analysis. The Spearman's rank correlation coefficient was calculated to measure the degree of association between the duration of detention and QOL scores. RESULTS: The mean QOL domain scores (out of 100) were 47.0, 57.5, 41.9, and 60.5 for the environmental, physical, psychological, and social domains, respectively. The level of support detainees received from detention staff was significantly positively associated with detainees' physical (ßadjusted 3.93, confidence interval [CI] 0.06-7.80) and psychological (ßadjusted 5.72, CI 1.77-9.66) domain scores. There was also significant positive association between detainees' satisfaction with the care they received from detention staff and the domain scores. The general health score in the WHOQOL-BREF was significantly associated with the detainees' ability to understand the Swedish or English languages. Although not statistically significant, a longer duration of detention was negatively correlated with QOL scores. CONCLUSION: Immigrant detainees report low QOL. Services provided at the centres, especially the support received from detention staff, is positively associated with their QOL. A review of detention guidelines addressing language barriers, staff training, and duration of detention is highly recommended.