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.

[Life course epidemiology in migrant health research]. / Lebenslauforientierte Epidemiologie in der Migrationsforschung.

From free choice to forced flight, there are many reasons for migration. Accordingly, the backgrounds and living conditions of migrating people are also diverse. The different associated exposures affect the health of migrants and their children. To capture such a complex phenomenon, an approach is required that takes specific living conditions during the life course of migrants into account.An established methodological approach that can accomplish this is life course epidemiology. When applied to migrating populations, it examines exposures before, during, and after migration. In epidemiological research on the health of migrant populations, it is desirable to consider all three phases. This is countered by the fact that reliable data on the entire life course is not always available.A valid, timely collection and data protection-compliant linkage of longitudinal data from different sources can improve life course-related research on the health of migrants in Germany. In the future, corresponding data should also be included from the countries of origin of migrants.

[Othering in the context of migration: how Others emerge from social categories]. / Othering am Beispiel von Migration: Wie aus sozialen Kategorien die Anderen entstehen.

'Migrants' and 'refugees' are often categorized as Other, in a process called Othering. Using the example of forced migration, we develop a definition of Othering to make it useful for the analysis of health inequalities. We consider Othering as a social process that constructs and classifies differences in such a way that certain groups become socially visible as essential Others. On one hand, the process of Othering operates through a discursive practice that constructs differences, thereby transforming individuals into visible Others. On the other hand, it is based on a power asymmetry that enables the categorization of people, thereby marking them as different.Othering is not solely based on negative attitudes of individuals or groups. Rather, Othering is the result of a broad and historically evolved system of beliefs that gain credibility through power relations. Thus, we understand Othering as a powerful process that goes substantially beyond concepts of discrimination based on mere categorization processes. The concept of Othering stands out from other concepts of inequality by including the epistemic level as a key factor for inequality. Othering not only produces the Other epistemologically, but at the same time establishes a discursive legitimation for the unequal treatment of the Other.Drawing upon our understanding of Othering, we present practice-related findings on the consequences of Othering for the healthcare of 'migrants' and 'refugees'.

Psychosocial Attributes of Housing and Their Relationship With Health Among Refugee and Asylum-Seeking Populations in High-Income Countries: Systematic Review.

Objectives: Housing as a social determinant of health should provide not only shelter, but also a feeling of home. We explored psychosocial pathways creating a sense of home and influencing the relationship between housing and health among asylum seekers and refugees (ASR) in high-income countries. Methods: We performed a systematic review. To be included, studies had to be peer-reviewed, published between 1995 and 2022, and focus on housing and health of ASR in high-income countries. We conducted a narrative synthesis. Results: 32 studies met the inclusion criteria. The psychosocial attributes influencing health most often identified were control, followed by expressing status, satisfaction, and demand. Most attributes overlap with material/physical attributes and have an impact on ASR's mental health. They are closely interconnected with each other. Conclusion: Psychosocial attributes of housing play an essential role in the health of ASR; they are closely associated with material/physical attributes. Therefore, future research on housing and health of ASR should routinely study psychosocial attributes, but always in association with physical ones. The connections between these attributes are complex and need to be further explored. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021239495.

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.

Prevention of War: A Scoping Review on Primary Preventive Measures in Public Health.

Objectives: Wars and armed conflicts have a major impact on population health. As the discipline of public health aims to increase the health at population level, professionals play a significant role in dealing with war and armed conflict. There is need for research on prevention. This study aims to map the literature on existing public health approaches addressing the primary prevention of war and/or armed conflict. Methods: We performed a scoping review in the databases Web of Science, PubMed and Google Scholar, followed by a narrative synthesis. Results: We included 15 studies. We identified three main themes regarding preventive measures: 1) research on root causes of conflicts, surveillance and documentation of its health consequences; 2) education and awareness raising on the consequences of conflicts; and 3) interventions to change socio-economic and political conditions conducive to conflicts. Conclusion: A two-tiered conceptual framework emerges: For primary prevention of war, public health should promote human rights and the rule of law. To prevent armed conflict within states, public health should address the social determinants of health and aim to reduce poverty and inequity.

Racism in public health services: A research agenda.

Despite racism and its impact on health inequities being increasingly studied in health care settings, racism in public health services has so far been neglected in public health research. Studying racism in public health services provides many opportunities to explore the relationship between racism and health protection. We identify several research themes to be explored on (1) non-stigmatizing and community-driven risk communication, (2) surveillance by public health authorities of racialized minority groups, (3) racism experiences in everyday interactions with public health authorities, (4) legal consequences of encounters with public health authorities and (5) public health infrastructure, structural racism and the intersectionality of marginalization. Tackling these research themes will help to start building an evidence base on how racism interferes with equitable health protection and how to dismantle it.

[A guideline on discrimination-sensitive language in research on migration and health]. / Diskriminierungssensible Sprache in der Forschung zu Migration und Gesundheit ­ eine Handreichung.

BACKGROUND: Public health research has increasingly focused on migration as a determinant of health. Responsible research in this area requires an anti-discriminatory approach in its conduct, reporting and dissemination. A discrimination-sensitive use of language is a central element. Guidelines in this regard do not yet exist for the field of public health in German-speaking countries. METHODS: Within the framework of the project Improving Health Monitoring in Migrant Populations (IMIRA) at the Robert Koch Institute, a guideline on anti-discriminatory language in research on migration and health was developed. It consists of a manual and an overview of relevant terms and concepts. The needs, content and form of the guideline were developed in an action research process with project staff from the IMIRA project. RESULTS: The manual shows the following five basic principles for anti-discriminatory language use: (1) avoid generalisations, (2) formulate in a discrimination-sensitive way, (3) use self-designations and external designations, (4) recognise that terms are subject to constant change and (5) openly communicate one's own uncertainties. The overview, which is available online as a "living document", contains terms and concepts that are frequently used in association with the topic of migration. CONCLUSION: The guideline is intended to support researchers in using language in an anti-discriminatory way. This goes hand in hand with a reflection on one's own language use and strengthens responsible research on the topic of migration and health.

Why Othering should be considered in research on health inequalities: Theoretical perspectives and research needs.

•Othering is relevant to public health as an analytical lens that helps to understand the link between minority status and health inequalities.•To investigate health inequalities caused by Othering, it is necessary to include the semantic-symbolic construction of Others.•Othering operates as a discursive practice and occurs on multiple levels.•Research on Othering requires consideration of intersectionality and power structures derived from socially and historically grown hierarchies.•Interventions against Othering require deconstructive concepts - this means deconstructing the institutionalized and embodied normality of the We.

Corrigendum: How Can Schools of Public Health Actively Promote Peace?

[This corrects the article DOI: 10.3389/phrs.2021.1604459.].

Diurnal cortisol variation during pregnancy in Turkish origin and non-migrant women in a German birth cohort study.

BACKGROUND: Immigrants from Turkey experience health disadvantages relative to non-immigrant populations in Germany that are manifest from the earliest stages of the lifespan onwards and are perpetuated across generations. Chronic stress and perturbations of stress-responsive physiological systems, including the hypothalamus-pituitary-adrenal (HPA)-axis, are believed to in part mediate this relationship. Cortisol plays an important role in the association between maternal stress during pregnancy and many pregnancy-, birth- and offspring-related outcomes. We therefore examined whether maternal migrant background is associated with diurnal cortisol variation during pregnancy. METHODS: 109 pregnant women (incl. n = 32 Turkish origin women) that participated in a multi-site prospective cohort study in Germany collected saliva samples across the day on two consecutive days around 24 and 32 weeks gestation. Hierarchical linear models were applied to quantify associations between migrant background and diurnal cortisol variation across pregnancy. RESULTS: Women of Turkish origin exhibited a significantly lower cortisol awakening response (CAR) and a flatter diurnal cortisol slope (DCS) compared to non-migrant women after adjusting for household income. These relationships between migrant status and diurnal cortisol variation were mainly driven by 2nd generation migrants. DISCUSSION: A potential HPA axis dysregulation of Turkish-origin pregnant women may contribute to the intergenerational transmission of health disadvantages in this group.

Maternal self-conception and mental wellbeing during the first wave of the COVID-19 pandemic. A qualitative interview study through the lens of "intensive mothering" and "ideal worker" ideology.

Mothers tended to be responsible for most of the (additional) caregiving and domestic tasks during the COVID-19 pandemic while simultaneously having to pursue their work duties. Increased role conflicts, parenting stress, and exhaustion predict adverse mental health. We aimed to examine how women referred to and made sense of dominant gender norms in their arrangements of pandemic daily life and how these beliefs impacted their maternal self-conception. Qualitative interviews with 17 women were analyzed through the lens of "intensive mothering" ideology and "ideal workers" norms, emphasizing notions of maternal guilt rising from a perceived mismatch between the ideal and actual maternal self-conception. We found that mothers' notions of guilt and their decreases in health link to dominant discourses on motherhood and intersect with "ideal worker" norms. As such, these norms amplify the burden of gendered health inequalities.

How schools in Germany shape and impact the lives of adolescent refugees in terms of mental health and social mobility.

Schools are relevant settings for supporting refugee adolescents' mental health. As education and migration are important social determinants of health, we aim to integrate the qualitative findings of our mixed-methods study into a broader discussion regarding the role of schools and the potential effects on refugee adolescents' lives and mental health, as well as the impact of the COVID-19 pandemic. In this article, we present the findings of school-based actors' (i.e., teachers and school psychologists) perception of refugee adolescents' access to mental health care. The interviews highlight the importance of schools and social activities as main stabilizers and sources of support for refugee adolescents' mental health and the role trusting school-parent relationships play in mental health care help-seeking. Our data indicate that schools lack the resources to properly address these needs. However, these structural gaps are rooted into historical segregation and discrimination in the German educational system and left unaddressed, can increase stigma and intergenerational social inequalities, especially in connection to the COVID-19 pandemic. We conclude our article with a set of recommendations that could be relevant and implemented across different contexts to strengthen the role of the school setting in promoting the mental health and well-being of refugee adolescents.

Aetiological research on the health of migrants living in Germany: a systematic literature review.

BACKGROUND: Germany has become an important immigration country and health services need to adopt to meet the needs of an increasingly multicultural population. For public health planning, it is essential to understand the aetiology of health problems among migrant populations. The main objective was to systematically identify, evaluate and synthesise population-based studies that investigated exposure-outcome relationships among migrant groups in Germany. METHODS: In November 2019, we searched PubMed and LIVIVO, and updated this search in November 2020, to identify peer-reviewed publications that fulfilled our eligibility criteria: English or German language; study on disease aetiology among major migrant groups in Germany, according to the latest microcensus; publication date from inception to 01 November 2020 and observational or experimental study designs. For quality appraisal, we used the Critical Appraisal Skills Programme checklists. Outcomes under investigation were categorised according to the WHO major disease groups, and their associations with risk factors were synthesised as a heat map. RESULTS: Out of 2407 articles retrieved, we included 68 publications with a total number of 864 518 participants. These publications reported on cross-sectional data (n=56), cohort studies (n=11) and one intervention study. The population groups most frequently studied were from the Middle East (n=28), Turkey (n=24), sub-Saharan Africa (n=24), Eastern Europe (n=15) and the former Soviet Union (n=11). The outcomes under study were population group specific. There were consistent associations of demographic and socioeconomic factors with ill health among migrants in Germany. DISCUSSION: In this systematic review, we observed low risk of bias in two-thirds of the studies. There is an increasing body of evidence for aetiological research on migrants' health in Germany. Still, the directions of associations between a wide range of risk factors and major disease groups seem only partially understood. PROSPERO REGISTRATION NUMBER: CRD42018085074.

Using agent-based modelling to test hypotheses on the role of neighbourhood social mechanisms in the development of small-area health inequalities.

BACKGROUND: Small-area health inequalities may originate from differentials in the spatial distribution of environmental stressors on health. The role played by neighbourhood social mechanisms on small-area health inequalities is difficult to evaluate. We demonstrate that agent-based modelling (ABM) is a useful technique to overcome existing limitations. It allows testing hypotheses that social contagion has the potential to modify the effects of environmental stressors by reducing or increasing small-area health inequalities. METHODS: Parameters defining the strength of the effect of social contagion on health behaviour were used together with a stochastic model to obtain for every year the health outcome of every agent based on health the previous year, environmental stressors and health behaviour. Unequal spatial distribution of stressors was operationalised with spatial correlation structure. We measured changes in health inequalities using parameters of the spatial correlation structure of health after 10 years. In a further round of simulations, social contagion depended on the environmental stressors. RESULTS: A social contagion mechanism led to a reduction of small-area health inequalities together with an increase in the spatial reach of the effect of environmental stressors. An association between environmental stressor and social contagion mechanism led to a stronger localisation of the effect of environmental stressors. CONCLUSIONS: Hypotheses about the role of neighbourhood social mechanisms can be tested using ABM. The respective models provide a better understanding of mechanisms in the causal chain between environmental stressors and health inequalities. This can pave the way to the development of a new type of neighbourhood-based intervention informed by social mechanisms.

Decomposing intersectional inequalities in subjective physical and mental health by sex, gendered practices and immigration status in a representative panel study from Germany.

BACKGROUND: The mapping of immigration-related health inequalities remains challenging, since immigrant populations constitute a heterogenous socially constructed group whose health experiences differ by social determinants of health. In spite of the increasing awareness that population mobility and its effects on health are highly gendered, an explicit gender perspective in epidemiology is often lacking or limited. METHODS: To map inequalities in self-reported physical and mental health in Germany at the intersections of sex, gendered practices and immigration status, we used data from the German Socioeconomic Panel (SOEP) and applied an intercategorical intersectional approach conducting multilevel linear regression models. We differentiated between sex (male/female) as reported in the survey and gendered social practices, quantified through a gender score (on a femininity-masculinity continuum). RESULTS: We included 20,897 participants in our analyses. We saw an intersectional gradient for physical and mental health. Compared to the reference group, i.e. non-immigrant males with masculine gendered practices, physical and mental health steadily decreased in the intersectional groups that did not embody one or more of these social positions. The highest decreases in health were observed in the intersectional group of immigrant females with feminine gendered practices for physical health (-1,36; 95% CI [-2,09; -0,64]) and among non-immigrant females with feminine practices for mental health (-2,51; 95% CI [-3,01; -2,01]). CONCLUSIONS: Patterns of physical and mental health vary along the intersectional axes of sex, gendered practices and immigration status. These findings highlight the relevance of intersections in describing population health statuses and emphasise the need to take them into account when designing public health policies aiming at effectively reducing health inequalities.

Association between housing and health of refugees and asylum seekers in Germany: explorative cluster and mixed model analysis.

BACKGROUND: Accommodation for asylum seekers and refugees (ASR) in Germany differs in many ways depending on a range of political, structural, social, and environmental factors. These contextual differences present a challenge for assessing health impacts of refugee accommodation. We aimed to devise a broad typology of refugee accommodation that allows to assess associations between housing and health of ASR. METHODS: We performed a cluster analysis of population-based, cross-sectional secondary data in Germany to identify clusters of refugee accommodation. We then assessed health disparities across clusters by performing bivariate analysis and linear mixed model regression analysis. RESULTS: We identified four clusters, three of them reflected different types of private accommodation and one pointed to collective accommodation. The collective accommodation cluster clearly differed from the private accommodation clusters in terms of space, area, level of restrictions, social connections and respondent satisfaction. Across private accommodation clusters we also found differences in space, area, and level of restrictions. In regression analysis, belonging to one of the private accommodation cluster was significantly associated with better mental health compared to belonging to the collective accommodation cluster. Physical health was significantly lower in one private accommodation cluster characterized by poor access to public transport and a higher level of restrictions compared to a private accommodation cluster showing better connections and a lower level of restrictions. CONCLUSION: We demonstrate that unfavourable conditions cluster in collective accommodation with negative outcomes for mental health but not for physical health. We also found health disparities across types of private accommodation. We conclude that housing plays a role in the production of health inequalities in ASR but needs to be assessed in a differentiated, multidimensional way.

[Use of emergency rooms by so-called multiple users: results of a prospective study with special consideration of the migration status]. / Inanspruchnahme von Notaufnahmen durch sog. Mehrfachnutzer/-innen: Ergebnisse einer prospektiven Studie unter besonderer Berücksichtigung des Migrationsstatus.

Objectives: Can we identify predictive factors for the group of so-called multiple users (MU; 4 and more uses of an emergency department [ED] in the past 12 months)? Are people with a migration background more likely to be classified in the MU group? Methodology: Included were consecutive patients who visited three EDs in Berlin from July 2017 to July 2018. Using a questionnaire, diseases, reasons for visiting the ED and socioeconomic factors were recorded. Comparisons between migrants (1st generation), their descendants (2nd generation) and nonmigrants were assessed using logistic regression. Results: A total of 2339 patients were included in the evaluation (repeat rate 56%), of which 901 had a migration background. Young women (<30 years), chronically ill, pregnant women, patients with severe complaints and people with (self-assessed) moderate and poor health quality as well as those without medical referral had a greater chance of multiple use of ED. Conclusion: MU burden the already increasing patient volume of ED. However, they represent a heterogeneous group of patients, among whom people with a migration background are not common. Further research is warranted to better understand the factors that lead to frequent use and to develop effective strategies to address the complex health needs of MUs.

Development of a gender score in a representative German population sample and its association with diverse social positions.

Background: Gender as a relational concept is rarely considered in epidemiology. However, an in-depth reflection on gender conceptualisation and operationalisation can advance gender analysis in quantitative health research, allowing for more valid evidence to support public health interventions. We constructed a context-specific gender score to assess how its discriminatory power differed in sub-groups defined by social positions relevant to intersectional analyses, i.e., sex/gender, race, class, age and sexual attraction. Methods: We created a gender score with the help of multivariable logistic regression models and conditional probabilities based on gendered social practices and expressed on a masculinity-femininity continuum, using data of the German Socioeconomic Panel. With density plots, we exploratively compared distributions of gendered social practices and their variation across social groups. Results: We included 13 gender-related variables to define a gender score in our sample (n = 20,767). Variables on family and household structures presented with the highest weight for the gender score. When comparing social groups, we saw that young individuals, those without children, not living with a partner or currently living in a same-sex/gender partnership, showed more overlap between feminine/masculine social practices among females and males. Conclusions: The distribution of gendered social practices differs among social groups, which empirically backs up the theoretical notion of gender being a context-specific construct. Economic participation and household structures remain essential drivers of heterogeneity in practices among women and men in most social positions. The gender score can be used in epidemiology to support concerted efforts to overcome these gender (in)equalities-which are important determinants of health inequalities.