Men often exhibit lower rates of healthcare utilization. Particularly vulnerable groups-such as men belonging to gender minority groups and men with a migration background-may face additional barriers in accessing care. This study examined healthcare utilization patterns across diverse male gender subgroups in Switzerland, with attention to the role of migration status, while accounting for key sociodemographic factors. We analyzed a subset of the Swiss Health Survey (SHS) 2022, a nationally representative dataset of the general Swiss population. Our sample included individuals falling into one of the three groups: cisgender men, transgender men and gender diverse assigned male at birth (AMAB) individuals (assigned male at birth and identifying as nonbinary or another gender). Healthcare utilization was assessed through the number of general practitioner (GP) and specialist physician (SP) visits, use of mental health services, and utilization of complementary medicine. Additionally, we evaluated perceived quality of care for GP and SP visits. Four regression models were conducted to examine associations between healthcare utilization, gender identity, migration background and sociodemographic characteristics. After weighting, our study comprised 3,505,801 male cases, representing an unweighted sample size of N = 8,699. Among gender subgroups, transgender men showed higher utilization across all types of health care services, including GP and SP visits and mental health care compared to cisgender men. Gender diverse AMAB individuals reported lower use of GP and SP services, as well as complementary medicine, but higher use of mental health services. Perceived quality of GP and SP care was more often moderate or poor among gender diverse AMAB individuals. First-generation migrants used GP services slightly more frequently but accessed other services less often than men without migration background. Second-generation migrants showed similar patterns to those without migration background, except for lower use of complementary medicine. Key sociodemographic variables were associated with notable differences in health care utilization. Healthcare utilization in Switzerland differs by male gender identity and migration background. These findings underscore the need for more inclusive, identity-sensitive healthcare with a focus on gender diverse AMAB individuals. Addressing structural and access-related barriers is essential to ensure equitable healthcare utilization among male migrant populations, especially first-generation migrants.
Health Literacy (HL) has become popular in research for its potential in reducing health inequalities. HL is shaped by personal and situational factors, both having particular implications for migrant populations. This study adapted and validated the HLS19-Q12 in migrant and general populations of Finland using two large-scale population studies. We investigated methodological choices to ensure quality of HL measurement and monitoring across population groups. Finally, we examined the association between HL and socioeconomic, health- and migration-related factors in the general and migrant populations of Finland. We implemented the Nominal Categories Model (NCM) to empirically evaluate modeling assumptions, studied response functioning and measurement equivalence according to nativity in several language groups, including Finnish and English native (n=3673, n=379) and non-native (n=2077, n=1402) speakers, Russian native speakers (n=926). Methodological effects of opt-out and response format were investigated in the three language versions. Finally, we examined concurrent validity according to socioeconomic (i.e. sex, age, educational attainment, economic activity, economic deprivation, migrant-origin), health- (i.e. self-rated health, chronic disease, health-care use, smoking, obesity, cardiovascular disease risk score) and migration-related factors (i.e. length of residence, language proficiency, language barrier in healthcare) in the general and migrant populations under examination. Cronbach's alpha ranged from .93 to .96 and the u index indicated unidimensionality. Test information functions indicated the scale was most informative at low and medium levels of the trait continuum. The NCM showed acceptable fit and revealed expected ordering of Likert response categories, while the opt-out category showed inconsistencies. We found evidence of unbiased functioning of HLS19-Q12 respecting English and Finnish language nativity, and no evidence of acquiescence effects. Associations between HL and criterion factors were in line with expectations. This study introduced the Finnish version of HLS19-Q12 and approached valid and reliable HL monitoring as a key element within the field of social determinants of health. This study provided novel insights on HL while replicating findings reported in the literature. We provide specific recommendations for valid monitoring of HL and ponder over culturally and linguistically responsive policy making, in accordance with the Health in All Polices approach.
Forced migrants (i.e., asylum seekers and refugees) experience greater mental health disparities and inequities in care. Mental health services and systems lack clear policy on integrated mental healthcare. Understanding the causal mechanisms of integrated mental health for migrants can promote a resilient and adaptive health and social care system. However, to achieve a functional mental health service integration, there is a need to understand how and why mental health system integration works and under what health systems conditions. The purpose of this realist review protocol will be to outline a process for refining an initial programme theory (IPT), developed through deliberative dialogues with key interest groups in British Columbia, Canada, and to test the IPT against the global evidence base. A realist review is an interpretive methodological approach to synthesising the literature based on the realist philosophy of science. Realist reviews are pragmatic approaches to theory development because they involve the participation of real-world actors or people who work within complex systems. Realist reviews are particularly useful for synthesising complex knowledge. We plan to conduct a seven-step review process, with iteration between each step. Steps 1-3 have already been completed in our previous work and included the development of an IPT, which will be refined systematically by exploring the global literature and consulting with an international advisory group. These will be used iteratively to identify, test and refine the programme theory. The quality of included literature will be appraised using the relevance, richness and rigour criteria and the realist quality appraisal tool, TAPUPASM (transparency, accessibility, propriety, utility, purposiveness, accuracy, specificity and modified objectivity). Steps 4-7 will include data extraction and realist analysis through retroductive theorising using the ICAMO (intervention, context, actor, mechanism and outcome) heuristic to help distinguish actors and resources from contexts, mechanisms and outcomes. Ethics approval for the deliberative dialogue interviews that inform this realist review and IPT were obtained by the University of British Columbia (ref: REB Number: H22-03195). Study recruitment occurred between 21 November 2023 and 16 January 2024. All participants provided informed consent to take part in deliberative dialogues and to have their interviews audio recorded and transcribed for the purpose of this research. We will disseminate results of the review through academic papers, conference presentations and through iterative interest group workshops and discussions. CRD42024580083.
Background: Torture, banned under international treaties such as the UN Convention Against Torture, remains a widespread violation with profound health consequences. The Istanbul Protocol (IP) sets global standards for the medical documentation of torture highlighting the important role of healthcare providers. A limitation of existing research on torture's health impacts is that studies are largely cross-sectional and reliant on self-reported clinical data. Norway's detailed healthcare registry data offers a robust opportunity to conduct longitudinal, population-based studies, advancing our understanding of torture's long-term effects on refugees and its public health implications.Objectives: This study has two main aims: (1) to examine the frequency of torture-related diagnostic codes and the factors associated with their use in primary and specialized care among adult Syrian refugees resettled in Norway, and (2) to link self-report data on torture exposure in adult refugees from Syria with data on HCSU over a 6-year follow-up to explore group differences in utilization patterns.Methods: Study participants include the RBMI cohort (N = 14,350), comprised of all adult refugees from Syria resettled in Norway in 2015-2017; and the REFUGE cohort - a subsample of the RBMI cohort - comprised of those in the RBMI cohort who participated in a nationwide survey study in 2018. Aim 1 will be addressed using data (2015-2024) from the Norwegian Registry for Primary Health Care (KPR) and the Norwegian Patient Registry (NPR), which contain information on all contacts with primary- and specialized healthcare services throughout Norway (e.g. date of contact, diagnostic code given). To address aim 2, we will link 2018 survey data on torture exposure to the abovementioned registry data on HCSU. In addition to descriptive statistics, multivariable, two-part hurdle regression models will be used to analyse data since we expect zero inflation and overdispersion of the outcomes (HCSU).Stage of study: This manuscript reports Stage 1 of a Registered Report; analyses will be conducted after in-principle acceptance. Refugees and asylum seekers who have been exposed to torture are vulnerable to both somatic and mental health problems.This study links survey data on torture exposure among adult refugees from Syria resettled in Norway with longitudinal registry data on healthcare service utilization to examine patterns of health-seeking behaviour and service use in torture-exposed vs. non-exposed refugees.The study further explores the use of torture-related diagnostic codes at primary – and specialized care level by healthcare personnel in Norway during the provision of care to Syrian refugees.Portions of the text were refined using generative AI (ChatGPT5, Le Chat Pro) for grammar and style. The authors reviewed and take full responsibility for the content. Antecedentes: La tortura es una de las violaciones más graves de los derechos humanos, prohibida por tratados internacionales como la Convención de las Naciones Unidas contra la Tortura y el Convenio Europeo de Derechos Humanos. A pesar de estas protecciones, la tortura sigue siendo una práctica generalizada. El Protocolo de Estambul (PE) establece normas mundiales para la documentación médica de la tortura, destacando el importante papel de los profesionales de la salud. Numerosos estudios han demostrado la existencia de una clara relación entre la exposición a la tortura y los efectos adversos para la salud; sin embargo, las pruebas se basan principalmente en datos transversales y autoinformados de subpoblaciones clínicas. Los estudios longitudinales basados en la población contribuirían de manera significativa a mejorar nuestra comprensión de cómo la exposición a la tortura influye en la trayectoria de salud de los refugiados y contribuye a aumentar la carga de salud pública en general. Los amplios datos del registro sobre la utilización de los servicios de salud (HCSU por sus siglas en ingles) que existen en Noruega ofrecen la oportunidad de explorar este tema con datos sólidos. Objetivos: Este estudio tiene dos objetivos: (1) investigar la frecuencia y las correlaciones de los códigos de diagnóstico relacionados con la tortura en la atención primaria y especializada entre los refugiados sirios adultos reasentados en Noruega, y (2) vincular los datos autoinformados sobre la exposición a la tortura en refugiados adultos procedentes de Siria con los datos sobre HCSU durante un seguimiento de seis años para explorar las diferencias entre grupos en los patrones de utilización. Métodos: El estudio se basa en la encuesta nacional REFUGE de 2018, realizada a 902 refugiados sirios adultos reasentados en Noruega. Los datos de la encuesta se vincularán con los datos del registro sobre HCSU del Registro Noruego de Atención Primaria y el Registro Noruego de Pacientes, que abarca el período 2015-2024. Este conjunto de datos fusionados se utilizará para abordar el objetivo 2. El objetivo 1 del estudio utilizará únicamente los datos del registro para el marco de muestreo completo de la encuesta REFUGE (N = 14.350). Los análisis estadísticos emplearán modelos de regresión multivariable de dos partes para tener en cuenta la inflación cero y la sobredispersión. Fase del estudio: Este manuscrito informa sobre la fase 1 de un informe registrado; los análisis se llevarán a cabo tras la aceptación en principio
The number of forcibly displaced people has reached unprecedented levels, exposing refugees, asylum seekers, and beneficiaries of subsidiary protection to cumulative adversities that severely affect health. Non-communicable diseases - particularly mental health conditions - represent a growing yet inadequately addressed component of this burden, with mental health remaining poorly integrated into non-communicable disease care frameworks. Within the NCD framework, mental disorders are increasingly recognized as chronic, disabling conditions with profound social and economic consequences. This scoping review mapped and synthesized evidence on mental health outcomes and associated risk factors among forcibly displaced adults in host countries. It also examined how mental health has been conceptualized and integrated within the broader non-communicable disease framework. We conducted a scoping review in accordance with established methodological frameworks and reported it in accordance with the PRISMA-Scoping Review guidelines. Six databases were searched for studies published between 2000 and 2020. Eligible studies included observational, qualitative, mixed-methods, and review articles addressing mental health outcomes or associated risk factors among forcibly displaced adults in host countries. Data was extracted using a standardized tool and synthesized narratively. Of 4,341 records identified, 231 met the inclusion criteria, and 82 reported mental health outcomes. Depression, anxiety, and post-traumatic stress disorder were most common, with prevalence consistently higher than in host populations. Pre-migration trauma - such as war exposure and torture - and post-migration stressors, including unemployment, discrimination, social isolation, language barriers, and legal insecurity, significantly worsened mental health. Women and older adults were particularly vulnerable. Barriers to access, cultural incongruence, and limited-service availability were recurring challenges. However, substantial heterogeneity in study design, sampling strategies, and assessment instruments limited direct comparability across contexts. Mental health disorders among forcibly displaced populations constitute a critical yet often overlooked aspect of the global non-communicable diseases burden. Addressing them requires integrated, culturally competent, trauma-informed care and supportive social and legal measures to improve equity and inclusion. Policy responses must therefore extend beyond clinical care to address structural determinants, including legal status, employment, housing, and social integration.
Depression, anxiety, and stress are widespread mental health conditions globally. Migrant workers, in particular, are vulnerable to experiencing these mental health challenges, including Nepali migrant workers. There have been limited studies on adverse living and working conditions prevalent in their circumstances and development of these mental illnesses among this population. The study aims to assess association between mental health and living and working conditions among Nepali migrant workers which, otherwise, has not been explored or examined. We conducted a cross-sectional study with 334 Nepali migrant workers employed in Korea, Malaysia, Saudi Arabia, Kuwait, UAE, and Qatar using convenience sampling. We collected the data using two approaches; an online self-administered questionnaire for migrant workers living in their respective countries of employment and interview with migrant returnees at Tribhuvan International Airport in Nepal. We fitted three hierarchical multivariate logistic regression models and gsem models to explore potential association between depression symptoms, anxiety symptoms, stress symptoms and living and working conditions, respectively. Depression, anxiety and stress is highly prevalent among Nepali migrant workers working in Korea, Malaysia, Saudi Arabia, Kuwait, UAE, Qatar. About 20 %, 20 % and 15 % of the study participants had symptoms of depression, anxiety symptoms and stress symptoms, respectively. About 49 % and 36 % of study participants had poor working conditions and poor living conditions, respectively. The analyses showed that there are associations of depression symptoms, anxiety symptoms and stress symptoms with living and working conditions, respectively. The odds of having depression symptoms (aOR: 2.76, 95 % CI: 1.27-6.01, p value=0.010), anxiety symptoms (aOR: 3.93, 95 % CI: 1.71-8.98, p value=0.001), and stress symptoms (aOR: 4.81, 95 % CI: 1.80-12.82, p value=0.002) was higher among study participants with poor living conditions compared to good living conditions.Meanwhile, the odds of having depression symptoms (aOR: 4.03, 95 % CI: 1.83-8.90, p value=0.001), anxiety symptoms (aOR: 2.33, (95 % CI: 1.10-4.92, p value=0.026), and stress symptoms (aOR: 3.18, 1.30-7.75, p value=0.011) was higher among study participants with poor working conditions compared to good working conditions. The high prevalence of depression, anxiety, and stress among Nepali migrant workers due to poor conditions necessitates action. Pre-departure mental health programs are crucial, and both origin and destination governments must ensure safe and dignified conditions for these workers. Implementing these measures can alleviate mental health challenges and enhance their well-being.
The passage of north-bound migrants through Mexico has increased dramatically in the last decade, with an increasing proportion of minors. However, there is still little evidence on the health status and living conditions of migrant minors in transit through Mexico. The aim of this study was to better characterize the evolution of health status and its contributing factors in this population from the place of origin to the period of travel. We conducted a cross-sectional mixed-methods study with migrant caregivers staying with minors in shelters in northern Mexico. Quantitative data were collected through surveys using validated tools to assess minors' well-being and health-related social needs and were analyzed descriptively and inferentially. Qualitative data were obtained through focus groups using a semi-structured interview guide and analyzed through thematic analysis. Information was collected on 200 minors between July and September 2024. Caregivers reported precarious and unsafe living conditions at origin and along the journey, as well as a series of barriers to accessing health services. Deterioration in the mental and physical health of minors was observed between the pre-departure and travel periods. Our study illuminates adversities faced by migrant children and adolescents in Latin America along the migratory journey and emphasizes the impact of these adversities on their well-being. There remains a need to continue supporting the implementation of interventions that contribute to the well-being of minors in transit in the region.
Cross-border migration presents increasing challenges to healthcare systems globally. Ensuring equitable healthcare access for immigrant populations, particularly in Southeast Asia, requires a thorough understanding of the barriers to effective service delivery. This scoping review aimed to synthesize the existing literature on the challenges related to the delivery of healthcare services to immigrant communities from Southeast Asia. While previous studies (e.g., Brandenberger et al., 2019) applied the 3C framework to migrants and refugees globally, this review generates new insights by focusing specifically on Southeast Asia, a region underrepresented in the literature. By applying the 3C model in this context, our review identifies region-specific challenges, such as immigration policies, financial barriers, and COVID-19 impacts, that extend beyond the findings of earlier global reviews. A comprehensive search was conducted in ProQuest, PubMed, ScienceDirect, and Scopus databases on October 13, 2024, for studies published between January 1, 2011, and October 13, 2024. The search strategy used tailored keywords, including "challenges," "healthcare services," "immigrants," and "Asia." Inclusion criteria focused on peer-reviewed, English-language articles reporting on challenges in healthcare service delivery among immigrant populations in Southeast Asia. Data extraction and synthesis were guided by the 3C model: communication, continuation of care, and confidence in the healthcare system. The search identified 656 records, of which 7 studies met the inclusion criteria after a multi-stage screening process. Key challenges identified across the included studies were: Communication barriers, including language differences, cultural misunderstandings, and limited health literacy; Issues with continuation of care, such as poor health literacy, difficulties navigating healthcare systems, barriers to accessing services (e.g., due to legal status or financial constraints), and lack of coordination between healthcare and social services; and Lack of confidence in the healthcare system, stemming from distrust, lack of understanding, and negative experiences, including perceived discrimination. This review highlights the complex challenges in delivering healthcare services to immigrants from Southeast Asia. These challenges, encompassing communication, continuation of care, and confidence, necessitate targeted and multifaceted interventions. Addressing these issues through culturally competent care, enhanced communication strategies, and policy reforms that promote equitable access is crucial for improving the health and well-being of immigrant populations and fostering more inclusive healthcare systems within the region.
Malaria remains one of the most pressing public health challenges in Sub-Saharan Africa (SSA), which continues to shoulder over 90% of the global burden of malaria cases and deaths. Despite major investments in control and treatment, the region faces persistent transmission heterogeneity, with pockets of low but sustained incidence that often fuel larger seasonal outbreaks. Each year, during the hot and dry season, multiple low-transmission hotspots-ranging from 3 to 150 cases per 10,000 person-weeks-emerge in many peri-urban and rural-urban fringe zones in western SSA. These hotspots frequently precede widespread outbreaks that occur with the onset of the rainy season. While intensive malaria control programs have reduced incidence in many high-transmission areas, the persistence of such low-transmission hotspots throughout the dry months remains poorly understood. In this study, we focus on Ouagadougou, the capital of Burkina Faso, where malaria incidence demonstrates striking spatiotemporal patterns. We hypothesize that seasonal rural-urban migration of labourers-driven largely by agricultural and economic cycles-plays a pivotal role in sustaining dry-season transmission, seeding subsequent rainy-season epidemics. To examine this hypothesis, we develop a data-driven malaria model and analyze with statistical inference methods to compare the impacts of seasonal, regular, and permanent migration patterns, using empirical incidence and mobility data. Our analysis indicates that seasonal migration most accurately explains the low-transmission endemicity in dry months and their amplification into widespread rainy-season outbreaks. High seasonal migration maintained a low but persistent level of transmission, preventing local fade-out, and significantly intensified transmission once favourable ecological conditions returned during the rains. These findings demonstrate how cyclical patterns of human mobility can drive malaria persistence even in periods otherwise unsuitable for transmission. These findings highlight the importance of incorporating human mobility, particularly seasonal labour migration, into malaria transmission models and control strategies. From a global health perspective, accounting for mobility-driven persistence mechanisms can strengthen malaria elimination programs across Sub-Saharan Africa, where seasonal migration is widespread. By integrating migration dynamics into intervention planning, policymakers can better anticipate epidemic risk and target resources to vulnerable communities, thereby moving closer to the long-term goal of malaria elimination.
Men, particularly those belonging to gender minority groups, often experience poorer physical health outcomes. This study examined global health and quality of life (QoL) across diverse male gender subgroups in Switzerland. While emphasising male gender diversity, we aimed to identify key sociodemographic risk factors associated with reduced global health and QoL. We analysed a subset of the Swiss Health Survey 2022, a cross-sectional nationally representative health-related dataset from the general Swiss population. Our sample included individuals falling into one of the three groups: cisgender men, transgender men (assigned female at birth with male gender identity) and men with 'other' gender identities (assigned male at birth but identifying as non-binary or non-specified gender identity). Global health and QoL were assessed using the Minimum European Health Module (MEHM) and the global QoL item of the WHOQOL-Bref. Four binary logistic regression models examined the association between male gender identities, sociodemographic data and MEHM and QoL outcomes. Our study comprised 3 505 801 male cases after weighting. Of these, 12.9% reported fair to very poor health. Key risk factors included being unemployed, migration background and being a transgender man. The strongest protective factor was higher education. Chronic conditions were reported by 33.3% men, with unemployment again being the most relevant risk factor. Identifying as a man with 'other' gender identities emerged as a protective factor. Regarding QoL, 8% stated impaired QoL, while the male gender identity 'other' was the strongest risk factor and tertiary school education the most relevant protective factor. Risk and protective factors vary across different global health outcomes and QoL in men. These findings highlight the importance of disaggregating male gender categories beyond the binary to better understand the complexity of health disparities. A differentiated, gender-inclusive approach is essential for accurately identifying vulnerable groups and tailoring public health interventions accordingly.
Refugees, asylum seekers, and undocumented migrants face significant structural and social barriers when accessing, or attempting to access, primary care delivered by the NHS in the United Kingdom. The aim of this research is to conduct a critical interpretive synthesis of primary research articles, identified via a systematic search of several online databases. This review approach was chosen in order to develop a new synthesis of the constructed identities and experiences of refugees, asylum seekers and undocumented migrants, and contribute to a further understanding of the barriers and facilitators that these populations face in relation to primary care access. This research used an interdisciplinary framework, guided by Penchansky and Thomas' theory of healthcare access, as well as Bhaba's, Spivak's and Berry's post-colonial theories. Differences in social cues, the impact of the past, and the role of communities are examples of the various barriers and enablers that refugees, asylum seekers, and undocumented migrants face in relation to primary care in the UK. This analysis generated a new model, the Tangibility of Access, which theorises that recognising the tangibility of various identities and experiences can provide a deeper insight into persisting barriers of primary care access. These findings highlight the implications of assuming the nature of identities and experiences in research, and identifying how differences in the knowledge of these vulnerable groups between research and policymaking can lead to continued difficulties surrounding primary care access. Further interdisciplinary research is necessary to determine the causal effects of deterrents to approaching primary care, and provide insights into how the quality of primary care can be improved, especially concerning intangible identities and experiences. A holistic perspective is needed to challenge assumptions regarding the identities and experiences of refugees, asylum seekers, and undocumented migrants, which may prove harmful to help-seeking behaviour if not confronted.
Migration through the Darién Gap en route to the US peaked in 2023, with hundreds of thousands of people in transit exposed to physical and psychological health hazards. However, systematic data on mental health conditions for this population remain limited. This study explored the prevalence of psychological symptoms, mental disorders, exposure to psychological trauma, and health-related quality of life among migrants in transit through Darién and described age- and sex-based differences. In January 2022, we conducted a cross-sectional mental health assessment at a government-run Migrant Reception Station in Darién, Panama. Randomly selected adults and adolescents aged ≥12 years completed the Refugee Health Screener-15 (RHS-15) and the EUROHIS-QoL-8. Those who screened positive were offered clinical evaluation by mental health specialists using the Mini International Neuropsychiatric Interview. Among 137 participants (median 30.0 years [IQR 11.0]; 54.1 % male), 65.0 % screened positive for psychological distress, and 35.6 % met the diagnostic criteria for at least one psychiatric disorder. Trauma- and stress-related disorders (24.4 %) and depressive disorders (17.0 %) were most prevalent. Females reported higher exposure to psychological trauma during the crossing relative to males (43.6 % vs. 23.3 %; p = 0.01) and higher prevalence of history of mental disorder (25.8 % vs. 5.5 %; p = 0.001). A larger proportion of adolescents and younger adults [12-24 years] scored at-risk for suicide compared with older participants [ages 25 years and older] (36.7 % vs. 10.5 %, p = 0.001). Findings highlight significant mental health burden during transit and suggest the potential utility of targeted screening and referral mechanisms in reception settings.
Evidence on how poverty and social determinants influence adverse maternal and perinatal outcomes in the UK is limited. While ethnicity and area-level deprivation are well described, fewer studies examine the cumulative impact of poverty-related factors such as low income, employment insecurity, housing, and access to social support. We analysed 67,308 pregnancies from the eLIXIR cohort using linked NHS records. Social determinants were defined using the WHO framework as structural (ethnicity, migration status, area deprivation) and intermediary (housing, employment, financial hardship, social support, barriers to care). The primary outcome was a composite adverse perinatal outcome. Binary logistic regression models with random intercepts accounted for repeated pregnancies, and adjusted risk ratios (aRRs) were estimated controlling for key sociodemographic and clinical factors. Structural poverty-related social determinants of health were associated with increased risk of adverse perinatal outcomes, including Black (aRR 1.50, 95% CI 1.42-1.59), Asian (aRR 1.49, 95% CI 1.39-1.59), and other minoritised ethnic backgrounds (aRR 1.50, 95% CI 1.42-1.59), residence in the most deprived areas (aRR 1.10, 95% CI 1.01-1.20), non-UK birth (aRR 1.20, 95% CI 1.15-1.25), and recent migration (aRR 1.32, 95% CI 1.14-1.53). Intermediary poverty-related social determinants of health were independently associated with increased risk beyond ethnicity and deprivation, including lack of social support (aRR 1.21, 95% CI 1.02-1.42), unemployment (aRR 1.16, 95% CI 1.10-1.23), financial hardship (aRR 1.17, 95% CI 1.01-1.35), living in social housing (aRR 1.16, 95% CI 1.09-1.24), transfer of care between hospitals (aRR 1.27, 95% CI 1.18-1.37), missed appointments (aRR 1.19, 95% CI 1.04-1.37), and unscheduled maternity care use (aRR 1.21, 95% CI 1.14-1.29). Women exposed to multiple overlapping poverty-related social determinants of health had a substantially higher likelihood of adverse perinatal outcomes (aRR 1.23, 95% CI 1.12-1.35). Structural and intermediary social determinants related to poverty have a substantial and cumulative impact on maternal and perinatal outcomes, independent of individual clinical risk. Addressing these inequities requires integrated, cross-sector strategies that extend beyond healthcare to the wider social conditions influencing maternal and child health. Not applicable.
In sub-Saharan Africa, the burden of diabetes and hypertension is high, alongside a high prevalence of HIV. Whether these conditions can be managed in an integrated way in the community is unknown. We aim to compare integrated community-based care with integrated facility-based care for people with HIV, diabetes, and hypertension in Tanzania and Uganda. This open-label, multicountry, cluster-randomised trial was conducted in 14 primary care facilities across Tanzania and Uganda. Adults aged 18 years or older with a diagnosis of HIV, type 2 diabetes, or hypertension (or a combination); receiving regular care at the health facility for at least 6 months; considered clinically stable; living within the catchment area and planning to stay for at least 6 months; and willing to receive care in the community were enrolled. In each facility, patients were grouped into clusters of 8-14. Each group was randomly assigned (1:1) using an online data management system, to integrated facility care or community care. In facility care, participants shared the same registration and waiting areas, were managed by the same physicians and health-care workers, and used the same pharmacy and laboratory services. In community care, a nurse and a trained lay worker supported the groups at focal points in the community with groups meeting once per month. Follow-up was 12 months. The first coprimary endpoint was a composite of blood pressure or fasting glucose control (defined as blood pressure <140/90 mm Hg in participants with hypertension alone, fasting glucose <7·0 mmol/L in those with diabetes alone, or both indicators controlled in those with both conditions) and the second was plasma viral load suppression for participants with HIV alone (defined as <1000 copies per mL or undetectable viral load). Both endpoints were assessed in the intention-to-treat population. Generalised estimating equation models accounted for clustering. This trial was registered with the ISRCTN registry, ISRCTN15319595 (completed). Between Jan 30 and Oct 6, 2023, 2940 patients with HIV, diabetes, or hypertension (or a combination of these conditions) who lived close enough together to be placed into a group were identified as having appointments to attend at the participating facilities. 765 (26·0%) patients were not screened and 2175 (74·0%) were screened for eligibility. 203 (9·3%) patients were ineligible, four (0·2%) did not consent, and 104 (4·8%) could not be grouped into viable clusters. 1864 (63·4%) patients were assigned into 124 groups, and groups were randomised (62 to community care and 62 to facility care). There were more females than males (1302 [76·6%] of 1700 vs 398 [23·4%]). Among those with diabetes or hypertension (or both), 38 (6·3%) of 602 in the community care group versus 43 (7·1%) of 609 in the facility care group were excluded, with nine (3·7%) of 242 versus ten (4·0%) of 247 excluded among participants with HIV. The composite of blood pressure or fasting glucose control did not significantly differ between the two groups in participants with hypertension or diabetes (or both; 317 [55·2%] of 574 in the community care group vs 304 [53·2%] of 571 in the facility care group; adjusted risk difference 1·80 [95% CI -4·52 to 8·12]; p=0·58), whereas most participants with HIV alone reached viral suppression (227 [99·1%] of 229 vs 229 (98·7%) of 232; adjusted risk difference 0·44 [-1·12 to 1·99]; pnon-inferiority<0·0001). There were seven deaths in each study group. In sub-Saharan Africa, integrated community care could reach a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. National Institute for Health and Care Research.
This prospective cohort study used linked Swedish administrative registers and pension payment data to examine post-retirement migration patterns and health selection among Finnish migrants compared to native-born Swedes. The cohort included individuals born between 1938 and 1955 who were resident in Sweden at age 64, with follow-up from age 65 until death or the end of 2021 (n = 1794,196; 80,313 Finnish-born). Health status was assessed using the Charlson Comorbidity Index (CCI), while pension payments were used to identify country of residence and mortality occurring after emigration. Post-retirement emigration was substantially more common among Finnish migrants (3.0 %) than native-born Swedes (0.3 %), primarily due to return migration to Finland. Contrary to the "salmon bias" hypothesis, poorer health reduced rather than increased the likelihood of emigration for both groups. Among Finnish migrants, lower CCI scores, male sex, being unmarried, and lower income predicted a higher likelihood of post-retirement migration. Sequence analyses revealed three distinct Finnish migration trajectories: early return, late return, and return with onward migration. Mortality did not differ significantly between Finnish migrants who remained in Sweden and those who resided in Finland or other countries; adjusted models even indicated slightly lower mortality among return migrants Extending follow-up abroad with pension data did not change mortality estimates, indicating unrecorded deaths abroad likely did not bias results. The findings indicate positive health selection into return migration and no evidence of a salmon bias effect. Post-retirement migration among Finnish migrants in Sweden is rare and has little impact on migrant-native mortality differences.
Evidence shows that immigrants tend to have better health upon arrival, but they experience faster health deterioration than non-immigrants. However, rarely do we assess the role of loneliness in shaping health disparities by migration status. This study examines how loneliness mediates the relationship between migration status and health. Using nationally representative data from the 2012-2020 German Socio-Economic Panel, we apply a parallel process latent growth curve model with mediation analysis to examine the direct associations of migration status with mental and physical health trajectories, as well as the mediating role of loneliness, by gender and age at migration (6609 non-immigrants; 634 immigrants). Among women loneliness mediates the relationship between migration status and mental health (β = -0.013, 95 % CI = -0.022 - -0.006, p < 0.01). Immigrants are more likely to experience loneliness, which is associated with poorer mental health. Analyses that account for gender and age at migration differences reveal that loneliness mediates the relationship only among women who moved to Germany after age 18 (β = -0.015, 95 % CI = -0.024 - -0.008, p < 0.001). Loneliness contributes to mental health disparities between immigrant and non-immigrant women. Immigrant women who migrated after age 18 are particularly vulnerable. We do not observe the same mechanism among men, nor for physical health. Given that the mechanisms vary by age at migration and gender, future studies should tailor their analyses to specific population subgroups to better understand the drivers of migration-related health disparities.
Mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD) are highly prevalent among forcibly displaced populations. Prevalence rates of common mental health conditions have been studied in refugee groups. However, research is sparse regarding the heterogeneity of psychiatric symptoms and quality of life (QoL) profiles among individuals with recent displacement experiences. The current study employed Latent Profile Analysis (LPA) to identify profiles of psychopathology and QoL in a sample of 510 recently arrived refugees in Sweden. The associations of profile membership with socio-demographic factors were thereafter investigated. Three distinct profiles were identified: a severe psychopathology/low QoL profile (36.27%), a PTSD-dominant/preserved QoL profile (33.14%) and a mild psychopathology/high QoL profile (30.59%). Nationality and residence status were moderately associated with profile membership. Individuals with Afghan nationality were over-represented, and those with Syrian nationality under-represented, in the severe psychopathology/low QoL profile. This association is likely explained by residence status: 82% of individuals in the severe psychopathology/low QoL profile lacked a residence permit, with only 3.6% of Afghans having received a residence permit, compared to 59.1% of Syrians. The results underscore the heterogeneity of psychopathological symptoms and QoL in individuals with recent displacement experiences, as well as a significant influence of contextual factors like residence status on their mental health and QoL. These findings may have implications for informing psychological treatments and migration policies.
Migrants in Europe often face barriers to healthcare, contributing to poorer health outcomes. While healthcare utilisation has been studied within Beveridge systems (eg, the UK) and Bismarck systems (eg, Germany), less is known about healthcare use by migrants within the Netherlands' hybrid model. The Dutch model combines a Bismarckian base with Beveridge-like supplements. We investigated the use of general practitioner (GP) services, specialist care, allied health services and complementary medicine among major migrant groups in Amsterdam (South Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin) compared with the Dutch-origin population. We used pre-pandemic Healthy Life in an Urban Setting data (2015; n=21 614) to avoid biases from intra-COVID-19 and post-COVID-19 healthcare disruptions/alterations. Structured questionnaires assessed healthcare use and reasons for seeking care. Poisson regression with a log link and robust (sandwich) standard errors examined associations between migration background and healthcare utilisation, adjusting for demographics, acculturation, health literacy, lifestyle and chronic conditions. Sensitivity analyses explored motivations for care use and overall health status. All migrant groups reported higher or similar use of GP services compared with the Dutch-origin population. Most migrant groups (except Ghanaians) also reported higher or similar use of specialist and allied health services. Conversely, use of complementary medicine was higher among Dutch-origin participants than among migrants. Many migrant groups in Amsterdam show higher use of mainstream healthcare services compared with previous reports from other European settings. Further studies should examine and dissect these patterns to inform improvements in other European settings.
More than 50 thousand people lost their lives in the earthquake that occurred in Türkiye in 2023. This study aimed to evaluate the Sexual and Reproductive Health (SRH) services provided in earthquake region in Hatay province in Türkiye with qualitative and quantitative methods. The research type is mixed; cross-sectional and phenomenological. The recorded data were evaluated for cross-sectional phase and purposeful and snowball sampling was conducted for qualitative phase. Data were collected through five focus group interviews (one healthcare workers group--5 staff- and four women group--16 women-) and 13 in-depth interviews (4 academics, 6 NGO, 3 service providers) as totally 34 participants. Thematic content analysis was conducted. Eighty three percentage of 15,841 women's applications were reached by mobile services. All of women were given health education. The frequency of genitourinary infection is 25.0%. Family Planning (FP) method was given to 35.3% of the women, cotton underwear was given to 72.0%, and sanitary pads were given to 22%. Emerging themes included social determinants, the gap in SRH services, community based mobile services and service provision by NGOs like HASUDER (Association of Public Health Specialists) and intersectoral collaboration. Reported that pre-existing gaps in SRH services were exacerbated after the earthquake, with major barriers including lack of privacy, poor hygiene, limited family planning access, low SRH awareness. Related to social determinants, gender and migration-related challenges such as language barriers, economic hardship, cultural isolation restricted service access. NGOs played a crucial role in addressing unmet needs. However, bureaucratic barriers and limited public sector collaboration were noted. Deteriorated living conditions, and widespread healthcare disruptions across all service levels further deepened vulnerabilities. The HASUDER mobile services were highlighted as critical in reaching women, adolescents, and migrants. The earthquake deepened health system gaps, while NGOs became essential in bridging services and building resilience. Strengthened coordination, infrastructure, and inclusive SRH integration are urgently needed. Community-based mobile service delivery is vital.
Global progress toward the Sustainable Development Goals (SDGs) is severely off track. Iran hosts the world's largest migrant and refugee population, but sanctions, inflation, and workforce migration have strained its capacity. Since the attitudes of service providers influence whether inclusive policies are translated into practice, this study explores frontline staff perspectives on access to public health services for non-citizens in one of Tehran's largest public health networks. We conducted a cross-sectional survey among staff in three public health centers that serve migrant and refugee populations. The questionnaire assessed five Likert scale outcomes: support for separate centers, shared user fees, prioritization of citizens under conditions of scarcity, equal service provision, and preference for working with citizens. Demographic variables included age, sex, years of experience, and role (clinical vs. non-clinical). Items were analyzed descriptively; subgroup comparisons were conducted using two-sided Mann-Whitney U tests. Of approximately 150 eligible healthcare workers, 87 provided complete responses. Agreement with prioritizing citizens was highest at 93.1% (median 5). Support for equal service provision was lowest, with 56.3% of participants expressing disagreement (median 2). A preference for working with citizens was endorsed by 61.9% of the respondents (median 4) and differed by age, experience, and role, with younger, less-experienced, and clinical staff reporting stronger preferences (all p < 0.01). Healthcare workers' perspectives can serve as a rapid, low-burden proxy indicator for equitable service delivery. In this exploratory study, workers favored citizen prioritization and fee-based models under conditions of scarcity, with the lowest support expressed for equal access for non-citizens; these preferences were strongest among younger and clinical staff. Adapted service delivery models, targeted training, and clear operational guidance are needed to support equitable access in resource-constrained settings.