The urgent need for valid data on access to healthcare in Europe.

The probability of experiencing an unmet need for medical or dental care can be expressed either (a) as a proportion of the whole population studied or (b) as a proportion of those who had a need. Only (b) yields a valid measure of access to care. Using (a) combines access to care with state of health. Unfortunately, the main data source used by researchers (the European Union Survey of Income and Living Conditions, EU-SILC) uses method (a), rendering the literature to date subject to unknown errors. The authors argue that there is an urgent need for Eurostat to publish data using method (b).

Adopting an ethical approach to migration health policy, practice and research.

Migration health is affected by decision making at levels ranging from global to local, both within and beyond the health sector. These decisions impact seeking, entitlements, service delivery, policy making and knowledge production on migration health. It is key that ethical challenges faced by decision makers are recognised and addressed in research and data, clinical practice and policy making on migration health. An ethical approach can provide methods to identify ethical issues, frameworks for systematising information and suggesting ethically acceptable solutions, and guidance on procedural concerns and legitimate decision making processes. By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. Adopting an ethical approach to migration health benefits governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves. First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do through an 'all things considered' approach. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions - from 'bedside rationing' to collection of big data or in policy making - that can ensure that migrants' interests are considered. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups. An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses.

Moving upstream: Changing policy scripts on migrant and ethnic minority health.

This article uses the concept of 'policy scripts' to explore the aims and assumptions underlying policies on migrant and ethnic minority health. Firstly, it analyses the shift in health policies from 'downstream' approaches (emphasising health care for the sick and injured) to 'upstream' ones (emphasising health protection for the whole population). The field of migrant health has been relatively slow to move upstream. Two factors appear to have impeded this shift: (a) the reluctance of the 'social determinants of health' movement to regard migrant status and ethnicity as important causes of health inequities; and (b) the one-sided emphasis on short-term emergency health provisions for migrants arising from the recent increase in forced migration worldwide, in particular the sudden peak in mixed migration to the EU in 2015. The article contends that (a) the usual arguments against treating migration and ethnicity as health determinants do not stand up to critical examination; and (b) the overwhelming emphasis on unauthorised entrants which characterises current discussions of migration policy, including health, is out of all proportion to their volume relative to that of other migrants. Fortunately, recent policy initiatives at UN level have the potential to restore the balance between 'upstream' and 'downstream' approaches, as well as between unauthorised entry and 'routine' migration.

How can we further rights-based and evidence-based policies on migrant and ethnic minority health?

There is an urgent need to draw the attention of politicians and the public to the health inequities facing migrants and ethnic minorities to foster health policy reforms based on human rights and sound evidence. Today, it is more important than ever for researchers and organisations promoting migrant health to join forces and intensify their efforts to get policies improved. A workshop was held to consider how this should be done. Three speakers put forward in turn perspectives based mainly on human rights, scientific evidence and a combination of both.

The MIPEX Health strand: a longitudinal, mixed-methods survey of policies on migrant health in 38 countries.

BACKGROUND: Within health systems, equity between migrants and native-born citizens is still a long way from being achieved. Benchmarking the equitability of policies on migrant health is essential for monitoring progress and identifying positive and negative aspects of national policies. For this purpose, the 2015 round of the Migrant Integration Policy Index (MIPEX) was expanded to include a strand on health, in a collaborative project carried out between 2013 and 2017 in 38 countries. METHODS: Indicators of policies to promote equity were derived from the 2011 Recommendations of the Council of Europe on 'mobility, migration and access to health care' and used to construct a questionnaire compatible with MIPEX methodology. This yielded scores for Entitlement, Accessibility, Responsiveness and Measures to achieve change. RESULTS: As a measuring instrument, the questionnaire has a high degree of internal consistency, while exploratory factor analysis showed a coherent relationship between its statistical structure and the four scales it comprises. Measures to achieve change were strongly associated with Responsiveness, but not at all with Entitlements and only slightly with Accessibility. Examining the results from the sub-sample of 34 'European' countries, wide variations in the equitability of policies were found: these were mainly associated with a country's wealth (GDP), but differences between EU13 and EU15 countries were too extreme to explain completely in such terms. CONCLUSIONS: The MIPEX Health strand is a robust measurement tool that has already yielded a number of important results and is providing a valuable resource for both researchers and policy-makers.

Building Responsive Health Systems to Help Communities Affected by Migration: An International Delphi Consensus.

Persons affected by migration require health systems that are responsive and adaptable to the needs of both disadvantaged migrants and non-migrant populations. The objective of this study is to support health systems for populations affected by migration. MATERIALS AND METHODS: An international Delphi consensus process was used to identify policy approaches to improve health systems for populations affected by migration. Participants were leading migrant health experts from Americas, Europe, Middle East, Asia, and Australasia. We calculated average ranking scores and qualitatively analyzed open-ended questions. RESULTS: Participants identified the following key areas as priorities for policy development: health inequities, system discrimination, migrant related health data, disadvantaged migrant sub-groups, and considerations for disadvantaged non-migrant populations. Highly ranked items to improve health systems were: Health Equity Impact Assessment, evidence based guidelines, and the International Organization for Migration annual reports. DISCUSSION: Policy makers need tools, data and resources to address health systems challenges. Policies need to avoid preventable deaths of migrants and barriers to basic health services.

How should health service organizations respond to diversity? A content analysis of six approaches.

BACKGROUND: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches? METHODS: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches. RESULTS: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender. CONCLUSIONS: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes.

Why do ethnic Chinese in the Netherlands underutilize mental health care services? Evidence from a qualitative study.

Chinese immigrants in the Netherlands are less likely than other ethnic groups to utilize mainstream mental health care services. This study investigated the experiences of Chinese with mental health problems, to inform measures to make services more responsive to the needs of this group. Qualitative methods of analysis were applied to interview data in order to explore ways of finding help, barriers to accessing mainstream mental health care, experiences in care, factors jeopardizing the quality of care, and views on mental health services among Chinese migrants in the Netherlands. Rather than recruiting individuals with mental health problems, an indirect method was used in which ethnic Chinese participants were invited to tell us about one or more Chinese individuals in their social environment whom they regarded as having (had) mental health problems (Symbol: see text). Although most Chinese regarded mainstream Dutch care as the appropriate resource for dealing with mental health problems, many barriers to access and threats to care quality were reported. In contrast to the widely accepted view that cultural differences in health beliefs underlie the low utilization of mental health services by Chinese in the West, the main obstacles identified in this study concerned practical issues such as communication problems and lack of knowledge of the health system. Respondents also described concerns about entitlement to care and discrimination (actual or anticipated). Measures suggested by respondents for improving care included increased use of interpreters and cultural mediators, encouraging migrants to increase their language proficiency, and better dissemination of information about the health system. The article concludes with a discussion of the policy implications of these findings.

Tuberculosis among migrant populations in the European Union and the European Economic Area.

BACKGROUND: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report 'Key Infectious Diseases in Migrant Populations in the EU/EEA' commissioned by The European Centre for Disease Prevention and Control. METHODS: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. RESULTS: In 2010, of the 73,996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. CONCLUSION: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants' vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA.

Migration and health in an increasingly diverse Europe.

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

Migration experiences, employment status and psychological distress among Somali immigrants: a mixed-method international study.

BACKGROUND: The discourse about mental health problems among migrants and refugees tends to focus on adverse pre-migration experiences; there is less investigation of the environmental conditions in which refugee migrants live, and the contrasts between these situations in different countries. This cross-national study of two samples of Somali refugees living in London (UK) and Minneapolis, Minnesota, (USA) helps to fill a gap in the literature, and is unusual in being able to compare information collected in the same way in two cities in different countries. METHODS: There were two parts to the study, focus groups to gather in-depth qualitative data and a survey of health status and quantifiable demographic and material factors. Three of the focus groups involved nineteen Somali professionals and five groups included twenty-eight lay Somalis who were living in London and Minneapolis. The quantitative survey was done with 189 Somali respondents, also living in London and Minneapolis. We used the MINI International Neuropsychiatric Interview (MINI) to assess ICD-10 and DSM-IV mental disorders. RESULTS: The overall qualitative and quantitative results suggested that challenges to masculinity, thwarted aspirations, devalued refugee identity, unemployment, legal uncertainties and longer duration of stay in the host country account for poor psychological well-being and psychiatric disorders among this group. CONCLUSION: The use of a mixed-methods approach in this international study was essential since the quantitative and qualitative data provide different layers and depth of meaning and complement each other to provide a fuller picture of complex and multi-faceted life situations of refugees and asylum seekers. The comparison between the UK and US suggests that greater flexibility of access to labour markets for this refugee group might help to promote opportunities for better integration and mental well-being.

Good practices in migrant health: the European experience.

Migrants comprise a growing proportion of European populations. Although many are healthy, those who do need healthcare often face barriers and the care they receive may be inappropriate to their needs. This paper summarises good practices identified in a review of health services for migrants in Europe. Governments should ensure that migrants are entitled to health services, that the services are appropriate to their needs and that data systems are in place to monitor utilisation and detect inequities. Health services should adopt a 'whole organisation approach', in which cultural competence is viewed as much as a task for organisations as for individuals. Health workers should take steps to overcome language, social and cultural barriers to care. In each case, existing examples of good practice are provided. At a time when support is growing in some countries for political parties pursuing anti-immigrant agendas and governments in all countries are pursuing austerity policies, there is a greater need than ever for the public health community to ensure that migrants have access to services that are effective and responsive to their needs.

Responding to diversity: an exploratory study of migrant health policies in Europe.

There has been growing international attention to migrant health, reflecting recognition of the need for health systems to adapt to increasingly diverse populations. However, reports from health policy experts in 25 European countries suggest that by 2009 only eleven countries had established national policies to improve migrant health that go beyond migrants' statutory or legal entitlement to care. The objective of this paper is to compare and contrast the content of these policies and analyse their strengths and limitations. The analysis suggests that most of the national policies target either migrants or more established ethnic minorities. Countries should address the diverse needs of both groups and could learn from "intercultural" health care policies in Ireland and, in the past, the Netherlands. Policies in several countries prioritise specific diseases or conditions, but these differ and it is not clear whether they accurately reflect real differences in need among countries. Policy initiatives typically involve training health workers, providing interpreter services and/or 'cultural mediators', adapting organizational culture, improving data collection and providing information to migrants on health problems and services. A few countries stand out for their quest to increase migrants' health literacy and their participation in the development and implementation of policy. Progressive migrant health policies are not always sustainable as they can be undermined or even reversed when political contexts change. The analysis of migrant health policies in Europe is still in its infancy and there is an urgent need to monitor the implementation and evaluate the effectiveness of these diverse policies.

Barriers to health care for chinese in the Netherlands.

This study examines utilisation of the Dutch health care system by Chinese people in the Netherlands as well as their attitudes to the system, paying special attention to mental health. Information was gathered by semistructured interviews (n = 102). The main issues investigated are access, help-seeking behaviour, and quality of care. Results showed that most respondents used Dutch health care as their primary method of managing health problems. Inadequate knowledge about the system and lack of Dutch language proficiency impede access to care, in particular registration with a General Practitioner (GP). Users complained that the care given differed from what they expected. Results also showed that the major problems are to be found in the group coming from the Chinese-speaking region. Western concepts of mental health appear to be widely accepted by Chinese in the Netherlands. However, almost half of our respondents believed that traditional Chinese medicine or other methods can also help with mental health problems. The provision of relevant information in Chinese appears to be important for improving access. Better interpretation and translation services, especially for first-generation migrants from the Chinese-speaking region, are also required.