Suicide among immigrants in Europe--a systematic literature review.

BACKGROUND: Concerns about increased suicide risk among immigrants to European countries have been raised. We review the scientific literature on differences in suicide among immigrants compared with the majority populations in Europe's major immigration countries. METHODS: We searched the databases PubMed and PsycINFO for peer-reviewed epidemiological studies published in 1990-2011, which compared suicide risks of adult immigrant groups with the risks of the majority population in European countries. Hits were screened by two researchers. RESULTS: We included 24 studies in the review. No generalizable pattern of suicide among immigrants was found. Immigrants from countries in which suicide risks are particularly high, i.e. countries in Northern and Eastern Europe, experienced higher suicide rates relative to groups without migration background. Gender and age differences were observed. Young female immigrants from Turkey, East Africa and South Asia are a risk group. CONCLUSION: Immigrants 'bring along' their suicide risk, at least for the initial period they spend in the immigration country. Health-care planners and providers need to be aware of this 'imported risks'. However, most immigrant groups do not have an increased suicide risk relative to the local-born population; some may even experience substantially lower risks.

Utilisation of psychiatrists and psychologists in private practice among non-Western labour immigrants, immigrants from refugee-generating countries and ethnic Danes: the role of mental health status.

PURPOSE: The stressful migration process has been associated with higher vulnerability for mental health problems, implying a greater need for mental healthcare among immigrants compared with native-born. Our objective was to investigate whether potential differences in the use of psychiatrists and psychologists in labour immigrants, immigrants from refugee-generating countries (RGC), and ethnic Danes could be fully explained by mental health status. METHODS: We conducted a nationwide survey in 2007 with 3,573 individuals aged 18-66 comprising ethnic Danes, labour immigrants (Pakistan and Turkey), and immigrants from RGC (Iran, Iraq, Lebanon, and Somalia). Survey data was linked to healthcare utilisation registries. Using Poisson regression, contacts with private practising psychiatrists and psychologists were estimated. Analyses were adjusted for socioeconomic factors and mental health status. RESULTS: Overall, 2.2 % among ethnic Danes, 1.4 % among labour immigrants and 6.5 % among immigrants from RGC consulted a psychiatrist or psychologist. In adjusted analyses, for psychiatrists, compared with ethnic Danes, labour-immigrant women (multiplicative effect = 1.78), and immigrant women from RGC (multiplicative effect = 2.49) had increased use, while labour-immigrant men had decreased use (multiplicative effect = 0.03). For psychologists, immigrant men from RGC had increased use (multiplicative effect = 2.96), while labour-immigrant women had decreased use (multiplicative effect = 0.27) compared with ethnic Danes. CONCLUSIONS: Mental health status had a somewhat explanatory effect on the use of psychiatrists and psychologists. These selected parts of the Danish mental healthcare system seem responsive to health needs across different population groups, particularly for immigrants from RGC. Yet more attention should be given to non-Western labour immigrants to meet their mental health needs.

Survey nonresponse among ethnic minorities in a national health survey--a mixed-method study of participation, barriers, and potentials.

OBJECTIVES: The participation rate in the Danish National Health Survey (DNHS) 2010 was significantly lower among ethnic minorities than ethnic Danes. The purpose was to characterize nonresponse among ethnic minorities in DNHS, analyze variations in item nonresponse, and investigate barriers and incentives to participation. DESIGN: This was a mixed-method study. Logistic regression was used to analyze nonresponse using data from DNHS (N = 177,639 and chi-square tests in item nonresponse analyses. We explored barriers and incentives regarding participation through focus groups and cognitive interviews. Informants included immigrants and their descendants of both sexes, with and without higher education. RESULTS: The highest nonresponse rate was for non-Western descendants (80.0%) and immigrants 25 (72.3%) with basic education. Immigrants and descendants had higher odds ratios (OR = 3.07 and OR = 3.35, respectively) for nonresponse than ethnic Danes when adjusted for sex, age, marital status, and education. Non-Western immigrants had higher item nonresponse in several question categories. Barriers to non-participation related to the content, language, format, and layout of both the questionnaire and the cover letter. The sender and setting in which to receive the questionnaire also influenced answering incentives. We observed differences in barriers and incentives between immigrants and descendants. CONCLUSIONS: Nonresponse appears related to linguistic and/or educational limitations, to alienation generated by the questions' focus on disease and cultural assumptions, or mistrust regarding anonymity. Ethnic minorities seem particularly affected by such barriers. To increase survey participation, questions could be sensitized to reflect multicultural traditions, and the impact of sender and setting considered.

Policies of access to healthcare services for accompanied asylum-seeking children in the Nordic countries.

AIMS: Asylum-seeking children constitute a vulnerable group with high prevalence and risk for mental health problems. The aim of this study was to compare policies of access to healthcare services, including physical examination and screening for mental health problems on arrival, for accompanied asylum-seeking children in the Nordic countries. METHODS: This study was based on the national reports "Reception of refugee children in the Nordic countries" written by independent national experts for the Nordic Network for Research on Refugee Children, supplemented by information from relevant authorities. RESULTS: In Sweden, Norway and Iceland, asylum-seeking children had access to healthcare services equal to children in the general population. On a policy level, Denmark imposed restrictions on non-acute hospitalisations and prolonged specialist treatments. Regarding health examinations, Sweden deviated from the Nordic pattern by not performing these systematically. In Denmark, Iceland, and some counties in Sweden, but not in Norway, screening for mental health problems was offered to asylum-seeking children. CONCLUSION: Access to healthcare services for asylum-seeking children differs in the Nordic countries; the consequences of these systematic differences for the individual asylum-seeking child are unknown. For asylum-seeking children, access to healthcare has to be considered in a wider context that includes the core conditions of being an asylum-seeker. A comparative study at policy level needs to be supplemented with empirical follow-up studies of the well-being of the study population to document potential consequences of policies in practice.

Interpreting ethnic inequalities in healthcare consumption: a conceptual framework for research.

BACKGROUND: The increasing diversity of the Western-European population demands identification of potential ethnic healthcare inequities. We developed a framework that helps researchers in interpreting ethnic inequalities in healthcare consumption in equity terms. From this framework, we develop recommendations for the design of future studies. METHODS: The framework was developed by analysing three typical studies on ethnic inequalities in healthcare consumption with respect to the potential of interpreting their results as healthcare inequities. RESULTS: Analysing the effects of ethnic variations in healthcare consumption on health outcomes provides important clues about the presence of potential ethnic healthcare inequities. Interpretation of ethnic variations in healthcare consumption as potentially inequitable requires appropriate adjustment for medical need for healthcare, patient preferences and treatment adherence. Because of the central position of medical need, studies need to be disease-specific and based on standardized assessment of risk factors and disease characteristics. A longitudinal study design is necessary to prevent reverse causation. CONCLUSION: The framework shows that ethnic inequalities in healthcare consumption can be justified if healthcare received meets the need for healthcare in all groups and is in accordance with informed patient preferences. It also shows that ethnic equality in healthcare consumption may hide healthcare inequities. We recommend further research on ethnic healthcare inequities using multi-ethnic cohort designs combined with linkage to healthcare registries. We also recommend research to identify clinically relevant ethnic differences in disease profiles and optimization of treatment regimens.

Self-perceived need for interpreter among immigrants in Denmark.

AIM: Starting in June 2011, immigrants who have lived for more than 7 years in Denmark have to pay a user-fee for interpreters in GP consultations and when hospitalised. We do not know yet how many immigrants will be affected by this amendment to the Danish Health Act and which socioeconomic factors characterise the immigrants who might be affected. To shed light on this, we investigated self-perceived need for interpreter (SNI) in GP consultations among participants from the largest non-Western immigrant groups in Denmark, the association between socioeconomic factors and SNI, and the characteristics of the immigrants potentially affected by the act amendment. METHODS: Survey data on 2866 immigrants from former Yugoslavia, Iraq, Iran, Lebanon, Pakistan, Somalia, and Turkey, linked to registry information on socioeconomic factors were examined. We compared unadjusted proportions of SNI by country of birth. Logistic regression analyses were performed to investigate associations between SNI and socioeconomic factors. RESULTS: Overall, 20% of immigrants living longer than 3 years in Denmark and 15% after 7 years reported a need for interpretation in their encounters with GPs. Of the latter group, the majority were outside the labour force (72.3%) and reported poor health (56%). Sex, age, length of stay, education, employment and household income were important factors for SNI. CONCLUSIONS: The amendment to the Health Act will primarily affect immigrants with modest household income, poor health and who are outside the labour force, thereby contributing and creating ethnic and social inequalities in access to health care in Denmark.

Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study.

BACKGROUND: Healthcare obtained abroad may conflict with care received in the country of residence. A special concern for immigrants has been raised as they may have stronger links to healthcare services abroad. Our objective was to investigate use of healthcare in a foreign country in Turkish immigrants, their descendants, and ethnic Danes. METHODS: The study was based on a nationwide survey in 2007 with 372 Turkish immigrants, 496 descendants, and 1,131 ethnic Danes aged 18-66. Data were linked to registry data on socioeconomic factors. Using logistic regression models, use of doctor, specialist doctor, hospital, dentist in a foreign country as well as medicine from abroad were estimated. Analyses were adjusted for socioeconomic factors and health symptoms. RESULTS: Overall, 26.6% among Turkish immigrants made use of cross-border healthcare, followed by 19.4% among their descendants to 6.7% among ethnic Danes. Using logistic regression models with ethnic Danes as the reference group, Turkish immigrants were seen to have made increased use of general practitioners, specialist doctors, hospitals, and dentists in a foreign country (odds ratio (OR), 5.20-6.74), while Turkish descendants had made increased use of specialist doctors (OR, 4.97) and borderline statistically significant increased use of hospital (OR, 2.48) and dentist (OR, 2.17) but not general practitioners. For medicine, we found no differences among the men, but women with an immigrant background made considerably greater use, compared with ethnic Danish women. Socioeconomic position and health symptoms had a fairly explanatory effect on the use in the different groups. CONCLUSIONS: Use of cross-border healthcare may have consequences for the continuity of care, including conflicts in the medical treatment, for the patient. Nonetheless, it may be aligned with the patient's preferences and thereby beneficial for the patient. We need more information about reasons for obtaining cross-border healthcare among immigrants residing in European countries, and the consequences for the patient and the healthcare systems, including the quality of care. The Danish healthcare system needs to be aware of the significant healthcare consumption by immigrants, especially medicine among women, outside Denmark's borders.

Expert opinion on "best practices" in the delivery of health care services to immigrants in Denmark.

INTRODUCTION: Delivery of health care to immigrants is an emerging field of interest. Immigrants are frequently characterised by health outcomes that are inferior to those of other groups with regard to morbidity and mortality. In addition, health professionals report difficulties associated with the encounter with immigrant patients. MATERIAL AND METHODS: A Delphi process with eight Danish experts from the field of immigrant health was performed as part of an EU project. The objective of the Delphi process was to investigate expert opinion on "best practice in the delivery of healthcare to immigrants". Initially, 60 factors were suggested by the experts. Next, these factors were summarised into 32 factors that the experts were invited to rate and, if possible, agree on. RESULTS: The top 11 factors identified in the Delphi process were access to interpreters, quality of interpretation, ensuring medication compliance, having sufficient consultation time, coherence of offers, interdisciplinary collaboration, allocation of resources, the role of the practitioner, acknowledgement of the individual patient, education of health professionals and students and access to telephone interpretation to supplement other services. CONCLUSION: The Delphi process can be a valuable tool in the investigation of expert opinion and may thereby help to guide future policy directives. In the light of the importance experts placed on access to interpreters and on the quality of the interpretation services offered, it seems as an untenable strategy to introduce as from June 2011 self-payment for interpretation services provided to immigrants who have stayed in the country for more than seven years.

Registry data for cross-country comparisons of migrants' healthcare utilization in the EU: a survey study of availability and content.

BACKGROUND: Cross-national comparable data on migrants' use of healthcare services are important to address problems in access to healthcare; to identify high risk groups for prevention efforts; and to evaluate healthcare systems comparatively. Some of the main obstacles limiting analyses of health care utilization are lack of sufficient coverage and availability of reliable and valid healthcare data which includes information allowing for identification of migrants. The objective of this paper was to reveal which registry data on healthcare utilization were available in the EU countries in which migrants can be identified; and to determine to what extent data were comparable between the EU countries. METHODS: A questionnaire survey on availability of healthcare utilization registries in which migrants can be identified was carried out among all national statistic agencies and other relevant national health authorities in the 27 EU countries in 2008-9 as part of the Migrant and Ethnic Minority Health Observatory-project (MEHO). The information received was compared with information from a general survey on availability of survey and registry data on migrants conducted by Agency of Public Health, Lazio Region, Italy within the MEHO-project; thus, the information on registries was double-checked to assure accuracy and verification. RESULTS: Available registry data on healthcare utilization which allow for identification on migrants on a national/regional basis were only reported in 11 EU countries: Austria, Belgium, Denmark, Finland, Greece, Italy, Luxembourg, the Netherlands, Poland, Slovenia, and Sweden. Data on hospital care, including surgical procedures, were most frequently available whereas only few countries had data on care outside the hospital. Regarding identification of migrants, five countries reported having information on both citizenship and country of birth, one reported availability of information on country of birth, and five countries reported availability of information on citizenship. CONCLUSION: Lack of registry data in 16 EU countries, shortage of data on healthcare utilization, and the diversity in the definition of migrant status hampers cross-national comparisons and calls for an urgent establishment of registries, expansion of the existing registry information, and adoption of a common, generally acceptable definition and identification method of migrants across the EU.

[Challenges for health-care professionals in the treatment of ethnic minorities with type 2 diabetes].

This literature review describes health-care professionals' perspective on roles and approaches in encounters with ethnic minorities with type 2 diabetes, including perceived barriers and potentials. They shift between roles in encounters with ethnic minority patients and they consider language and cultural barriers to have an impact on roles, communication as well as time consumption. They emphasise the importance of patient-centeredness and insight into patients' cultural background; however, they report lack of competences to provide good quality in diabetes care to ethnic minority patients.

[Interpretation in the Danish health-care system]. / Tolkebrug i det danske sundhedsvæsen.

Communication between health professional and patient is central for treatment and patient safety in the health-care system. This systematic review examines the last ten years of specialist literature concerning interpretation in the Danish health-care system. Structural search in two databases, screening of references and recommended literature from two scientists led to identification of seven relevant articles. The review showed that professional interpreters were not used consistently when needed. Family members were also used as interpreters. These results were supported by international investigations.

Issues to consider when measuring and applying socioeconomic position quantitatively in immigrant health research.

The relationship between migration and health is complex, yet, immigrant-related inequalities in health are largely influenced by socioeconomic position. Drawing upon previous findings, this paper discusses issues to consider when measuring and applying socioeconomic position in quantitative immigrant health research. When measuring socioeconomic position, it is important to be aware of four aspects: (1) there is a lack of clarity about how socioeconomic position should be measured; (2) different types of socioeconomic position may be relevant to immigrants compared with the native-born population; (3) choices of measures of socioeconomic position in quantitative analyses often rely on data availability; and (4) different measures of socioeconomic position have different effects in population groups. Therefore, caution should be used in the collection, presentation, analyses, and interpretation of data and researchers need to display their proposed conceptual models and data limitations as well as apply different approaches for analyses.

[Migrant status and access to health-care services in Denmark]. / Migrantstatus og adgang til sundhedsydelser i Danmark.

Access to health-care services in Denmark is dependent on migrant status. Emergency care is available to all migrant groups though people not officially residing in the country may be subjected to payment. For regular immigrants and persons with refugee status access to health-care is regulated by The Health Act, whereas access to non-acute health-care for other migrant groups such as asylum seekers, undocumented migrants and persons subjected to human being trafficking is mainly regulated by The Alien Act. The most vulnerable migrant groups are the ones with the most restricted access to care.

Inequality in self-rated health among immigrants, their descendants and ethnic Danes: examining the role of socioeconomic position.

OBJECTIVES: We investigated inequalities in self-rated health between immigrants, their descendants, and ethnic Danes and explored mediation by socioeconomic position and interactions between country of origin and socioeconomic position. METHODS: Cross-sectional survey data on self-rated health from 4,985 individuals aged 18-66 years including immigrants from seven non-Western countries, their descendants, and ethnic Danes was linked to registry-based data on education, employment status, and income as indicators of socioeconomic position. Using multiple logistic regression analysis, we estimated the association between country of origin and self-rated health. RESULTS: Immigrants reported poorer health compared with ethnic Danes [age-adjusted odds ratio (OR) = 2.0-7.3 for men; 2.1-10.5 for women, dependent on country of origin] as well as their descendants (OR = 1.6-3.8 for men; 1.5-2.0 for women). Adjustment for socioeconomic position attenuated this association. Stratified analysis indicated that the effect of socioeconomic position on self-rated health varied across the groups. CONCLUSION: Policies addressing inequalities in health between immigrants, their descendants, and ethnic Danes should target underlying socioeconomic inequalities. Further research of the effects of socioeconomic position on health among immigrants and descendants is needed.

Poorer self-perceived health among migrants and ethnic minorities versus the majority population in Europe: a systematic review.

OBJECTIVES: Knowledge about self-perceived health can help us understand the health status and needs among migrants and ethnic minorities in the European Union (EU) which is essential to improve equity and integration. The objective was to examine and compare self-perceived health among migrant and ethnic minority groups in the EU countries. METHODS: Publications were ascertained by a systematic search of PUBMED and EMBASE. Eligibility of studies was based on the abstracts and the full texts. Additional articles were identified via the references. The final number of studies included was 17. RESULTS: Publications were identified in 5 out of the 27 EU countries. In regard to self-perceived health, most migrants and ethnic minority groups appeared to be disadvantaged as compared to the majority population even after controlling for age, gender, and socioeconomic factors. Only limited cross-country comparisons could be carried out, still they revealed a parallel pattern of self-perceived health among similar migrant/ethnic minority groups. CONCLUSIONS: Policies to improve social and health status, contextual factors, and access to healthcare among migrants and ethnic minorities are essential to reduce ethnic inequalities in health.

Quality of cancer care among foreign-born and US-born patients with lung or colorectal cancer.

BACKGROUND: Disparities in care have been documented for foreign-born cancer patients in the United States. However, few data are available regarding patients with lung and colorectal cancer. In the current study, the authors assessed whether patient-reported quality and receipt of recommended care differed between US-born and foreign-born cancer patients. METHODS: The authors collected surveys and medical records for a population-based cohort including white, Hispanic, and Asian adults (2205 US-born and 890 foreign-born individuals) with lung or colorectal cancer diagnosed in California from 2003 through 2005. Logistic regression was used to assess the association between nativity and patient-reported quality of care and receipt of recommended treatments (adjuvant chemotherapy for stage III colon cancer, adjuvant chemotherapy and radiotherapy for stage II/III rectal cancer, and curative surgery for stage I/II nonsmall cell lung cancer). The authors also assessed whether language explained any differences in care by nativity. RESULTS: Overall, 46% of patients reported excellent care, but foreign-born patients were less likely than US-born patients to report excellent quality of care (adjusted odds ratio [AOR], 0.80; 95% confidence interval [95% CI], 0.65-1.00), a difference partly explained by the language of the survey, an indicator of English proficiency. Rates of recommended therapies ranged from 64% to 85%; foreign-born patients were less likely to receive chemotherapy and radiotherapy for stage II/III rectal cancer (AOR, 0.35; 95% CI, 0.12-0.99). Rates of other treatments did not differ significantly by nativity. CONCLUSIONS: Foreign-born cancer patients reported lower quality of care and were less likely to receive some cancer therapies than patients born in the Unites States. Better coordination of care and communication regarding cancer treatments and expanded use of interpreters may lessen these disparities.

[The effect of length of stay and number of relocations on asylum-seeking children's mental health--secondary publication]. / Betydning af opholdstid og antal flytninger på asylbørns psykiske helbred--sekundaerpublikation.

Among asylum-seeking children aged 4-16 years living in the asylum centres managed by the Danish Red Cross in 2006, we investigated mental health in relation to length of stay and number of relocations. Mental health was evaluated using the Strengths and Difficulties Questionnaire (SDQ). We found that children who had been asylum-seeking for more than one year had an increased risk of having mental difficulties (odds ratio 5.5; 95% confidence interval 1.8-16.3); four or more relocations in the asylum system were also associated with a higher risk of mental problems (odds ratio 3,0; 1,4-6,7).

[The mental health of asylum-seeking children in Denmark]. / Psykisk helbred blandt asylbørn i Danmark.

INTRODUCTION: There is growing concern for the mental health of asylum-seeking children due to protracted periods of stay at asylum centres and an increasing need for psycho-social measures. The objective of this study is to survey asylum-seeking children's mental health in Denmark. MATERIALS AND METHODS: The population comprised all asylum-seeking children aged 4-16 years living at asylum centres run by the Danish Red Cross. In order to assess their mental health the Strengths and Difficulties Questionnaire (SDQ) was employed along with four questions from the Health Behaviour in School-Aged Children questionnaire (HBSC). The respondents were teachers of the 4-16 year-old and the 11-16 year old children. The data collection took place from October to December 2006. We received responses for 246 children, equivalent to 95% of the study population. RESULTS: Based on SDQ, 35% of asylum-seeking children showed evidence of having a psychiatric disorder. The results from the SDQ were supported by the results from the HBSC which showed that asylum-seeking children had numerous physical and psychological symptoms, poor self-perceived quality of life and a fragile social network. CONCLUSION: Emotional and behavioural problems were highly prevalent among asylum-seeking children--also in comparison to children in the general population. This is in accordance with former studies. The causes of the children's condition should be reviewed and relevant psychological and psychiatric treatment should be secured. Furthermore, the long-term consequences of asylum-seeking children's poor mental health need to be clarified.