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Initial health assessments for newly arrived migrants, refugees, and asylum seekers

• Related content
• Peer review
• Felicity Knights , GP academic clinical fellow , joint first author 1 ,
• Shazia Munir , GP/clinical lead, refugee and asylum seeker services , joint first author 2 ,
• Haja Ahmed , journalist and refugee patient co-author 3 ,
• Sally Hargreaves , associate professor in global health 1
• 1 The Migrant Health Research Group, Institute for Infection and Immunity, St George’s, University of London, London, UK
• 2 Refugee and Asylum Seeker Services, Health Inclusion Team, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
• 3 London, UK
• Correspondence to S Hargreaves s.hargreaves{at}sgul.ac.uk

What you need to know

Consider screening for communicable diseases (including active and latent TB, hepatitis B/C, HIV, and parasitic infections) dependent on country of origin, and offer catch up vaccinations for all newly arrived children, adolescents, and adults to align with the host nation’s schedule

Non-communicable diseases may be undiagnosed or poorly controlled; maintain and review medication supplies

Consider nutritional deficiency, oral health, pregnancy, contraception, mental health, and traumatic experiences

Show kindness and empathy during all encounters, as interaction with healthcare workers can markedly influence migrants’ lives in new countries. Take a holistic, person-centred approach, and signpost patients to services, voluntary support, and translated health information

Migrant, refugee, and asylum seeker populations in Europe have increased in recent years, including in response to the current conflicts in Afghanistan, Syria, and—more recently—Ukraine. 1 2 3 Countries neighbouring those in crises, and transit countries, are most affected, but so are many other host nations across the world. 1 2 3

People fleeing conflict or humanitarian crisis, undocumented migrants, refugees, asylum seekers, and people who have been trafficked, may be more vulnerable than other migrants. 4 Health service delivery to these groups can be complex and has implications for health systems and front line clinicians tasked with meeting the needs of these diverse populations.

This article outlines how primary care services and multidisciplinary teams can meet the initial healthcare needs of newly arrived migrants. We include some specific new guidance on health provision for newly displaced populations from Ukraine; however, the main focus is on refugees and asylum seekers from Afghanistan who have arrived in the UK in large numbers over the past year or so, and for whom UK GPs have requested specific guidance. That said, the advice presented is broadly applicable to all countries hosting migrant groups from any country.

Evidence regarding best practice for migrants as a patient group is limited. This article draws primarily on the available specialist guidance and the authors’ clinical and professional experience.

What is an effective consultation?

In the UK, everyone has the right to register and consult with a GP ( boxes 1 and 2 ). Entitlements vary between countries and migrant groups. Where required, provide support in registration, navigation, and attendance of appointments, remembering that digital registration and triage systems introduced during the covid-19 pandemic may pose challenges. All services have a role in signposting and supporting access to a full and holistic assessment, regardless of where patients initially present.

UK NHS entitlements

Primary care.

Everyone living in the UK is entitled to register and consult with a GP, free of charge

Proof of address, identification, and immigration status are not required for GP registration.

Secondary care

NHS services that are free regardless of immigration status include:

accident and emergency services

NHS 111 advice service

diagnosis and treatment of communicable diseases

diagnosis and treatment of sexually transmitted infections

testing and treatment of covid-19

family planning services

palliative care services provided by charity or private provider

treatment for conditions caused by torture, female genital mutilation, domestic or sexual violence.

Groups who are eligible for free secondary care are:

refugees, asylum seekers, and their dependants

refused asylum seekers living in Northern Ireland, Scotland, and Wales

refused asylum seekers living in England, who receive Section 95 or Section 4 2 support

children looked after by the local authority

immigration detainees

people who have been subject to modern slavery and human trafficking

people treated under the Mental Health act.

For groups that are chargeable for secondary care, such as undocumented migrants, urgent or immediately necessary care must be given, regardless of ability to pay. Maternity services are always immediately necessary

Maternity care

Maternity care is free for refugees and asylum seekers. For groups that may be chargeable, maternity services are always immediately necessary.

Refugees, asylum seekers, and other migrants may be able to access free vitamins (folic acid, vitamins C and D) through the Healthy Start Scheme.

Maternity prescription exemption forms should be provided.

Help with prescription charges, dental, and optical care

People with low income, including refugees, asylum seekers, refused asylum seekers, and undocumented migrants, can apply to the NHS low income scheme for help with medical costs, including prescription charges, dental treatment, and sight tests. Individuals must fill in an HC1 form and will receive an HC2 certificate if eligible. A maternity exemption form entitles pregnant patients to free dental treatment. Further details are available in the ‘Patient resources’ box, below.

Refugees and asylum seekers from Afghanistan in the UK

Resettled refugees—The UK government has established the Afghan Relocations and Assistance Policy to resettle those who supported British efforts in Afghanistan. 5 In addition, the Afghan Citizens Resettlement Scheme has committed to welcome 5000 refugees in the first year and 20 000 in the coming years. 6 Clinical guidance is available specifically for Afghans arriving via these schemes 5

Asylum seekers—1974 applications for asylum from Afghan nationals were filed in the year ending September 2021. 7 This number is likely to rise and does not include unknown numbers of undocumented Afghan migrants who have not submitted an asylum claim. Unlike resettled refugees, these individuals do not receive the same benefits, are not able to work, and live with the uncertainty of the outcome of their asylum claim

Arrivals from Afghanistan have typically been housed in contingency and temporary accommodation such as hotels. In many parts of the country, individuals have remained in these settings for many months awaiting more permanent accommodation

The UK Health Security Agency (UKHSA) recommends inquiring about circumstances before migration, the journey, and current circumstances (including discrimination) within a person centred assessment of any presenting migrant patient. 8

General Medical Council guidance states that “all possible efforts must be made to ensure effective communication with patients.” This should involve use of independent professional interpreters:

Consider patient preference regarding interpreter dialect, gender, and cultural background, as these may have an impact on trust and disclosure of information

Book interpreters in advance, particularly for languages where it may be more difficult to find an interpreter

Record the names and identification numbers of interpreters to allow rebooking and continuity.

In the consultation, enable effective communication by being compassionate, listening actively, gaining trust, and building rapport. Whenever possible, offer longer appointment times and follow-up appointments with the same healthcare professional to enable this, to ensure all health concerns are addressed, and to provide continuity of care.

When referring to specialist services, be open with patients about expected wait times to help manage expectations.

“It is hard for me, telling my story again and again. My doctor knows what happened to me. It is better for me. I don’t have to explain everything to her every time.” Asylum seeker from Afghanistan.

The following section focuses on the specific needs of migrants from Afghanistan.

For migrants from Ukraine, box 3 summarises the current healthcare recommendations.

Clinical considerations for migrants from Ukraine

The ECDC recommends that current healthcare provision for displaced populations from Ukraine 9 (predominantly women, children, and older people at the time of writing) in transit and bordering countries includes access to emergency care, addressing basic needs (food, shelter, ensuring supply of medicines and medical equipment), and access to healthcare professionals. Preventing interruptions in medical supplies and care are essential to avoid excess mortality and morbidity in the coming weeks from cardiovascular disease, and chronic infectious and non-infectious diseases. 10 In the longer term, a more holistic approach might be needed; one that considers catch-up vaccination for both children and older groups (including for polio and measles, as outbreaks of these conditions occur in Ukraine), 9 and access to host health systems. 11

What clinical issues to consider?

Refugees are often described as facing a “triple burden” of infectious diseases, non-communicable diseases, and mental health issues. Some conditions “cluster,” owing to shared exposure to life threatening events, epidemiological burden in the country of origin, and risk factors related to the journey to the host country (examples might include diabetes, depression, and poverty, or diabetes, obesity, and lack of social network) ( fig 1 ). 12 Migrants’ health may deteriorate in the host country because of socioeconomic challenges, substandard accommodation, lack of digital access or digital literacy, and restricted access to healthcare, education, and labour opportunities. 13

Key health considerations when assessing newly arrived migrants, refugees, and asylum seekers

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Communicable disease

The UKHSA 8 and the European Centre for Disease Prevention and Control (ECDC) offer up-to-date advice on screening for communicable diseases. 14

The United Nations High Commissioner for Refugees and International Organisation for Migration prescribe pre-entry testing for hepatitis B and C and chest radiography for tuberculosis (TB), but this is not possible for people leaving in emergency evacuation. Furthermore, a delay often occurs between testing and travel of resettled refugees; hence repeat testing may often be required in the host country.

TB screening

The incidence of TB in Afghanistan is ~189 per 100 000 population. 15 UKHSA suggests using chest radiography to screen people who are newly arrived from Afghanistan for active TB. 5 However most cases of active TB in the UK are likely due to reactivation of latent infection (LTBI). The National Institute for Health and Care Excellence (NICE) recommends that new entrants aged under 65 from high incidence countries, such as Afghanistan, are screened for latent TB using interferon-gamma release assay via a single blood test; this is most suitable for underserved groups (including refugees and asylum seekers). 16 In England, UKHSA’s latent TB testing and treatment programme exists in primary care for people aged 18-35, who have arrived from high incidence countries (including Afghanistan) within the last five years. 17 Uptake of screening is limited in some migrant groups. 14 Challenging the stigma and misconceptions around TB may help to address this. 18 For children, contact local TB services regarding the pathways for LTBI screening.

Hepatitis B screening

The ECDC recommends screening for hepatitis B in migrants from countries with intermediate (HBsAg prevalence ≥2%) and high (HBsAg prevalence ≥5%) prevalence. 5 14 The prevalence of hepatitis B in Afghanistan is considered relatively high. 5

Strongyloidiasis screening

Afghanistan has a high probability of being endemic for Strongyloides , a potentially serious but commonly asymptomatic infection. ECDC guidance recommends serological screening for strongyloidiasis, 14 irrespective of number of years since leaving endemic countries, particularly in individuals who are immunosuppressed.

Hepatitis C and HIV screening

Afghanistan is not considered to have a high prevalence of HIV or to be HCV endemic, and therefore routine screening on arrival is not warranted. 14 Consider testing if other risk factors are present.

Sexual health screening

When warranted, offer a full sexual health screen—including testing for HIV, hepatitis B and C, syphilis, chlamydia, and gonorrhoea—as part of an overall health assessment, taking care to be culturally sensitive (for example, some migrants may wish to discuss this only with health professionals of the same gender). Consider that if the person has a history of sexual assault or rape; they may struggle to disclose their trauma. A trauma informed approach is recommended (see below).

Patients who are febrile or unwell

Consider a wide range of differentials, including the infections mentioned above, as well as malaria and typhoid.

Catch up vaccination

Some groups may be under-immunised and/or require additional vaccines to align them with host countries’ vaccination schedules. 19 The World Health Organization’s Immunisation Agenda 2030 calls for greater emphasis on catch up vaccination across the life course, ie, seeking every opportunity to catch up missed vaccines, doses, and boosters in children, adolescents, and older individuals. Polio is endemic in Afghanistan (41 cases reported in 2021) and measles outbreaks still occur. 20

The UKHSA advises to assume that patients are unimmunised if they are unable to provide reliable written or verbal vaccination history, and to offer vaccination according to the host country’s vaccination schedule. 21 The UK catch up vaccination schedule for migrants aged 10 years and older is summarised in figure 2 .

Catch up vaccinations to consider in migrants aged 10 and older. Reproduced from 22 MMR=measles, mumps, rubella; Td/IPV=tetanus, diphtheria, polio; HPV: human papillomavirus vaccine; PPV=pneumococcal vaccine; MENACWY=meningococcal conjugate vaccine

Some populations might have a low uptake of vaccination for covid-19 (eg, survey data using non-probability convenience sampling found nearly a third of people surveyed in Afghanistan showed limited intent to vaccinate against covid-19 23 ). Consider strategies to overcome any barriers to health or vaccine systems (including vaccine hesitancy), eg, through outreach, longer appointment times, and translated patient information. 24 A toolkit to improve vaccine uptake is available from Doctors of the World (see box, ‘Additional educational resources’) and ECDC. 25 26 The UKHSA provides guidance on managing people who may have been vaccinated in other countries. 27

Offer written information about testing, treatment, and vaccination for covid-19 in the patient’s language.

Non-communicable disease

Some patients may present with poorly controlled non-communicable diseases (NCDs), or may be experiencing complications owing to interruption or lack of medical care, loss of medication, and limited access to, or knowledge about, health systems in the host country. 8 2016 data from WHO suggest that around 8% of people in Afghanistan had diabetes; ~14% were overweight; ~2% were obese; and, in 2010, NCDs accounted for 35% of deaths. 28 WHO also estimates that 35% of men in Afghanistan smoke. 29 A 2021 cross sectional study of refugees from Afghanistan in Iran noted that 94% had less than adequate fruit or vegetable consumption, 20% had hypertension, 51% had central obesity, and 69% had dyslipidaemia. 30

Ask about any tobacco consumption, including sheesha (tobacco smoked through a hookah) and naswar (powdered tobacco usually placed inside cheeks).

Nutritional and metabolic considerations

Consider nutritional and metabolic conditions (including anaemia in preschool children and in adults) in all newly arrived migrants (look for pallor, glossitis, dry skin/hair, symptoms of anaemia, etc). 5 If clinically indicated, request iron studies, haematinics, and haemoglobinopathy screening (to check for thalassaemia). Assess for vitamin A deficiency (dry eyes, dry skin/hair, poor night vision/other sight problems). Consider vitamin D testing and/or supplementation, especially if risk factors (such as skin pigmentation and limited sun exposure owing to cultural dress) are present. Consider calculation of body mass index, checking blood pressure, and testing for diabetes and hyperlipidaemia. 5 In children, plot serial weight and height on growth charts, monitor for faltering growth, and consider vitamin supplementation (A, C, and D) for children aged 0-4 (in the UK, this is available for free with the “Healthy Start” programme). 31 Offer lifestyle advice with careful contextualisation and awareness of social, financial, and practical constraints.

Oral health

Oral health is often overlooked and some migrant groups may not have had access to dentists for a considerable time. Explore dental symptoms and encourage attendance for routine dental care at the earliest opportunity. 8 All forms of tobacco consumption (see above) can affect oral health.

Medication history

Ask about any pre-existing treatment. Patients may be taking medication that is not available in the host country or has an unrecognisable name. In these cases, switch according to best practice guidelines and review response to treatment. Explain where and how to collect medication, how to order repeat prescriptions, and advise about any prescription charges and exemptions.

Mental health

Mental distress does not always equate to mental illness. Cultural and linguistic differences can inappropriately increase the likelihood of a diagnosis of mental illness. 32 On top of the multiple challenges of adapting to living in a new country, people may have experienced conflict, violence, multiple losses, torture, sexual assault, and/or be at risk of exploitative situations.

Be mindful of cultural perceptions/stigma and impacts of mental health presentations and diagnoses. 33

Patients may present with somatic symptoms, such as headaches, chest pain, back pain, and abdominal symptoms.

Use a trauma informed approach

Ask open questions while remaining sensitive to patient cues about topics they may not want to discuss (full details are not essential to assess mental health adequately). Use a trauma informed approach ( fig 3 ). Be alert to symptoms of depression and anxiety, and in the context of trauma, specifically inquire about symptoms of post-traumatic stress disorder. 35

The core principles of trauma informed approaches, which acknowledge the impact previous trauma may have had on an individual, and offer care in the context of this. The focus is on developing relationships, understanding experiences, and building resilience to provide a strong foundation for recovery 34

Ask about trauma

Do not be afraid to ask about trauma, but be respectful of potential re-traumatisation. Advise patients that you will be asking difficult questions that they can choose not to answer. Move at the patient’s pace, listen, and ensure post-disclosure support. 34

Reproductive health

When appropriate, consider pregnancy and refer to antenatal services, offer vitamins (folic acid, vitamins C and D), and offer breastfeeding support; contraception, and explain and offer cervical screening.

Abusive situations

People may be victims of gender based violence, domestic violence (spousal or interfamily violence), honour based violence, trafficking or forced migration, modern slavery, and forced marriages. 36 Follow relevant local safeguarding procedures and seek advice if you have concerns.

Female genital mutilation

Consider female genital mutilation (FGM), particularly if the patient is from a region where it is known to be practised, if they have a family history of FGM, or if they present with genitourinary symptoms. Limited information is available about the practice of FGM in Afghanistan. Further resources are available through the UK Home Office’s FGM unit. 37

How can we improve access to care and services?

Use a holistic and patient centred approach to assess patients’ needs. Initiatives including the Doctors of the World UK’s Safe Surgeries’ Toolkit offer advice on overcoming common barriers. Other suggestions include:

Better support for GPs in understanding the diverse health needs in different migrant groups

Digital tools that offer GPs immediate tailored advice on screening and catch up vaccines, based on country of origin (currently being explored 6 38 )

Record patient’s spoken and written language preferences, avoiding assumptions regarding literacy

Encourage staff familiarity with translated written resources (see box, “Patient resources”)

Training and understanding of best practice in use of professional interpreters 5

Offer social prescribing to enable access to relevant services and community groups, such as immigration related support, language classes, financial and educational support, and community participation and socialisation opportunities 39

Due to challenging financial situations, signpost to voluntary services and food banks, and explain entitlements to welfare benefits, support with prescription fees, or transport to appointments

Link newly arrived people and individual family members to the local community (eg, host country language classes, acculturation opportunities). 8

Patient perspectives

“My wife, son, and I left Afghanistan during the evacuation following the Taliban takeover of Kabul. It was a traumatic experience in many ways—there was not enough time to plan, we had to leave all our essential personal belongings behind, and had to go through Taliban lines. I was injured with a gun barrel by a Taliban member, and my wife and son were terrified. We were relieved after arriving in the UK. We were given a warm welcome and the feeling of being fully taken care of, and we stayed in a quarantine hotel for 10 days. We worried about those we had left behind, feeling sad for our country, for losing everything we had worked very hard for—our home, job, possessions, family, and friends—perhaps the confinement in the hotel made our feelings worse. After this, we were moved to a bridging hotel. Health services were not automatic. I am fluent in English and so I was able to proactively seek care for my pregnant wife, but others may not have done. By the time the date of her scan arrived, we had moved again to our permanent address. It would be useful to have all the records linked up to save repeating our story and blood tests, and to have some written information in our own language. We have now had a scan and are pleased our baby is fine. We are grateful that we are together and safe.”– Anonymous

“Immigration is a difficult choice. There is a complete break from family, traditions, and customs, and a transition into a new life. I was a sick single mother with four children and took refuge in a new country after a long journey of suffering in my country. During this time, we suffered physical and psychological problems. Everything was different—language, community, country. Even my fears were different. The first impression with healthcare can change a lot in the new life of a refugee. A smile and kindness can open many doors towards a future and close the door of fear and hesitation. My doctors were able to gain the trust of my children, breaking the barrier of fear from a doctor, because a doctor in my country means injection. I could speak a little English but being able to speak in my own language with an interpreter and seeing the same doctor helped me a lot. Now my daughters are studying science and want to be doctors, too. I am studying in college and will publish my online newspaper soon.”– Haja Ahmed

Additional educational resources

(all freely available and do not require registration).

BMA Guidance: Refugee and asylum patient health toolkit: https://www.bma.org.uk/advice-and-support/ethics/refugees-overseas-visitors-and-vulnerable-migrants/refugee-and-asylum-seeker-patient-health-toolkit https://www.bma.org.uk/advice-and-support/ethics/refugees-overseas-visitors-and-vulnerable-migrants/refugee-and-asylum-seeker-patient-health-toolkit

Liverpool John Moores University resources: https://www.ljmu.ac.uk/microsites/resources-for-professionals-who-support-asylum-seekers-and-refugees

Public Health England, Afghanistan, Migrant Health Guide: https://www.gov.uk/guidance/afghanistan-migrant-health-guide

Doctors of the World, Safe Surgeries Toolkit for general practices to provide a welcoming and equitable service for all patients and address the barriers faced by migrants in vulnerable circumstances: https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/safe-surgeries-toolkit/

Patient resources

(all are freely available and do not require registration), translated health information.

Doctors of the World: patient information leaflets in multiple languages. Resources include how to register with a GP, migrants’ right to healthcare, covid-19 vaccination, wellbeing, self-care, and keeping young people healthy: https://www.doctorsoftheworld.org.uk/translated-health-information/

Doctors of the World: resources specifically for Afghan patients are available in Dari, Pashto, Farsi, or Urdu: https://www.doctorsoftheworld.org.uk/news/list-of-multilingual-resources-for-afghans/

Refugee Council: patient communication cards, introduction cards, guide to using the GP, and which NHS service to use in multiple languages, including Dari: https://www.refugeecouncil.org.uk/get-support/services/therapeutic-wellbeing-resources/

Family tracing

Red Cross International Family Tracing helps find missing relatives abroad who have been separated by war, natural disaster, or migration: https://www.redcross.org.uk/get-help/find-missing-family . UK Freephone telephone number +44 808 196 3651

General advice, support, and counselling

Refugee Council offers advice, counselling, and practical support to refugees and asylum seekers: https://refugeecouncil.org.uk/

Refugee Council InfoLine signposts refugees and asylum seekers to relevant organisations: UK Freephone telephone number +44 808 196 7272, Monday-Thursday 9 30 am to 12 30 pm

Barnardos Boloh Helpline offers advice, signposting, and emotional support to asylum seekers. UK freephone telephone number +44 800 151 2605. Monday-Friday 10 am to 8 pm, Saturday 10 am to 3 pm. [email protected]

Support and information specifically for people from Afghanistan

https://refugeecouncil.org.uk/information/information-for-afghans/guidance-and-support/support-and-information-for-people-affected-by-the-crisis-in-afghanistan/

UK government welcome pack for Afghan locally employed staff: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1004550/Afghanistan_LES_Welcome_Pack.pdf

Support for people who have experienced torture

Freedom from Torture provides therapy and support for people who have experienced torture: https://www.freedomfromtorture.org/help-for-survivors . UK telephone number +44 207 697 7777

Helen Bamber Foundation provides therapy and support for people who have experienced torture and/or been trafficked, and other forms of extreme physical, sexual, and psychological violence: https://www.helenbamber.org/ . UK telephone number +44 203 058 2020. [email protected]

Help with prescription charges, dental treatment, and sight tests

Refugees, asylum seekers, and other migrants can apply for the NHS Low Income scheme, which helps pay for some medical costs, including prescription charges, dental treatment, and sight tests: HC1 online application form: https://services.nhsbsa.nhs.uk/apply-for-help-with-nhs-costs/apply-online . Advice is available is different languages on the telephone or online. UK freephone telephone number +300 330 13 43. https://www.nhsbsa.nhs.uk/advice-other-languages

Education into practice

What changes could your department make to ensure migrants’ needs are met? For example, what would a “welcome pack” from your practice look like? What cultural competence training do your staff members require?

What interpreting services and translated health information do your clinical and administrative staff know how to access and use effectively?

How would you explore the experiences and journey that a refugee patient has taken?

How patients were involved in the creation of this article

One of the authors, Haja Ahmed, a journalist from Sudan, is a refugee who resettled in the UK with her four children on a government resettlement scheme five years ago. She provided her personal insights and experiences of arriving in a new country and navigating her way through the NHS.

We also spoke to several refugees and asylum seekers from Afghanistan, specifically asking what issues they had faced with accessing healthcare, and what would be helpful for clinicians to know when seeing newly arrived refugees from Afghanistan. Their advice led to several amendments, including highlighting how healthcare workers’ interaction substantially influences patients’ new lives in a new country, and the anonymous quotes included.

Comments from external patient reviews echoed the views of other patient contributors and were also incorporated.

How this article was created

We combined advice from relevant guidelines and advice documents from Public Health England (PHE, the now UK Health Security Agency), NICE, The European Centre for Disease Prevention and Control, and the World Health Organization’s Regional Office for Europe, with our professional and clinical experience. We also searched PubMed and the Cochrane Database of Systematic reviews for articles published in English. We used the search terms “Afghan,” “Afghanistan,” “Refugee,” “Asylum Seeker,” and “Migrant” in combination with the terms “Health” or “Healthcare.” We limited the search to peer reviewed systematic reviews published over the past 10 years to capture recently available evidence and guidelines. We found 298 articles to inform this article creation.

We thank Angela Burnett (Freedom from Torture and GP), Dominik Zenner (Queen Mary’s University of London and GP), and Anna Miller (Doctors of the World UK) for their expert insights and advice regarding specific sections of this article. We thank the Health Inclusion team at Guy’s and St Thomas’ NHS Trust for its support and sharing of front line clinical expertise, particularly Krishna Misra, joint Clinical Lead of Refugee and Asylum Seeker Services (GP). SH acknowledges funding from the National Institute for Health Research (NIHR Advanced Fellowship NIHR300072), the Academy of Medical Sciences (SBF005\1111), the Novo Nordisk Foundation (Mobility—Global Medicine and Health Research grant), and the World Health Organization. FK is supported by a Health Education England/National Institute for Health Research (NIHR) academic clinical fellowship.

Contributorship and guarantor: FK, SH, and SM conceived the article and are guarantors. SM was the contact for patient involvement. FK and SM contributed equally to this paper and are joint first authors. All authors made substantial contributions to the text and were involved in drafting and revising the work and in final approval. All authors accept responsibility for the accuracy and integrity of the work.

Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Provenance and peer review: commissioned, based on an idea from the author; externally peer reviewed

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ .

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• ↵ Public Health England. Tuberculosis by country: rates per 100 000 people. https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people
• ↵ National Institute for Health and Care Excellence. Clinical knowledge summaries. Tuberculosis. 2019. https://cks.nice.org.uk/topics/tuberculosis/
• ↵ Public Health England. Latent TB infection testing and treatment programme for migrants: Presenting data between 1 April 2015 to 31 March 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/967517/LTBI-testing-and-treatment_2019_to_2020.pdf
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• ↵ UK Health Security Agency. Guidance: Vaccination of individuals with uncertain or incomplete immunisation status. 2022. https://www.gov.uk/government/publications/vaccination-of-individuals-with-uncertain-or-incomplete-immunisation-status
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• ↵ Doctors of the World. Vaccine Confidence Toolkit. https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/vaccine-confidence-toolkit/
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Migrant Health and Human Rights

Program director: kathleen page.

Globalization, climate change, violence, discrimination, and poverty are driving millions of people away from their homes and shaping the modern world. In this context, migration is increasingly conceptualized as a public health issue. Growing xenophobia, anti-immigrant policies, and the politicization of migration and the international system for the protection of refugees has further eroded basic human rights protections. Undocumented immigrants (and others with tenuous legal residency status) and their families represent a particularly vulnerable population whose health and human dignity have been consistently challenged by immigration integration policies and enforcement activities.

The Program on Migrant Health and Human Rights brings together experts in public health methods, health services research, health policy, advocacy, and clinical care to advance research and advocacy through the lens of human rights, and to develop pragmatic solutions that can make a difference. This includes advancing and influencing the conversation regarding the “right to health” among those excluded from healthcare and social services based upon immigration status.

We seek to inform immigration and integration policies in the US and abroad through rigorous science and cutting-edge research. The program focuses on four main areas of research. First, using quantitative and qualitative approaches, we investigate the adverse health-related consequences of hostile immigration policies, detention, and immigration enforcement on health outcomes, both within and beyond our country’s borders. This includes direct impact on health, as well as indirect impact of the “chilling effect” on healthcare and social service access and utilization. Second, we develop tools to reach “hidden” immigrant populations and assess their physical and mental health wellbeing. Third, we study the spillover effect of immigration and integration policies on children of immigrants, and other citizens and legal permanent residents in mixed-status families. Fourth, we develop models and interventions to expand access to healthcare for immigrants, with a focus on those who are systematically excluded from services.

Our team has projects related to the Venezuelan migrant crisis and at the US-Mexico southern border. Within the US, the team has several projects on the health and human rights of undocumented migrants as well as asylum seekers, focused on topics ranging from HIV, interpersonal violence, COVID-19, mental health, and access to healthcare and social services.

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Migration & vulnerability

Migration and health

Definitions, data sources , further reading.

Migration places individuals in situations which may impact their physical and mental well-being. Conditions surrounding the migration process may increase the vulnerability of migrants towards poorer health outcomes, or conversely enable wellbeing and access to healthcare. The impacts on the health of migrants have multiple determinants and may change over time. These impacts may differ across migrant categories and legal status. Migration also cuts across economic and social policies, human rights and equity issues, development agendas, and social norms – all of which are relevant to migration health.  The  2030 Sustainable Development Agenda , the Global Compact of Migrants and Refugees and other international instruments have outlined data at the nexus of migration and health critically important to monitor the Agenda’s progress, including specific progress on the  health-related goal and targets  to ensure that “no one is left behind” irrespective of their migration status.

Health is defined as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” ( WHO, 2005 ).   Health is also a basic human right and an essential component of sustainable development; being and staying healthy is a fundamental precondition for migrants to work, to be productive and to contribute to the social and economic development of their communities of origin and destination. 

The concept of migration and health (or migration health) encompasses the idea that there are various factors and conditions that influence the health of migrants. These are referred to as social determinants of health (SDH). A range of socioeconomic, legal, cultural, environmental, and physical environments to individual factors such as lifestyle, age, hereditary, and behavioral factors that impact the health of migrants (Figure 2). Migration itself is considered a  social determinant of health  because of its potential to impact health outcomes due to factors such as changes in living conditions and access to healthcare. Migrants’ health care access is also to a large extent determined by the availability, accessibility, acceptability, appropriateness, affordability and quality of services in the host community or country.  There may be differences in the disease profiles and health risk factors between migrant and host populations, or inequalities in the access/uptake of preventive interventions and in treatment outcomes. 

The relationship between migration and health is complex. and its impact varies considerably across migrant groups, from person to person within such groups, and during the phases of migration (Figure 2). Migrants are affected by social inequalities and are exposed to several experiences during the migration process which put their physical, mental and social well-being at risk. Conditions surrounding the migration process may exacerbate health vulnerabilities and risk behaviors. Conversely, it can be an enabler for achieving better health trajectories, such as the case of a newly arrived refugee as part of a humanitarian settlement programme getting access to treatment for a chronic disease. Due to their irregular status, stigma, discrimination, language, cultural barriers and low-income levels, irregular migrants may be excluded from accessing primary health care services, vaccination and health-promotion interventions.  

A growing body of research evidence points to varying gradients of benefits and risk factors for the health of migrants (and their families) through the stages of migration ( BMJ, 2024 ; WHO, 2022 ; PLOS, 2020 ) (Figure 2).  The process of migration includes different phases (pre-departure, travel and transit, destination and integration, and return), where the health of migrants can be adversely affected or be positively enabled. The interplay and impacts of migration on the health of migrants themselves. Human mobility may also impact on public health with respect to the prevention and control of emerging infectious diseases. For instance, moving from a country with high malaria endemicity to one which is on verge of elimination.

Some countries/territories enforce mandatory detention for many irregular migrants where h ealth-related vulnerabilities may exacerbate due to lack of access to health services, nutrition, inadequate hygiene and sanitation within densely populated living spaces, and  violence. The length of detention has been associated with the severity of mental disorders and psychosocial issues.  

Many international migrant workers are employed in precarious work settings, within dangerous , difficult and demeaning (3Ds ) jobs ( ILO, n.d. ), with low wages, hazardous working conditions, with limited social protection and occupational health rights. Migrants’ access to health services has increasingly been a key indicator of people-centered, rights-based, inclusive and equitable health systems that aim at reducing health inequities, but the social exclusion of vulnerable migrant groups continues to be common in the absence of explicit affirmative policies. 

Migration health data may be broadly defined as data relevant to characterizing the health and social determinants of various migrant populations (e.g. the non-communicable disease burden in international labor migrants); data relating to extent of access to health care system by migrant typology; to data to better understand disease spread across geospatial areas along human mobility pathways. Data can be both quantitative, such as epidemiological profiles on refugee populations; and qualitative, describing risk and resiliency factors.

Despite the clarion calls for better migration data to inform public health policy and practice, migrants are largely invisible in official data due to lack of integration of migration variables within routine National/Sub-National Health Information Systems (HIMS) ( Vidal, E. M., & Wickramage, K. P., 2024 ). Routine data sources range from population health surveys, (vertical) disease control programs, hospital registries to health insurance schemes (Table 1). The lack of inclusion of migrant variables within HIMS makes disaggregation of health outcomes by migrant status challenging – making it hard to track progress at national/global levels, leading to opinion based, rather than evidence-based decision making.

Migration health data exists not only within health sector but may also be collected through operations/services rendered by other sectors such as Immigration and border management, refugee resettlement services, Foreign Employment Bureau, Health Insurance providers and through harnessing big data (Figure 3). Such sources of MH data often remain unmapped and unlinked to health authorities and HIMS. For instance, analysis of health insurance claims/payments made within international labour migrant health insurance schemes are housed within Foreign Employment authorities and can provide critical data on morbidities, injuries and deaths of outbound migrant workers, who often work precarious employment settings ( IOM, 2021 ).  There is a need to make better use of existing data captured through the health and migration management ecosystems. Methods such as data linkage may be used to ‘link’ disparate data sets and provide insights on migrant health outcomes, especially across the migration trajectory ( Burns et al., 2019 ; Bozorgmehr et al., 2023 ).

The utilization of innovative ‘big data’ signifies a significant opportunity to harness migration health data in conjunction with sophisticated analytical techniques like machine learning. By harnessing diverse data sources such as mobile phone Call Data Records (CDR), satellites, and social media, and integrating/superimposing data from population mobility mapping methods ( IOM DTM , HBMM ) including community-based approaches ( IOM PMM ), data relevant to human mobility and health can be generated.  In particular, the integration of CDRs acquired from telecommunications and social media platforms with relevant Geographic Information System (GIS) data, alongside a broad array of datasets encompassing epidemiological maps, climatological maps, precipitation maps, and vectorial density data, flight and travel information, has emerged as a potent approach for comprehending the dynamics of infectious disease transmission ( Li et al., 2023 , Perrotta et al., 2022 ). This multifaceted strategy enables a better understanding of disease spread patterns and facilitates the development of targeted interventions.

Examples of Routine data sources at the national/sub-national level:

A) Civil registration, vital statistics and population censuses:

Administrative data sources and censuses provide information on the births and deaths (and cause of deaths) of people. If information on a person’s length of stay/date of entry into a country, citizenship status and country of birth are captured, such data may identify whether someone is a migrant, and be used to analyze health outcomes based on these variables. However only very few countries capture variables by migratory status ( Bozorgmehr et al., 2023 ).

In Denmark , a comprehensive Civil Registration System ( CRS ) assigns a unique 10-digit Civil Personal Register number to all individuals, including refugees and specific migrant groups. This system records vital data such as country of birth, citizenship, date of immigration, and parental nationality, aiding in the identification of refugees and migrants. Additionally, the personal identifier is interconnected across various national registers, including health, education, and labor. By integrating these systems, health information can be efficiently linked with migration indicators, reducing the burden on healthcare personnel by eliminating the need for independent data collection. The CPR-number can also be utilized within data-linkage as an important research tool in epidemiological research e.g., as regards cancer and psychiatric epidemiology. It is possible to investigate the association between disease or death in individuals and place of birth and residence, immigration and emigration status and environmental exposures at place of residence.

B) Household surveys:

Demographic and Health Surveys  (DHS) are nationally representative household surveys that provide data on a wide range of health- and nutrition-related information. The program has collected data through more than 400 surveys in over 90 countries. The high-income countries that are often the destination for international migrants normally do not conduct household surveys. Respondents to DHS are usually female head of households, and such surveys are tailored to the needs of a particular country while containing several basic components that are comparable across all countries. DHS surveys are not designed to specifically target international migrants in the sampling design. In the DHS-VII, international migrants are those who choose "abroad" in response to the variable "region of previous residence". To identify non-migrants the DHS uses "years lived in place of residence".   While there are clear limitations to this migrant variables/identifier, DHS data can beused toanalyze health outcomes collected in survey. A 2012  review  of 85 DHS national surveys found that a dedicated module with detailed information on migration was only be present in 12 surveys.  For children, their migration status can sometimes be identified through their mothers' migration status. In cases where a separate section on international migration appears in the questionnaire, children who left the household to go abroad can also be identified, along with their basic characteristics.

Multiple Indicator Cluster Survey (MICS) is a household survey programme developed by UNICEF in the mid 90's to assist countries in filling data gaps for monitoring the situation of children and women. It is capable of producing statistically sound, internationally comparable estimates of these indicators. In the 6th iteration of the survey (MICS6), two types of migratory status are featured: international migrant and non-migrant (which includes internal migrants). For MICS, international migrants refer to those who choose "overseas/outside of country" in response to the variable "place of living prior to moving to current place" and "province prior to moving to current place". The survey also uses different variables from DHS to identify non-migrants. The MICS uses "duration of living in current place". In the MICS, respondents who answer "always/since birth" are included as non-migrants.

Findings from household surveys:

The immunization of children is paramount for maintaining public health and community well-being. Measles, one of the most highly contagious viruses to humans, serves as a barometer for both inadequate vaccination coverage and limited access to essential healthcare services, particularly among vulnerable populations. Analysis of survey data available only from 8 out of 15 countries published by WHO reveals lower measles vaccination rates among international migrant children compared to those in the host population, highlighting disparities in healthcare accessibility and the need for targeted interventions (Table 1).

Table 1: Children who received Measles vaccination, by migrant status (percentage)

* Dataset reproduced from: World report on the health of refugees and migrants. For DHS, refers to children born in the last 3 years who received measles vaccine 1. They are considered to have received the vaccine if it was written on the child's vaccination card or reported by the mother. For MICS, refers to children ever given MR vaccination.

Household Survey Databank (Banco de Datos de Encuestas de Hogares; BADEHOG): is a repository of The United Nations Economic Commission for Latin America and the Caribbean (ECLAC). It is made up of a set of household surveys conducted by the countries of Latin America and the Caribbean since the 1990s. These surveys are conducted by the National Statistics Offices or other public agencies of the respective countries and share the characteristic of being the source of information officially used to measure poverty, inequality and various social indicators. BADEHOG indicators vary slightly between survey countries in Latin America and the Caribbean. Response used to assess migratory status is emergent from question: "Where were you born?", with values that include terms such as bordering country, other country or outside of the country.

The Living Standards Measurement Study  (LSMS ) is another household survey programme focused on generating high-quality data for evidence-based policy making. The migration module of LSMS surveys typically includes questions on place of birth, most recent place of residence, reasons for moving, number of times moved and types of migration (including inter-district, rural-urban and international migration).  

C) Disease control programs:  Mobile and migrant populations pose a unique challenge to disease elimination campaigns as they are often hard to survey and reach with treatment. There is increasing recognition by national disease prevention and control programs, such as tuberculosis and malaria, in adopting migrant inclusive strategies at national, sub-national and cross-border level to meaningfully control disease spread, limit (re)introduction ( Adams et al., 2022 ; WHO, 2015 ). Regional cooperation efforts to combat disease spread via migration routes have led to establishment of ‘cross-border’ data collection and joint-monitoring mechanisms such as the Mekong Basin Disease Surveillance programme.

D) Health institution-based records : National Hospital Registries provide data on health-related information pertinent to hospitalization, and National Epidemiological Disease surveillance systems provide information on diseases, conditions and outbreaks that may affect public health. However, most providers and insurers do not routinely collect data by legal status or on the national origin of the cases registered. Name-based algorithms have been used as an etiological tool to “data-mine” such registries to provide valuable information on health status. Such approaches  in cancer registries have been utilized in effectively comparing  disease burden among migrant groups ( Razum et al., 2001 ).

E) Migration Health Assessment Records: Some states mandate migrant screening for selected disease conditions at pre-departure as pre-condition to travel for purposes of work, study, humanitarian/refugee resettlement, for family reunification etc.  Post-arrival screening of migrants of migrants also take place on mandatory requirement or on voluntary basis. Data from such health assessments provide important data sources of various migrant populations but remain poorly analyzed and often unliked to National Health Systems ( Wickramage & Zenner, 2019 ; Wickramage & Mosca, 2014 ).

In 2022, IOM provided reporting of 904,000 health assessments of immigrants and refugees . IOM also generates applied research and analytics of the health profiles of refugees to inform policy and practice ( Deal et al., 2019 ; Pernitez-Agan et al., 2019 ). The information can be used to better understand the prevalence of diseases such as tuberculosis, conditions such as malnutrition and new pathologies among populations examined, to enable health authorities in both sending and receiving countries to better address the health of migrants.

F) Health Insurance Claims Data from Foreign Employment Bureaus, Migrant Worker Insurance agencies and Occupational Health Surveys : Health insurance claims of migrant workers and their families from providers (both government and private sectors) may provide data on morbidities, mortality (in case of migrant worker deaths), disability and data on deportations based on medical grounds. Systematic review and meta-analysis on migration and occupational health of international migrant workers employed in 13 countries and territories from 25 low-income and middle-income countries, mostly employed in unskilled manual labour found that migrant workers are at significant risk of work-related ill health and injury ( Hargreaves et al., 2019 ). Migrant workers had various physical and psychiatric morbidities, and workplace accidents and injuries were relatively common. 

G)  An IOM report in 2021 provided an assessment of available sources of data on migrant worker fatalities at the global, regional and country levels. Key sources include national employer notification and social insurance systems, migrant welfare funds, embassies in destination countries and records of repatriated remains. The existence and quality of data are highly variable across countries, with knowledge concerning migrants mostly coming from middle- and high-income regions. Data on deaths of migrant workers in much of the developing world remain extremely scarce. The presence of relatively large informal sectors and loose health and safety regulation likely entail higher risks for native and migrant workers in regions of the world precisely where data are most lacking. However, poor quality and gaps in coverage limit the current usefulness of these data both for deepening understanding of trends and guiding intervention efforts. Measuring occupational fatalities is particularly challenging among undocumented and informal migrant populations, the groups most likely to have poor health and safety outcomes. Finally, although national population/labour statistics estimate that work-related diseases kill six times more people than fatal injuries, virtually no data are regularly and systematically produced at the national or international levels documenting occupational diseases among migrants.

Other Data Sources:

H) Bespoke HIMS: As outlined in recent reviews ( Chiesa et al., 2019 ), Health information management in the context of forced migration and displacement are characterised by numerous stand-alone customized HIMS housed within humanitarian agencies and coordination clusters. These range from surveillance data and health service records at displaced camps, to bespoke data capturing systems. Health records, implemented specifically for forced migrant, seem to have the potential to address some of the challenges that they face in accessing health care, in particular in strategic hotspots, cross-border settings and for migrants on the move.

I)  The IOM electronic personal health record (ePHR)  provides an example of a bespoke HIMS platform to enhance health care workers’ understanding of migrants’ individual health needs. Prompted by increased arrivals to Europe in 2015 and 2016, a structured health record was developed to support health assessments for newly arriving migrants, with co-funding from the European Commission . This initiative evolved into a full electronic personal health record system within IOM, facilitating the secure transfer of information between health providers across different facilities and countries, critical given migrants' mobility. Currently operational in reception facilities across seven countries, including Bulgaria, Croatia, Cyprus, Greece, Italy, Serbia, and Slovenia, plans are underway to expand the system further. Additionally, with support from the Italian Government, the electronic Personal Health Record has been tailored to local needs in Sicily, featuring user-friendly interfaces, smart technology, and automated coding to minimize manual data entry. It offers real-time visualization of health status and disease demographics, meeting European exchange format standards, and informing health service provision and monitoring of illnesses and diseases according to International Health Regulations.  Since its inception in January 2017, the system has captured 19,733 records of 14,440 individuals, predominantly young males. Nearly three-quarters of individuals did not have any recorded ICD-10 illnesses, with respiratory diseases and common infections being the most frequently reported health issues. Additionally, around 11% of individuals were recorded as having a mental illness in this cohort, reflecting a primarily young and healthy population exposed to adverse conditions and overcrowding in reception facilities, with a significant minority experiencing recent psychological trauma ( Zenner et al., 2022 ).

J) Indexes/indicator frameworks assessing the migrant inclusion and integration in health:

The Migration Governance Indicators (MGI): developed by IOM to support requesting governments to examine the comprehensiveness of their migration policies and identify best practices and areas for potential improvement. While the MGI does not rank migration governance practices of countries, it provides a framework for governments at the national and local levels to gradually improve their migration management systems. Data collected in 100 countries between 2018 and 2023 show that in half of the assessed countries, all migrants have access to all government-funded health services under the same conditions as nationals, regardless of their migratory status ( IOM, 2024 ).

The MIPEX Health strand : The MIPEX Health strand is a component of the Migrant Integration Policy Index (MIPEX), which evaluates policies aimed at integrating migrants in various countries. Specifically focusing on healthcare access, it assesses whether migrants have equal access to healthcare services as native-born citizens, the availability of health insurance coverage, cultural and language support for migrants within healthcare settings, access to preventive healthcare services, and the provision of mental health support. By examining these factors, the MIPEX Health strand provides insights into how effectively countries are addressing the healthcare needs of migrant populations and identifies areas for policy improvement.

K. Big data:

Big data presents opportunities to comprehend the influence of migration on the spread of infectious diseases, aiding in predicting outbreaks and addressing immediate health concerns of displaced individuals ( Franklinos et al., 2021 )

Additionally, big data applications can cater to the healthcare needs of settled migrants and pinpoint variations in patient responses to treatments, allowing for tailored healthcare interventions. A key consideration regarding the application of big data in migration health data and research is the ethical considerations and safeguarding practices are required when involving varied stakeholders in big data analytics.

BioMosaic  is a software application that allows combining and visualizing immigration statistics, and health and demographic data. It was developed by the United States ’ Center for Disease Control and Prevention’s (CDC)  Division of Global Migration Health  in collaboration with Harvard University and the University of Toronto. BioMosaic shows foreign-born populations, census demographic data, and health-data indicators to the US county level. Targeted health communications, or public-health interventions, can be developed with the application by identifying foreign-born populations clustered in specific areas, or link census data on social determinants of health, such as income, education, language proficiency and access to healthcare.  

Way forward in Improving migration health data  

Enhancing national capacity to collect, analyze, share and manage migration data is a cornerstone of effective migration data management. However, despite the clarion calls for better migration data, migrants are largely invisible within routine health information systems and health data. Investments in better migration health data is needed to help reduce the health risks and costs associated with migration, identifying resource priorities, calibrate financing and enhancing public health.Tracking health outcomes relevant to SDGs and disease control programs, and inter and intra country comparisons towards progress towards health goals become impossible without strategies to enable migrant inclusive health and migration management systems at national level. For instance, supporting countries to adopt a migration module on existing health surveys, disease-specific registries and improving sampling methods would provide greater depth of data. To make making the invisible visible, a number of strategies have been proposed (derived in part from the WHO World report on the health of refugees and migrants ).

It is also important to consider that collecting and disseminating migrant health data raise significant ethical concerns, particularly regarding the right to privacy as outlined in Article 17 of the International Covenant on Civil and Political Rights, alongside security considerations. The protection and privacy of migrant health data are major concerns. The inappropriate sharing of data can have serious consequences, such as limiting access to health care and other services, or even deportation. Introducing new or harmonized systems could greatly enhance understanding of migration and migrant health, yet implementation must be closely supervised to guarantee anonymization of all data and secure sharing across various entities, given the substantial protection risks involved. Additionally, ensuring interoperability among national and regional databases containing migrant information is crucial for advancing efforts towards improved information systems.

Importance of Migration Health Research

Migration Research becomes critical in a world where there is little data emergent from routine health and other systems. However, despite the steady increase in migration health research undertaken over the past two decades, the paucity of research evidence on international migration health is still significant, given the magnitude and complexity of migrant flows. For instance, migrant workers, especially those from developing regions comprise over half of all international migrants. Yet published research papers about labour migrants represent only 6·2% of the total international migration and health research output in the past 16 years ( Sweileh et al., 2018 ). Less than 1% of research on international migration health published were from low-income countries.

Investments in research need to be linked to policy making. Enhancing capacities and mentorship among researchers in developing regions is crucial. The MHADRI network is the worlds largest network of migration health academics, researchers, UN and policy makers devoted to advancing migration health especially in the Global South. Research process at national/sub-national level linked to inter-sectoral policy making process with meaningful engagement of academia, migrants and civil society is powerful in galvanizing political action, leading to formulation of evidence based national migration health policies .

IOM Migration Health Research Portal: online portal  is a repository of all migration health related data stemming from IOM’s global health programmes.The portal also houses the Migration Health Research Bulletin and the Migration Health Research Podcast (also streamed through Spotify ) which are platforms to highlight key areas of research from IOM’s migration health programs globally.  

To develop sustainable robust migrant sensitive health services, migration health data and research is critical for understanding the health conditions, social determinants, costs and the barriers to health care system accessibility, affordability, approachability, acceptability and appropriateness, and the migrants’ ability to perceive, to seek, to reach, to pay, to engage and advocate for health care.

International Organisation for Migration

Migration Health Factsheets

International Organisation for Migration. Geneva. 

IOM Migration Health Research Portal

Integrating Migration into Health Interventions: A Toolkit for International Cooperation and Development Actors

May 2022. International Organisation for Migration, Geneva. 

Migration Health 2021 Impact Overview

August 2022. International Organisation for Migration, Geneva. 

World Health Organisation

Promoting the health of refugees and migrants: experiences from around the world

March 2023. World Health Organisation, Geneva. 

Refugee and Migrant Health Toolkit

January 2023. World Health Organisation, Geneva. 

World report on the health of refugees and migrants

July 2022. World Health Organisation, Geneva. 

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Promotion of Resilience in Migrants: A Systematic Review of Study and Psychosocial Intervention

• Review Paper
• Open access
• Published: 29 July 2021
• Volume 24 , pages 1328–1344, ( 2022 )

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• Maria Ciaramella   ORCID: orcid.org/0000-0002-0943-656X 1 ,
• Nadia Monacelli 2 &
• Livia Concetta Eugenia Cocimano 1  

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This systematic review aimed to contribute to a better and more focused understanding of the link between the concept of resilience and psychosocial interventions in the migrant population. The research questions concerned the type of population involved, definition of resilience, methodological choices and which intervention programmes were targeted at migrants. In the 90 articles included, an heterogeneity in defining resilience or not well specified definition resulted. Different migratory experiences were not adequately considered in the selection of participants. Few resilience interventions on migrants were resulted. A lack of procedure’s descriptions that keep in account specific migrants’ life-experiences and efficacy’s measures were highlighted.

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Introduction

In the past decades, migration has been dominating media and political discourses in Europe [ 1 ], as well as in the USA and Canada [ 2 ]. When discussing migrants and the impact of migration, we often refer to migrants as one group. This is partially due to the fact that migration policy creates a clear legal and then psychosocial boundary between the rights and freedoms of migrants and the population permanently residing in a country [ 3 , 4 ]. For instance, from a legal perspective, an economic migrant is defined as person who leaves his/her country of origin purely for economic reasons in order to seek material improvements in his/her livelihood (European commission: Migration and Home Affairs). In the same perspective, a migrant becomes a refugee when he or she is recognised as a person who is forced to move and seek international protection. The person is recognised as being subject to a migratory movement in which there is an element of coercion, including threats to life and livelihood who requires protection from the host country. (United Nations Convention relating to the Status of Refugees adopted in Geneva on 28 July 1951).

Therefore, the legal criterion can categorise people regardless of their personal experience. Anyhow, like other groups within the population, migrants do not constitute a singular type with similar impacts, nor are migrant populations evenly distributed (or evenly received) across and within countries. These migrants come for a variety of reasons such as work, study, join or form a new family, receive protection from violence and persecution.

It can reasonably expect that all these different existential conditions involve very different experiences. Moreover, the history of migration illustrates the profound and multiple associations between migration and human vulnerability.

Although psychosocial suffering can characterise most of the migratory experiences, both individual or collective, the depth, pervasiveness and persistence over time of this suffering are linked to the specificity of each individual migratory experience. In particular, in our contemporaneity, the stressors that cause displacement are compounded by the risks of the migratory journey and the precarious living conditions in transit and arrival countries: uncertainty linked to asylum procedure and legal status, difficulties in accessing services, lack of work and economic difficulties, adequate housing, low resources to support oneself and one's family and social isolation. [ 5 , 6 , 7 ]. These factors, together with the loss of the original social environment and cultural meaning system, can contribute to the migrant's internal fragility (affecting the sphere of his or her thoughts, memory, affects, behaviours and future perspective) and external fragility (in his or her relations with others and the world).

Therefore, host countries find themselves having to face these important risks of fragility of the migrant population. Both the way in which migrants manage the integration process and the benefit they will bring to a given community depend on the severity of these risks and whether they can be solved. In this perspective, the type and quality of psychosocial interventions assume a relevant value for the entire community.

The construct of resilience, also understood in a broad sense as a key ability to thrive in the face of adverse and painful experiences that enables one to achieve a well-balanced state of psychosocial health [ 8 ], is undoubtedly a useful construct. In the variety of their approaches, resilience studies, on the one hand, provide numerous tools for studying the fragility/resources of migrant populations and, on the other hand, provide insights into intervention strategies to promote their psychosocial well-being and integration.

Resilience and Migration

Indeed, resilience has aroused considerable interest in the migratory experience and several literature reviews proposed to systematise the results on the resilience process in the potentially multi-traumatic contexts of migration [ 9 , 10 , 11 , 12 ].

Resilience and Psychosocial Interventions

In recent years, the WHO has endorsed the effectiveness of a range of scalable psychological interventions in particular for people suffering from mental health disease as disabling stress, depression and anxiety. A general psychosocial health, according to the WHO, could be obtained through interventions with a focus on the interrelation between individual life-history, i.e. people’s thoughts, emotions and behaviours, and social circumstances.

In their review, authors [ 13 ] analysed design intervention aimed at promoting resilience in different application contexts, taking into account the different definition of the construct of resilience proposed in the literature. The authors concluded that, regardless to the context, interventions based on an outcome-oriented definition of resilience are the most effective. Assuming resilience as a result of the interaction of protective factors, stressors and mental health status, ensures greater effectiveness of the intervention. This approach allows a pre-post evaluation of the dimensions involved in the resilience process and thus enables an assessment of the effectiveness of the intervention itself.

Psychosocial intervention and migration

The literature on this issue is quite extensive. In order to account for the main challenges involved, we refer to two studies proposed at different times.

These two works [ 14 , 15 ] highlighted critical gaps in research on the adequacy of clinical practice or psychosocial intervention programmes targeting the migrant population. In particular, the first of these works complained about insufficient attention to the cross cultural factors that should be included since the first ideation phase of psychosocial intervention. According to the authors, cultural background is an important factor that can influence the outcome of the intervention as a whole as well as that of the specific treatment. Individuals experience and manifest psychosocial disease or mental illness’s symptoms in different ways and diagnosis can change depending on cultures. Therefore, every aspect of the intervention, from planning to methodology design, from analysis to results’ discussion, have to be considered in light of changing cultural contexts. Thus, the development and testing of culturally sensitive psychosocial interventions in the migrant population is critical to the field.

More recently, a meta-analysis [ 15 ] revealed that psychosocial interventions had a clinically significant effect on PTSD, depression and anxiety outcomes. The authors underline the importance of this beneficial effect for populations exposed to continuous post-migration stressors. They concluded that, considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of existing data on the effectiveness of psychosocial interventions, these interventions should be made routinely available as part of the health care of refugees and asylum seekers in distress.

This review aimed to systematise papers reporting experiences of specific psychosocial interventions focused on promoting resilience among migrants in the host country.

The main questions that guided our analysis are the following:

The first question concerns the type of population that has been involved in the research. Migration experience, as mentioned above, can imply drastically different individual and collective experiences. Which of these different experiences are considered in the research, and why did the researchers involved this type of population?

The second issue concerns the theoretical framework and the consequent dimensions analysed by the researchers. The construct of resilience is far from a single definition and, as evidenced by a large body of literature, can be defined on the basis of very different theoretical paradigms. Different aspects have been studied, from the precursors of resilience, understood as personality traits, learned skills or protective factors, to research aimed at detecting the ‘state of resilience’, i.e. whether people can be considered resilient or not at a given time and on the basis of which characteristics. In this review, we therefore focused on the specific objects of study proposed by the authors: which aspects of resilience were the object of their work? To what extent did their findings contribute to the understanding of resilience and especially resilience as applied to psychosocial interventions targeting migrant populations?

In the bibliographic survey on the relationship between resilience, psychosocial intervention and migration, only empirical studies published in peer-reviewed journals were included. Books, book chapters, conference proceedings, reviews, editorials, reports, dissertations and other similar publications were excluded.

Only articles written in English and in French were included. Year constraints were used; the publication range was from 1993 to 2019. This choice was made because 1993 represents the year in which the first theoretical publications on resilience began to provide a conceptualisation of the construct [ 16 ]. The search terms were chosen according to the search requirements, and they were; resilience AND migration AND intervention; resilience AND adult AND asylum seekers OR refugees; resilience AND immigration AND adult; resilience AND immigrants AND intervention; resilience AND emigrants. The search was conducted in four databases: PsychInfo, Web of Science, Scopus and Pubmed.

In none of the articles obtained in the database research was found the term emigrant. Therefore, it would not seem to correspond to a category of research recognised in the literature.

Regardless of specific characteristics, the studies included concerned only adult participants. Studies with samples of minors were excluded from the research, being a population that requires specific attention [ 11 , 17 ]. In fact, the international community, through the International Convention on the Rights of the Child (1989), has established specific rights and needs to children precisely because of the stage of development in which they find themselves. Consistently, the reception of these minors requires highly specific intervention strategies, actions and projects and, in all likelihood, an equally specific study. Researches conducted using a qualitative, quantitative and mixed method were included.

This systematic review was conducted in accordance with PRISMA guidelines ( http://prismastatement.org/ ).

Proceeding with these methods, a total of 4.242 citations was obtained. After a first reading of the title, abstract and keywords, 3.944 articles were excluded. Despite advanced search filters, most of the search results did not meet the selection criteria described before. In most of the articles excluded, the relation between resilience and migration was not studied. Furthermore, many publications about resilience correlated to medicine, veterinary medicine, anthropology or sociology were excluded.

In many articles excluded, the function of the mother–child dyad in the resilience process was investigated. 148 articles were excluded because of duplicates.

150 full-text articles were assessed for eligibility and 60 of them were excluded because they did not fulfil the eligibility criteria. As a result of these exclusions the publication time range was also reduced. 90 studies were included in this systematic review: 89 articles fall within a publication range from 2000 to 2019 and only one article dated 1993 (Fig.  1 ).

Studies selection procedure according to PRISMA Diagram

Three independent reviewers revised all abstracts and full-text analysed, and disagreements were resolved via group discussion. All authors were involved in all parts of the research.

The selected articles were uploaded on Nvivo 12 Plus and after an accurate reading, text extracts were aggregated into 4 main analysis categories, called main nodes in the software, and corresponding to our 4 analysis questions: participants, definition of resilience, object of study and intervention. Subsequently, a content analysis was made at each main node and organised into subordinate nodes. The Nvivo 12 software allows easy and systematic management of a large amount of textual material. Giving the possibility to work simultaneously on the main sources (the articles) and on the text sections, never losing the link between them (from source to extract and vice versa), Using Nvivo 12 reduces the risk of information loss.

Participants

Participants were organised following gender and migrant’s status. The latter included economic migrants, asylum seekers and refugees.

In 47 articles, both men and women were included, among which the prevalence of participants was male. However, in these studies gender was a purely descriptive dimension. With only two exceptions [ 18 , 19 ], in none of them was gender operationalised and the results obtained were not explained on the basis of this dimension.

In 29 studies, only women were involved. Consequences due to the violence experienced, sexual violence and exploitation, experience of pregnancy and childbirth in a foreign country, pregnancy followed by sexual violence, international marriages and the difficulty for women to access mental health services are the most studied topics in these works [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ].

In other four studies [ 20 , 30 , 31 , 32 ], only men were involved. Three of them did not explain why they chose male participants. One author addressed the issue of intersectionality, included gay Latino men in order to highlight the need to consider the risks of multiple discrimination that these people may also experience from their communities of reference, even in the context of migration.

In the remaining 10 articles, gender was not described.

Economic Migrants

Many studies implicitly referred to those who are legally identified as economic migrants. In fact, participants were described as migrants on the basis of their country of origin. They mainly belong to the most representative community of migrants in the context considered [ 19 , 23 , 25 , 27 , 28 , 30 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ].

In other studies, the authors did not provide any further specification of the specific country and described the origin of the participants by referring to vast geopolitical areas such as "Latinos/as immigrants", "south Asian immigrant", "African immigrants", "southeast immigrants", "northeast immigrants", "former USSR immigrants", "Asian Indian immigrants", "Asian and African American immigrants" [ 32 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ].

In few studies, broader descriptions to vast geopolitical areas were made and, then, the countries of origin were deeper highlighted [ 60 , 72 , 73 , 74 , 75 ].

Students [ 67 ] as well as the so-called "internal labour migrants" [ 47 ] are considered the same as migrants looking for new opportunities even if they move within their own country.

Two studies [ 26 , 76 ] involved migrants, social workers and care professionals. In studying main factors of resilience in migrants, the authors included the point of view of social workers. Their experience could reveal vulnerable or strength points in institutional paths.

Asylum Seekers and Refugees

In a second group of studies, the description of the origin country was usually related to the legal status of participants [ 18 , 20 , 21 , 22 , 24 , 29 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 ]. The authors highlighted the difference of existential experience related to uncertain asylum seekers status and final legal refugee status. So, they described their post-migration status.

The asylum seekers’ conditions, characterised by uncertainty, difficulty to obtain a work permit and citizenship document in the host country, lack or impossibility of employment, could determine high levels of psychological disease in this population target [ 20 , 22 , 97 ]. The asylum seekers were described at a higher risk of developing psychological suffering than the other category of migrants [ 97 ].

Concerning refugees, even if they have a final legal status, authors emphasised the suffering due to the impossibility of return’s perspective, the lack of social support, the feelings of isolation and alienation.

Despite these deep different existential conditions, in a smaller group of studies, authors did not take into account the difference between refugees and/or asylum seekers and migrants [ 98 , 99 , 100 , 101 ].

The Definition of Resilience

The analysis of the 90 publications allowed to distinguish three groups of articles: the first group included the articles with a not explicit definition of resilience, in the second group resilience was defined as coping or personality trait and in the last articles’s group authors defined resilience as a process (Table 1 ).

In the first typology of articles [ 21 , 27 , 28 , 32 , 34 , 37 , 38 , 44 , 46 , 51 , 56 , 57 , 58 , 60 , 63 , 66 , 69 , 70 , 71 , 78 , 79 , 83 , 86 , 87 , 94 , 102 ] authors did not give an explicit definition of resilience. They indicated resilience either in their aims or results, as a factor to study well-being, mental health or illness in the migration process without referring to a precise theoretical model. Despite the lack of definition of the construct, authors [ 38 , 69 , 71 , 78 ] identified internal and external factors or resources that could favour resilience, such as locus of control, social support and workplace or household satisfaction. With reference to the specific topic of migration, authors identified several sources of resilience, depending on different motivations of departure, volunteer or forced, attitude of migrants on the migration process and level of identification with the host culture and its values like resilience’s personal and family resources and the possibility to send money to family member [ 38 , 69 ].

In the second group of articles a growing consensus emerged that considers resilience and coping or personality trait as closely related [ 22 , 23 , 24 , 25 , 29 , 33 , 35 , 39 , 42 , 49 , 50 , 55 , 61 , 62 , 65 , 74 , 75 , 81 , 82 , 84 , 85 , 90 , 91 , 93 , 96 , 98 , 101 , 103 , 104 , 105 ]. Resilience is then defined as patterns of responses that aid to explore and negotiate social, political and environmental resources [ 85 ] and through some coping abilities, such as strength, courage and perseverance that characterise an individual during change [ 74 ].

Furthermore, some authors [ 29 , 33 , 65 , 96 , 98 ] defined resilience as a personality trait that helps the individuals to protect themselves from psychological disorders resulting from exposure to violent incidents. In addition, resilience minimises the negative effects of stress and promotes adaptation. Therefore, resilience was conceived as a stable element of personality like locus of control, introversion, extraversion and self-efficacy that could influence immigrant adaptation (103).

While for some authors [ 49 , 75 , 81 , 91 , 105 ] resilience was defined as a functional ability employed in migrant's past traumatic experiences; for others, resilience referred to the ability to cope with future adversities [ 101 ]. Therefore, in some studies [ 91 , 93 , 101 ] resilience was conceptualized as a tool to support a broader process of acculturation or adaptation.

The last group conceptualised resilience as a process. In these studies, authors utilised theoretical models that define resilience as a dynamic process in which psychological, social and environmental factors give a not pre-established trajectory to individuals or families during time. This favours the opportunity to regain, maintain or develop their well-being despite adversities [ 18 , 19 , 20 , 26 , 30 , 31 , 36 , 40 , 41 , 41 , 43 , 47 , 48 , 52 , 53 , 54 , 59 , 64 , 67 , 68 , 72 , 73 , 76 , 80 , 88 , 89 , 92 , 95 , 97 , 99 , 100 , 106 , 107 ]. The literature has highlighted a wide range of factors that protect and promote the resilience process. According to the authors, individuals were not only able to cope and adapt to adverse conditions (reactive capacity), but also to seek and create options (proactive capacity). In this way, they develop greater competence (positive outcomes) in dealing with a threat or risk. The individuals were able to make decisions by using the available resources to overcome the adverse or traumatic experience [ 20 , 40 , 41 , 43 , 47 , 64 , 73 ].

Other authors [ 80 ] highlighted among the social factors, family cultural values, the possibility of mutual psychological support and strong social ties. Also, according to authors (72, 19] resilience was a process influenced by the good functioning of the family, the members' ability to make sense of the crisis from past and present experiences, to stay connected, to cope with the crisis, and to move forward in their lives. In other cases, therefore, family resilience was explored by particular characteristics of the family like their belief systems, organizational patterns, and communication processes [ 88 ].

Methodological Approaches

About the methodological approaches, a first distinction between research articles (85 articles) and intervention strategies (5 articles) was made.

Subsequently, a further distinction between qualitative vs quantitative approach in the 85 research articles was presented.

Articles with a qualitative methodological approach were 40: individual interviews [ 18 , 20 , 24 , 27 , 30 , 33 , 35 , 40 , 48 , 52 , 54 , 57 , 58 , 61 , 75 , 80 , 86 , 88 , 89 , 95 , 101 ], focus groups [ 25 , 41 , 62 , 71 , 73 ] and participating observations [ 26 , 56 , 96 ]; furthermore, 5 studies [ 21 , 22 , 29 , 62 , 99 ] used both in-depth interviews and focus groups and 3 studies [ 56 , 76 , 92 , 103 ] both semi-structured interviews and participating observation. Finally, in 2 articles [ 21 , 86 ] a case study method was utilised.

A primary aim of the authors that have chosen a qualitative methodological approach was to highlight the narration of individual experiences. Indeed, some authors included the entire life history and migration experience in their analysis. In this way, three main moments (before migration—during migration—after arrival in the host country) were identified [ 20 , 30 , 35 , 41 , 57 , 58 , 61 , 62 , 86 , 99 , 104 ]. Some others [ 22 , 76 ] focused on the whole migration experience. In their study, authors [ 73 ] preferred to conduct the analysis starting from the two main thematic areas: the arrival and time spent in the host country and the resources and strategies used to cope with these difficulties. Other authors preferred to explore specific themes with more targeted stimulus questions to identify participants’ personal, family, social and contextual resources and strategies fostering resilience [ 18 , 21 , 24 , 25 , 29 , 33 , 40 , 48 , 75 , 96 ].

About the language of interview, the participants' native language was preferred by the authors. Subsequently, the materials were translated into English [ 75 , 84 , 104 ].

About data analysis procedure, in some cases the authors followed specific models of qualitative analysis as phenomenological approaches [ 18 , 57 , 80 , 104 ]. However, the preferred analysis approach was a content analysis.

Articles with a quantitative method were 35. In these articles, many different tests about resilience and other psychological and clinical dimensions were used. Furthermore, some studies investigated resilience starting from the family resilience framework.

The main standardized resilience tests utilised were the Resilience Scale (RS), the Connor-Davidson Resilience Scale (K-CD-RISC) and Brief Resilience Scale (BRS) [ 39 , 49 , 72 , 84 , 85 , 98 ]. In a study [ 28 ] was described the Multidimensional Trauma Recovery and Resiliency Scale (MTRR) that measures trauma and resilience in refugee populations. Additionally, authors reported a positive and therapeutic function of the standardized interview as reported by participants themselves. In another study [ 29 ] that aimed to investigate the life condition of Southeast Asian immigrant women who divorced in Taiwan, authors wanted to develop and test a Chinese version of Resilience Scale. According to the authors, there are some differences between divorced Southeast Asian immigrant women and divorced women in other populations. These differences were explained because of their different cultural and gender values. The final 16-item RS-C resulted in a three-factor model (personal competence, family identity and social connections). However, authors suggested additional research on the RS-C to further establish its reliability and validity.

The following questionnaires were used to investigate other psychosocial dimensions studied in the migration process: Migration and Settlement Questionnaire, Questionnaire Social Support, Social Support Index, Relation and Friend Support Index, Subjective Happiness Arab Acculturation Scale, the Demands of Immigration (DI) scale, the Migration Quality of Life Scale and Social Provisions Scale. In this way, authors aimed to measure the stress of acculturation, the perception of social exclusion and discrimination, the process of personal and family resilience [ 82 , 85 , 91 , 93 ].

In addition, some studies often integrated psychosocial tests with clinical tests to measure the specific mental health status. The main tests were: Depression Anxiety Stress Scale, Harvard Trauma Questionnaire, 90-item Symptom Checklist (SCL-90-R), General health questionnaire (GHQ-12). For example, authors [ 106 ] used an online questionnaire, proposed both in English and Farsi, which included questions on migration experience, levels of depression and resilience.

In the studies that investigated resilience in the family context utilised specific measurement: the Family Problem Solving Communication Index (T-PSC), Family Hardiness Index, F-COPES, Family Time and Routine Index (FTRI), Family Attachment and ChangeaBility Index 8.

Finally, mixed-methodology studies (10 articles) aimed to integrate personal and narrative results [ 51 ] and statistical data obtained through standardized tests [ 31 , 36 , 64 , 68 , 97 , 100 ]. In their study, authors [ 43 ] used data collected through questionnaires to build workshops or focus groups for the second qualitative phase of their study. In another study [ 45 ] the interviews were used to create ad hoc scales in line with the participants' reports.

Intervention Procedures

As anticipated, only 5 articles described the intervention strategies aimed to measure, enhance or foster the resilience process in the migration context [ 18 , 74 , 101 , 105 ]. Two of them [ 74 , 105 ] involved only groups of economic migrants. In the other two articles [ 18 , 74 ] only refugees were included. The last work [ 101 ] involved both economic migrants and refugees.

The first publication [ 18 ] described a model of intervention called LINC (Linking Human Systems Community Resilience) and applied in post-war Kosovo following emergencies of worrying levels of circulation and abuse of substances, especially among the younger generation after the population’s return in the origin country. These generations seemed to be the most vulnerable target, because they were influenced by a highly tragic collective history inscribed in the past of the community itself. According to authors, this type of intervention was used in different communities around the world where drastic and sudden political changes or environmental disasters occurred. In these cases, there was an increase in the needs of the population, especially in terms of mental health. According to authors, LINC Community Resilience extends the concept of resilience to the level of community encouraging people to view themselves as competent in the face of overwhelming circumstances. Authors strengthened protective resources already present in the community to protect it by risk factors such as the feeling of shame and the sense of threat to the family identity. According to authors, family cohesion, the main historical and cultural values of the community, the positive function of these values’ transgenerational narrative and the attribution of new meanings to the tragic past’s events were considered protective factors. Authors highlighted that the imposition of interventions culturally distant from the context of application was avoided. As a result of LINC intervention, the creation of a Centre for treatment, education and research on addiction have been seen. This centre worked on a program that provides specific training for professionals to strengthen the community's resources: local multicultural skills, awareness of one's own values, strengths, prejudices and use of one's own skills (concreteness, authenticity, and self-disclosure) to build a relationship of trust. In this way, the client and family could share their stories to build sustainable recovery.

The authors of the second publication [ 101 ] drew on previous studies indicating that people with language barriers have the greatest difficulty integrating into Australian society. At the same time, they noted the lack of specific language learning programmes aimed at the adult migrant population. They therefore set out to strengthen the resilience process of adult migrants in Australia by implementing a culturally sensitive language learning programme. The participants of their study were migrants and refugees, both men and women, from 30 different countries all over the world, except North America. BRiTA is a set of modules that aims to encourage the emergence and the sharing in groups of the protective factors and resources already present in each person. Following the application of BRiTA Future, the authors [ 56 ] observed a reduction of the risk of marginalization through this sharing. The authors highlighted the need for more rigorous measurements.

In the third research paper [ 74 ] was described the CAMINO intervention tool developed for Latinos community. According to authors, migrants from South and Central America (Mexico, Cuba, Dominical Republican, Puerto Rico) to the United States represented the majority of the migrant population. Their great need to access the health care system poses a critical issue because of the complexity of their migratory experience. Despite efforts to recognise their cultural strengths and vulnerabilities, authors highlighted the need to develop culturally-sensitive psychosocial and clinical interventions. According to authors, CAMINO was a culturally-sensitive tool. It facilitated the selection and evaluation of key elements of each participant's pre and post migration experiences: the impact of community and family support, acculturation stress level, history of migration, language preference, idioms of distress and resilience, origins. In this program, resilience was a subcategory that defined the participants' response in extreme situations of difficulty. This response will depend on the participants' perception of their own strength, their sense of mastery and their expectations for a definitive solution. CAMINO consisted of six macro-areas investigated through a series of questions, recommended by the authors. These areas were not exclusive and do not follow a pre-established order. This article described the intervention procedure, without reporting the results of its implementation.

Instead, the fourth intervention [ 105 ] aimed to improve life satisfaction and guarantee good higher educational goals for refugee survivors who participated in educational programs in Canada. According to authors, the traumatic experience and the language difficulties hinder social inclusion. To promote it and favour life satisfaction is important to foster psychological capital. According to the authors, resilience is the fourth dimension of a greater psychological capital’s concept, together with hope, efficacy and optimism. The intervention was divided in three phases: a preliminary group discussion to explore needs, barriers, expectations, and experiences that refugees who are trauma-survivors faced in pursuing higher education in Canada. In the second phase, these shared needs determined the content of the educational program’ sessions. It consisted of a 14-weeks course organized into weekly four-hour workshops that covered pertinent topics emerged by group discussions. In the third phase, participants have started the educational program’s structured course. Furthemore, authors have administered psychosocial tests to measure their self-esteem, psychological capital, life satisfaction, and level of participation in their respective communities at three different moments (entry point -week 1, mid-point -week 8, and exit point -week 14). The goal of the last phase was to give resources and educational support to respond to refugees' own needs to help them identify and pursue their social, educational, and vocational trajectories in the host country. Authors reported as a result that the participants’ psychological capital, specifically the dimensions of resilience and optimism, was positively correlated with their life satisfaction. In this study, authors did not describe the content of the educational program, but it only reported its results.

Finally, the last intervention [ 72 ] was an action research aiming to promote health empowerment for women who migrated in Taiwan from Vietnam, Indonesia, Philippines, Thailand and Cambodia and engaged in transnational marriages. The growing number of transnational marriages had a great impact on social and public health. According to authors, these women suffered intersectional discrimination for both marriage and migration experiences in the host country. The authors wanted to promote a deep sharing of the meanings among participants and their resignification of adverse and/or traumatic events to make sustainable and beneficial changes in their health and well-being. Authors reported four areas of intervention to gain the aim: increasing health literacy, facilitating the ability to build social networks, increasing the sense of self-esteem and building psychological resilience. Therefore, they described the need to build psychological resilience to transform life distress of women and their children into a more positive future outlook. The intervention promoted the participants' ability to identify problems and work together to find a solution.

Conclusions

This systematic review aimed to contribute to a better and more focused understanding of the link between the concept of resilience and psychosocial interventions in the migrant population.

The emergency of the migration issue, on the one hand, impacts a large proportion of the world’s population in both the roles of host and guest, and, on the other hand, produces a vast amount of work in academia. This led us to delve into the literature in order to outline the information that would be useful for the definition of practical interventions for the benefit of individuals and communities.

Looking at the vastness of the existing literature, there was a need to somehow systematise what had been studied in this specific field.

What have we learned from these studies?

The participants involved in these studies are mainly defined according to formal and legal criteria, and they can be easily distinguished into economic migrants, asylum seekers and refugees.

This distinction positions migrants in relation to the host country, but offers very little information in relation to their migration experience [ 108 ].

This categorisation criterion [ 109 ], leads to a homogenisation of the target group that risks obscuring the recognition of the needs of the individuals.

If all migrants are united by the fact that they have experienced migration, each of them has had a personal experience of it, rooted in his/her personal life.

Similarly, it appears that in the description of participants the different geopolitical origin and cultural specificities have not been adequately taken into account. Yet it is precisely in these personal experiences, which also take on significance depending on cultural background, that possible resilience factors can be identified. What happened before I left? Who do I leave behind? Who will be able to greet me on arrival? What are my chances of coming back? What did I risk to leave?

These are all existential questions that should allow psychologists to better define migrants' potentials risks and resources, regardless of the legal category to which they have been attributed.

The studies consulted in this review, whether conducted with qualitative or quantitative methodologies, tend to measure, at a given time, stable dimensions as strength, perseverance, courage, self-esteem, self-discipline, self-control, self-efficacy, capacity for action, ability to solve problems or manage stress. When considered, the more social dimensions that might influence resilience or its process are social support, workplace or household satisfaction and community ties. It seems also that, on a family level belief system, remittances to family in the origin country, good functioning, organizational pattern and communication processes of family are all favorable conditions for resilience. On the contrary, dramatic departures, bereavements, difficult identification with the host culture, sense of alienation, difficulty in accessing employment, health and social services are risk factors that may undermine resilience or its outcomes.

On the basis of this information, we should deduce that if a person feels strong, capable, competent, able to cope with problems and able to solve them, if he/she has not had to face too traumatic or adverse experiences, if he/she has a good family and social support network, then, in all likelihood, we can consider him/her a resilient person.

This information, which inevitably sounds a bit tautological, can be applied to any existential context and informs us very little about the migrant's condition and how it would be useful to intervene in order to promote the process of resilience and thus his/her well-being.

As a matter of fact, resilience’s construct is difficult to operationalise because of its polysemic definitions. It should also be noted that a large number of publications refer to the construct of resilience without making the theoretical framework explicit. This difficulty determined the main obstacle to plan efficiency interventions [ 13 ]. In migration contexts, there are few works that described resilience interventions. They mostly were group-oriented, enhancing personal and social factors already present in the participants' life stories and co-constructing the procedure’s priorities. The interventions aimed to foster migrants’ resources or factors that involve psychosocial dimensions of the migration process, such as migrant’s social ties, agency, proactive capacity and their knowledge of language, cultural values or health and social system of host countries [ 110 ].

The results of resilience studies did not translate into a clear prevention and treatment programme [ 111 ] and did not adequately address the need to re-elaborate the trauma that could characterise the migration experience in most cases. On one hand, the not well-described procedures hinder other professionals from adopting them. Specifically, psychosocial dimensions of the migration process—migrant’s awareness of culture, cultural aspects (such as norms, customs, language, lifestyle, social contest) and their capacity to distinguish between culture and pathology—in the interventions’ planification have not been described [ 14 ]. Often, the intervention’s efficiency and implication for the population involved have not been reported.

On the other hand, little attention was paid to the need to overcome trauma to foster resilience. As argued in the literature [ 111 , 112 ], through clinical and psychosocial interventions, it was important to foster emotional support and genuine encounters with peers or care professionals in order to aid people to deal with pain, loss and injury related-trauma favouring a positive future outlook. The resilience interventions should take into account a relational perspective to try to rebuild migrants’ new life [ 113 , 114 ] and to obtain a new balanced-psychosocial health. Therefore, a full view of the resilience strategies’ impact to promote a general psychosocial health status and wellbeing was not inferred.

Furthermore, within the studies’ participants a lack of involvement of care professionals working with migrants has emerged. They are a key element in the relational care process with the hosted migrants. These professionals co-build a relationship within the health and support system to favour migrants’ resilience trajectory [ 112 ]. The involvement of professionals should be an integral part of the future research. We can therefore assume that the success of the intervention will also partly depend on the outcome of this specific helping relationship.

This systematic review has some limitations. The search terms selected and used in the review could limit the number of results, although we tried several different combinations to avoid it. The search term “immigrant” does not seem to be adequate to review’s aim because it does not correspond to a category of research. The research has been carried out choosing “intervention” as a keyword. Future research could expand the topic adding other literature relevant keywords.

Furthermore, only a qualitative analysis was conducted. To assess the efficacy of interventions to foster resilience, a more in-depth methodological analysis, such as a quantitative analysis of reported articles’ measures and results, could have been conducted.

This systematic review tried to offer an exhaustive picture of the literature on the promotion of resilience in the migratory context. It has highlighted a gap in the literature on this topic-related. A clear definition of resilience in the migration process could allow to recognise which protective factors and resources were relevant to plan other interventions. These should take into account the cultural appropriateness and the traumatic dimensions of the migratory experience. Finally, it could be relevant to incentivise the authors to complete exhaustive procedures for reliable interventions and measurement of their efficacy.

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Ciaramella, M., Monacelli, N. & Cocimano, L.C.E. Promotion of Resilience in Migrants: A Systematic Review of Study and Psychosocial Intervention. J Immigrant Minority Health 24 , 1328–1344 (2022). https://doi.org/10.1007/s10903-021-01247-y

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Migrant health research in the Republic of Ireland: a scoping review

• Nazmy Villarroel 1 ,
• Ailish Hannigan 1 , 2 ,
• Santino Severoni 3 ,
• Soorej Puthoopparambil 1 , 3 , 4 &
• Anne MacFarlane   ORCID: orcid.org/0000-0002-9708-5025 1 , 2  

BMC Public Health volume  19 , Article number:  324 ( 2019 ) Cite this article

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Migration to European countries has increased in number and diversity in recent years. Factors such as access to healthcare, language barriers and legal status can impact the health outcomes of migrant groups. However, little is known about the evidence base on the health status of migrants in the Republic of Ireland. Our aim was to scope existing peer-reviewed research on the health of migrants in Ireland and identify any gaps in the evidence.

We conducted a scoping review of peer-reviewed research on the health of migrants in the Republic of Ireland. Eleven electronic databases were searched for peer-reviewed, empirical articles published between 2001 and 2017. Search terms were adapted from a World Health Organisation review. Findings were analysed using the 2016 World Health Organisation Strategy and Action Plan for Refugee and Migrant Health in the World Health Organisation European region, which outlines nine strategic areas that require collaborative action.

Of 9396 articles retrieved, 80 met inclusion criteria, with the majority (81%) published since 2009. More than half of the studies had a quantitative design (65%). Migrants studied came from Eastern Europe, Asia and Africa and included labour migrants, refugees and asylum seekers. Most studies related to two World Health Organisation strategic areas; 4: “achieving public health preparedness and ensuring an effective response”, and 5: “strengthening health systems and their resilience”.

There is growing attention to migrant health in Ireland with a balance of qualitative and quantitative research. While much of the identified research is relevant to three of the World Health Organisation strategic areas, there are significant gaps in the other six areas. The study design could be replicated in other countries to examine and inform migrant health research.

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Migration is a longstanding and global phenomenon. People migrate for many reasons and there is no universally accepted definition of ‘migrant’. This has consequences for public health because it can impact on eligibility for healthcare and it presents difficulties in developing a standardised evidence base [ 1 ]. For the purpose of this paper, we employ a broad definition of ‘migrant’ from the International Organization for Migration (IOM), which is also used in World Health Assembly (WHA) resolutions 61.17 and 70.15 (see Table  1 ) [ 2 , 3 ]. References to refugees are made following the definition from United Nations High Commissioner for Refugees (UNHCR) (see Table 1 ) [ 4 ].

Migration has become an increasingly significant phenomenon in Europe. Based on the most recent report on world migration from the IOM, 4.7 million people migrated to one of the European Union (EU)-28 countries in 2015, compared with approximately 1.8 million people in 2005 [ 5 , 6 ]. Consequently, a number of European countries with long histories of emigration have experienced unprecedented inward patterns of migration, including Spain, Portugal and the Republic of Ireland [ 7 ]. The focus in this paper is on the Irish setting.

There are multiple types of migration to Ireland, [ 8 ] EU/European Economic Area (EEA) nationals who are free to move, live and work in Ireland with no special permission; migrants who move for work or study reasons, through marriage, civil partnership or close family relationship; and the asylum system. In addition, there are Refugee Protection Programmes (RPP) established by the Government.

Migration patterns in the Republic of Ireland began to change in a significant way from the late 1990s. There was a sharp rise in the number of asylum applications in 1999, from several hundred to over 7000 per annum; this peaked at just over 10,000 in 2000 and 2001 [ 9 , 10 ]. Subsequently, the number of labour migrants (defined as those seeking work or employed in the host country), [ 11 ] also rose during an economic boom in Ireland and the enlargement of the EU during the 2000s [ 7 ]. In late 2008, the country encountered a severe economic recession. As a result, there was increased outward migration and decreased inward migration. [ 8 ] explains that the latter was related to three factors: a drop in asylum applications across Europe, the impacts of EU enlargement in 2004 on intra-EU migration patterns, and the rise in unemployment as a consequence of the recession in Ireland. The number of immigrants coming to Ireland rose again by 2014 [ 12 ].

According to the latest Census (2016), net inward migration has increased significantly [ 13 ]. Current figures show that 17% of the population were born abroad; [ 13 ] the fifth highest rate in the EU-28. Ireland has the ninth highest proportion of migrants in the World Health Organisation (WHO) European region [ 14 , 15 ]. At the last Census, the top five countries of origin for non-Irish nationals in Ireland are Poland, the United Kingdom, Lithuania, Romania and Latvia [ 13 ].

The census data shows that the gender balance of non-Irish nationals is almost evenly split. The age profile is younger compared with the general population: Nearly half of all non-Irish nationals are aged between 25 and 42 compared with less than a quarter of Irish nationals [ 13 ]. Patterns of family and household arrangements differ across groups. For example. Spanish, Brazilian, Italian and French nationals were most likely to be single while Indian nationals had the largest proportion of married persons [ 13 ]. Almost 15% of the workforce is Ireland is made up of non-Irish nationals with the largest numbers working in wholesale and retail sectors. The unemployment rate for non-Irish nationals is nearly 3% higher than Irish (15.4% compared with 12.5%) and there was a relationship between higher educational status and employment status [ 13 ].

In 2017, there were 1910 new asylum applications (the five top countries of origin were Syria, Georgia, Albania, Zimbabwe and Pakistan) and 5670 pending applications (the five top countries of origin were Pakistan, Albania, Zimbabwe, Nigeria, Georgia [ 16 ]. In addition, the most recent RPP was established by Government Decision in 2015 as a direct response to the humanitarian crisis that developed in Southern Europe as a consequence of mass migration from areas of conflict in the Middle East and Africa [ 17 ]. This has three strands:

Relocation Strand for asylum seekers from Greece and Italy through the EU relocation mechanism established by two EU Council Decisions in 2015

Resettlement Strand for programme refugees focused on resettling UNHCR refugees from Lebanon

Other mechanisms such as the acceptance of unaccompanied minors previously resident in the unofficial camp in Calais, France [ 17 ].

One of the great challenges of this newly diverse population for the Irish State is to adequately support the health of migrants. Although mortality rates in migrants are sometimes below those of the host population, [ 18 , 19 ] available data suggest that they tend to be more vulnerable to certain communicable diseases, occupational health hazards, injuries, poor mental health, diabetes mellitus, and maternal and child health problems [ 20 ]. In addition, the health of refugees on the move in Europe is jeopardised by their poor living circumstances and barriers to accessing healthcare [ 21 ]. Once in the host country, refugees and migrants can encounter barriers to healthcare services in terms of their entitlement to healthcare, communication and language difficulties and attitudinal discrimination [ 22 ]. Previous studies investigating the health of migrants compared with host populations in Europe have shown mixed results. A review on the health status of migrants in Europe showed that the migrant population appeared to be more disadvantaged compared to the host population [ 23 ]. Another study found that most countries had either higher or lower health service utilisation patterns among migrants, depending on the type of health service used, e.g. utilisation of emergency services is higher, while utilisation of specialist services is lower [ 24 ].

It is important to strengthen the evidence base in Ireland on migrant health in order to develop knowledge about any such differences between migrants and the Irish-born population. A review of Irish research on refugees’ and asylum seekers’ health was carried out in 2001 and again in 2004 [ 25 , 26 ]. However, there has been no review since. This is problematic for several reasons. First, there is a sustained increase of inward migration, including through the aforementioned Government’s recent involvement in the Refugee Resettlement Programme [ 17 ]. Second, there is an emerging cohort of children of migrants living in Ireland for the first time in Irish history. Third, there have been a series of initiatives and developments in policy and service provision, [ 22 ] that provide evidence about health status and health utilisation [ 27 ]. Finally, WHO Europe has provided important leadership, publishing a WHO Strategy and Action Plan (SAAP) for Refugees and Migrants in Europe. This provides a firm policy imperative for advancing the field, with guidance on nine strategic areas for priority action (Table  2 ) [ 28 ]. The implementation of this policy in each country requires sound and up-to-date national evidence for policy-makers and practitioners alike. The objective of this study was, therefore, to conduct a scoping review of existing peer-reviewed research on the health of migrants in the Republic of Ireland and to use the WHO-SAAP to identify any gaps in the evidence.

This is a scoping review - a mapping of literature about a broad topic where many different study designs might be applicable - following the principles suggested by Arksey and O’Malley, with consideration of modifications suggested by Levac, Colquhoun and O’Brien [ 29 , 30 ].

This work was presented at the 1st World Congress on Migration, Ethnicity, Race and Health 2017 [ 31 ].

The scoping review involved a six-stage framework.

Stage 1: Identifying the research question

The scoping review framework suggests a broad and clearly articulated research question, defining concepts, target population, health outcomes, and scope, while accounting for the aim and rationale of the review [ 29 , 30 ]. The research question for the review was: ‘What is the scope, main topics and gaps in evidence in the existing literature on health of migrants residing in the Republic of Ireland?’ The definition of migrant used in the study was that as defined in the Introduction, .whilst the definition of health was considered to be, not simply the absence of disease, but a state of bodily, mental and social well-being [ 32 ].

Stage 2: Identifying relevant studies

The scoping review framework recommends searching multiple literature sources to increase comprehensiveness of the topic under study [ 29 ]. The initial plan was to include grey literature. However, as the database search progressed, there was a larger volume of peer-reviewed literature than anticipated, so we focused on peer-reviewed literature only. We chose the databases and search terms based on a recent comprehensive WHO review in the field of migrant health, [ 1 ] and consulted a medical librarian in the University of Limerick regarding its adaptation for this review. We systematically searched 11 electronic databases: Psychinfo, PsycArticles, CINAHL, Medline, Academic Search Complete, Social Sciences Full Text (H.W. Wilson), Cochrane library, Embase, Web of Science, Econlit, and Lenus. The terms below were used in this search:

(asylum* OR refugee* OR migrant* OR migrat* OR emigrant* OR emigrat* OR immigrant* OR nomad* OR foreign* OR ethnic* OR displaced OR stateless OR state-less OR noncitizen* OR non-citizen* OR outsider* OR newcomer* OR “newly arrived” OR “new arrival*” OR “recent entrant*” OR “non national” OR non-national) AND (health*) AND (Ireland* OR Irish*).

Stage 3: Study selection

Inclusion and exclusion criteria were established through an iterative process. We agreed on the initial selection criteria based on the research question and by focusing on empirical research on the health of migrants in the Republic of Ireland. All study designs, intervention types, and migrant groups were included. The final selection criteria are shown in Additional file  1 .

Stage 4: Data charting

We used EndNote to manage retrieved items and extracted the data under the following headings: authors, publication year, title of the study, geographic location of the study, data collection period, study design, target population, target migrant group, definition of migrant group, participant group, study objective(s), data collection methods, and main study findings. We also recorded whether the study had a primary focus on migrant health or not. If authors made an explicit link between the study rationale and migration or migrant health, it was classified as having a ‘primary focus’ on migrant health. Their definition of ‘migrant’ was also recorded. If authors did not make this explicit link, the study was not classified as having a primary focus and details of data relevant to migrant health reported in the paper were recorded.

Although there are no well-established criteria for a scoping review to quality-appraise included studies, we added this step to maximise the robustness of our review. We used the criteria suggested by Kuper et al. [ 33 ] for qualitative studies; the Effective Public Health Practice Project Quality Assessment Tool (EPHPP) for cross-sectional quantitative designs, and the Newcastle Ottawa Scale [ 34 , 35 ] for cohort studies. We classified the methodological quality of all studies as low, moderate, or high.

Stage 5: Collating, summarizing and reporting results

We used the stated aims and objectives of each included paper to identify the main research topic. We then deductively analysed and categorised each paper to the nine strategic areas in the WHO’s SAAP (see Table 2 ), [ 28 ] by iteratively developing coding rules during the analysis process.

NV and SP completed the first round of analysis. NV, AH and AM conducted the second round of analysis using independent categorisation of papers, followed by team meetings to examine any discrepancies and to develop clear guidelines for categorisation of papers to one or more strategic areas (studies sometimes covered issues in more than one strategic area). The findings of the analysis were shared with SP and SS for critical commentary, and the final analysis was agreed by all authors.

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram is given in Fig.  1 and a completed PRISMA checklist is included as Additional file  2 . Of 7799 records screened, 3350 (43%) were excluded because they were unrelated to migrant health and 2283 (29%) were excluded because they involved migrants in countries other than the Republic of Ireland. We identified 80 articles about migrant health in the Republic of Ireland. These are listed and numbered S1 to S80 in Additional file  3 and summarised in table form in Additional file  4 .

PRISMA flow chart illustrating selection of records included in scoping review

Overall findings

The majority of studies were published since 2009 ( n  = 65, 81%), and had a primary focus on migrant health ( n  = 66, 82%). The others had a secondary focus which were population-based papers that collected demographic data relevant to migration, such as country of birth, ethnicity or nationality.

Of the available information on funding (78/80 papers), a funding source was acknowledged for 39 (50%) of them, most commonly the Health Research Board, which is the main funding body for health research in Ireland (19 of the 39, 49%).

Of the 80 papers, 38 (48%) were academic authorship only, 22 (28%) were joint academic/healthcare or clinical academic authors, 11 (14%) were healthcare only and the remaining nine (11%) included mixtures of academic/community/advocacy/government/healthcare authorships (one had no affiliation).

A standardised definition for the migrant population of interest was provided in only 12% [S9, S30, S37, S53, S54, S55, S59, S71, S72, S78] of papers and these were mostly for refugees and asylum seekers with reference to UNHCR definitions. Fifty other studies provided a description of the population of interest in their specific study, with considerable variation in the use of terminology.

Of the included studies, 28 (35%) had a qualitative design, and 52 (65%) a quantitative design. For qualitative studies, in general the authors did not report which specific qualitative tradition or design [ 31 ] they had used, and the most common method for data collection was semi-structured interviews ( n  = 10). Quantitative studies were mainly cross-sectional ( n  = 23, 29%) and retrospective case series ( n  = 2, 3%), with three cohort studies and one case–control study. Based on the quality appraisal criteria, more than half of the articles (57%) were of low quality, 29% moderate quality, and 14% high quality. The low-quality studies were categorised as such because they were not representative of the target populations and/or did not provide enough information about the study design to complete the appraisal.

10% of the studies ( n  = 8) were based in a primary care setting. In eight studies (10%), data from Ireland were included as part of a larger international study. They related to a number of topics: 20 on maternal health [S11, S15, S18, S20,S 22, S25, S30, S32, S34, S36, S47, S49, S62, S63, S67, S71, S72, S73, S76, S79] 16 on access and utilisation of healthcare [S21, S35, S37, S38, S39, S42, S44, S46, S51, S53, S54, S65, S68, S69, S70, S74], 15 on infant and child health [S3, S6, S10, S16, S33, S40, S43, S50, S55, S57, S58, S64, S66, S75, S77], nine on infectious diseases [S1, S2, S4, S7, S19, S29, S31, S45, S52], eight on diversity in healthcare staffing [S5, S8, S9, S13, S17, S23, S24, S41], six on mental health [S28, S56, S59, S70, S78, S80] and six on ‘other’ topics such as occupational health [S12, S14, S60] and health behaviours [S26, S27, S48].

We categorised all studies onto the WHO-SAAP strategic areas to identify gaps in evidence, to which we now turn.

Categorisation of included studies to the WHO-SAAP strategic areas

The categorisation of included studies to the WHO-SAAP strategic areas is shown as Fig.  2 . There were no studies categorised to strategic area 1, on establishing a framework for collaborative action, or strategic area 2, on advocating for the right to health of refugees, asylum seekers and migrants.

Percentage of studies categorised to each strategic area ( n  = 80)

Strategic area 3: Addressing the social determinants of health

Twenty-three studies (29%) (Additional file 1 [S11–S14, S16, S17, S21, S23, S24, S32, S48, S49, S51, S57, S59, S60, S66, S67, S70, S73, S77, S79, S80]) addressed the social determinants of health. The majority ( n  = 16, 70%) had a quantitative design and a primary focus on migrant health ( n  = 22, 96%). Employment was the focus of seven studies (30%), including the prevalence of work-related injuries in migrant workers compared to the host population [S12, S14, S60] and the experience of migrant workers in the healthcare system [S13, S17, S23, S24]. Over half of these studies ( n  = 13, 56%) were also categorised to strategic area 4 and addressed a range of issues; exploring the evidence for a ‘healthy immigrant effect’ [S48, S49]; the relationship between legal status and health outcomes [S59, S70]; and the influence of country of birth, ethnicity and citizenship on breastfeeding behaviours [S11, S32, S79].

Strategic area 4: Achieving public health preparedness and ensuring an effective response

The majority of studies ( n  = 47, 59%) were categorised to strategic area 4 [S4, S3, S6, S11, S15, S16, S18–S20, S22, S25, S28–S34, S40, S43–S50, S53, S55–S65, S67, S70, S72, S73, S75, S76, S78–S80], mostly in the context of providing evidence on the health needs of migrants. The majority of these studies had a quantitative design ( n  = 36, 77%) and a primary focus on migrant health ( n  = 38, 80%), and were also categorised to another strategic area ( n  = 42, 89%), most commonly strategic area 5 ( n  = 19, 40%) and strategic area 3 ( n  = 13, 28%). Studies which were only categorised to strategic area 4 focused on maternal or child health [S15, S22, S25, S40, S50].

Strategic area 5: Strengthening health systems and their resilience

Half of the studies ( n  = 39, 49%) addressed the health system’s capacity to respond to the needs of migrants and refugees [S5, S8, S9, S13, S17, S21, S23, S24, S30, S35–S39, S41–S44, S46, S47, S51, S53–S56, S58, S60–S65, S68, S71, S72, S74–S76, S78]. Migrant health was the primary focus of the majority of these studies ( n  = 36, 92%), with the remaining three studies providing information on the health system’s capacity through an analysis of findings by demographic characteristics, including country of birth [S43, S47, S75]. Of the 39 studies, 24 (62%) had a qualitative design.

Seventeen studies focused on healthcare workers (nurses, midwives, hospital-based doctors, general practitioners, primary and social care providers, carers). Nine of these studies [S21, S36, S38, S42, S53, S54, S61, S72, S74] explored the experiences of healthcare workers in providing care to migrants and refugees and their own training needs to ensure the delivery of culturally sensitive healthcare. Eight of these studies [S5, S8, S9, S13, S17, S23, S24], and [S41], focused on migrant healthcare workers in the health system, including a survey of their perceptions and attitudes to integration and their plans to remain working in Ireland.

Language barriers, the lack of access to interpreting services and the need for implementation of guidelines for effective cross-cultural communication were addressed in 12 studies, with a range of stakeholders and settings [S35, S36, S37, S38, S39, S42, S51, S55, S71, S72, S74, and S78].

Nine studies focused on maternity services, including migrants’ experiences of these services [S30, S62, S63, S71]; the experience of maternity service providers in caring for migrant and refugee women [S36, S72]; and a comparison of delivery and perinatal outcomes by country of birth [S47, S75, S76].

Strategic area 6: Preventing communicable diseases

Twelve (15%) studies focused on communicable diseases: four on Human Immunodeficiency Virus (HIV) [S1, S3, S4, S52], four on tuberculosis [S2, S19, S29, S45], two on malaria [S7, S33], one on communicable diseases in childhood [S16] and one on infectious rashes in pregnant women [S31]. The majority ( n  = 10, 83%) did not have a primary focus on migrant health but profiled the participants and analysed findings by demographic characteristics, including country of birth. Eight studies were retrospective chart reviews in one or two hospital clinics and, while they provided some information on epidemiological surveillance, they are not population representative. One qualitative study explored the challenges and opportunities for HIV testing in African migrants [S1]. Where universal access was provided, e.g. vaccinations for childhood communicable diseases, one population-representative cohort study explored the ethnicity of the mother and uptake of vaccinations [S16].

Strategic area 7: Preventing and reducing the risks posed by non-communicable diseases

Fifteen (19%) studies [S6, S10, S12, S14, S18, S20, S26, S27, S28, S34, S43, S47, S58, S69, and S73] addressed the risks of non-communicable diseases. All were quantitative in design and the majority ( n  = 10, 67%) had a primary focus on migrant health. Five studies focused on nutrition and alcohol use, all in pregnant women, including studies on their diet [S34], body composition [S18], weight gain [S20], alcohol consumption [S47] and Vitamin D status [S73]. Two studies focused on the prevalence of smoking; one with a primary focus on migrant health comparing Polish migrants’ smoking habits to the host population [S26]. Only two studies had an explicit aim to compare health literacy between the host population and migrants; one in the context of diabetes self-care [S69] and one on Vitamin D status in pregnancy [S73].

Strategic area 8: Ensuring ethical and effective health screening and assessment

Five (6%) studies addressed health screening, all in the context of communicable diseases (two on HIV [S1, S52]; one on tuberculosis [S19], one on communicable diseases in childhood [S16] and one on infectious rashes in pregnant women [S31]). All five studies were also categorised under strategic area 6, and four had a quantitative design. Two of the studies had a primary focus on migrant health; one which explored the immunity to infectious rashes in pregnancy by nationality of the mother (including the host population) [S31], and one which explored the challenges and opportunities for HIV testing in African migrants [S1]. There were no examples of research on health screening and assessment for non-communicable diseases in migrants.

Strategic area 9: Improving health information and communication

Only one study was categorised to Strategy 9. It used participatory research methods to involve migrants and other stakeholders in a dialogue to develop a guideline for effective cross-cultural communication in general practice consultations [S51]. No studies were focused on strengthening health information systems for improved data collection on migrant health.

Summary of results

This is a comprehensive scoping review of peer-reviewed published research about migrant health in the Republic of Ireland. To our knowledge, it is the only review that uses the WHO-SAAP (2016) [ 28 ] as a framework to analyse the field and develop recommendations. There is a significant amount of research activity, particularly since 2009. Most research is quantitative, with a primary focus on migrant health. Few studies provided a standardised definition for the migrant population of interest, but most provided a working definition for their project. Most studies are of low–moderate quality. They tend to be regional in focus with very few examples of international collaborations. A large amount of the research is relevant to the social determinants of health, public health preparedness and health system adaptations as described in the WHO Strategy (strategic areas 3, 4 and 5 respectively) and a lesser amount is relevant to the study of communicable and non-communicable diseases and health screening (strategic areas 6, 7 and 8 respectively). There is a dearth of research about frameworks for collaborative action, advocacy and human rights and improving health information systems (strategic areas 1, 2 and 9 respectively).

Methodological critique

We were rigorous in our approaches to all stages of the review, which adhered to the key principles of the scoping review framework [ 29 , 30 ] and PRISMA guidelines. An optional stage in scoping reviews for stakeholder engagement, recommended by Levac et al. [ 30 ], was not conducted. We did however, have representation from policy (SS, SP and academic sectors (SP NV, AH, AM) in our review team. Our process included a quality appraisal, which is beyond the recommendations in the literature for scoping reviews [ 29 , 30 ].

There were limitations to our search. This scoping review only includes studies within our search capacity (e.g. accessible on databases searched). The database searches did not include the grey literature because the amount of relevant peer-reviewed literature surpassed expectations. This means that there may be research on WHO priority areas that we have not identified.

Using the WHO SAAP [ 28 ] as our analytic framework was a strength as it allowed us to locate the Irish research in an international policy context, which is important for strengthening the imperative for responses by policy makers, service planners and practitioners. This is also positive for developing international research collaborations. It was analytically challenging at times to differentiate between the strategic areas, particularly because of some overlap in the description of areas 3, 4 and 5: social determinants of health and public health preparedness and health system reliance. Our analysis does not synthesise the findings per topic and per migrant group. This is the logical next step for expanding the evidence base on migrant health in Ireland, as is the conduct of systematic reviews on the evidence available around specific topics and groups.

Connections with existing literature

This scoping review is a major contribution to the field in Ireland because it updates two previous reviews [ 25 , 26 ]. It provides an apposite update on evidence about migrant health that can be used to monitor future trends in the amount of research activity being conducted and to identify relevant research questions to expand the evidence base.

The majority of studies do not provide a standardised definition of which migrant group they are concerned with, and the ones that do tend to be about refugees and asylum seekers, using the UNHCR definitions as an authoritative source. Others provide a project-specific definition. This is in keeping with findings from a recent review of definitions and terminology in the field [ 1 ].

The finding that a large number of studies focused on the social determinants of health, public health preparedness and health system adaptations (strategic areas 3, 4 and 5), with a smaller number focused on communicable diseases and health screening (strategic areas 6 and 8), contrasts with the results of a previous scoping review on migrant health in Spain, which found that the epidemiology of infectious diseases was the predominant theme [ 36 ]. Similarly, a review of research on the health of Latin-American migrants in Europe found that the largest proportion of research focused on communicable diseases (38%), with few studies addressing health determinants, including health service use (8%) and broader structural and socio-economic factors (7%) [ 37 ]. It was also interesting to note that there was a primary focus on migrant health across all the strategic areas relating to public health preparedness and health system adaptations (strategic areas 4 and 5). In contrast, studies that related to communicable diseases and screening (strategic areas 6 and 8) had a primary focus on a specific disease, such as tuberculosis, and variables examined included those that relate to migrants (for example, country of origin or ethnicity). This indicates that, even though migrants are coming from countries where the prevalence of communicable diseases is higher than in Ireland, [ 38 ] researchers in Ireland who set out to generate empirical data about migrant health to date do not appear to have directed their attention to negative and risky aspects of migrant health for the host population. These findings are in contrast with Spanish research, [ 36 ] which highlights that the research landscape on migrant health can vary considerably by country/migrant population group. This points to the WHO-SAAP as a helpful framework to elucidate the approaches to migrant health research within and across countries, as well as its role in identifying research gaps.

With regard to research gaps in the Irish setting, we note a lack of studies about collaborative action, advocacy on human rights and improving health information systems (strategic areas 1, 2 and 9). This finding warrants attention. It suggests that health researchers would benefit from thinking about action orientation studies and collaborations with scholars of law and political science. This would create valuable cross-fertilisation of ideas to generate relevant inter-disciplinary projects. On the specific issue of health information systems, this certainly needs attention. The need for a robust and comparable evidence base within and across countries, with involvement of migrants, has been well argued [ 1 ]. Some of the authors of this review are involved in a participatory research project to explore: (i) where data about health and ethnicity in Ireland are routinely collected in information systems and (ii) the implementation of an ethnic identifier in primary care [ 39 , 40 ].

The nature of the evidence base, for example the dominance of quantitative studies and the low methodological quality of studies, is noted. This finding resonates with concerns which have been previously raised over the methodological quality of research in the field of migrant health [ 41 ].

We found that evidence about migrant health may be found in studies whose primary focus was not on migrant health; studies that provide information on the topic through an analysis of findings by demographic characteristics, including country of birth. This finding reflects the nature of the field which is not neatly bound, and where migrant health issues are not always different from the native population’s health issues. The inter-relationships between migrant and ethnic minority health are important and well documented; for example, the WHO published a briefing on how health systems can address health inequities for migrants and ethnic minority groups [ 42 ]. The recognised need for attention to structural and intersectional aspects of migrant health is also relevant [ 43 ].

Implications for policy, practice and research

Findings of this review should be presented to key stakeholders in the Irish Government and Health Service Executive so that the current and evolving policy and practices around migration and integration are informed by evidence. Establishing a national Centre for Migrant Health, following international best practice in countries such as Norway, Denmark and the Former Yugoslav Republic of Macedonia, [ 22 ] would be a major step forward for policy and practice. This would be a significant mechanism for moving past current ad-hoc arrangements for co-ordinating and consolidating knowledge and its dissemination [ 22 ].

The gaps in knowledge identified using the WHO-SAAP about collaborative action, advocacy and human rights and improving health information systems need attention to expand the evidence base, and a detailed synthesis of findings about other areas should, as mentioned above, be conducted.

The evidence base about migrant health in Ireland is growing considerably. The WHO-SAAP was a useful framework for analysing the nature and relevance of the research, revealing some key gaps to be addressed. This process could be replicated to scope research on migrant health in other countries. This would provide a comparable and robust oversight of the state of the art within, and across, countries.

Abbreviations

European Economic Area

Effective Public Health Practice Project Quality Assessment Tool

European Union

Human Immunodeficiency Virus

International Organisation for Migration

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Refugee Protection Programme

Strategy and Action Plan

United Nations High Commissioner for Refugees

World Health Assembly

World Health Organisation

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Acknowledgements

We thank Dr. Maria Roura for her insightful comments on our manuscript.

The Irish Health Research Board, as part of the project “Ethnic Minority Health in Ireland - Building the evidence base to address health inequities” (HRA-PHR-2015–1344) and the University of Limerick. Funders did not influence the study design, collection, analysis or interpretation of data nor the writing of the manuscript.

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All data analysed during this study comes from the papers reviewed and the details of these are included in this published article as Additional file 3 .

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AMacF and AH conceived this study. NV and SP conducted the search and the analysis and write up was conducted by AMacF, AH, NV, SP and SS. All authors read and approved the final manuscript.

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Additional files

Additional file 1:.

Table of Inclusion and Exclusion Criteria. This file provides information on inclusion and exclusion criteria used to appraise papers for the scoping review. (DOCX 13 kb)

Additional file 2:

PRISMA 2009 checklist. This file shows how the scoping review meets the criteria for the PRISMA checklist. (DOC 51 kb)

Additional file 3:

List of studies included in the Scoping review (S1-S80). This file provides the full reference for each paper included in the scoping review. (DOCX 24 kb)

Additional file 4:

Summary Table of Included Papers. This file provides summary information on each paper included in the scoping review. There are details of the citation; whether migrant health was a primary/secondary focus of the research; authors’ description of migrant population OR information on data collected relevant to migration; study design; main research topic; and WHO SAAP Strategic Area. (DOCX 19 kb)

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Villarroel, N., Hannigan, A., Severoni, S. et al. Migrant health research in the Republic of Ireland: a scoping review. BMC Public Health 19 , 324 (2019). https://doi.org/10.1186/s12889-019-6651-2

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State Health Coverage for Immigrants and Implications for Health Coverage and Care

Akash Pillai , Drishti Pillai , and Samantha Artiga Published: May 01, 2024

Note: This brief was updated on May 8, 2024 to reflect the final rule published on May 3, 2024 which will extend eligibility for health coverage to DACA recipients.

As of 2022, there were 21.2 million individuals who are noncitizen immigrants residing in the U.S., accounting for about 7% of the country’s total population. Among noncitizen immigrants, about six in ten are lawfully present immigrants while the remaining four in ten are undocumented immigrants. Noncitizen immigrants, particularly those who are undocumented, face significant barriers to accessing health coverage and care and are significantly more likely than citizens to be uninsured. These higher uninsured rates reflect more limited access to private coverage and eligibility restrictions for federally funded coverage options. Some states have taken up options in Medicaid and the Children’s Health Insurance Program (CHIP) to expand coverage for lawfully present immigrants and/or established fully state-funded programs to fill gaps in coverage for immigrants. This brief provides an overview of state take-up of these options and state health coverage programs for immigrants regardless of status. It also examines how health coverage and care for immigrants vary by state coverage policies using data from the 2023 KFF/LA Times Survey of Immigrants .

There has been increased state action to expand coverage to immigrants, including immigrant adults, in recent years although these efforts are limited by funding constraints. As of March 2024, 12 states and D.C. provide fully state-funded coverage for income-eligible children regardless of immigration status, six states plus D.C. provide fully state-funded coverage to some income-eligible adults regardless of status, and most states have taken up options in Medicaid and CHIP to expand coverage to lawfully present immigrant children and pregnant women. Data and research suggest that coverage expansions for immigrants are associated with lower uninsured rates, with immigrant adults in states that provide more expansive coverage half as likely to be uninsured as those in states with less expansive coverage (11% vs. 22%). Despite these expansions, uninsured rates remain high among noncitizen immigrants, with 18% of lawfully present immigrant adults and half of likely undocumented immigrant adults reporting being uninsured. It remains to be seen whether there will be continued movement to expand coverage for immigrants going forward and if existing expansions will be sustainable over time.

Health Coverage for Immigrants

Noncitizen immigrants have high uninsured rates because they have more limited access to private coverage due to working in jobs that are less likely to offer coverage and face eligibility restrictions for federally funded coverage options . Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to eligibility restrictions that result in some, particularly recent immigrants, being ineligible to enroll even if they meet other eligibility criteria. For example, many must meet a five-year waiting period before qualifying for Medicaid or CHIP. Lawfully present immigrants can purchase coverage through the Affordable Care Act (ACA) Marketplaces and may receive tax credits for this coverage without a waiting period. Undocumented immigrants are ineligible to enroll in Medicaid or CHIP or to purchase coverage through the ACA Marketplaces. Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments may help cover the costs for emergency care provided to immigrants who remain ineligible for Medicaid but are not coverage for individuals.

Medicaid and CHIP Options for Lawfully Present Immigrants

In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some immigrants, such as those with Temporary Protected Status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country. For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of March 2024, 37 states plus D.C. have taken up this option for children and 30 states plus D.C. have elected the option for pregnant people (Figure 1). Michigan also has indicated plans to remove the waiting period for lawfully residing immigrant children and pregnant people.

A total of 22 states have also extended coverage to pregnant people regardless of immigration status through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option (Figure 2) . Colorado plans to implement this coverage by January 2025. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage regardless of immigration status either through a CHIP state plan amendment or using state-only funding. Additionally, ten states (California, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to individuals regardless of immigration status to align with the Medicaid extension established by the American Rescue Plan Act, and Maryland extends coverage for four months postpartum through its health services initiative.

Fully State-Funded Coverage

Beyond state take-up of options in Medicaid and CHIP, some states provide fully state-funded coverage to fill gaps in coverage for some individuals regardless of immigration status. States vary in the eligibility and scope of benefits offered through these coverage programs. These programs extend coverage to lawfully present immigrants who are in the five-year waiting period for Medicaid or CHIP or do not have “qualified status” and are ineligible for federally funded coverage as well as undocumented immigrants. These programs also extended coverage to Deferred Action for Childhood Arrivals (DACA) recipients who previously were not considered lawfully present for purposes of eligibility for federally-funded health coverage programs. However, effective November 1, 2024, new regulations will change the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing.

As of March 2024, 12 states plus D.C. provide comprehensive state-funded coverage for children regardless of immigration status (Figure 3) . These states include California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. By 2025, Colorado and Minnesota plan to offer state-funded Medicaid-like coverage to income-eligible children regardless of immigration status. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of March 2024, six states (California, Colorado, Illinois, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status (Figure 4) . Some additional states  cover  some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

• California extended state-funded Medicaid coverage to  young adults ages 19-25 regardless of immigration status in January 2020, and adults  ages 50 and older  became eligible on May 1, 2022. The state further extended coverage to income-eligible adults ages 26 to 49 regardless of immigration status in January 2024, making all low-income immigrants in the state eligible for state-funded health coverage regardless of immigration status.
• Colorado uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 300% of the federal poverty level (FPL) regardless of immigration status through a section 1332 waiver . Colorado previously provided subsidized plans with $0 premiums through SilverEnhanced Savings , but the program has paused enrollment for 2024 due to funding constraints.
• D.C. provides health coverage to low-income residents regardless of immigration status through its longstanding locally funded Healthcare Alliance program.
• Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors ( HBIS ) program in December 2020. Coverage also was extended to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults ( HBIA ) program in 2022. As of March 2024, Illinois has  paused enrollment for both the HBIS and HBIA programs due to funding constraints.
• New York extended state-funded Medicaid coverage to individuals ages 65 and older regardless of immigration status beginning in 2023.
• Oregon extended state-funded coverage to all adults who meet income and residency criteria regardless of immigration status as of July 1, 2023.
• Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 250% FPL regardless of immigration status through a section 1332 waiver. Starting July 2024 , Washington will allow individuals regardless of immigration status with incomes up to 138% FPL to apply for coverage under a state-funded Medicaid-look alike program, subject to funding availability.

In addition to these states, Maryland plans to allow income-eligible individuals to purchase Marketplace coverage regardless of immigration status through a section 1332 waiver without subsidies, pending waiver approval by the Centers for Medicare and Medicaid Services (CMS). Minnesota plans to allow income-eligible individuals regardless of immigration status to enroll in MinnesotaCare, a state-subsidized sliding scale program for low-income residents no sooner than 2025, subject to funding availability.

Impact of State Coverage Expansions on Health Care Access and Use

Data suggest that state coverage options for immigrants make a difference in their health coverage and health care access and use . The 2023 KFF/LA Times Survey of Immigrants shows that immigrants residing in states with more expansive coverage policies for immigrants have higher rates of health coverage, are less likely to postpone or go without care, and are more likely to receive care and to have a trusted health care provider compared to their counterparts living in states with less expansive coverage policies, as described below. (See Box 1).

Box 1: Classifying States by Coverage Policies for Immigrants

The 2023 KFF/LA Times Survey of Immigrants is a nationally representative survey focused on understanding immigrants’ experiences that included questions related to health care access. The survey data were analyzed by expansiveness of health coverage for immigrants in the state in which they reside. States were classified as having less, moderate, and more expansive coverage policies based on whether states have taken up the ACA Medicaid expansion to low-income adults broadly, options in Medicaid and CHIP to cover immigrants, and/or provide state-funded coverage to at least some groups (such as children) regardless of immigration status as follows:

More expansive coverage . States were classified as having more expansive coverage if they have implemented the ACA Medicaid expansion to low-income adults, have taken up options in Medicaid and CHIP to cover immigrants, and provide state-funded coverage to at least some groups (such as children) regardless of immigration status. Even when state-funded coverage is limited to children, the availability of this coverage may reduce fears among immigrant adults about applying for coverage for themselves if they are eligible for other options.

Moderately expansive coverage . States were classified as having moderately expansive coverage if they implemented the ACA Medicaid expansion to low-income adults and have taken up at least two options available in Medicaid and CHIP to expand coverage for immigrants, including covering lawfully-residing immigrant children or pregnant people without a five year wait or adopting the CHIP From-Conception-to-End-of-Pregnancy option to cover income-eligible pregnant people regardless of immigration status.

Less expansive coverage . States were identified as having less expansive coverage if they have not implemented the ACA Medicaid expansion to low-income adults and/or have taken up fewer than two options in Medicaid or CHIP to expand coverage for immigrants and do not offer state-funded health coverage to immigrants.

Immigrant adults in states that provide more expansive coverage, including the ACA Medicaid expansion for low-income adults and at least some state-funded coverage for immigrants, are half as likely to be uninsured as those in states with less expansive coverage (11% vs. 22%) . This difference is driven by higher rates of Medicaid and other public coverage (including state-funded coverage) in states with more expansive coverage compared to those with less expansive policies (23% vs. 9%) while rates of private and Medicare coverage are similar (Figure 5).

Reflecting higher rates of health coverage, immigrant adults in states with more expansive policies are somewhat less likely to say they skipped or postponed care due to cost . Immigrants in states with more expansive policies are half as likely to report delaying or going without medical care (4% vs. 10%) or dental care (7% vs. 14%) due to cost than those in less expansive states (Figure 6).

Differences in use of care among immigrants by state coverage policies are smaller, which may reflect use of safety-net resources available to uninsured immigrants such as community health centers and emergency rooms . Most (77%) immigrant adults in the U.S. report seeking health care in the past year. The shares reporting seeking health care are slightly lower in states with less expansive coverage (74%) compared to those in states with more expansive coverage (79%), although the majority still report seeking care. This pattern may reflect use of safety-net resources available to uninsured immigrants such as community health centers or emergency rooms. Immigrant adults are more likely than U.S.-born adults to say they rely on community health centers (CHCs) as their usual source of care, reflecting CHCs’ in providing free or low-cost care to low-income and uninsured populations and their ability to provide culturally and linguistically appropriate care. Immigrants in states with less expansive policies are somewhat more likely to say they use a CHC (33% vs. 28%) and somewhat less likely to say they use a private doctor’s office (39% vs. 44%) (Figure 7). Immigrant adults in states with less expansive policies are also less likely to report having a medical provider they trust to answer questions about their health than those in more expansive states (68% vs. 78%).

Other research suggests that state coverage expansions for immigrants can reduce uninsurance rates, increase health care use, lower costs, and improve health outcomes . Noncitizen children are more likely to be uninsured and experience more delays in health care due to cost than their citizen siblings. Citizen children with a noncitizen parent are also more likely to be uninsured than citizen children with U.S-born parents. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a  34%  decline in uninsurance rates. Similarly, a  study  found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care and  improved outcomes  including increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated with reduced postpartum care utilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to be less than half the per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California could reduce poverty among noncitizen immigrants and their families.

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• More States Are Providing Fully State-Funded Health Coverage to Some Individuals Regardless of Immigration Status

Also of Interest

• Understanding the U.S. Immigrant Experience: The 2023 KFF/LA Times Survey of Immigrants
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants
• Key Facts on Health Coverage of Immigrants

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Understanding and Responding to Climate Migration through a Health Equity Lens: New Peer-Reviewed Article

The climate crisis collides with migrant health at each stage of migration. In a new open-access article entitled “ The Climate Migrant: Health Risks Before, During, and After Migration ,” and published in the Journal of the National Hispanic Medical Association , Migrant Clinicians Network’s Amy K. Liebman, MPA, Marysel Pagan Santana, DrPH, and Claire Seda discuss the impact of the climate crisis before, during, and after migration. The authors conclude that to advance health equity as climate migration increases, both our health systems and national policy need to shift.

“’Climate migrant’ is a broad term, so in this article, we seek to specify how the climate crisis is affecting migration by identifying different types of climate migrants,” explained Amy Liebman, MPA, Chief Programs Officer of Workers, Environment, and Climate at Migrant Clinicians Network. “By better understanding the specific circumstances of different migrants, we can improve our clinical and policy approaches to protecting their health and increasing their access to health care, when needed.”

The full article is available on the Journal of the National Hispanic Medical Association webpage. In this special issue focused on migration, Migrant Clinicians Network authors contributed two additional articles. One outlines the work of Migrant Clinicians Network as a clinical organization seeking health justice. The other offers a case study of Health Network, an award-winning program offering continuity of care for asylum seekers and migrants.

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Enhancing immigrant families’ mental health through the promotion of structural and community-based support.

• 1 Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
• 2 Department of Child and Adolescent Psychiatry, New York University Grossman School of Medicine, New York, NY, United States

Immigrant communities in the United States are diverse and have many assets. Yet, they often experience stressors that can undermine the mental health of residents. To fully promote mental health and well-being among immigrant communities, it is important to emphasize population-level policies and practices that may serve to mitigate stress and prevent mental health disorders. In this paper, we describe the stressors and stress experienced by immigrant families, using Sunset Park, Brooklyn as an example. We discuss ways to build structures and policies in support of equitable environments that promote mental health at the population level and enable families and their children to thrive.

Introduction

Immigrants to the United States (U.S.) and their U.S.-born children numbered approximately 87.7 million people, or close to 27 percent of the population, in 2022, an increase of approximately 14.7 million (or 20 percent) from 2010 ( 1 ). In the United States, immigrant communities are diverse, have many assets and often benefit from personal resilience, strong family connectedness, faith-based supports, and cultural pride ( 2 ). But, many immigrant communities face numerous challenges, due in large part to environmental and structural inequities which are often experienced as stressors that can undermine the mental health of residents ( 3 ). For example, immigrants in the U.S. have often experienced trauma from conditions in their home countries, discrimination in the U.S., and struggles with U.S. immigration processes and policies ( 4 ). Further, many immigrant communities experience economic hardships ( 5 ), and those who do not have authorized legal status (e.g., those who are undocumented, those who are applying for asylum) are often left feeling uncertain about what benefits they are eligible for and how receiving benefits might impact them in the future ( 6 ). When immigrant parents experience compromised mental health, their children can have long-term negative consequences as well ( 7 ).

The COVID-19 pandemic exacerbated stress and mental health inequities nation-wide ( 8 , 9 ), catalyzing the need to re-examine public investments in mental health promotion, prevention and treatment, especially in families from historically marginalized populations. Scholars and advocates are increasingly recognizing the potential of population-level policies and programs to prevent mental health disorders and reduce inequities ( 10 ). In this manuscript, we argue that inclusive policies and tailored programming for families are critical to addressing inequities, decreasing stress, and preventing the escalation of mental health problems in immigrant communities. We describe a range of policies and programs that could help promote mental health at the population-level and lead to a more equitable society.

The lived experiences of immigrant groups in the United States vary widely given differences in country of origin, eligibility for discretionary legal status or citizenship, and time since immigration, as well as the immigration-related policies and practices in the city and states in which they live. This manuscript considers the extant literature on stress and mental health in diverse immigrant communities throughout the United States. At the same time, it highlights the experiences of Chinese and Latinx immigrant families in one community in New York City (NYC) as a way to consider strategies for applying inclusive policies and tailoring programming based on immigrant group characteristics and local context. NYC is one of more than 180 cities and counties in the U.S. that is a sanctuary city ( 11 ) (with limits on whether and how officials share information with the Federal government about non-citizens) ( 12 ) and New York State has relatively inclusive policies impacting immigrant families, especially compared to states such as Arizona and Texas ( 13 ). We focus on the neighborhood of Sunset Park, Brooklyn in NYC because the authors work with and in this community on a place-based initiative with a strong mental health focus called Together Growing Strong (TGS). TGS aims to strengthen the health, well-being, and development of children in Sunset Park by supporting families, educators, health practitioners, and community stakeholders. Two authors (BK and LB) are on the TGS leadership team and three oversee distinct aspects of the work (NR, RB-G, and JN). Our perspective in this manuscript is informed by our work in this community.

Stress and mental health in immigrant communities

Immigrants make up 14% of the U.S. population. In 2022, nearly one-third of immigrants had entered the U.S. since 2010. More than one-quarter (27%) of immigrants were reported to be Asian, 20% White, and 9% Black; 44% were of Hispanic or Latinx origin. About one-quarter of immigrants living in the U.S. in 2022 were born in Mexico and 6% were born in China ( 1 ). The vast majority of immigrants in the U.S. (83%) speak a language other than English at home, with Spanish being most common ( 14 ). A large majority (96%) of the immigrant civilian labor force is employed, yet immigrants have slightly higher rates of poverty than those born in the U.S., and one-quarter of immigrants have less than a high school diploma ( 1 ).

Similar to many immigrant communities throughout the country, Sunset Park includes vibrant enclaves of immigrants from China and Latin America, with inter-generational families and communities that are tight knit. More than 26,000 families and 32,000 children under the age of 18 live in Sunset Park. In contrast to the U.S. overall, nearly one-half of Sunset Park’s 130,000 residents were born outside the U.S.; about three out of four residents speak a language other than English at home. The vast majority (93%) of the civilian labor force is employed, but one in five residents in Sunset Park live below the poverty line, more than one-third have less than a high school degree, and 7% live in overcrowded housing ( 15 ).

When the COVID-19 pandemic hit, families in many immigrant communities throughout the U.S., including Sunset Park, experienced additional stressors including isolation during quarantine, fear of returning to work as “essential workers” in the healthcare and food industries, grief over illness and death of friends and family, job loss leading to worries about financially supporting a family, enhanced food insecurity, and general uncertainty about school and childcare closures ( 16 ). In addition, exclusionary and xenophobic policies, as well as rhetoric blaming China for COVID-19, contributed to an increase in hostility toward immigrants, including bullying, language-based discrimination, and anti-Asian hate, which were linked to worse mental health in immigrant communities ( 17 , 18 ). There is strong evidence that stress resulting from a broad range of circumstances, including financial hardship, is associated with mental health disorders ( 19 – 21 ). Further, unique stressors faced by immigrants, such as restrictive immigration policies and policing, have been shown to be associated with anxiety and depression ( 4 , 17 ), contributing to substantial mental health inequities. In fact, in states with more restrictive immigration policies, Latinx immigrants report poorer mental health ( 13 , 22 ).

In Sunset Park, a 2021 TGS study surveyed pregnant and postpartum women about stressors, perceived stress and mental health, and provides an example of the association between the stress felt by an immigrant community in the wake of the pandemic and mental health symptoms. The study used a convenience sample and recruited women through health centers, social service providers, and texting platforms; 671 women completed surveys online or by telephone in Chinese, Spanish and English languages. About one-third of women surveyed had moderate to severe anxiety scores and one-quarter had moderate to severe depression scores, based on PROMIS scales ( 23 ); self-reported worry about basic needs, such as rent and food, was associated with higher depression and anxiety scores.

Policies to support families and promote equity

Policies that strengthen families’ assets and provide additional support by addressing social determinants of health can be effective in helping caregivers and others avoid and manage stressors that interfere with mental health ( 24 ). Studies across states (i.e., Pennsylvania, Arizona, and California) find that social support is associated with decreased mental health symptoms and moderates the association between stress and poor mental health ( 25 – 27 ). In Sunset Park, the 2021 TGS survey found that women who reported “usually” or “always” getting the support they needed when they felt stressed had lower mean depression and anxiety scores than other women.

In this paper, we focus on policies that address financial hardship, as immigrant communities often have high rates of poverty ( 5 ) due to underemployment, labor exploitation, and barriers to employment and economic opportunity ( 28 ). Paid family leave is one example of a scalable federal policy that supports families and is associated with decreased postpartum psychological distress symptoms among mothers with infants ( 29 ). Yet, the U.S. is the only developed country that does not guarantee a period of paid and job-protected leave for new mothers ( 29 ), thus bypassing an opportunity to promote equity. Further, unconditional cash transfers, minimum living wages, job programs, and affordable housing options might enable individuals to confidently provide for their families, which would greatly reduce stress and leave room for caregivers to focus on other aspects of life, such as pursuing educational opportunities or spending quality time with their children.

Although there is growing interest in advancing these kinds of federal policies for the general population, many immigrant families are not eligible for certain existing government initiatives ( 30 ). For example, households with mixed immigration status families were excluded from federal COVID-19 economic relief efforts such as the CARES act ( 31 ), leaving many in precarious financial situations. Studies of local-level unconditional cash transfer efforts to support households that were ineligible for the CARES act found significant improvement in mental health among recipients ( 32 ), suggesting that policies that alleviate food and housing insecurity could support mental health in immigrant communities. Other supportive policies specific to immigrant communities, such as legal support to address restrictive immigration policies and enforcement practices, and advocacy for humane immigration policies, may be helpful in reducing stress and promoting mental health as well. However, immigrant communities are heterogeneous, and additional research is needed to better understand which policies might have the greatest mental health impact for different immigrant groups ( 33 ), and how some policies may need to be tailored to ensure that immigrant families are not excluded.

Equitable access to mental health prevention and treatment

While necessary, increasing general support through inclusive federal, state and local policies will not be sufficient to improve the mental health of all immigrant families. Investment in preventive interventions can also help equip families, educators, and healthcare providers with the tools they need to support mental health. To truly promote health equity, preventive interventions should be designed with and for racially and culturally diverse communities ( 34 ). When interventions are not co-created in this context, there is a need to evaluate fit, access and effectiveness with the targeted community, and in most cases thoughtful adaptations will be necessary to achieve the desired impact. Although the literature highlights the tension between adhering to fidelity of evidence-based interventions (EBIs) and adapting EBIs to specific stakeholder groups, many scholars have concluded that it is feasible and imperative to do both ( 35 ). For EBIs that were not developed for a specific population, the core concepts may seem relevant but framing and implementation often need to be culturally adapted to fully engage the community and ultimately attain optimal outcomes.

Several evidence-based preventive interventions (EBIs) developed specifically for immigrant families, like Madres a Madres ( 34 ) and Abriendo Puertas ( 36 ), have been shown to be effective. Further, researchers across the country have described cultural adaptations of existing EBIs ( 37 ). Similarly, EBIs that are part of TGS, including ParentCorps ( 38 ), Reach Out and stay Strong, Essentials for new mothers (ROSE) ( 39 ), PlayReadVIP (formerly known as VIP) ( 40 ), and Healthy Steps ( 41 ), have been either developed with or adapted for families of young children in culturally-relevant ways that promote mental health. For example, ROSE, a postpartum depression prevention intervention, was originally developed and tested with Latinx and Black women. As part of TGS, the intervention has been adapted for the Chinese immigrant community in Sunset Park through deep community engagement, manual adaptations, and iterative rounds of pilot testing. The adaptation process ( 42 , 43 ) included a literature review in both Chinese and English languages, interviews with mental health experts in the Chinese-American community, community focus groups that informed intervention modifications, and pilots of the culturally adapted intervention. Although the core, evidence-based components remain, the adapted version is framed to meaningfully engage and center the Chinese immigrant community (e.g., “self-care” is reframed to “creating balance and harmony”). Ongoing research is evaluating whether this adapted version leads to desired outcomes with Chinese immigrant families.

Unfortunately, preventive EBIs are often difficult to sustain in immigrant communities due to cost, as many immigrants do not have any insurance coverage ( 5 ) and for those who have Medicaid, reimbursing preventive behavioral health services is challenging ( 44 ). Many programs are, in part, often supported by private dollars, but this is not sustainable or scalable. Enabling sustainable, billable support for preventive behavioral health programs is critical, and can be efficient and cost-effective, leading to savings in multiple sectors of society in the long-run ( 45 ). Expanding Medicaid to include more coverage of preventive behavioral health services would greatly assist in this effort.

The federal government has supported some pregnant and parenting people by funding distinct programs. For example, The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program funds home visiting programs among families facing increased risk ( 46 ), and Head Start, a long-standing federally-funded early childhood program, mandates evidence-based parenting programs in under-resourced communities ( 47 ). At the state level, the California Medicaid Program (MediCal) funds the Comprehensive Perinatal Services Program (CPSP), which provides enhanced services, including psychosocial counseling, to patients ( 48 ). Similar funding opportunities should be expanded to include other preventive services and populations. Hospital systems’ community benefit plans could also offer an innovative way to invest in immigrant communities and fund preventive services. While many hospitals primarily conceive of their community benefit efforts as providing financial assistance to patients ( 49 ), under the Affordable Care Act (ACA), not-for-profit hospitals are required to assess community need and develop programs to address needs that are identified ( 50 ). In Sunset Park, for example, NYU Langone Health’s community benefit plan helps fund some of the TGS programs mentioned above.

Further, communities throughout the U.S. have limited access to mental health services, in large part because of the dearth of mental health professionals ( 51 ). This problem is exacerbated in immigrant communities where there is a need for mental health professionals who speak languages other than English and are representative of diverse communities. Because mental health has distinct conceptualizations in different cultures, access to culturally responsive and linguistically aligned services from providers who are skilled in centering families’ values, beliefs, and lived racialized experiences is critical to high-quality and equitable care ( 52 ). Funding must be available to hire and retain mental health professionals who reflect the immigrant communities they serve. Investing in linguistically and culturally diverse young people from immigrant communities and encouraging them to pursue careers in mental health is one specific way to address the culturally reflective service provider gap. This includes, but is not limited to, providing opportunities for youth to learn about different career options and boosting financial assistance for internships and academic programs. Federal and state-level scholarship programs could support this approach, and the ACA requirements for Community Benefit Plans could be leveraged to address this gap. Expanding the workforce to include peer-providers and foreign-trained mental health professionals would also enable greater access to culturally aligned providers. Municipal authorities should explore procedures for credentialing and compensating both of these untapped community resources, and they should be included in Medicaid reimbursement plans.

In addition, enhanced cultural training would enable all mental health professionals to understand how different immigrant communities conceptualize mental health—including the meaning of different symptoms and help-seeking behaviors. Cultural values and norms can impact how mental health is understood, and can lead to stigmatization ( 53 , 54 ). For example, individuals from some immigrant backgrounds hold beliefs that mental health issues not be communicated outside a tight-knit group of family and friends ( 55 ); in other cultures, disclosure of mental illness to family and friends is dissuaded ( 54 ). Cultural mental health competency and humility can help providers address stigma related to mental health and identify culturally relevant ways to engage communities in mental health prevention and treatment.

Cultural competency, however, is not the only important lens in mental health care. Families face intersecting social vulnerabilities ( 56 ), including those related to gender, sexual orientation, legal status, religion and others. Immigrant families may be part of multiple marginalized groups; understanding how these interact in an intersectional framework that recognizes multiple levels of oppression is essential to providing mental health care in immigrant communities.

Academic programs that train mental health service professionals need to ensure that their curricula emphasize the importance of recognizing and addressing structures and power dynamics that shape clinical interactions, such as racism and many other forms of bias ( 57 ). It is recognized that mental health providers require specialized training in the mental health disorders most prevalent in the communities they serve. In immigrant communities, this means being prepared to recognize and treat distress, mental health symptoms and disorders related to pre-and post-immigration trauma ( 4 ). Accrediting institutions should consider ways to ensure that issues of racism, immigration trauma, and gender and sexual orientation equity are meaningfully included in training curricula.

Even when mental health services are available by providers with cultural competence and humility, barriers to utilizing care exist for many immigrant families. Studies underscore numerous logistical barriers to care, such as cost, transportation, childcare, and hours of operation ( 58 ). During the pandemic, telemedicine was successfully offered as a way to address barriers in accessing care ( 59 ). However, this mode of service delivery presents additional barriers for families who do not have access to technology, have low digital literacy skills, have limited or no access to broadband, or do not have privacy in their homes ( 60 ). Nationally, one in 10 families headed by Hispanic immigrants had no access to the internet in 2016. Similarly, in Sunset Park, Brooklyn, 15% of households do not have internet access, in stark contrast to 5% in a neighboring community with a smaller immigrant popultion ( 61 ). Even when families do have access to the internet, connection speed for many is slow ( 62 ), rendering meaningful use of websites and apps nearly impossible. While the availability of virtual services should continue post-pandemic to help families access care, relying on this mode as a substitute for in-person care delivery leaves out some of the most under-resourced families ( 59 ). Ensuring that mental health services address the broad range of psychological, technical and logistical barriers faced by immigrant families is essential to achieving mental health equity.

Mental health is a critical component of long, healthy and fulfilling lives. Focusing on inclusive policies and tailored programming that create equitable environments where people can provide for themselves and their families might help reduce stress and prevent many mental health problems among immigrant communities. For some, this type of support will not be enough and prevention and treatment services are critical to promote mental wellness. Mental health providers should be linguistically and culturally representative of the community, allowing for maximum comfort, mutual understanding, and equitable access to services. With a multi-pronged approach involving policies and programs to promote mental health and prevent and treat mental health problems and disorders, immigrant communities can get what they need, when they need it, and all families can be supported to thrive.

Data availability statement

Publicly available datasets were analyzed in this study. We analyzed census data in this article ( data.census.gov ).

Ethics statement

The studies involving humans were approved by NYU Langone Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

BK: Conceptualization, Funding acquisition, Writing – original draft, Writing – review & editing. RB-G: Writing – original draft, Writing – review & editing. NR: Writing – original draft, Writing – review & editing. JN: Writing – original draft, Writing – review & editing. LB: Conceptualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by philanthropic funds.

Acknowledgments

The authors acknowledge Yi-Ling Tan, Grace Tian, Kathleen Hopkins, Sue Kaplan, Alan Mendelsohn, Paulo Pina, Cristina Gonzalez, and Meleen Chuang for their contributions to this manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: mental health, immigrant health, structural intervention, prevention, health promotion, health equity, maternal support, family-focused policy

Citation: Kerker BD, Barajas-Gonzalez RG, Rojas NM, Norton JM and Brotman LM (2024) Enhancing immigrant families’ mental health through the promotion of structural and community-based support. Front. Public Health . 12:1382600. doi: 10.3389/fpubh.2024.1382600

Received: 05 February 2024; Accepted: 18 April 2024; Published: 01 May 2024.

Reviewed by:

Copyright © 2024 Kerker, Barajas-Gonzalez, Rojas, Norton and Brotman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Bonnie D. Kerker, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The WHO Department of Health and Migration aims to promote knowledge sharing, build on existing capacities and stimulate a research agenda on health and migration. The Department of Health and Migration organizes the yearly Global School on Refugee and Migrant Health with the aim of supporting countries and territories to build competency on the public health aspects of migration and to promote the development and dissemination of knowledge, attitude and practices based on the exchange of experiences and evidence.

This course consists of video recordings from the 2023 School, which focuses on addressing the social determinants of health among refugees and migrants.

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The primary aim of the yearly Global School on Refugee and Migrant Health is to contribute to promoting health among migrants, refugees, and their host populations. Each year, the Global School programme is developed around an overarching thematic area, built by merging and exchanging country knowledge and experiences in close collaboration with WHO regional offices, WHO country offices and governments.

This course was developed from previous recording sessions held during 2023. Technical content is delivered innovatively through video reportages, presentations and panel discussions with engagement of international experts, representatives from WHO and other United Nations agencies, and field actors from different regions and disciplines relevant to the area of health and migration.

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• Gain a Record of Achievement by earning at least 80% of the maximum number of points from all graded assignments.

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Volume 39, Issue 3, June 2024

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“The months immediately following their arrival is the time when refugee newcomers need support of all kinds,” writes Karen Jacobsen. Photo: Shutterstock

Who Are the Immigrants Coming to the U.S. on Humanitarian Grounds, and How Can They Be Supported?

Refugees and asylum-seekers fleeing violence and persecution can adapt more quickly with support of their diaspora communities, says expert

Immigration has become  a defining issue in the 2024 elections and a major challenge in many U.S. cities. Over the past several years, wars and armed conflict, violent persecution and desperate poverty have displaced millions of people worldwide and propelled the arrival in the U.S. of thousands seeking protection,  mainly at the U.S.-Mexico border . 

Large cities such as  New York, Miami, Denver and Boston are struggling to house new arrivals and meet their basic needs. Cities are looking for ways to support these new arrivals—some for a short time, others for months, years, or permanently.

I study forced migration, government responses to it, and how refugees and asylum-seekers integrate into new settings . My focus is on humanitarian arrivals—people who enter the U.S. legally as asylum-seekers, resettled refugees, or under various temporary protection programs, also known as parole. 

In total, the Biden administration has admitted or authorized admitting roughly 1.5 million people under these programs since 2021. Cities need help to cope with these waves of new arrivals. The good news is that with support, refugees and people receiving asylum successfully integrate into life in the U.S. and contribute more to the national economy than they cost .

Entering the U.S. on Humanitarian Grounds

People immigrate to the United States for many reasons and receive different types of visas and treatment when they arrive. Here are the main types of humanitarian admissions.

Humanitarian Parole: The federal government can give certain groups permission to enter or remain in the U.S. if it finds “ urgent humanitarian or significant public benefit reasons ” for doing so. People who enter through parole programs must have an approved financial supporter in the U.S. They typically can stay for one to two years and may apply for authorization to work. 

Currently, the federal government is admitting  a maximum of 30,000 people per month under a parole program for immigrants from Cuba, Haiti, Nicaragua, and Venezuela. The Biden administration has also admitted people from Afghanistan and Ukraine through other parole programs. In total, the Biden administration has admitted  more than 1 million people through these programs.

Refugees and Asylees: People who can show that they have experienced persecution, or have a well-founded fear of being persecuted based on their race, religion, nationality, social affiliations, or political opinion, can apply for refugee status or asylum. Asylum is granted to people who are already in the U.S. Refugee status is provided to people who are vetted abroad and approved for resettlement.

Resettled refugees and people granted asylum can apply for authorization to work in the U.S. After one year in the U.S., they are eligible to apply for legal permanent residence, also known as a green card.

For fiscal year 2024, Biden has approved a maximum of 125,000 refugee admissions . There is no limit on the number of people who may be granted asylum each year. 

Image: Courtesy of The Conversation

Applicants for asylum, however, must  go before an immigration judge in the U.S., who will decide whether their fears qualify them to be allowed to remain. U.S. immigration courts are heavily backed up, with  more than 2 million asylum applications pending . Asylum applicants can remain in the U.S. while their case is pending, but they cannot receive work permits  for six months after they apply for asylum .

Where the New Immigrants Settle

As has been the case since at least 2010 , Texas and Florida are top U.S. destinations for migrants , along with cities in New York, Illinois, and Colorado. Counties where new migrants make up more than 2% of the population include Queens, New York; Miami-Dade, Florida; and Denver, Colorado.

In cities, many humanitarian immigrants find work in the hospitality and health care industries. Others move to small towns in rural areas, where they work in long-standing migrant sectors such as meatpacking, health services, and agriculture.

People who come with an intent to stay are motivated to put down roots and become part of their new communities. But becoming established can take time, and newcomers’ needs can stress city neighborhoods that are already struggling with housing and employment problems. The months immediately following their arrival is the time when refugee newcomers need support of all kinds.

Working with Diaspora Communities

New arrivals often move to particular towns or city neighborhoods because they know that people from their country are well established there. These residents are familiar with the new arrivals’ home language and cultures and understand their needs. 

For example, there are  over 40,000 Ukrainians in Rochester, New York, and about 134,000 in New York City. The U.S. also has large communities of parolees, including Haitians, Venezuelans, and Cubans, and long-standing diasporas of resettled refugees and asylum recipients from many parts of the world.

I see established diasporas as a critical resource for supporting new immigrants and maximizing benefits for host communities. By working with diaspora individuals and families to support new arrivals, federal and state governments could redirect funds that are now going to hotels and shelters. 

For example, Boston has struggled in recent months to house large numbers of Haitian immigrants , placing several thousand families at hotel and motel sites—an unusual and expensive practice born of necessity. An alternative might be to offer cash payments or tax breaks to some of the state’s 81,050 Haitian residents in return for housing new Haitian arrivals for a few months.

Diaspora households can offer information about navigating city bureaucracies, finding jobs, and accessing banking services, in addition to the comfort of familiar food and company. These communities can be an enormous help to new immigrants as they become established and begin to contribute to the city.

Such incentives could also be aimed at non-diaspora communities and people who are willing to help newcomers. A direct community support system, with safeguards built in to protect both the refugees and their hosts, would cost a city or state much less than paying for hotel rooms.

Faster Work Permits Would Speed Integration

Speeding up work authorizations for new arrivals can shorten the time they need support from the government. Under federal law, most nonresident foreign nationals must obtain an  employment authorization document to apply for jobs in the U.S. 

Currently, although the Biden administration is trying to move more quickly, these applications are taking  more than six months to process . Once immigrants have work permits in hand, diasporas and host neighborhoods could receive tax breaks or other economic benefits in return for helping them find work. 

There are other things cities and the federal government can do to support new humanitarian arrivals. Banks could be encouraged to support refugee business, as some are already doing . For example, Re:start Financial is  a neobank —a tech company that provides online banking services—based in Austin, Texas, and founded in 2021 by a group of immigrants. It allows immigrants who do not yet have permanent addresses or Social Security numbers to open free online banking accounts with nontraditional documentation from their home countries.

With adequate support, new arrivals usually find their feet and become self-reliant within a few months . Using federal and state resources to enlist host neighborhoods and diaspora communities in this process would help ensure that everyone benefits.

Karen Jacobsen is  the Henry J. Leir Professor in Global Migration and the Associate Dean of Research at The Fletcher School of Law and Diplomacy.

Immigrants with Darker Skin Tones Perceive More Discrimination

Tapping Community Volunteers to Resettle Afghan Refugees

Lessons Learned from a Civic Semester in the Southwest

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An Afghan migrant, age 17, drowned in a Bosnian river. Here's how citizens responded

Ingrid Gercama

Vanja Stokić

A photo of Ajmal Khan on his way to Western Europe to find work, taken by a travel companion and sent by Khan to his family in Afghanistan via WhatsApp. The 17-year-old drowned when crossing the Drina River near the city of Bijeljina in Bosnia-Herzegovina — part of a common route for migrants as they head toward wealthier European countries. Courtesy of the family hide caption

A photo of Ajmal Khan on his way to Western Europe to find work, taken by a travel companion and sent by Khan to his family in Afghanistan via WhatsApp. The 17-year-old drowned when crossing the Drina River near the city of Bijeljina in Bosnia-Herzegovina — part of a common route for migrants as they head toward wealthier European countries.

Thousands of migrants have died or gone missing in Europe — many of them in the Western Balkans. In Bosnia-Herzegovina, for example, dozens of migrants have drowned in the Drina, a river between Bosnia and Serbia, as they try to reach wealthier nations. It is hard for relatives to find out what happened to their loved one. Bosnian volunteers try to help. They arrange to bury the bodies of migrants no one claims, take bone samples for future DNA testing to confirm the identity of a decedent and help with repatriation or funerals.

BIJELJINA, Bosnia-Herzegovina — "His mother begged me to find his body, so that his family could give him a proper funeral at home, in Afghanistan," says Stana Gul Ahmadzai, age 32, of Kabul. "But I had no idea where to start."

Ajmal's mother is a widow. Her 17-year-old son, Ajmal, drowned in the Drina, a river marking the border between Bosnia-Herzegovina and Serbia, on July 31, 2022. It was one stage of a trek that would put him closer to his dream: to help his mother and two sisters by finding work in one of the wealthier countries of the European Union (EU).

The teenager decided to leave after the Taliban took over in August 2021. "Even people who studied could not get jobs, only Islamic scholars," says Ahmadzai. "It was also the prospect of living in a country without freedom of speech, that made him decide to make that difficult journey."

With the help of human traffickers in Turkey, Ajmal ended up in Bosnia and Herzegovina, a mountainous nation in the Western Balkans — part of a popular route to Western Europe because migrants believe that border police in Bosnia — a non-EU country — aren't as likely to target migrants who enter illegally as they are in the neighboring country Croatia, which is in the EU.

A friend who traveled with Ajmal informed the family of their son's death on via WhatsApp.

"His dream cost him his life," says Ahmadzai. "We did not know what to do."

The teenager is one of thousands of migrants who die each year on a journey from countries in the Global South to find employment in Western Europe. Many drown crossing the Mediterranean. Others die while traveling over land.

On the far edge of a graveyard in the Bosnian city of Bijeljina, 16 gravestones of migrants are marked with the letters N.N. (standing for "Nomen Nescio," which means "I do not know the name" in Latin). Ingrid Gercama for NPR hide caption

On the far edge of a graveyard in the Bosnian city of Bijeljina, 16 gravestones of migrants are marked with the letters N.N. (standing for "Nomen Nescio," which means "I do not know the name" in Latin).

According to an International Organization for Migration (IOM) report, an estimated 29,000 individuals lost their lives along migration routes to Europe between the years 2014 and 2021. Since 2021, the IOM has recorded an additional 5,684 deaths on migration routes to and within Europe, on land and in the sea.

In the Western Balkans, since 2014, approximately 360 migrants have disappeared, according to IOM. Most come from Afghanistan, Eritrea, Ethiopia, Pakistan and Syria. Around a third of them are believed to have drowned, says IOM.

How the citizens of Bosnia-Herzegovina try to help

For the families of the deceased, there is often no closure. If contact with their loved one comes to a halt, they may not be able to find out why. Even if they do learn that the family member died, they might not be able to arrange for a respectful burial in a foreign country many miles away – or cannot afford to bring the body home.

In Tuzla, the third largest city in Bosnia-Herzegovina, a group of citizens is taking responsibility to help.

"When the media speaks about refugees, they use numbers and don't speak of people with human rights," says Nihad Suljić of Tuzla, who helps families of lost migrants: "Maybe in Bosnia we better understand someone searching for their loved ones because we searched for thousands in Srebrenica after the genocide" – when some 8,000 men and boys were killed in 1995.

Nihad Suljić of Tuzla helps families of lost migrants; Nenad Jovanović is part of the Bosnian Mountain Search and Rescue operations, which recovers the bodies of those who drown in the Drina River. They're dropping four white roses in memory of those who perished. "Even experienced swimmers have problems in the Drina, let alone those who meet the water for the first time," says Jovanović. Ingrid Gercama for NPR hide caption

Nihad Suljić of Tuzla helps families of lost migrants; Nenad Jovanović is part of the Bosnian Mountain Search and Rescue operations, which recovers the bodies of those who drown in the Drina River. They're dropping four white roses in memory of those who perished. "Even experienced swimmers have problems in the Drina, let alone those who meet the water for the first time," says Jovanović.

The Drina, where Ajmal drowned, is a treacherous river. On average it's 700 feet from bank to bank, with swirling currents. There are bridges but for migrants who've entered the country illegally, the risk of being apprehended by police is too great. So they sometimes swim. Or they do what Khan did – attempt to cross in a flimsy rubber vehicle in the dark of early morning to evade police patrols. Khan's boat capsized.

The authorities have confirmed 45 deaths of migrants attempting to cross the Drina.

The bodies are usually spotted by citizens living by the river. The Bosnian Mountain Search and Rescue operations recovers the bodies. But it may be impossible to identify the body.

According to the local police, many migrants do not carry identity papers. They may have lost the documents while traveling. Or they may have believe that without proof of citizenship from a particular country they could somehow qualify for refugee status or avoid being sent back to their homeland by the authorities if they are apprehended for entering the country illegally.

When found in this part of Bosnia, the body will then be sent for autopsy in the Sveti Vračevi hospital in the city of Bijeljina. Dr. Vidak Simić, a pathologist, will store the body for a certain period of time in case the family reaches out; take a bone sample for any future DNA tests (carried out with the permission of a prosecutor) if the family does come forward and can submit DNA for a possible match.

He records information on each body: gender, estimated age, scars and distinguishing marks, estimated time of death, where the body was found and a photo.

After a few days but typically as quickly as possible as the hospital has limited refrigerator capacity, the body is buried in a public graveyard in one of the cities or towns around Bijeljina. Simić notes the grave's location in his database, together with a number he assigns to the bone sample he took.

If the identity of the deceased is not known, the tombstone is simply marked with N.N., Nomen Nescio – "no name" in Latin.

How families learn the fate of their loved one

So how do family members back home learn of the death of a migrant – and then connect with the helpful people in Tuzla and Bijeljina if that's where the death occurred?

To learn more about their loved one's fate, relatives start to Google and social media for any clues.

The website of the International Committee of the Red Cross (ICRC) helps families locate missing migrants through its Family Links Network . FLN has an online tool called "Trace the Face," a virtual photo gallery. Family members of missing migrants can submit a missing relative's photo for inclusion in the hope that someone who knows what happened will reach out.

"We will do everything in our power to help a family in their search for missing loved ones," ICRC representative Marko Matović from the Bosnian capital of Sarajevo wrote to NPR in an email.

When a family registers a missing member with the Red Cross, the organization contacts the authorities (ministries, police, prosecutors, forensic institutions) who attempt to put the family in contact with the relevant parties.

But authorities don't always help or don't have the necessary information.

"It is the responsibility of the country's authorities to undertake actions needed to ensure an adequate tracing of a missing migrant," says Matović, but they "often, lack of standardized procedures and insufficient coordination between institutions hamper the tracing process."

This is where volunteers like Nihad Suljić come in.

When the authorities fail to find their loved one, some families turn to the Facebook group " Dead and missing in the Balkans." On March 16, for example, a family asked for help from "anyone who knows anything" about a young migrant from Afghanistan named Hanifullah Ahmadzah.

Suljić is part of this Facebook group and tries to track down details if the missing migrant was in the part of Bosnia where he lives. Sometimes, relatives also directly use social media of WhatsApp to reach out to Suljić, whose work has been covered by television and radio.

The search for the 17-year-old from Kabul

Stana Gul Ahmadzai eventually did discover the group " Dead and missing in the Balkans," He posted a photo of his cousin Ajmal, stated his age and where he died, and asked if anyone had found the body.

In response, Suljić reached out to police sources to see if they had found a body matching the descriptions that Ahmadzai had shared.

These details could help family members identify a lost loved one. However, if the family wishes to bring the body home for reburial, an identification by phone would not be enough for the Bosnian authorities to release it.

If the family members can provide a DNA sample, Simićc will get permission to do a DNA test on the relevant bone sample he has stored in his hospital refrigerator.

Simić stores samples longer than the 6 months required by Bosnian law because he wants to give families in faraway places a fighting chance of finding their relative: "I'm breaking the rules a bit, but I'm not afraid," he says.

Ideally, a relative will come to Bosnia for a blood or saliva test. Otherwise, they can send a notarized test.

"We managed to identify several people, who were then returned to their hometowns," says Simić, who is proud of his work: "Last year I received photos from a cemetery in Afghanistan, where a young man that we identified was buried. One family is now at peace."

Ahmadzai is grateful for the help from Simić and Suljić.

Nihad Suljić and Nenad Jovanović of Bosnia let white roses go in the Drina River to honor the 45 migrants who have drowned there en route to wealthier countries in Europe. "It is difficult to see the bodies [of the drowned migrants] in the state that they are in," says Jovanović. "It is a tragedy that only one person loses their life because of the politics of migration." Ingrid Gercama for NPR hide caption

He came into contact with Suljić online, and the police Search and Rescue operation found a record of a body matching the description of Ajmal.

Suljić asked Ahmadzai for a DNA test of a relative. It cost a substantial amount of money because the relative had to travel to Pakistan for the test and to have it notarized.

The results were sent to Dr. Simić by email to compare to the bone sample Dr. Simić had taken from Ajmal. It was a match.

Ajmal had been buried in the Bosnian city of Zvornik. Unfortunately there was a time lapse in getting the paperwork signed off from the prosecutors' office. When the family finally got his body, it was "damaged and unrecognizable," says Ahmadzai, who adds "governments should reform protocols for missing people, so delays can be avoided."

And while he and his family are grateful for the help, he notes that many other families of missing migrants still live in limbo.

"Many families [in Afghanistan] don't know how to read or write," he says. "Many don't have the money for travel or repatriation. How will they find their loved ones?"

Ingrid Gercama is a freelance investigative journalist and anthropologist reporting on current affairs, politics, conflict and social issues from the Western Balkans and Africa.

Vanja Stokić is a human rights journalist, based in Banja Luka, Bosnia and Herzegovina.

Correction April 29, 2024

In an earlier version of this story, a photo caption stated that the teenage Afghan migrant drowned in the Drina River in the city of Tuzla. In fact, he drowned when crossing the Drina river near the city of Bijeljina. The caption has been corrected.

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NYC policy on how long migrant families can stay in shelters was ‘haphazard,’ audit finds

FILE- An immigrant family show their paperwork to security guards at the Roosevelt Hotel, Tuesday, Jan. 9, 2024, in New York. A New York City policy imposing 60-day limits on shelter stays for migrant families has been rolled out haphazardly over the past six months — with the city failing to notify pregnant women that they may be exempt, a new audit by the city’s comptroller has found. (AP Photo/Mary Altaffer, File)

FILE - David Quero, left, and his a pregnant Maria Quero, center, from Venezuela, leave the Row Hotel with their belongings, Tuesday, Jan. 9, 2024, in New York. A New York City policy imposing 60-day limits on shelter stays for migrant families has been rolled out haphazardly over the past six months — with the city failing to notify pregnant women that they may be exempt, a new audit by the city’s comptroller has found. (AP Photo/Mary Altaffer, File)

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NEW YORK (AP) — A New York City policy imposing 60-day limits on shelter stays for migrant families was rolled out haphazardly over the past six months — with issues such as the city failing to notify pregnant women they may be exempt, a new audit by the city’s comptroller has found.

The city began evicting migrant families in early January in order to ease pressure on its strained shelter system . However, women in their last trimester of pregnancy were exempted after news that 26-year-old who was nearly nine months pregnant was among those moved out.

That policy was never actually written down or communicated properly to agencies, shelter providers or the women themselves, according to the report released by Comptroller Brad Lander this week.

“No written policy was ever promulgated. Staff and contractors did not get that information. The notice that you get when you get a 60-day notice doesn’t tell you that if you’re pregnant, you’re exempt,” Lander said Thursday at a news conference.

The city’s policy allows families to reapply for shelter beds, although doesn’t guarantee another bed.

Addressing concerns that kids might wind up on the other side of the city from their schools, city officials said at the time that they would try to keep families in or near the districts where their children are enrolled.

But Lander’s audit says educators and families reported to his office that they didn’t receive this courtesy. It said at least three families at an elementary school in Brooklyn left the shelter system not because they were ready, but because they were offered placements in other boroughs.

Lander urged Mayor Eric Adams to suspend the 60-day rule until the end of the school semester.

The report did not systematically document housing, health, or educational outcomes for immigrants leaving a shelter. Lander said the city hasn’t done that either, tracking only whether immigrants stayed in the shelter system or not.

Responding to Lander’s report, the mayor’s office says the 60-day eviction notices — along with 30-day notices for single adult migrants — are one of the few tools it has to nudge migrants out of shelters.

“Nearly half of all families who have seen their 60-day notices expire, and more than 65 percent of all migrants that have come through our care, have moved out of our shelter system — without a single migrant family with children being forced to sleep on the street,” City Hall spokesperson Kayla Mamelak said in a statement.

Fewer than one in five children were disenrolled from their school after their family’s eviction notice expired, according to the statement.

New York is one of the few cities in the U.S. legally obligated to provide shelter to all people who ask for it, the result of a decades-old legal case. Separately, U.S. schools are legally obligated to enroll immigrant students who are minors, regardless of their parent’s immigration status.

Mamelak reiterated the city’s position that the Biden administration needs to fill in funding gaps for refugee resettlement programs. Those federal programs benefit virtually none of the 65,000 immigrants in the New York shelter system — many of whom are asylum applicants or have temporary legal status but not refugee status.

“A national humanitarian crisis requires a national solution,” Mamelak said.

Immigrant advocates say they’re having to help hundreds of parents individually negotiate with shelter officials to let them stay in their neighborhood.

Shuffling families between shelters is a daily problem for New York City council member Gale Brewer and her staff in Manhattan, who have handled dozens of cases flagged by schools and other community members.

“We’ll get a call: ‘They’re on their way to Queens,’ and we panic,” Brewer said.

Some of the schools in her district benefit from immigrant students because they are under-enrolled, and homeless students bring additional funding. The schools are often a good fit for the students because they have diverse language offerings.

Staff members, school workers and parent volunteers hurriedly assemble paperwork for the kids. To help families remain in their current shelter or get moved to one nearby, Brewer says city officials have stuck to an informal agreement — a system she likens to a modern-day “underground railroad.”