Overcoming denominator problems in refugee settings with fragmented electronic records for health and immigration data: a prediction-based approach.

BACKGROUND: Epidemiological studies in refugee settings are often challenged by the denominator problem, i.e. lack of population at risk data. We develop an empirical approach to address this problem by assessing relationships between occupancy data in refugee centres, number of refugee patients in walk-in clinics, and diseases of the digestive system. METHODS: Individual-level patient data from a primary care surveillance system (PriCarenet) was matched with occupancy data retrieved from immigration authorities. The three relationships were analysed using regression models, considering age, sex, and type of centre. Then predictions for the respective data category not available in each of the relationships were made. Twenty-one German on-site health care facilities in state-level registration and reception centres participated in the study, covering the time period from November 2017 to July 2021. RESULTS: 445 observations ("centre-months") for patient data from electronic health records (EHR, 230 mean walk-in clinics visiting refugee patients per month and centre; standard deviation sd: 202) of a total of 47.617 refugee patients were available, 215 for occupancy data (OCC, mean occupancy of 348 residents, sd: 287), 147 for both (matched), leaving 270 observations without occupancy (EHR-unmatched) and 40 without patient data (OCC-unmatched). The incidence of diseases of the digestive system, using patients as denominators in the different sub-data sets were 9.2% (sd: 5.9) in EHR, 8.8% (sd: 5.1) when matched, 9.6% (sd: 6.4) in EHR- and 12% (sd 2.9) in OCC-unmatched. Using the available or predicted occupancy as denominator yielded average incidence estimates (per centre and month) of 4.7% (sd: 3.2) in matched data, 4.8% (sd: 3.3) in EHR- and 7.4% (sd: 2.7) in OCC-unmatched. CONCLUSIONS: By modelling the ratio between patient and occupancy numbers in refugee centres depending on sex and age, as well as on the total number of patients or occupancy, the denominator problem in health monitoring systems could be mitigated. The approach helped to estimate the missing component of the denominator, and to compare disease frequency across time and refugee centres more accurately using an empirically grounded prediction of disease frequency based on demographic and centre typology. This avoided over-estimation of disease frequency as opposed to the use of patients as denominators.

"I don´t put people into boxes, but " A free-listing exercise exploring social categorisation of asylum seekers by professionals in two German reception centres.

Newly arriving asylum seekers in Germany mostly live in large reception centres, depending on professionals in most aspects of their daily lives. The legal basis for the provision of goods and services allows for discretionary decisions. Given the potential impact of social categorisation on professionals' decisions, and ultimately access to health and social services, we explore the categories used by professionals. We ask of what nature these categorisations are, and weather they align with the public discourse on forced migration. Within an ethnographic study in outpatient clinics of two refugee accommodation centres in Germany, we conducted a modified free-listing with 40 professionals (physicians, nurses, security-personnel, social workers, translators) to explore their categorisation of asylum seekers. Data were qualitatively analysed, and categories were quantitatively mapped using Excel and the Macro "Flame" to show frequencies, ranks, and salience. The four most relevant social categorisations of asylum seekers referred to "demanding and expectant," "polite and friendly" behaviour, "economic refugees," and "integration efforts". In general, sociodemographic variables like gender, age, family status, including countries and regions of origin, were the most significant basis for categorisations (31%), those were often presented combined with other categories. Observations of behaviour and attitudes also influenced categorisations (24%). Professional considerations, e.g., on health, education, adaption or status ranked third (20%). Social categorisation was influenced by public discourses, with evaluations of flight motives, prospects of staying in Germany, and integration potential being thematised in 12% of the categorisations. Professionals therefore might be in danger of being instrumentalised for internal border work. Identifying social categories is important since they structure perception, along their lines deservingness is negotiated, so they potentially influence interaction and decision-making, can trigger empathy and support as well as rejection and discrimination. Larger studies should investigate this further. Free-listing provides a suitable tool for such investigations.

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.

Barriers and drivers to COVID-19 vaccination among the migrant and non-migrant population in Germany, 2021.

BACKGROUND: During the Coronavirus Disease 2019 (COVID-19) pandemic, immunization programmes struggled to reach all population groups equally. While migrant groups face multiple barriers to health systems, including vaccination, little is known about their vaccine uptake. METHODS: We conducted a cross-sectional telephone survey on adults with and without migration history in Germany to investigate barriers and drivers to COVID-19 vaccination (11 April 2021 to 18 December 2021). Interviews were conducted in six languages. We used logistic regression models and a mediation model to analyze the association between migration history and vaccine uptake. Furthermore, we determined the effect of psychological determinants (5C model) on vaccine uptake. RESULTS: The survey comprised 2039 individuals, including 1015 with migration history. Of these, 448 were interviews conducted in languages other than German. Individuals with migration history had a significantly lower vaccine uptake but, while still unvaccinated, had a higher intention to get vaccinated (P = 0.015) compared with those without migration history. The association between migration history and vaccine uptake was no longer significant when other factors were included in the regression model (odds ratio = 0.9; 95% confidence interval: 0.57-1.47). Socio-economic index, language skills and discrimination experience fully mediated this association. Among the psychological determinants, 'higher confidence' and 'higher collective responsibility' increased the chance of individuals with migration history to be vaccinated. CONCLUSION: Migration history alone cannot explain vaccine uptake; socio-economic index, language skills and discrimination experiences need to be considered. To achieve vaccine equity, future public health policy should aim to reduce relevant barriers through tailored interventions.

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.

Intimate partner violence during COVID-19: systematic review and meta-analysis according to methodological choices.

BACKGROUND: Intimate Partner Violence (IPV) is the most common form of interpersonal violence and a major public health problem. The COVID-19 pandemic might have contributed to an increase in IPV experiences. To evaluate changes in IPV prevalence during the pandemic, it is important to consider studies' methodological characteristics such as the assessment tools used, samples addressed, or administration modes (e.g., face-to-face, telephone or online interviews), since they may influence disclosure and were likely affected by pandemic-imposed mobility restrictions. METHODS: Systematic review and meta-analysis of empirical studies addressing IPV against women, men, or both, during the COVID-19 period. We searched six electronic databases until December 2021, including articles in English, German, Spanish, French or Portuguese languages. We extracted and synthesised characteristics of studies related to sampling (clinical, community, convenience), type assessment tool (standardised questionnaire, specifically created questions), method of administration (online, telephone, face-to-face), and estimates of different forms of IPV (physical, sexual, psychological). IPV estimates were pooled stratified by study characteristics using random-effects models. RESULTS: Of 3581 publications, we included 103 studies. Fifty-five studies used a standardized instrument (or some adaptations) to assess IPV, with the World Health Organisation Questionnaire and the Revised Conflicts Tactics Scales being the most frequent. For 34 studies, the authors created specific questions to assess IPV. Sixty-one studies were conducted online, 16 contacted participants face-to-face and 11 by telephone. The pooled prevalence estimate for any type of violence against women (VAW) was 21% (95% Confidence Interval, 95%CI = 18%-23%). The pooled estimate observed for studies assessing VAW using the telephone was 19% (95%CI = 10%-28%). For online studies it was 16% (95%CI = 13%-19%), and for face-to-face studies, it was 38% (95%CI = 28%-49%). According to the type of sample, a pooled estimate of 17% (95%CI = 9%-25%) was observed for studies on VAW using a clinical sample. This value was 21% (95%CI = 18%-24%) and 22% (95%CI = 16%-28%) for studies assessing VAW using a convenience sample and a general population or community sample, respectively. According to the type of instrument, studies on VAW using a standardized tool revealed a pooled estimate of 21% (95%CI = 18%-25%), and an estimate of 17% (95%CI = 13%-21%) was found for studies using specifically created questions. CONCLUSIONS: During the pandemic, IPV prevalence studies showed great methodological variation. Most studies were conducted online, reflecting adaptation to pandemic measures implemented worldwide. Prevalence estimates were higher in face-to-face studies and in studies using a standardized tool. However, estimates of the different forms of IPV during the pandemic do not suggest a marked change in prevalence compared to pre-pandemic global prevalence estimates, suggesting that one in five women experienced IPV during this period.

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.

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.

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).

[Racism and discrimination in the context of health inequalities-a narrative review]. / Rassismus und Diskriminierung im Kontext gesundheitlicher Ungleichheit ­ ein narratives Review.

Racism and discrimination as social determinants of health are becoming increasingly recognised in public health research in Germany. Studies show correlations with physical and mental health and even changes at the cellular level. In addition to the adverse health effects of interpersonal and direct discrimination, the relevance of structural and institutional racism for health inequalities has been little explored. This narrative review synthesises and critically discusses relevant and recent research findings and makes recommendations for action in research and practice.Structural and institutional aspects of discrimination and racism are closely linked to health. Systemic discrimination in education, employment, housing and healthcare affects overall, mental and physical health, access to prevention and care, and health behaviour.An analysis of the relationship between living, housing and working conditions and the health situation of people with (and without) a history of migration - in general and in relation to racism and discrimination - seems necessary in order to derive targeted measures for structural prevention, rather than focusing on purely behavioural prevention. In addition to practical interventions (trainings, education, and community-based approaches), the further development of methodological aspects in the field of data collection and analysis is important in order to address this issue comprehensively in research and practice.

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.

[The Migration and Health Teaching Network: consolidating and developing education and training]. / Das Lehrnetzwerk Migration und Gesundheit: Aus- und Weiterbildung konsolidieren und weiterentwickeln.

Patients with migration history often encounter barriers to accessing healthcare in Germany, which lowers the quality of care available to them and can affect their overall health. These barriers in access to healthcare are due to both adverse health policies and a lack of migration-related - and diversity-sensitive - content in medical and other health profession teaching. Although most healthcare professionals regularly care for patients with individual or generational migration experience in Germany, teaching content relevant to the healthcare of these patients has not yet been anchored in the curriculum. At best, it is taught in the form of electives or other optional courses.To address this gap, the Teaching Network Migration and Health was created with the goal of promoting the development of human rights-based, diversity-sensitive, and equity-oriented curricula at medical and healthcare professions schools. It aims to (1) connect individuals active in teaching and promote the exchange and collaborative development of teaching materials, (2) use this collective knowledge and experience to develop a model course on migration and health, and (3) develop strategies for the longitudinal implementation of this course into the regular medical and other health professional school curricula. These efforts are flanked by evaluative accompanying research. Anyone interested in joining the network is invited to join and strengthen the network by contacting the authors.

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.

Diversity competence training for health professionals in Europe: a modified delphi study investigating relevant content for short or online courses.

BACKGROUND: Diversity is a reality in our societies, requiring health professionals to adapt to the unique needs of all patients, including migrants and ethnic minorities. In order to enable health professionals to meet related challenges and reduce health disparities, long and demanding training courses have been developed. But due to busy schedules of professionals and often scarce resources, a need for shorter training courses exists. This study aims to investigate which topics and methods should be prioritised in designing basic diversity training courses that provide health professionals the opportunity to foster this competence. METHODS: The study provided an expert panel of 31 academic and clinical migrant health experts with the content and methods of an existing diversity training course. The panel was asked to prioritise training topics and teaching methods in a two-stage process, using an adapted Delphi method. In the first stage, experts rated 96 predefined items, commented on those items, provided answers to eight open-ended questions and suggested additional content for a short course. In the second stage, they commented on the ratings from Round 1, and rated new suggested content. Consensus for training topics was set to 80% and for teaching methods 70%. RESULTS: The entire panel deemed 'health effects of migration (pre-, during- and post-migration risk factors)' to be important or very important to include in a short/online, basic diversity training (100% consensus). Other high-scoring items and therefore topics to be included in trainings were 'social determinants of health' (97%) and 'discrimination within the healthcare sector' (also 97%). A general trend was to focus on reflective practice since almost all items regarding reflection reached consensus. 'Reflection on own stereotypes and prejudices' (97%) was the highest-rated reflection item. 'Opportunities and best practices in working with interpreters' was the highest-scoring skills item, both on consensus (96%) and mean value (5.77). CONCLUSIONS: Experts' prioritizations of teaching content and methods for diversity training can help the design of short (online) trainings for health professionals and reduce unnecessary course content, thereby fostering professional development and enabling diversity competence trainings to be implemented also when time and/or financial resources are limited.

[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.

Recommendations for collecting and analysing migration-related determinants in public health research.

Background: According to the definition of the German Federal Statistical Office, about every fourth person living in Germany has a so-called migration background (MB), i.e., the person or at least one of their parents was born without German citizenship. However, MB has been defined differently in many studies. Also, the MB summarises people in different living situations, making differentiated analysis in health science more difficult. This article formulates recommendations for the collection and analysis of migration-related, as well as social and structural, determinants of health. Indicators for capturing relevant determinants of health: As part of the Improving Health Monitoring in Migrant Populations project (IMIRA), the previous approaches to operationalise and measure migration-related determinants were revised based on literature research and exchange formats, such as workshops, meetings, congress contributions, etc. Instead of MB, the country of birth of the respondents and their parents, duration of residence, citizenship(s), residence status, and German language proficiency should be recorded as minimum indicators and analysed as individual variables. Further social and structural determinants, such as socioeconomic position, working and housing conditions, or self-reported discrimination, should be included. Conclusions: In order to describe health inequalities and to specifically identify the needs of people with a history of migration, a mutual and differentiated consideration of migration-related and social determinants of health is essential.

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.

Mandatory, voluntary, repetitive, or one-off post-migration follow-up for tuberculosis prevention and control: A systematic review.

BACKGROUND: Post-migration follow-up of migrants identified to be at-risk of developing tuberculosis during the initial screening is effective, but programmes vary across countries. We aimed to review main strategies applied to design follow-up programmes and analyse the effect of key programme characteristics on reported coverage (i.e., proportion of migrants screened among those eligible for screening) or yields (i.e., proportion of active tuberculosis among those identified as eligible for follow-up screening). METHODS AND FINDINGS: We performed a systematic review and meta-analysis of studies reporting yields of follow-up screening programmes. Studies were included if they reported the rate of tuberculosis disease detected in international migrants through active case finding strategies and applied a post-migration follow-up (defined as one or more additional rounds of screening after finalising the initial round). For this, we retrieved all studies identified by Chan and colleagues for their systematic review (in their search until January 12, 2017) and included those reporting from active follow-up programmes. We then updated the search (from January 12, 2017 to September 30, 2022) using Medline and Embase via Ovid. Data were extracted on reported coverage, yields, and key programme characteristics, including eligible population, mode of screening, time intervals for screening, programme providers, and legal frameworks. Differences in follow-up programmes were tabulated and synthesised narratively. Meta-analyses in random effect models and exploratory analysis of subgroups showed high heterogeneity (I2 statistic > 95.0%). We hence refrained from pooling, and estimated yields and coverage with corresponding 95% confidence intervals (CIs), stratified by country, legal character (mandatory versus voluntary screening), and follow-up scheme (one-off versus repetitive screening) using forest plots for comparison and synthesis. Of 1,170 articles, 24 reports on screening programmes from 7 countries were included, with considerable variation in eligible populations, time intervals of screening, and diagnostic protocols. Coverage varied, but was higher than 60% in 15 studies, and tended to be lower in voluntary compared to compulsory programmes, and higher in studies from the United States of America, Israel, and Australia. Yield varied within and between countries and ranged between 53.05 (31.94 to 82.84) in a Dutch study and 5,927.05 (4,248.29 to 8,013.71) in a study from the United States. Of 15 estimates with narrow 95% CIs for yields, 12 were below 1,500 cases per 100,000 eligible migrants. Estimates of yields in one-off follow-up programmes tended to be higher and were surrounded by less uncertainty, compared to those in repetitive follow-up programmes. Yields in voluntary and mandatory programmes were comparable in magnitude and uncertainty. The study is limited by the heterogeneity in the design of the identified screening programmes as effectiveness, coverage and yields also depend on factors often underreported or not known, such as baseline incidence in the respective population, reactivation rate, educative and administrative processes, and consequences of not complying with obligatory measures. CONCLUSION: Programme characteristics of post-migration follow-up screening for prevention and control of tuberculosis as well as coverage and yield vary considerably. Voluntary programmes appear to have similar yields compared with mandatory programmes and repetitive screening apparently did not lead to higher yields compared with one-off screening. Screening strategies should consider marginal costs for each additional round of screening.