Challenges and Opportunities for Implementing Diversity Competence in a Medical Education Curriculum: A Qualitative Study of Perceptions Among Students and Teachers.

OBJECTIVES: Medical education is under continuous pressure to introduce new curriculum content to ensure that physicians possess the competences that the population needs. Diversity competence (DC) is a relatively new area within medicine, challenging the existing curriculum. Frameworks and guidelines have been developed to provide support and assistance to educators in integrating DC into medical programs. However, integrating DC into curriculum has proven difficult and is therefore still not included in many European medical programs. The purpose of the study is therefore to identify the challenges and opportunities for implementing DC including a focus on migrant and ethnic minorities in a medical education program. METHODS: From November 2-20, 2020, focus group discussions with medical students, junior physicians and course leaders were conducted. The participants were recruited via Facebook, newsletters, and emails. Two interview guides were developed and used as guidance for topics to be discussed. The focus group discussions were conducted partly physically and partly digitally. The interviews were transcribed and were analyzed using thematic analysis. RESULTS: Three main challenges and opportunities were identified across the focus groups. Challenges: (i) a disparaging discourse about humanistic and social disciplines within the curriculum, (ii) limited levels of DC among teachers, and (iii) need for institutional support. Opportunities: (i) a clear interest in strengthening teachers' DC levels, (ii) incentives for improving the image of humanistic and social medicine, and (iii) relevant courses for implementing DC. CONCLUSION: Our results showed that action in this area is needed. The themes identified indicated that there are within the curriculum many opportunities to implement DC, but they also illuminated the challenges. The results suggested both a need for focusing on individual competences for medical teachers and students, and also for organizational change and support in favor of DC training.

The general health status of newly arrived asylum seekers in Denmark.

AIMS: The number of asylum seekers in Europe is increasing and is likely to do so continuously due to conflicts, poverty and climate. Asylum seekers are exposed to many health risk factors related to their migration process and this study aimed to explore their general health status on arrival at an immigration country. METHODS: A retrospective study including 1907 general health assessments (GHAs) of adult asylum seekers arriving in Denmark between 1 September 2017 and 31 December 2019 was undertaken. The GHA is offered to all adult asylum seekers as part of the health-care reception programme. Only asylum seekers who attended the GHA within 1 month of their arrival in Denmark were included. Data comprised sociodemographic factors, health outcomes, and indication of exposure to trauma and torture. Data were described by absolute and relative frequencies, means and through regression analyses. RESULTS: The majority of asylum seekers were male (58.6%) of Middle Eastern origin with a mean age of 33.6 years (SD = 12.1). More than half (60.1%) of the participants had one or more physical health complaints, whereas mental health complaints were less frequent (25.0%). Asylum seekers, who had been exposed to trauma were more likely to have physical health complaints (OR 1.52, 95% CI 1.22;1.89) and to have symptoms of mental health problems (OR 12.71, 95% CI 8.76;18.45). These complaints were substantially elevated for survivors of torture. CONCLUSIONS: This relatively high prevalence of health complaints, both physical and mental, emphasises the necessity of providing appropriate and timely health care from the very beginning of the asylum process.

Vaccination status and needs of asylum-seeking children in Denmark: a retrospective data analysis.

OBJECTIVES: Asylum seekers to Europe may come from war-torn countries where health systems have broken down, and there is evidence that asylum-seeking children have low coverage of childhood vaccinations, as well as uptake of immunisations in host countries. Such gaps in immunisation have important implications for effective national vaccination programmes. How we approach vaccination in children and adults entering Western Europe, where as a group they face barriers to health services and screening, is a growing debate; however, there are limited data on the vaccination status of these hard-to-reach communities, and robust evidence is needed to inform immunisation strategies. The aim of this study was to explore the vaccination status and needs of asylum-seeking children and adolescents in Denmark. STUDY DESIGN: We conducted a retrospective data analysis of anonymised patient records for asylum-seeking children and adolescents extracted from the Danish Red Cross database. METHODS: We retrospectively searched the Danish Red Cross database for children and adolescents (aged 3 months-17 years) with active asylum applications in Denmark as of October 28, 2015. Data were extracted for demographic characteristics, vaccination status and vaccinations needed by asylum-seeking children presenting to Red Cross asylum centres for routine statutory health screening. RESULTS: We explored the vaccination status and needs of 2126 asylum-seeking children and adolescents. About 64% of the study population were male and 36% were female. Eight nationalities were represented, where 33% of the total of children and adolescents were not immunised in accordance with Danish national guidelines, while 7% were considered partly vaccinated, and 60% were considered adequately vaccinated. Afghan (57% not vaccinated/unknown) and Eritrean (54% not vaccinated/unknown) children were the least likely to be vaccinated of all nationalities represented, as were boys (37% not vaccinated/unknown) compared with girls (27% not vaccinated/unknown) and children and adolescents aged between 12 and 17 years (48% not vaccinated/unknown) compared with 6- to 11-year olds (26%) and 0- to 5-year olds (22%). The health screenings resulted in 1328 vaccinations. The most commonly needed vaccines were diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b, (DTaP/IPV/Hib) which comprised 49% of the vaccines distributed, followed by the pneumococcal vaccine (Prevnar) (28%) and measles, mumps and rubella (MMR) vaccine (23%). CONCLUSIONS: The finding that nearly one-third of asylum-seeking children and adolescents in Denmark were in need of further vaccinations highlights the gaps in immunisation coverage in these populations. These results point to the need to improve access to health services and promote national vaccine programmes targeted at these communities to facilitate vaccination uptake and increase immunisation coverage to reduce the risk of preventable infectious diseases among asylum-seeking children.

Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools.

Background: : It is estimated that children below 18 years constitute 50% of the refugee population worldwide, which is the highest figure in a decade. Due to conflicts like the Syrian crises, children are continuously exposed to traumatic events. Trauma exposure can cause mental health problems that may in turn increase the risk of morbidity and mortality. Tools such as questionnaires and interview guides are being used extensively, despite the fact that only a few have been tested and their validity confirmed in refugee children and youth. : Our aim was to provide a systematic review of the validated screening and measurement tools available for assessment of trauma and mental health among refugee children and youth. : We systematically searched the databases PubMed, PsycINFO and PILOTS. The search yielded 913 articles and 97 were retained for further investigation. In accordance with the PRISMA guidelines two authors performed the eligibility assessment. The full text of 23 articles was assessed and 9 met the eligibility criteria. Results : Only nine studies had validated trauma and mental health tools in refugee children and youth populations. A serious lack of validated tools for refugee children below the age of 6 was identified. : There is a lack of validated trauma and mental health tools, especially for refugees below the age of 6. Detection and treatment of mental health issues among refugee children and youth should be a priority both within the scientific community and in practice in order to reduce morbidity and mortality.

Utilization of health care services by migrants in Europe-a systematic literature review.

Introduction: Our study reviewed the empirical evidence on the utilization of health care services by migrants in Europe, and on differences in health service utilization between migrants and non-migrants across European countries. Sources of data: A systematic literature review was performed, searching the databases Medline, Cinahl and Embase and covering the period from January 2009 to April 2016. The final number of articles included was 39. Areas of agreement: Utilization of accident and emergency services and hospitalizations were higher among migrants compared with non-migrants in most countries for which evidence was available. In contrast, screening and outpatient visits for specialized care were generally used less often by migrants. Areas of controversy: Utilization of general practitioner services among migrants compared with non-migrants presents a diverging picture. Growing points: Compared with previous systematic reviews, the results indicate a clearer picture of the differences in health service utilization between migrants and non-migrants in Europe. Areas timely for developing research: A comprehensive comparison across European countries is impossible because the number of studies is still limited. Further research should also help to identify barriers regarding the utilization of health care services by migrants.

Multidrug-resistant tuberculosis and migration to Europe.

Multidrug-resistant tuberculosis (MDR-TB) in low-incidence countries in Europe is more prevalent among migrants than the native population. The impact of the recent increase in migration to EU and EEA countries with a low incidence of TB (<20 cases per 100 000) on MDR-TB epidemiology is unclear. This narrative review synthesizes evidence on MDR-TB and migration identified through an expert panel and database search. A significant proportion of MDR-TB cases in migrants result from reactivation of latent infection. Refugees and asylum seekers may have a heightened risk of MDR-TB infection and worse outcomes. Although concerns have been raised around 'health tourists' migrating for MDR-TB treatment, numbers are probably small and data are lacking. Migrants experience significant barriers to testing and treatment for MDR-TB, exacerbated by increasingly restrictive health systems. Screening for latent MDR-TB is highly problematic because current tests cannot distinguish drug-resistant latent infection, and evidence-based guidance for treatment of latent infection in contacts of MDR patients is lacking. Although there is evidence that transmission of TB from migrants to the general population is low-it predominantly occurs within migrant communities-there is a human rights obligation to improve the diagnosis, treatment and prevention of MDR-TB in migrants. Further research is needed into MDR-TB and migration, the impact of screening on detection or prevention, and the potential consequences of failing to treat and prevent MDR-TB among migrants in Europe. An evidence-base is urgently needed to inform guidelines for effective approaches for MDR-TB management in migrant populations in Europe.

Differences in hospital attendance for anaphylaxis between immigrants and non-immigrants: a cohort study.

BACKGROUND: The impact of migration on the risk of anaphylaxis remains unknown. We hypothesized that non-Western immigrants have a lower incidence of anaphylaxis compared to Danish-born. We investigated variations in hospital attendance for anaphylaxis between immigrants and Danish-born including time- and age- trends. METHODS: A register-based, historical prospective cohort design. Refugees or family reunified immigrants (n = 127 250) who, between January 1, 1994 and December 31, 2010, obtained residency permits in Denmark were included and matched in a 1 : 6 ratio on age and sex with Danish-born individuals (n = 740 600). Personal identification numbers were cross-linked to the Danish National Patient Registry identifying all first-time hospital attendances for anaphylaxis from January 1, 1994 and December 31, 2010. Incidence rate ratios were estimated, stratified for sex and region of birth, adjusting for age using a Cox regression model including the influence of duration of residence and age when residence was obtained. RESULTS: In total 1053 hospital attendances for anaphylaxis were identified: 89 among non-Western immigrants, 9 among Western immigrants and 955 among Danish-born patients. Both male (RR = 0.65; 95%CI: 0.46;0.90) and female (RR = 0.64; 95%CI: 0.48;0.85) non-Western immigrants had a significantly lower risk ratio of hospital attendance for anaphylaxis compared to Danish-born. Compared to Danish-born, non-Western immigrants living in Denmark during the entire follow-up period also showed a decreased risk (RR = 0.65; 95%CI: 0.34;1.25). Compared to Danish-born, non-Western immigrants who obtained residence permission as children had a decreased risk of hospital attendance for anaphylaxis (RR = 0.48; 95%CI: 0.25;0.91). CONCLUSION: This Danish register-based study using nationwide data revealed fewer hospital attendances for anaphylaxis among non-Western immigrants compared to Danish-born; however this protection was lost over time.

Diabetes-related tuberculosis in Denmark: effect of ethnicity, diabetes duration and year of diagnosis.

BACKGROUND: The association between diabetes mellitus (DM) and tuberculosis (TB) has been established on the basis of cross-sectional studies; however, only a few longitudinal studies have been conducted, with inconsistent results. OBJECTIVE: To study the effect of ethnicity and the presence and duration of DM on the risk of incident TB based on 15 years of follow-up of the entire Danish population. DESIGN AND METHODS: Using Poisson regression analysis, we estimated TB incidence in individuals with DM vs. those without DM by linking nationwide DM and TB registers to the National Civil Register at case level. RESULTS: The TB rate ratio was 1.9 in individuals with DM compared to non-DM individuals, regardless of country of birth, with the exception of African-born individuals (rate ratio 0.5). The risk decreased drastically within the first 2 years after the diagnosis of DM; no association was found with longer durations of DM. The risk also decreased the later the year of DM diagnosis. CONCLUSIONS: The study confirmed DM as a risk factor for TB, except in the case of African-born individuals. Other non-DM risk factors for TB could act as effect-modifiers on the DM-TB association. Implementing earlier DM diagnosis and improving metabolic control may reduce the risk of DM-related TB.

Migration from low- to high-risk countries: a qualitative study of perceived risk of breast cancer and the influence on participation in mammography screening among migrant women in Denmark.

Migrants are less likely to participate in mammography screening programmes compared with local-born populations in Europe. We explored perceptions of breast cancer risk and the influence on participation in mammography screening programmes among migrant women born in countries with low incidence rates of breast cancer. We conducted eight individual interviews and six group interviews including a total of 29 women aged 50-69 years living in Copenhagen, Denmark. Women were migrants born in Somalia, Turkey, Pakistan or Arab countries. Phenomenological analysis was used. Breast cancer was perceived to be caused by multiple factors, including genetics, health behaviour, stress, fertility and breastfeeding. Some women perceived breast cancer to be more prevalent in Denmark as compared with their country of birth, and perceived their risk of developing breast cancer to increase with length of stay in Denmark. Although most women agreed on the relevance of mammography screening, other cancers, chronic and infectious diseases and mental health problems were mentioned as equally or more important to target in public health programmes. A life course perspective comprising previous and current circumstances in country of birth as well as immigration country is important for understanding and influencing the screening behaviour of migrants.

Mortality from infectious diseases among refugees and immigrants compared to native Danes: a historical prospective cohort study.

OBJECTIVES: Refugees and immigrants are likely to be vulnerable to mortality from infectious diseases as a result of high prevalences in their countries of origin and barriers in access to healthcare in the recipient countries. Consequently, we aimed to compare and investigate differences in mortality from infectious diseases among refugees and immigrants and native Danes. METHODS: A register-based, historical prospective cohort design. All refugees (n=29139) and family-reunited immigrants (n=27134) who, between 1 January1993 and 31 December1999, were granted the right to reside in Denmark were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities owing to infectious diseases (based on ICD-10 diagnosis) were identified. Mortality ratios were estimated separately for men and women by migrant status and region of birth; adjusting for age and income; using a Cox regression model, after a mean follow-up of 10-12years after arrival. RESULTS: Female [hazard ratio (HR)=4.15; 95% CI: 2.38, 7.25] and male (HR=2.05; 95% CI: 1.27, 3.33) refugees experienced significantly higher mortality risks from infectious diseases than did native Danes, as was the case for male immigrants (HR=2.39; 95% CI: 1.20, 4.76) but less so for female immigrants (HR=1.23; 95% CI: 0. 50-3.01). Mortality by region of origin was notably higher for individuals from North Africa and sub-Saharan Africa. CONCLUSIONS: Higher mortality among refugees and immigrants than among the native population should lead to reflections on medical reception systems in recipient countries and subsequent possibilities of access to specialised diagnostic and curative healthcare.

Excess use of coercive measures in psychiatry among migrants compared with native Danes.

OBJECTIVE: To investigate differences in risk of compulsory admission and other coercive measures in psychiatric emergencies among refugees and immigrants compared with that among native Danes. METHOD: A register-based retrospective cohort design. All refugees (n = 29 174) and immigrants (n = 33 287) who received residence permission in Denmark from 1.1.1993 to 31.12.1999 were included and matched 1 : 4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Danish Psychiatric Central Register and the Registry of Coercive Measures in Psychiatric Treatment. RESULTS: Refugees (RR = 1.82; 95%CI: 1.45; 2.29) and immigrants (RR = 1.14; 95%CI: 0.83; 1.56) experienced higher rates of compulsory admissions than did native Danes. This was most striking for refugee men (RR = 2.00; 95%CI: 1.53; 2.61) and immigrant women (RR = 1.73; 95%CI: 1.45; 2.60). Moreover, refugees and immigrants experienced higher frequencies of other coercive measures during hospitalisation compared with native Danes. CONCLUSION: Coercive measures in psychiatry are more likely to be experienced by migrants than by native Danes.

Cancer incidence among 1st generation migrants compared to native Danes--a retrospective cohort study.

STUDY AIMS: To investigate the incidence of cancer among 1st generation migrants compared to native Danes, including time trends in the risk of cancer among migrants. METHODS: A retrospective cohort study design. Migrants were matched 1:4 on age and sex with a Danish born reference population. The cohort was linked to the Danish Cancer Register and cancer cases among migrants (n=537) and native Danes (n=2829) were identified. RESULTS: The overall cancer incidence did not differ significantly between migrants from East Europe and native Danes; whereas migrants from the Middle East and North Africa had a significantly lower incidence. All migrants had a significantly lower incidence of breast and colorectal cancer but male migrants from East Europe had a significantly higher incidence of lung cancer. CONCLUSIONS: The overall cancer incidence among migrants was lower compared to native Danes. The time trends of the study are interesting and a relevant topic for further research.

[Access to Danish health care by immigrant women. Access to hospital care among immigrant women with breast cancer compared with Danish women]. / Indvandrerkvinders adgang til det danske sundhedsvaesen. Adgang til hospitalsbehandling blandt indvandrerkvinder med brystkraeft sammenlignet med danske kvinder.

The study aim is to measure possible differences in access to health care among immigrant women with breast cancer compared with Danish women. We used tumour size at diagnosis as a proxy measure of access. The Danish Central Personal Register provided information from 1977-1996 on women between 20-75 years born in countries in which Islam is the dominating faith. These data were linked to the Danish Breast Cancer Cooperative Group, which registers data concerning tumour size. Sixty-five immigrant women with breast cancer were identified and matched with a control population of Danish women. The study showed larger tumours at diagnosis among women from ethnic minority groups compared to Danes. However, this tendency was not significant. Furthermore, mammographic screening had a significant effect on the tumour sizes of Danish women, but not on those of immigrants. The study indicates ethnic inequalities related to access to health services as measured by tumour size.

Effect of social class on tumour size at diagnosis and surgical treatment in Danish women with breast cancer.

This study examines the effect of socio-economic inequalities on the tumour size at diagnosis and the choice of surgical treatment in Danish women with breast cancer. The Danish Breast Cancer Cooperative Group (DBCG) registers all women with breast cancer in Denmark and provides clinical register data on tumour size and surgical treatment for 1594 women <75 yr diagnosed with breast cancer between 1991 and 1996. A questionnaire including questions on social class was sent to the women. The tumour size at diagnosis (an indicator of access to treatment) and the surgical procedure (lumpectomy or mastectomy) for patients who were potential candidates for lumpectomy were the main outcome measures examined. Social class was not associated with tumour size at diagnosis. The tumour size was associated with age and the existence of a mammographic screening program in the county. However, treatment was strongly related to social class. Among women considered candidates for lumpectomy 77% underwent lumpectomy in the highest social class, compared to 50% in the lowest social class. Treatment was associated with age, tumour size and hospital status. It was concluded that the study showed no socio-economic inequalities related to access to health services as measured by tumour size, though significant social differences were found regarding treatment.