World Report On The Health of Refugees and Migrants

World report on the
health of refugees
and migrants
Health for all,
including
refugees and
migrants:
time to
act now
World report on the
health of refugees
and migrants
World report on the health of refugees and migrants
ISBN 978-92-4-005446-2 (electronic version)

ISBN 978-92-4-005447-9 (print version)
© World Health Organization 2022
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike
3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes,
provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion
that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If
you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If
you create a translation of this work, you should add the following disclaimer along with the suggested citation:
“This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content
or accuracy of this translation. The original English edition shall be the binding and authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation
rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).
Suggested citation. World report on the health of refugees and migrants. Geneva: World Health Organization;
2022. Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit
requests for commercial use and queries on rights and licensing, see https://www.who.int/copyright.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as
tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and
to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-
owned component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and
dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed
or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable
for damages arising from its use.
iii
Contents

Foreword vii
Preface ix
Acknowledgements xi
Abbreviations and acronyms xvi
1. Population movement and health: an overview 1

1.1 Introduction 3
1.2 Definitions and terms 5
1.2.1 Key definitions 5
1.2.2 Populations not included in this Report 6
1.3 Global displacement and migration patterns 9
1.4 Migratory patterns in WHO regions 12
1.5 Age and gender 13
1.6 Displacement 14
1.7 Health and the dynamics of global displacement and migration 15
1.7.1 Urbanization 18
1.7.2 Brain circulation: brain drain versus brain gain 18
1.7.3 Sending money home 19
1.7.4 Left-behind families 20
1.7.5 Discrimination and xenophobia 21
1.7.6 People smuggling and human trafficking 21
1.7.7 Climate change 22
1.8 Health and migration policies 23
1.8.1 Key international frameworks 24
1.8.2 WHO resolutions and action plans 26
References 28
2. Determinants of refugee and migrant health 39

2.1 Introduction 41
2.2 Sex and gender 43
2.2.1 Health of women and girls 43
2.2.2 Health of men and boys 44
2.2.3 LGBTQI+ populations and sexual minorities 45
2.2.4 Menstrual hygiene management 47
2.3 Age 48
2.3.1 Unaccompanied or separated children 48
2.4 Education 50
2.4.1 Health outcomes 51
2.4.2 Access to education for refugee and migrant children 52
2.4.3 Employment challenges associated with level of education 53
2.5 Health literacy 53
2.5.1 Influence on health outcomes 54
2.5.2 Strategies to improve health literacy and communication 55
iv
2.6 Income 56
2.6.1 Health outcomes 56
2.6.2 Remittances and left-behind families 56
2.7 Migratory status 57
2.8 Social support 58
2.8.1 Acculturation 58
2.8.2 Parenting 58
2.8.3 Substance use 59
2.9 Air quality 60
2.10 Water, sanitation and hygiene 62
2.10.1 Access to safe drinking-water 62
2.10.2 Access to safe sanitation 62
2.10.3 Hygiene 63
2.11 Housing and living environments 64
2.11.1 Housing 65
2.11.2 Immigration detention 66
2.11.3 Housing barriers and solutions 68
2.12 Food and nutrition 69
2.12.1 Food assistance 71
2.13 Summary 71
References 73
3. Health status of refugees and migrants: a global perspective 91

3.1 Introduction 93
3.2 Occupational health 95
3.2.1 High-risk and physically demanding sectors of industry 97
3.2.2 Data challenges 100
3.3 Sexual and reproductive health 104
3.3.1 Contraception and family planning 104
3.3.2 Sexually transmitted infections 107
3.3.3 Sexual and gender-based violence 108
3.3.4 Female genital mutilation 109
3.4 Maternal and child health 110
3.4.1 Access to antenatal care 110
3.4.2 Obstetric, postpartum and postnatal health and access to care 112
3.4.3 Malnutrition and anaemia 112
3.4.4 Other child health issues 114
3.5 Noncommunicable diseases and major risk factors 115
3.5.1 Cardiovascular diseases 117
3.5.2 Cancer 117
3.5.3 Hypertension 119
3.5.4 Diabetes mellitus 120
3.5.5 Substance use 120
3.5.6 Obesity 121
3.6 Mental health 124
3.6.1 Depression and anxiety 124
3.6.2 Post-traumatic stress disorder 126
3.6.3 Suicide and self-harm 126
3.6.4 Schizophrenia and other psychotic disorders 127
3.6.5 Child mental health 128
v
3.7 Communicable diseases 129

3.7.1 HIV/AIDS 130
3.7.2 Tuberculosis 133
3.7.3 Malaria 138
3.7.4 Other communicable diseases 140
3.8 COVID-19 143
3.8.1 Burden of disease 144
3.8.2 Health and other impacts 144
3.8.3 Policy responses 150
3.8.4 Testing, treatment and vaccination 151
3.9 Summary 153
References 154
4. Refugee- and migrant-sensitive health systems 189

4.1 Introduction 191
4.2 Service delivery 193
4.2.1 Common barriers 193
4.2.2 Service models to meet refugee and migrant health needs 196
4.3 Health workforce 199
4.3.1 Sufficient staffing levels, training and resources 199
4.3.2 Supporting refugee and migrant health workers 201
4.3.3 Impact of migration 202
4.3.4 Better use of health professionals 203
4.3.5 Countries with a large migrant health workforce 203
4.4 Access to medical products, vaccines and technologies 206
4.4.1 Access to good-quality and affordable medicines 206
4.4.2 Access to vaccines 208
4.5 Health information systems 211
4.5.1 Data collection on refugee and migrant health 211
4.5.2 Dissemination and use of refugee and migrant health data 215
4.6 Financing 215
4.6.1 Refugee and migrant expenditure 215
4.6.2 Public health coverage 216
4.6.3 Mixed or private health insurance coverage 219
4.7 Leadership and governance 220
4.7.1 Legal access and entitlement: national policies 221
4.7.2 Refugee-hosting contexts 226
4.7.3 Regional leadership and strategies 227
4.8 Summary 229
References 230
5. Mapping progress towards global health goals: an exploratory review 247

5.1 Introduction 249
5.2 The challenge to meet 251
5.2.1 Making the health of refugees and migrants visible in major data sets 252
5.2.2 The SDGs and population movement 252
5.2.3 Moving forward on disaggregation 253
5.3 Review methodology 255
5.3.1 Criteria for inclusion 255
5.3.2 Data limitations 256
5.3.3 Definitions 259
vi
5.4 Review results 261

5.4.1 Housing 262
5.4.2 Health insurance 263
5.4.3 Health and access to health care services 266
5.4.4 Health services and protective interventions 267
5.4.5 Mental health 274
5.4.6 Drinking-water, sanitation and hygiene as a health determinant 276
5.5 Summary 276
References 279
6. Health and migration: the way forward 287

6.1 The current state of affairs 289
6.1.1 Population movement and health: an overview 290
6.1.2 Determinants of refugee and migrant health 291
6.1.3 Health status of refugees and migrants 292
6.1.4 Gaps and good practices in health systems 294
6.1.5 Refugees and migrants are not visible in global data sets:
Sustainable Development Goal targets will be missed 297
6.2 The way forward: health for a world in motion 298
6.2.1 Health and migration: a global health priority 298
6.2.2 Towards concerted efforts: a paradigm shift 299
6.2.3 Effectively integrating refugees and migrants into universal health
coverage and primary health care 299
6.2.4 Global action plan 301
6.3 Policy and practice 301
6.3.1 Develop short- and long-term public health action plans that
include refugees and migrants, and support their implementation 301
6.3.2 Strengthen the capacity and increase the sensitivity of health
systems to meet the specific health needs of refugees and migrants 301
6.3.3 Enhance understanding of the health promotion and health
needs of refugees and migrants 302
6.3.4 Actively include refugees and migrants within financial and
social protection systems 302
6.3.5 Strengthen accountability and indicators framework 303
6.3.6 Promote global research, strengthen knowledge production
and build research capacity in health and migration 304
References 305
Annex
Methodology 306
vii
Foreword
Today there are some one billion
migrants globally, about one in eight
people. The experience of migration
is a key determinant of health
and well-being, and refugees and
migrants remain among the most
vulnerable and neglected members
of many societies.
This report is the first to offer a global

review of health and migration and
calls for urgent and concerted action
to support refugees and migrants
across the world to access health
care services that are sensitive to their needs. It illustrates the pressing need to
study and mitigate the root causes of migration and to radically reorient health
systems to respond to a world increasingly in motion.
Whether by choice or by force, to be on the move is to be human and is part of

human life. Whatever a person’s motivation, circumstance, origin or migratory
status, we must unequivocally reiterate that health is a human right for all, and
that universal health coverage must be inclusive of refugees and migrants.
We live in challenging times. Disease, famine, climate change and war all
converge to threaten our global security, putting unprecedented pressures on
our societies and economies. Meanwhile, the COVID-19 pandemic continues
to have a disproportionate effect on the health and livelihoods of refugees and
migrants, with unique challenges for labour migrants.
At the start of 2022, the World Health Organization (WHO) and its partners
were responding to complex humanitarian crises in Afghanistan, Ethiopia,
Somalia, South Sudan, the Syrian Arab Republic and Yemen, each of which
has fuelled mass population movements and severely tested health systems in
host countries. Then came war in Ukraine, which pushed the total number of
displaced people above 100 million for the first time in history.
But the full extent of the impact of these upheavals is not yet understood
because, as this report demonstrates, refugees and migrants are not fully
visible in the available data – a serious gap that must be fixed. We must invest
in strengthening and implementing policies that promote refugee and migrant
health, guided by innovative data gathering and analysis.
viii
We urge governments, agencies, donors and other partners to think creatively

and act compassionately to improve the health of people on the move, and to
do so across all sectors of society.
I invite you to read this report and join WHO and our partners in our
commitment to build a healthier and more resilient world for all.
Dr Tedros Adhanom Ghebreyesus

Director-General
World Health Organization
ix
Preface
Every eighth person on the planet is a migrant or displaced, and the numbers are
growing. It is widely accepted that the experiences of displacement and migration
are key determinants of health and well-being; consequently, responding to
migration is crucial for global health. WHO is fundamentally committed to leaving
not one of these people behind. It has, therefore, invested in the gathering and
review of global evidence and created this World report on the health of refugees
and migrants. The report is the first of its kind to illustrate with such breadth and
specific detail the multitude of health challenges faced by hundreds of millions of
refugees and migrants, drawing on evidence that is as comprehensive as possible
from around the globe.
The report presents clear evidence that refugees and migrants can experience
poor health outcomes, primarily due to suboptimal working and living
conditions, which have a negative impact on the health and well-being of
refugees, migrants and asylum seekers, among others. Refugees and migrants
often experience much worse health outcomes than host populations,
compounded by their vulnerable circumstances and poor health determinants.
The report notes just how crucial it is to address the determinants of poor health
beyond the health sector when considering the health of refugees and migrants.
Two of the key findings of the report are the virtual absence of comparable data
across countries and over time on refugee and migrant health and the lack of
disaggregation according to migratory status within global health data sets.
The report shows critical gaps globally in data quality and knowledge and calls
for investment in fit-for-purpose data, surveillance and monitoring to support
robust evidence-informed policies and plans for implementation. If this vital
data gap remains, refugees and migrants will continue to be left behind, and
achieving the Sustainable Development Goals (SDGs) will be impossible.
Climate change and the increased number of conflicts mean increasing

numbers of people are on the move. The impact of anthropogenic climate
x
change is already felt across 80% of the world’s land area, which holds 85% of
the world’s population. It is predicted that over 200 million additional people
will be forced to move by 2050.
There are solutions. This report offers practical considerations to address

health disparities for refugees and migrants and to address the root causes that
negatively influence health. These include those that traditionally fall outside the
strict remit of the health sector, such as education, sex, age and migratory status.
Existing health systems should be reorientated to include refugees and migrants
in all services and programmes, in line with the principles of universal primary
health care and universal health coverage. The health determinants, status and
outcomes of refugees and migrants should be monitored to assess progress, or
lack thereof, towards the SDGs and other goals and targets. Because the health
and well-being of refugees and migrants cut across multiple sectors of society, the
health sector must play an important leadership and facilitating role.
With the magnitude of the challenge so plainly evident and with many promising
approaches identified, it is now possible for countries, institutions and researchers
to prioritize the actions and investments needed to monitor and improve health
and migration in line with the SDGs. WHO’s Thirteenth General Programme
of Work provides a framework for the urgent action necessary, prioritizing the
guiding principles of promoting health, keeping the world safe from disease
and focusing on the least-served, most vulnerable populations. These align with
the 2030 Agenda for Sustainable Development and its commitment to leave
no one behind. WHO’s Global action plan on promoting the health of refugees
and migrants also includes health as an essential component of protection and
assistance for refugees and migrants and good migration governance.
The world has rightly responded with national and international policies and
frameworks on health and migration, yet substantial disparities remain. What
we need now is action, and it will take whole-of-government and whole-of-
society approaches to ensure the health of refugees and migrants and their host
populations. With this report, WHO and its Health and Migration Programme
reiterate a commitment to promoting and advancing the health issues of all
refugees and migrants worldwide.
We hope this report will ring the alarm, inspire compassion, increase
understanding and, most of all, urge practical action towards universal health care
that leaves no one invisible, no one without essential and quality health services,
no one behind. Health for all, including refugees and migrants: time to act now.
Dr Zsuzsanna Jakab Dr Santino Severoni

Deputy Director-General Director
World Health Organization Health and Migration Programme
xi
Acknowledgements
WHO gratefully acknowledges the many experts and agencies who
contributed to the planning, development and review of this report.
Leadership and coordination
This report was developed under the overall strategic lead and technical
direction of Santino Severoni, Director, WHO Health and Migration Programme,
Geneva, Switzerland. Rifat Hossain, Technical lead, data and evidence, WHO
Health and Migration Programme, was responsible for coordinating the
development and production of the report. Soorej Puthoopparambil, Head,
WHO Collaborating Centre on Migration and Health Data and Evidence, Uppsala
University, Uppsala, Sweden, provided methodological and technical guidance
on the overall content of the report.
Technical writers
The report was drafted by Andrew Wilson, Leyla Alyanak and Felicity Thompson.
WHO contributors and reviewers
The following staff and consultants of the Health and Migration Programme
reviewed multiple drafts of the report, checking data and evidence, and/
or provided technical support: Richard Alderslade, Giuseppe Domenico
Annunziata, Rimu Byadya, Veronica Cornacchione, Mohammad Darwish, Cetin
Dikmen, Palmira Immordino, Kanokporn Kaojaroen, Joowon Kim, Alexandra
Ladak, Khawla Nasser Aldeen, Miriam Orcutt, Rita Sa Machado, Ana Cristina
Sedas, David Tellez and Marie Wolf. The following WHO staff and consultants
also contributed to the technical content and review of the report.
WHO headquarters
Elizabeth Aime-Mcdonald, Rajiv Bahl, Anand Balachandran, Valentina
Baltag, Julia Berenson, Gautam Biswas, Elaine Borghi, Francesco Branca,
James Campbell, Richard Michael Carr, David Clarke, Giorgio Cometto,
Bernadette Daelmans, Luz de Regil, Khassoum Diallo, Theresa Diaz, Tessa
Edejer, Albis Francesco Gabrielli, Philippe Glaziou, Laurence Grummer-
Strawn, Ahmadreza Hosseinpoor, Devora Lillia Kestel, Katherine Kirkby,
xii
Monika Kosinska, Etienne Krug, Joseph Douglas Kutzin, Jae-se Lee, Daniel
Low-Beer, Blerta Maliqi, Mary Mandahar, Silvio Mariotti, Michelle Mcisaac,
Claude Meyer, Gerardo Zamora Monge, Allisyn Carol Moran, Marjolaine
Nicod, Alana Margaret Officer, Kathy O’Neill, Sarah Paulin-Deschenaux,
Kumanan Rasanathan, Briana Rivas-Morello, Nathalie Laure Roebbel,
Sebastian Rositano, Sylvie Eliane Schaller, Gerard P. Schmets, Slim Slama,
Marcus Marcellus Stahlhofer, Chelsea Maria Taylor, Meelan Thondoo, Tamitza
Toroyan, Inka Weissbecker and Diane Wu.
WHO regional offices

WHO Regional Office for Africa: Ernest Dabire and Abdou Salam Gueye;
WHO Regional Office for the Americas: Candelaria Araoz, James Fitzgerald,
Julie Helene Issa, Camila Polinori and Ciro Ugarte; WHO Regional Office for
South-East Asia: Lin Aung, Aarti Garg, Stephen Paul Jost and Edwin Salvador;
WHO Regional Office for Europe: Jozef Bartovic, Kristina Mauer-Stender,
Elisabeth Waagensen and Gundo Weiler; WHO Regional Office for the Eastern
Mediterranean: Rana Al Naggar, Ali Ardalan, Hala El Shazly, Awad Mataria and
Tonia Rifaey; WHO Regional Office for the Western Pacific: Isabel Constance
Espinosa, Kira Fortune, Tsering Kalden Lama, Caroline Lukaszyk, Angela Pratt
and Jaitra Sathyandran.
Regional literature reviews
The report is based on comprehensive literature reviews of evidence from all WHO
regions, which were conducted under the supervision of WHO regional offices.
The literature review for the WHO African Region was conducted, synthesized and
written by Jo Vearey (lead), Yacine Ait Larbi and Marta Luzes, Samuel Hall, Nairobi,
Kenya, and Edward Govere, Thea de Gruchy, Langa Mlotshwa and Rebecca Walker,
African Centre for Migration and Society, Wits University, South Africa.
The literature review for the WHO Region of the Americas was conducted,
synthesized and written by Báltica Cabieses (lead), María Inés Álvarez, Alice
Blukacz, Marcelo Lizana, Alexandra Obach and Isabel Rada, Programa de Estudios
Sociales en Salud, Instituto de Ciencias e Innovaciones Médicas, Universidad del
Desarrollo, Santiago, Chile.
The literature review for the WHO South-East Asia Region was conducted,
synthesized and written by Anjali Borhade (lead), Nisha Bharti, Subhojit Dey, Isha
Jain and Vishika Yadav, Disha Foundation, New Delhi, India.
The literature reviews for the WHO European Region were conducted, synthesized
and written by the following teams: Gianfranco Costanzo (lead), Andrea Cavani,
Alessandra Diodati, Anteo Di Napoli, Concetta Mirisola, Alessio Petrelli and
Acknowledgements
xiii
Leuconoe Grazia Sisti, National Institute for Health, Migration and Poverty, Rome,
Italy; Alessandra Bettiol and Irene Mattioli, University of Florence, Florence, Italy;
and Pietro Amedeo Modesti, Careggi University Hospital, University of Florence,
Florence, Italy (for non-Russian-speaking countries); and Alexey Novozhilov,
Federal Research Institute for Health Organization and Informatics, Moscow,
Russian Federation (for Russian-speaking countries).
The literature review for the WHO Eastern Mediterranean Region was conducted,
synthesized and written by Jocelyn DeJong (lead), Chaza Akik, Zeinab Dirani, Layal
Hneiny and Eman Sharara, American University of Beirut, Beirut, Lebanon.
The literature review for the WHO Western Pacific Region was conducted,
synthesized and written by Lisa Grace S. Bersales (lead), Kristine Faith Agtarap,
Claire Berja, Clarinda Lusterio Berja, Michael Dominic Del Mundo and Aileen
Guyos, University of the Philippines, Manila, Philippines.
Synthesis of the evidence reviews
The regional evidence reviews were synthesized by the following teams:

Catherine K. Ettman and Sandro Galea (Boston University, United States of
America), Paul Spiegel, David Tellez, Maryada Vallet and Cyndy Vasquez (Johns
Hopkins University, United States of America); and Lisa Grace S. Bersales,
Kristine Faith Agtarap, Claire Berja, Clarinda Lusterio Berja, Michael Dominic Del
Mundo and Aileen Guyos (University of the Philippines, Manila, Philippines).
The following contributors provided valuable input and feedback on the analysis
and presentation of household survey data: Trevor Croft and Shea Rutstein
(Demographic and Health Surveys); Holly Newby (formerly of Demographic and
Health Surveys and the United Nations Children’s Fund); Atilla Hancioglu and
Turgay Unalan (Multiple Indicator Cluster Surveys, United Nations Children’s Fund );
Olivier Dupriez, Aivin Vicquierra Solatorio and Matthew John Welch (World Bank
and International Household Survey Network).
Institutional contributions
Numerous technical inputs and feedback were received from the following
experts: Elisa Benes, Bálint Náfrádi, Andonirina Rakotonarivo and Valentina
Stoevska (International Labour Organization); Julia Black, Nuwe Blick,
Frank Laczko and Elisa Mosler Vidal (International Organization for Migration
Global Migration Data Analysis Centre); Aleksandar Arnikov, Poonam Dhavan,
Chiaki Ito, Kit Leung, Janice Lopez, Maeva Peek, Guglielmo Schinina, Agan
Sweetmavourneen, Jacqueline Weekers, Kolitha Wickramage and Alice Wimmer
(International Organization for Migration, Migration Health Division); Grace
xiv
Sanico Steffan (Office of the United Nations High Commissioner for Human Rights);
Jan Beise, Daniela Knoppik, Ralf Moreno, Sebastian Palmas and Danzhen You
(United Nations Children’s Fund); Monica Aguayo, Miguel Castillo, Xavier Mancero,
Rolando Ocampo Fernanda Reynoso, Zulma Sosa and Daniel Taccari (United
Nations Economic Commission for Latin America and the Caribbean); Ann Burton,
Tarek Abou Chabake, Ibrahima Diallo, Sandra Harlass and Peter Ventevogel
(United Nations High Commissioner for Refugees); Enrico Bisogno, Tejal Jesrani
Haslinger, Claire Healy, Angela Me and Philipp Meissner (United Nations Office
on Drugs and Crime); Ginette Azcona, Antra Bhatt and Alembirhan Berhe (UN
Women); Gero Carletto and Olivier Dupriez (World Bank); S. Irudaya Rajan and Dilip
Ratha (World Bank Global Knowledge Partnership on Migration and Development);
Bjorn Gillsater, Harriet Mugera, Katherine Perkins and Charlotte Persson (World
Bank-UNHCR Joint Data Centre on Forced Displacement); Michael Flynn (Global
Detention Project, Geneva, Switzerland); Amal de Chickera, Ottoline Spearman
and Laura van Waas (Institute on Statelessness and Inclusion); Christelle Cazabat
(Internal Displacement Monitoring Centre, Geneva, Switzerland); Clara P.C. Fast
(Duke University, Durham, United States of America); and Laibah Ashfaq, Paige
Chu, Andrea Cortinois, Caitlin Manderville, Ryan Y. Ruan and Andrea Sanchez
Martinez (University of Toronto, Toronto, Canada).
External reviewers
The report was also subject to a comprehensive review by global experts on

the various areas covered: Shea Rustein (Demographic and Health Surveys);
Bernadette Nirmal Kumar (European Public Health Association/Lancet Migration);
Thomas H. Gassert (Harvard University, Cambridge, United States of America);
Iffat ElBarazi, Michal Grivna and Syed Mahboob Shah (Institute of Public Health,
College of Medicine and Health Sciences, United Arab Emirates University, Abu
Dhabi, United Arab Emirates); Anders Hjern (Karolinska Institute, Solna, Sweden);
Paul Bukuleke (Makarere University, Kampala, Uganda); Gianfranco Costanzo
and Leuconoe Grazia Sisti (National Institute for Health, Migration and Poverty
and WHO Collaborating Centre on Health and Migration Evidence and Capacity
Building, Rome, Italy); Cesar Infante Xibille (National Public Health Institute,
Mexico); Osman Dar (Royal Institute of International Affairs, London, United
Kingdom of Great Britain and Northern Ireland); Ibrahim Abubakar and Rita
Issa (University College London, London United Kingdom); Charles Agyemang
(University of Amsterdam, Amsterdam, the Netherlands); Francesco Castelli and
Beatrice Formenti (University of Brescia, Brescia, Italy); Steffanie Ann Strathdee
(University of California, San Diego, United States of America); Indika Karunathilake
(University of Colombo, Sri Lanka); and Jaime Miranda (Universidad Peruana
Cayetano Heredia, San Martin de Porres, Peru).
Acknowledgements
xv
Financial contributions
WHO gratefully acknowledges the financial contributions to the development

and production of this report provided by the Italian National Institute for
Health, Migration and Poverty, the German Federal Ministry of Health, the
Italian Ministry of Health, the Russian Federation and the Directorate-General
for International Partnerships of the European Commission through the Health
Systems Strengthening for Universal Health Coverage Partnership Programme.
xvi
Abbreviations and acronyms
ANC antenatal care

ART antiretroviral therapy
BADEHOG Household Survey Data Bank (Banco de Datos de Encuestas de Hogares)
BCG bacille Calmette–Guérin
BMI body mass index
CHW community health worker
COVID-19 coronavirus disease
CVD cardiovascular disease
DHS Demographic and Health Survey
DHS-VII Demographic and Health Survey (DHS) phase VII
EEA European Economic Area
e-health electronic health
EHR electronic health record
ESS European Social Survey
EU European Union
FGM female genital mutilation
GAP Global action plan on promoting the health of refugees and migrants, 2019–2023 (WHO)
GDP gross domestic product
GPW13 Thirteenth General Programme of Work, 2019–2023 (WHO)
HBV hepatitis B virus
HCV hepatitis C virus
HICS health insurance card scheme
HIS health information systems
HPV human papillomavirus
IDP internally displaced person
ILO International Labour Organization
IOM International Organization for Migration
IPV intimate partner violence
LGBTQI+ lesbian, gay, bisexual, transgender, queer and intersex
LTBI latent tuberculosis infection
MCH maternal and child health
MGI Migration Governance Indicator
m-health mobile health
xvii
MICS Multiple Indicator Cluster Survey

MICS6 Multiple Indicator Cluster Survey round 6
MIPEX Migrant Integration Policy Index
MSM men who have sex with men
NCD noncommunicable disease
NGO nongovernmental organization
NHWA National Health Workforce Accounts
OECD Organisation for Economic Co-operation and Development
OPV oral poliovirus vaccine
PHC primary health care
PISA Programme for International Student Assessment
PTSD post-traumatic stress disorder
SAVe Support Asylum and Vulnerabilities through e-health
SDG Sustainable Development Goal
SES socioeconomic status
SGBV sexual and gender-based violence
SRH sexual and reproductive health
STI sexually transmitted infection
TB tuberculosis
UASC unaccompanied or separated children
UDDT urine-diverting dry toilet
UHC universal health coverage
UNDESA United Nations Department of Economic and Social Affairs
UNHCR Office of the United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East
VPD vaccine-preventable disease
WASH water, sanitation and hygiene
WHO World Health Organization
xviii
The world witnessed most unprecedented consensus among governments and nongovernmental,
civil society and private sector organizations when the 2030 Agenda was adopted at the United
Nations General Assembly on 25 September 2015. It was a historic moment for humankind to
have this recognition of universal human rights and the rights to health and other basic services,
and to have the ultimate pledge to meet these goals and targets for all human beings, including
refugees and migrants, by 2030. We must also recall the promise we made in the same year to
tackle the climate crisis through the Paris Declaration.
Achieving peace and prosperity for all people and the planet by 2030 requires concrete and
concerted efforts that prioritize support to the vulnerable by understanding all their unique
challenges and needs and addressing them. This includes ensuring healthy lives and promoting
well-being. Good health and well-being are key to peaceful and prosperous societies.
Recognizing that migration and displacement have an impact on the health of the billion people
on the move, this report marks a welcome advance in thinking of migration and displacement
through one clarifying glass. The lens is universal health coverage and the idea that everyone has
a right to "complete physical, mental and social well-being and not merely the absence of disease
or infirmity", as stated in the WHO Constitution in 1946.
I commend WHO's report in highlighting the health issues related to refugees and migrants and
the call on the global community to collectively tackle this emerging challenge.
Ban Ki-moon
Chairman of Ban Ki-moon Foundation for a Better Future, 8th Secretary-General of United Nations
CHAPTER 1
Population
movement and
health:
an overview
2
A boy joins other displaced families in Yar Hussain camp in Swabi, 100 kilometres from Islamabad, Pakistan. © IOM / Saleem Rehmat
Population movement and health: an overview
3
1.1 Introduction
Displacement and migration are key determinants of health and well-being not
only for refugees and migrants but also for the populations in their countries
of destination, transit and origin (1–6). The relationship between health and
population movement is complex and dynamic. Health can improve when
people move from a conflict situation to a peaceful one or from an area of high
unemployment to one where better-paid, safe work is plentiful. However, poorer
health can result when refugees and migrants are exposed to conditions that
undermine good health during different phases of migration (7). Displacement
and migration can also result in interruption of health care provision or
treatment, leading to challenges in continuity of care. Migration has long been a
politically contested issue (8,9). Phenomena, such as conflict, income inequality,
economic shifts, urbanization and climate change, inevitably affect population
movement and their health. The COVID-19 pandemic vividly illustrated yet again
the impact of world events on the health of refugees and migrants (Box 1.1).
A WHO Thailand Migrant and Border Health Officer (centre), a health volunteer from Myanmar (right) and volunteers from Samut Sakhon
Hospital (left) visit a Burmese migrant worker and her child in her dormitory in Thailand to talk about how to stay safe from COVID-19.
© WHO / Ploy Phutpheng
4
Box 1.1.
COVID-19, migration and health
The COVID-19 pandemic reminded the world of the strong connection between health and migration and
highlighted how the inclusion of refugees and migrants in global preparedness and response plans is
essential to respond effectively to public health emergencies.
Shortly after WHO characterized the outbreak of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infections and subsequent COVID-19 as a pandemic, many countries introduced travel
restrictions and border closures, even though evidence for the efficacy of these measures was doubtful
(10). As a result, many migrants were not able to return to their countries of origin, refugees were not
able to travel onwards to their countries of destination, and home governments refused large numbers
of returnees (11). By mid-2020, the global number of international migrants had decreased by 2 million:
a 27% fall in the growth expected between July 2019 and June 2020 (12). Although individual asylum
applications temporarily fell worldwide between 2019 and 2020 to 1.3 million, a decrease of almost
1 million, the number of refugees rose to almost 20.7 million, an increase of nearly 250 000 (13).
A multitude of health-related clinical, logistic and social challenges have emerged for refugees and
migrants worldwide as a result of the pandemic. While some challenges are similar to those faced by the
populations in destination or transit countries, this report finds that some impacts of the pandemic are
heightened among, or even specific to, certain populations on the move. Chapter 3 reviews the impact
of COVID-19 on the health of refugees and migrants and Chapter 4 covers governmental responses.
Refugees and migrants may include essential also thrive when the entire population is
workers, health care providers, scientists and healthy (17,18). The health needs of refugees
artists, and they bring knowledge, experience, and migrants have to be recognized (19,20).
skills and more to the places where they Significant proportions of refugees and migrants
move (14–16). Countries benefit from the are healthy (19,20), but, like other populations,
contributions of refugees and migrants and they also have specific health needs (21–23). If
these health needs are ignored, both countries
and refugees and migrants can end up paying
more in the long run (24) than if the needs had
been anticipated, addressed and included
in national health policies, programmes and
The COVID-19 pandemic vividly services (25,26).
illustrated yet again the impact This introductory chapter frames international
of world events on the health of migration and displacement in the context
refugees and migrants. of health.
5
1.2 Definitions and terms challenges point to the need for more
higher-quality and standardized, disaggregated
This World report on the health of refugees data and definitions around health and
and migrants uses the term "refugees and migration (28).
migrants" in presenting evidence from
studies in which the population is not clearly 1.2.1 Key definitions
mentioned or includes several groups. Discussions on updating the definitions of
Whenever available, data that permit the international migrants are ongoing, with key
disaggregation of refugees and international questions centring around the length of stay
migrants are presented as such. The key and reason for displacement and migration.
definitions used in this report are summarized The terms and definitions most frequently used
in section 1.2.1, along with brief descriptions in this report are described below, although
of certain populations who are outside the the list is far from exhaustive.
report's purview. Use of the designations and
material in this report does not indicate an Migrant. A person who moves from one
opinion on the legal status of any country, place to another, whether across or within
territory, city or area or its authorities or on international boundaries. Despite the absence
delimitation of its frontiers or boundaries. of a universally accepted definition of
The term "country" as used in this report also "migrant", this definition is widely used (34).
refers, as appropriate, to territories or areas.
International migrant. Any person who
While the term "refugee" is defined in the 1951 changes his or her country of usual residence
Convention relating to the status of refugees (35). Unless otherwise identified, the
and the 1967 Protocol relating to the status migrants discussed in this report are
of refugees (27), there is no international international migrants.
consensus on the definition of "migrant".
This makes the work of synthesizing the state Refugee. Any person who meets the eligibility
of health and migration challenging (28). criteria under an applicable definition of
Thus, multiple definitions exist and discussions refugee, as provided for in international or
that aim to clarify terminology are ongoing, regional refugee instruments, under the
including discussions in 2021 at the 52nd mandate of the Office of the United Nations
United Nations Statistical Commission, one High Commissioner for Refugees (UNHCR) or
of which focused on common definitions for in national legislation. Under international
measuring concepts in migration (29). The law and the UNHCR's mandate, refugees are
1998 United Nations Recommendations on persons outside their country of origin who are
statistics of international migration defined in need of international protection because they
"international migrants" as people who fear persecution or a serious threat to their life,
changed their country of usual residency (30). physical integrity or freedom in their country of
The lack of consensus on the definition of origin as a result of persecution, armed conflict,
"migrant" creates challenges for systematically violence or serious public disorder (27,36).
collecting and analysing data about the health
of migrant populations. It also undermines Asylum seeker. An individual who seeks
the principle of health for all and increases international protection. In countries where
health inequities across refugee and migrant asylum cases are judged on a case-by-case basis
populations (28,31–33). The definitional using specific eligibility criteria, asylum seekers
6
are people whose claim has not been finally for the majority of workers in the informal
decided on by the country in which they have economy (40).
submitted it. Not every asylum seeker will
ultimately be recognized as a refugee, but There are also millions of people who are
every recognized refugee is initially an asylum described as stateless. Although their health
seeker (36). and living conditions are of enormous
importance to global health and development,
International migrant worker. This report the scope of this report is confined to refugees
uses the International Labour Organization and international migrants. The health of those
(ILO) definition of "all international migrants who move or are displaced within countries will
who are currently employed or unemployed receive in-depth attention in the near future.
and seeking employment in their present
country of residence" (37). Internal migration and displacement. Much
of this type of migration and displacement
Migrant in an irregular situation (also is thought to result from disparities in living
irregular migrant, undocumented conditions between rural and urban areas,
migrant). A person who moves or has as measured by unemployment, income,
moved across an international border and consumption or other non-monetary factors
is not authorized to enter or to stay in a (41,42). Gender plays an important and
state pursuant to the law of that state and to complex role in internal migration, as it does
international agreements to which that state is in migration across international borders. For
a party (34). example, significant numbers of women move
within their countries to become domestic
For full sets of definitions related to refugees workers or to take part in industries that hire
and migrants, see the UNHCR's Master women for specific types of work (43).
glossary of terms (36) and the International
Organization for Migration (IOM) Glossary on While large-scale rural-to-urban migration
migration (34). (section 1.7.1) rose along with burgeoning
economic expansion in the now-developed
1.2.2 Populations not included in economies from the 19th to the mid-20th
this report centuries, today's largest internal population
Together, internal migrants and internally shifts are in middle- and low-income countries,
displaced persons (IDPs) are considerably particularly China and India (41,44–46).
more numerous than their counterparts who As with international migration, data on the
cross international borders, although there health implications of internal migration
are no precise estimates of their numbers, and displacement remain incomplete
particularly for internal migrants. In 2013 and fragmented.
there were an estimated 763 million internal
migrants (that is, migrants who stay within IDPs. Individuals who are displaced by conflict
their country of origin), although the figures or disaster do not always cross an international
may be far higher due to the informal nature border. In fact, IDPs represent the majority
of much of this movement (38,39). Internal of the world's displaced, with 55 million
migration is one of the most significant globally at the end of 2020 (47). Of these, 48
characteristics of developing economies and million people had been affected by conflict
societies, in which internal migrants account or violence and 7 million had been displaced
7
due to disasters, including earthquakes and usual place of residence, environment and
climate-related issues. community, and separation from loved
ones can be overwhelming psychological
IDPs often show higher rates of undernutrition stressors (54,55). The most commonly
than non-displaced persons in similar reported impacts of internal displacement
circumstances. Displaced persons are not on mental health are post-traumatic
only forced away from their land and from the stress disorder (PTSD) and anxiety and
natural resources they used to rely on for food depression (56,57), but displacement can
but also tend to have less money to buy it. In also contribute to drug- and alcohol-use
2012 in Afghanistan, for instance, most families disorders and aggravate or increase the risk
displaced by conflict spent more than 75% of for developing chronic disorders, including
their limited income on food and still had to schizophrenia and psychosis (58).
reduce both its quality and its quantity (48). In
some contexts, IDPs may even be worse off than As many IDPs are displaced due to conflict,
refugees: a study conducted in Ethiopia, Kenya, women and girls carry the burden of caring
Sudan and Uganda showed that more than 15% for the family because men and boys are
of the IDPs suffered from acute malnutrition often absent. The need to look for food and
compared with 12% of the refugees (49). firewood sometimes raises risks of sexual
violence. Health facilities are often scarce in
The health needs of IDPs, who lack the formal areas where there are IDPs, making sexual
legal protections afforded to refugees, are and reproductive services inaccessible (59).
little understood, but research suggests they
experience equal or worse health outcomes Stateless person. The United Nations
than other conflict-affected populations (50). Convention Relating to the Status of Stateless
Persons defines stateless people as persons
Although the needs of IDPs for health care who are not considered to be nationals by
increase during displacement, their access to any state under the operation of its law (60).
health services usually deteriorates (51).They are Most live in their own countries and may have
often pushed away from familiar health systems, never crossed an international border (34,61).
practitioners and facilities, their financial However, many are migrants or refugees or have
resources are jeopardized and their social histories of migration and forced displacement
networks are destabilized, creating sometimes (62). Statelessness can both cause and be
unsurmountable barriers to accessing care. caused by migration. Moreover, displaced
IDPs with disabilities or illnesses requiring people are at a higher risk of becoming stateless
long-term treatment may see their conditions due to increased difficulties in proving their
deteriorate drastically after displacement (52). nationality, including as a result of conflicting
In a 2021 survey of people internally displaced nationality laws, the loss or destruction of
by violence in a country in the WHO African important documents, and a lack of access
Region, 17% said their access to health care to civil documentation or registration in their
had decreased during displacement, mainly country of refuge (62).
because they could no longer afford it (53).
There are an estimated 15 million stateless
Mental health is often undermined during people globally, with an additional tens of
displacement. Particularly for children millions whose nationality status is at risk (63).
and older people, sudden changes in their Although it is unclear how many migrants
8
or refugees are stateless, the figure is also nationality is obtained – for example, by
likely to be significant. This estimate includes being denied entry to hospital (65). In addition
Rohingya refugees, stateless Palestinians to the right to health, the lack of nationality
under the mandate of the United Nations also undermines the fulfilment of other
Relief and Works Agency for Palestine rights – including education, social security
Refugees in the Near East (UNRWA) and and an adequate standard of living – which
hundreds of thousands of stateless migrants are intrinsically linked to health (64,66).
and refugees in industrialized countries.
An example of how a barrier specific to
Stateless people share many of the challenges stateless people can be resolved was recently
that refugees and migrants face in accessing seen in Lebanon. Initially, registration for
health care, as well as additional unique COVID-19 vaccination required health care
problems owing to their lack of documented workers to input a nationality into the health
nationality. Because many health care systems information system, meaning that stateless
privilege citizens, stateless people often people could not register. Following advocacy
encounter barriers to access due to their lack by the civil society organization Oummal, the
of documentation, discrimination by health government added the category "stateless"
care providers and high fees, or have their to the registration portal, and this now allows
access limited to emergency medical care stateless persons to use their identity cards
(64). Discrimination often persists even when of stateless to access the vaccine (66).
In March 2022, Ukrainians fleeing the Russian invasion line up to leave the country from a train station in the city of Lviv. © WHO / Kasia Strek
9
1.3 Global displacement and number of forcibly displaced globally to be

migration patterns at 82.4 million (13).1 Refugees and asylum
seekers account for approximately 12% of
From 1990 to 2020, the global population international migrants, as estimated by the
increased from 5.3 billion to 7.8 billion. During United Nations Department of Economic and
those years, the total number of international Social Affairs (UNDESA) (67), and most of them
migrants increased from 153 million (2.9% of live in countries adjacent to their country of
the global population) to 281 million (3.6% origin (Fig. 1.2).
of the global population). About 48% of
international migrants are women (67) and Developing countries hosted 86% of the
some 36 million are children (67,68). The world's refugees and Venezuelan migrants
greatest increases in international migration (13). (Note that the term "Venezuelans
during the last decade have been due to family displaced abroad" is defined by the UNHCR
migration (including family reunification) as "persons of Venezuelan origin who are
and labour migration (12), although their likely to be in need of international protection
proportions of the total have changed little. under the criteria contained in the Cartagena
Since the early 2000s, circular migration Declaration, but who have not applied for
has also become more common, with asylum in the country in which they are
migrants moving temporarily for economic present" (13).)
opportunities and then returning to their home
countries, although the number of annual More than half of newly recognized refugees
circular migrants remains unclear during the first half of 2021 were from five
(Figs 1.1 and 1.2) (69). countries: the Central African Republic
(71 800 refugees), South Sudan (61 700), the
As of 2020, Europe and North America Syrian Arab Republic (38 800), Afghanistan
hosted the greatest number of international (25 200) and Nigeria (20 300). At the same point
migrants, followed by northern Africa and in time, there were 92 100 newly displaced
western Asia (67). The total numbers and Venezuelans (refugees, asylum seekers and
percentages of international migrants by World migrants) in Latin America and the Caribbean
Health Organization (WHO) region (including (70). By the end of 2020, more than three
migrants, refugees and asylum seekers) are quarters of the global refugee population
shown in Fig. 1.1. The top three host countries (15.7 million) was in a situation of protracted
by WHO region are shown in Fig. 1.2. displacement (13).
The number of people who have been forcibly

displaced globally continues to increase as a
result of conflict, humanitarian and climate-
related disasters. UNHCR has estimated the
1
In May 2022, after the writing of this report had been completed, UNHCR announced that the number of people forced to flee conflict,
violence, human rights violations and persecution had surpassed 100 million for the first time on record. The number of forcibly displaced
people worldwide was already rising towards 90 million by the end of 2021, propelled by new waves of violence or protracted conflict in
countries including Afghanistan, Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Myanmar and Nigeria. However, at the time
of writing in 2022, the war in Ukraine had displaced 8 million people within the country, and more than 6 million refugee movements from
Ukraine had been registered.
10
Fig. 1.1. International migrants, refugees and asylum seekers (percentage of the total population), by WHO region,
mid-2020
Region of the Americas European Region
International migrants: 6.7% (72 642 744) International migrants: 13.5% (100 816 833)
Male: 3.3% (35 395 181) Male: 6.6% (48 911 578)
Female: 3.4% (37 247 563) Female: 6.9% (51 905 255)
Refugees and asylum seekers: 18.4% (6 152 256) Refugees and asylum seekers: 5.0% (7 873 548)
Median age of all international migrants: 34.1 years Median age of all international migrants: 44.1 years
African Region
International migrants: 3.5% (22 049 842)

Male: 4.0% (11 569 246)
Female: 3.0% (10 480 596)
Refugees and asylum seekers: 21.0% (5 927 542)
Median age of all international migrants: 31.9 years
Eastern Mediterranean Region

Male: 16.0% (30 840 327)
Female: 6.8% (16 076 536)
South-East Asia Region

Male: 2.0% (5 743 000)
Female: 0.7% (6 025 016)
Western Pacific Region

Male: 7.8% (12 347 569)
Female: 8.0% (12 270 610)
Refugees and asylum seekers: 9.6% (712 849)
Not applicable
Source: United Nations Department of Economic and Social Affairs (67).

11
Fig. 1.2. International migrants, refugees and asylum seekers in the top three host countries, by WHO region, 2020
Region of the Americas European Region
International migrants Refugees and asylum seekers International migrants Refugees and asylum seekers
(% of total population) (% of international migrants) (% of total population) (% of international migrants)
Canada: 21.3% (8 049 323) Colombia: 93.5% (1 781 002) ermany: 18.8% (15 762 457)
G Türkiye: 64.6% (3 907 788)
United States: 15.3% (50 632 836) Peru: 70.9% (867 821) United Kingdom: 13.8% (9 359 587) Germany: 9.2% (1 455 947)
Argentina: 5.0% (2 281 728) United States: 2.3% (1 189 312) Russian Federation: 8.0% (11 636 911) France: 6.0% (510 080)
African Region
International migrants Refugees and asylum seekers

(% of total population) (% of international migrants)
Côte d’Ivoire: 9.7% (2 564 857) Uganda: 80.3% (1 381 122)

South Africa: 4.8% (2 860 495) Ethiopia: 67.7% (734 812)
Uganda: 3.8% (1 720 313) Democratic Republic of the Congo: 55.3% (526 931)

United Arab Emirates: 88.1% (8 716 332) Jordan: 87.3% (3 017 401)
Saudi Arabia: 38.6% (13 454 842) Lebanon: 82.0% (1 404 312)
Jordan: 33.9% (3 457 691) Pakistan: 43.6% (1 428 147)

Thailand: 5.2% (3 632 496) Bangladesh: 40.4% (854 820)

Bangladesh: 1.3% (2 115 408) India: 4.2% (207 334)
India: 0.4% (4 878 704) Thailand: 2.7% (98 418)
Top three host countries of international migrants by WHO region International migrants Refugees and asylum seekers
Top three host countries of refugees and asylum seekers by WHO region
Australia: 30.1% (7 685 860) China: 29.2% (304 041)
Top three host countries of both categories by WHO region Malaysia: 10.7% (3 476 560) Malaysia: 5.2% (179 744)
Japan: 2.2% (2 770 996) Australia: 2.0% (154 129)
Not applicable
Source: United Nations Department of Economic and Social Affairs (67).

12
1.4 Migratory patterns in and criminal activity. In 2021 the Bolivarian

WHO regions Republic of Venezuela experienced the
largest movement of refugees and migrants
Migratory patterns in the six WHO regions worldwide, after the Syrian Arab Republic.
vary greatly, depending on travel routes and More than 5.6 million Venezuelans were
methods, reasons for displacement and outside their country of origin towards the end
migration, demographics, and the context of 2021; of these, more than 80% had fled to
in which displacement and migration countries in Latin America and the Caribbean,
occurs. All of these have important impacts most notably Colombia, Ecuador and Peru (73).
on the health of refugees and migrants.
WHO South-East Asia Region. In general,
WHO African Region. Almost 75% of migrants this Region sends migrants to other areas,
from countries in sub-Saharan Africa remain particularly to North America, Europe,
within the continent. Approximately 20% travel countries in the Gulf Cooperation Council, and
to Europe, North America, the countries of Australasia. Flows of international migration
the Gulf Cooperation Council and Asia along include movement from Myanmar to Thailand
the Central Mediterranean Route (the most (74); from Nepal (75), Bangladesh and Bhutan
dangerous), Western Mediterranean Route, to India (76); from many of the Region's
Eastern Mediterranean Route, West African countries to the Maldives (77); and from Timor-
Route and Western Balkan Route (see Box 3.1). Leste to Indonesia (78). Rohingya refugees
Fleeing poverty and conflict and seeking better from Myanmar are the biggest refugee group,
opportunities and environmental conditions with close to 1 million living in Bangladesh
remain important drivers. Even so, the COVID-19 (79). There are smaller groups of refugees from
pandemic significantly reduced migratory flows Myanmar on the Thailand–Myanmar border
within the Region and to Europe due to the (80), Sri Lankans in India, and Bhutanese in
restrictions on movement (71–73). Nepal, with diverse refugees in Indonesia
waiting to go to Australia (81).
WHO Region of the Americas. Migration
towards North America remains prominent, WHO European Region. The main drivers
mostly from other parts of the Americas, as well of international migration into Europe are
as from Asia (notably China, India and the intraregional labour migration as a result of the
Philippines). The United States of America is European Union (EU), people fleeing conflict in
the largest recipient of migrants worldwide, the Middle East and sub-Saharan Africa via the
with 18% of total global migrants (51 million) Central and Western Mediterranean Routes,
in 2020 (12). The largest migration corridor in labour migration from Asia and Latin America,
the world is between the United States and nationals of central and eastern Europe
Mexico, which is a key country of origin, settling in western and southern Europe, and
transit and destination. As well as economic migration between the Russian Federation
factors, displacement and migration from and countries of the former Soviet Union.2 In
Central America and the Caribbean reflect 2020 Europe hosted approximately 6.8 million
environmental events, such as droughts and refugees and people in refugee-like situations,
hurricanes, as well as generalized violence with Türkiye alone hosting nearly 3.7 million
2
The data presented here do not include the mass displacement resulting from the conflict in Ukraine that began on 24 February 2022.
13
refugees, about 15% of all people displaced

across borders globally. In 2019 the Russian
Federation was the major destination country With many women migrating
(12 million) and country of origin (11 million) during their prime childbearing
for international migration in the Region
(67,73,82,83).3
years, the health needs of women
and girls in any given situation are
WHO Eastern Mediterranean Region.
Large flows of labour migration have occurred
often different from those of men,
into, from and within the Region, with much and they require additional
of the intraregional movement focused on the
high-income countries of the Gulf Cooperation
medical services for prenatal,
Council (84). In 2017 the Region's countries labour and delivery care, and for
hosted 23.8 million migrant workers, about
14.5% of the global total (85). Many countries in
postpartum care. However, the
this Region remain affected by protracted and health of men and boys is also
unresolved conflicts, including Afghanistan, affected by gender-based risks.
Somalia, the Syrian Arab Republic and Yemen.
These conflicts have resulted in large numbers
of refugees, including 6.7 million from the
Syrian Arab Republic and 2.6 million from
Afghanistan, most of whom are hosted in the
Region itself (13,86,87).
1.5 Age and gender
WHO Western Pacific Region. In 2020
Australia was among the top 10 host countries, The gender and age distributions of refugees
while China and the Philippines were among and migrants vary across WHO regions
the top 10 origin countries (12). Malaysia (Fig. 1.1). In most regions the difference between
and Singapore are both prominent host and the numbers of males and females is less than
origin countries (73). Migration for seasonal 10%, but in the WHO Eastern Mediterranean
employment is widespread in the Pacific Island Region the proportion is almost double for
nations, with Tonga and Vanuatu sending male refugees and migrants. With many women
significant numbers of people to Australia migrating during their prime childbearing years,
and New Zealand for work in industries the health needs of women and girls in any
such as agriculture and hospitality (88). In given situation are often different from those
2015 approximately 85%, or 16.2 million, of of men, and they require additional medical
the world's internally displaced population services for prenatal, labour and delivery care,
migrated as a result of natural disasters in Asia and for postpartum care (22,90–92). However,
and the Pacific (88). The largest sources of the health of men and boys is also affected by
refugees in 2020 were China and Viet Nam (89). gender-based risks (Chapter 2).
3
In May 2022, after the writing of this report had been completed, UNHCR announced that the number of people forced to flee conflict,
violence, human rights violations and persecution had surpassed 100 million for the first time on record. UNHCR estimated that during
the early part of 2022 the war in Ukraine had displaced 8 million within the country and that more than 6 million refugee movements from
Ukraine had been registered.
14
Refugees and other forcibly displaced

populations often have distinct protection
While many countries hosting and health needs. For example, women and
refugees have policies allowing girls often lack access to urgent reproductive
health services and are at increased risk of
refugees to access health and sexual violence (59,90). While many countries
social protection services, that hosting refugees have policies allowing
refugees to access health and social protection
access may be partial, entail services, that access may be partial, entail
prohibitive out-of-pocket prohibitive out-of-pocket expenditures and
involve additional barriers, including distance
expenditures and involve to facilities, language and discrimination by
additional barriers, including providers (96,97).
distance to facilities, language The sudden arrival of large numbers of

and discrimination by providers. refugees and asylum seekers can severely test
public health and social protection services
(98,99). Examples of particular challenges
include a lack of access to health insurance,
barriers to accessing care (including language,
previous interactions with medical care
At mid-year in 2020, migrants aged 65 years services, and understanding of diagnoses,
and older accounted for an estimated treatment options and use of medicines),
34.3 million (12.2%) of all international the quality of care and satisfaction with
migrants, calculated using the foreign-born care (including a lack of continuity of care
or foreign population as a proxy for and cultural sensitivity, and barriers to
international migrants (67,93). understanding and navigating the health
system). Women and girls often lack access
to urgent reproductive health services and
1.6 Displacement are at increased risk of sexual violence
(59,90). In response to these challenges,
The UNHCR estimates that 82.4 million people global assessments have been conducted
were forcibly displaced worldwide at the to report on the ability of various states to
end of 2020, and 34.5 million of these were address influxes of refugees and migrants
refugees, asylum seekers and Venezuelan (98,100). These assessments highlight
migrants (13). These populations should be a potential strains on health care systems,
focus of efforts to improve population health, which may be due to a country's size or
given the additional challenges, stressors resources or its position as transit country in
and health-eroding environmental exposures the migratory pathway or to receiving a large
they may have experienced (94,95). Fig. 1.1 displaced population; they emphasize the
shows the total number and proportion of need for international assistance to address
refugees and asylum seekers by WHO region. the risk of infectious diseases (101,102).
15
1.7 Health and the dynamics Understanding the determinants of

of global displacement displacement and migration can help health
and migration systems, policy-makers and practitioners
safeguard and promote the health of
Displacement and migration are major refugees and migrants (105,106). For
determinants of health for large numbers of example, a comparative health advantage
people worldwide (103). This report describes observed among some refugees and
in detail various aspects of health and migrants is partly the result of selection
migration, taking into account a number of bias: younger, healthier persons are able
frameworks for thinking about how migration to migrate due to the health requirements
affects the health of populations (104). that some need to fulfil prior to departure,
Health education sessions help promote healthy eating and prevent diabetes in Jordan’s Zaatari refugee camp. © WHO / Tania Habjouqa
16
especially if seeking international a chronic disease moves from one place

employment (107,108). The health of to another, their health situation may be
refugees and migrants compared with that worsened during the migration or transit phase
of host populations after arrival is also because they have limited or intermittent
partly related to the overall health of the access to health care services (115). Another
host country's populations, as well as to the example includes changes in dietary patterns
services that the refugees and migrants are after migration, which may increase the
able to access (109). risk for diseases (108) or, conversely, result
in improved health outcomes (116–118).
Displacement and migration do not happen
in a vacuum. As summarized in the social– This social–ecological model represents
ecological model in Fig. 1.3, the contexts personal health as the product of multiple
that surround migration – before, during, factors, cascading outwards from individual
after and on return – influence the health characteristics and behaviours to the social and
of refugees and migrants as much as their economic conditions that shape people's lives
individual characteristics. Population growth (119). Determinants of health at various levels
and decline are major drivers of migration of the model affect the health of refugees and
as people move to access resources. People migrants differently during the different phases of
may choose to migrate to seek economic displacement and migration. For example, while
opportunity, medical treatment, educational a language barrier might not exist in the country
opportunity or an improved standard of of origin, it becomes a relatively significant barrier
living (111). Others may instead be forced for a refugee or migrant seeking health care and
to leave their homes or places of residence utilizing health services. Similarly, belonging
(displacement). Countries may implement to a minority group might lead to persecution
policies to encourage or discourage migration and eventually to displacement, but might also
depending on their own needs, to respond become the most important reason to be granted
to the sensitivities of their own labour force, protection in another country (refugee status, for
to support social services, for humanitarian example). The intersections of the determinants
reasons or in response to political pressures of health and the different phases of migration
(24,112,113). Additionally, factors such as with those of the life course (120) may result in
ageing, urbanization, conflict and climate distinct, immediate health outcomes, such as
change may influence trends in both in the tragic cases of preventable deaths during
displacement and migration and the health transit or over time, for example, in the delayed
needs of refugees and migrants (114). onset of illness (83,115,119,120).
Fig. 1.3 illustrates the determinants that can A comprehensive approach to protecting
influence the health and well-being of refugees and promoting the health of refugees
and migrants at different levels, starting and migrants must take into account the
from that of the individual and becoming full set of determinants of health in each
intertwined throughout the four phases of context, both throughout the displacement
displacement and migration. It highlights the and migration process and across the life
importance of micro-, meso- and macro-level course. In many ways, policies that promote
factors that influence the health vulnerabilities the health of refugees and migrants also
of refugees and migrants during all four promote the health of the larger population,
phases. For example, when someone with including the host population (121–123).
17
Fig. 1.3. Determinants of health and phases of migration
Transit
phase
cioeconom
General so nmental ic, cultural
and enviro conditions
Pre-migration
phase
working conditio
Living and ns
Social and community networks
Individual lifestyle factors
Arrival and
Age, sex and integration
hereditary factors phase
Return
phase
Source: reproduced by permission of the publisher from Dahlgren & Whitehead (110).
The experience of displacement and In the coming decades, several trends

migration is itself a determinant of health, and will influence both displacement and
examining different phases of displacement migration and the health needs of
and migration helps to illuminate its impact refugees and migrants. These trends are
(111). Important cross-cutting factors include particularly important for policy-makers
sex, age, race or ethnicity, and a variety of who are considering how refugees and
socioeconomic conditions experienced migrants contribute to and require
during the four phases of migration (124). different responses from health systems.
18
1.7.1 Urbanization Urbanization may also be associated with

Urbanization is perhaps the salient global poor mental health when conditions include
demographic shift of the first half of the 21st overcrowding, limited resources and the
century, with more than half the world now loss of social support systems (132). Key
living in urban areas (125). Urbanization refers to assessing the influence of urbanization
to the movement of persons from more rural on health is an understanding of health
to more urban, or densely populated, areas. inequities (129) and of the differences
People often move to urban centres, either in between urban dwellers with assets versus
their home countries or internationally (126), urban dwellers without assets. Urbanization
to seek economic opportunity and access to can also be associated with better health
resources, such as education, employment, indicators, particularly for persons who
health care and efficient governance. improve their social and economic well-being
Urbanization provides opportunities for as a result of moving to more urbanized areas.
social and economic progress (127,128); Given that the number of urban dwellers
however, adapting to urban living is complex, is projected to grow to 6.7 billion by 2050,
given the associated reductions in physical focusing on the health of urban refugees and
activity, increased pollution, overcrowding, migrants has become urgent (125).
poor nutrition, risk of communicable
diseases, changes in land use, urban heat 1.7.2 Brain circulation:
island effects, and shifts in lifestyle choices, brain drain versus brain gain
nutritional patterns and human behaviours The movement of skilled labour may result
(129,130). Women living in poor urban areas in a so-called brain drain, typically from
are disadvantaged in terms of access to lower-income countries, and a brain gain
employment, health facilities and secure in higher-income countries in a process
housing, and their ability to complete their known more generically as brain circulation
education, and they are more subject to the (133,134). Host countries benefit from brain
social and economic effects of crises such as gain – that is, the migration of highly skilled
the COVID-19 pandemic (131). and productive trainees and workers,
particularly those who conduct research and
provide medical care. Including people with
diverse experience and backgrounds in high-
skill workplaces can advance technologies,
science and governance. Additionally,
migrants may return home with new skills or
The experience of displacement share their skills or knowledge with networks
and migration is itself a in their countries of origin.
determinant of health, and Conversely, brain drain may worsen the

examining different phases of availability of services, such as health care, if
displacement and migration highly skilled doctors and nurses leave lower-
income countries seeking better economic
helps to illuminate opportunity. Studies of skilled health care
its impact. workers who left their home countries found
that key to the decision to migrate were
interests in professional advancement, social
19
support and finding intellectual communities pickup in economic activity and employment
(135). As a result of their departure, fewer in countries that are major destinations for
skilled workers were left to address the needs migrants, grounded partly in the exceptional
of the populations remaining in their countries COVID-19 emergency fiscal stimuli and
of origin. The departure of nurses, for example, accommodative monetary policies.
reduced access to and services for populations
in their home countries (135–137). However, In most other areas, remittances have also
this loss may be partly offset because the flow recovered strongly, registering growth of
of human capital and talent to other countries 5–10% in Europe and Central Asia, the Middle
can lead to positive outcomes in terms of East and northern Africa, southern Asia and
remittances and of a transfer of skills back to sub-Saharan Africa, but at a slower pace of
their home countries (138). 1.4% in eastern Asia and the Pacific, excluding
China (139). The key contributing factors
1.7.3 Sending money home are the willingness of migrants to support
Remittances are an important and their families in times of need, together with
positive economic result of migration for the fiscal stimuli and employment support
migrants themselves and for family and programmes implemented in the United
friends remaining in their home countries. States and European destination countries,
Once migrants have accessed economic which provided many migrants with the
opportunities, they often send remittances financial wherewithal to increase support to
to their families. Remittances account for their families at home. In the Gulf Cooperation
a large fraction of the global movement of Council countries and the Russian Federation,
funds. Despite predictions that remittances the recovery of outward remittances was
would fall due to the COVID-19 pandemic also facilitated by stronger oil prices and the
(in part as a result of travel restrictions resulting pickup in economic activity.
and the economic downturn), remittances
proved to be resilient (139). The economic In 2021 the top five remittance recipients in
recovery in 2021 followed the resilience current US dollars were India, China, Mexico,
of remittance flows seen in 2020, which the Philippines and Egypt. As a share of
declined by a modest 1.7% to US$ 549 billion gross domestic product (GDP), the top five
in the face of one of the deepest global remittance recipients in 2021 were smaller
recessions. Remittances now stand at more economies: Tonga, Lebanon, Kyrgyzstan,
than threefold above official development Tajikistan and Honduras (Fig. 1.4). The United
assistance and are more than 50% higher States was the largest source country for
than foreign direct investment, excluding remittances in 2020, followed by the United
in China. This underscores the importance Arab Emirates, Saudi Arabia and Switzerland.
of remittance flows in supporting spending Remittances increase or maintain consumer
in recipient countries during periods of spending and soften the blow of economic
economic hardship (140). hardship, such as during the COVID-19
pandemic. Remittances are expected to
In many low- and middle-income countries, continue growing in 2022, but there are
migrants stepped up their support to families challenges, such as the COVID-19 crisis, which
back home, especially to countries affected still poses one of the greatest risks to flows to
by the spread of the COVID-19 Delta variant. low- and middle-income countries, especially
Their ability to help was enabled by a welcome as fiscal stimulus programmes in migrant
20
Fig. 1.4. Top remittance recipients among low- and middle-income countries, 2021 estimates
100 100
90 87 90
80 80
% of gross domestic product

70 70
60 60
US$ (billions)
53 53
50 50 44
40 36 33 33 40 35
30 28
30 30 27 26 25
23 24 24
18 18 21
20 16 20
10 10
0 0
India
China
Mexico
Philippines
Egypt
Pakistan
Bangladesh
Viet Nam
Nigeria
Ukraine
Tonga
Lebanon
Kyrgyzstan
Tajikistan
Honduras
El Salvador
Nepal
Jamaica
Lesotho
Samoa
Country Country
Source: reproduced by permission of the publisher from Ratha et al. (139).
destination countries cannot continue migration depends on factors such as the

indefinitely (140). legal continuum of care, opportunities for
children to have contact with their parents
1.7.4 Left-behind families and the support received from guardians and
Migration affects not only people who the community. Migration can also help to
move but also their family and community lift families from poverty, where remittances
members who remain: an estimated 193 are used to fund health care, medicine and
million family members of migrant workers nutritious food; create autonomy for women;
are left behind (i.e. family members who and provide opportunities for the families and
remain in the country of origin) (141). communities of those who migrate (14–16).
Outward migration can lead to brain drain At the same time, several reviews and meta-
(section 1.7.2) and care drain in communities analyses show negative health effects on
of origin: migration of individuals to high- the left-behind children of migrant workers.
income countries to undertake care jobs for These include, for example, the unreliability
the host population can create a care deficit of remittances, which may disrupt health
for their own families, especially for children care for children who are left behind (145–
and older people (142–144). More research is 147). Children who stayed behind in their
needed to understand the health effects on home country also faced increased risks for
family members who are left behind. Whether depression, conduct disorder, substance
labour migration can help to enhance the use, and wasting and stunting relative to the
well-being of children affected by labour children of non-migrants (146). Differences
21
between the children of migrants and non- The smuggling of migrants is defined in the
migrants were not found for other outcomes United Nations Protocol Against the Smuggling
around nutrition, abuse, diarrhoea or of Migrants by Land, Sea and Air as the
unintentional injury. "procurement, in order to obtain, directly or
indirectly, a financial or other material benefit,
Family separation can affect the health of the irregular entry of a person into a State
outcomes of the families of both international Party of which the person is not a national or a
and internal migrants. However, despite permanent resident" (153).
the potential negative health outcomes,
economic opportunities remain a significant In contrast, trafficking in human beings is
motivation for migration. defined by the United Nations Protocol to
Prevent, Suppress and Punish Trafficking in
1.7.5 Discrimination and Persons, Especially Women and Children as
xenophobia the "recruitment, transportation, transfer,
While migration provides many benefits, harbouring or receipt of persons, by means
refugees and migrants may face hateful of the threat or use of force or other forms of
treatment or attitudes. Xenophobia or coercion, of abduction, of fraud, of deception,
othering is the treatment of people as of the abuse of power or of a position of
outsiders because of their language, culture, vulnerability or of the giving or receiving of
appearance or place of birth. Xenophobia payments or benefits to achieve the consent of
may expose refugees and migrants in host a person having control over another person,
countries to discrimination, mistreatment for the purpose of exploitation" (154).
or violence, and it has serious public health There are few data about the health status
consequences. In addition to limiting or specific health care needs of smuggled
access to health services, xenophobia may refugees and migrants or those who are
also lead to migrants developing chronic trafficked (155,156). The absence of good data
stress syndrome and a variety of other also reflects the complexities of gathering
problems, such as anxiety, sleep disorders information about "mixed migration", the
and depression (148–151); it can also lead term applied when a number of people are
to health systems and health care providers travelling together for different reasons but
being unaware of and unresponsive to the using the same routes and means of transport,
health needs of refugees and migrants, and to often with false or no official documents (157).
the exclusion of the most vulnerable among
them (149,152). According to the United Nations Office on
Drugs and Crime's Observatory on Smuggling
1.7.6 People smuggling and of Migrants, many smuggled refugees
human trafficking and migrants are subject to physical and
While much migration occurs without psychological abuse perpetrated by a variety
contravening laws or regulations, a significant of actors, including smugglers but also private
yet unmeasurable portion of migrants is individuals, non-state armed groups and
exploited by criminal networks. Although state authorities (158). For example, research
different in legal terms, people smuggling and suggests that smuggled migrants from
human trafficking share many similarities in western Africa, northern Africa and the central
how they are carried out, and are sometimes Mediterranean undertake huge risks while
hard to distinguish from each other. crossing the desert or sea. Many lack food
22
and water, and some have seen their travel The health implications of conditions along
companions die as a result (158). migrant smuggling routes make it all the
more urgent to pursue Target 10.7 of the
Women and girls face serious health Sustainable Development Goals (SDGs),
risks, especially if they are simultaneously which commits the international community
breastfeeding and taking care of children or are to facilitating the orderly, safe, regular and
pregnant, or a combination of these. Similar to responsible migration and mobility
children and older people, they are more likely of people.
to be abandoned during a smuggling journey.
Moreover, abuses are highly gendered (159). 1.7.7 Climate change
Whereas women and girls are more likely to be Climate-related displacement and migration
exposed to sexual violence and to lack access are emerging as growing international
to health services, men and boys (the majority concerns (160,161). Recent studies suggest
of smuggled people on most routes) also that the impact of anthropogenic climate
experience physical violence, forced labour change may already be felt across 80% of
and inhuman and degrading treatment. the world's land area, which has 85% of the
population (162).
The enforcement of certain laws may also
have implications for health. The detention of Although the link between climate change
irregular migrants by government authorities and the movement of people is complex,
often involves exposure to insanitary and climate change is undoubtedly already
dangerous conditions in detention centres, as shifting patterns of mobility and will
well as to food and water deprivation. Abuse increasingly do so. Climate migrants are
and violence were commonly reported in a defined as "persons who, predominantly for
study of those who arrived in Italy using the reasons of sudden or progressive change
Central Mediterranean Route (159). in the environment due to climate change,
are obliged to leave their habitual place
of residence, or choose to do so, either
temporarily or permanently, within a State or
across an international border" (34).
Rapid-onset climate-related crises are already

displacing large numbers of people. In
2020, for example, of the 40.5 million newly
Policies and programmes that internally displaced people, 76%
separate families, limit access (30.7 million) were forced to move by
to medical or social services, or disasters, virtually all of which were

weather related, even if not all were
condone or promote violence, directly attributable to climate change. In
discrimination, prolonged comparison, 24% (9.8 million) were displaced
by conflict and violence (47). In addition,
detention or illicit trafficking one of the most recent models, and the only
yield poor health. one focusing on people internally displaced
by slow-onset climate processes, estimates
that 140 million people could be internally
23
displaced by 2050 in only sub-Saharan Africa, 1.8 Health and migration

Latin America and southern Asia (160). policies
Often, climate change affects human health Health and migration policies should be
directly, such as when hazards cause applied in countries of origin, transit and
injuries and deaths. The effects of climate destination and be formulated with the
change can also be indirect, brought about participation of refugees and migrants
through factors such as changes in the themselves, in line with wider efforts to include
epidemiological patterns of vector-borne mobile populations within health systems. The
diseases due to shifts in mean temperatures, Comprehensive Refugee Response Framework
increased air pollution from wildfires, or formulated in 2016 provides pragmatic and
the diminishing availability of food and socially inclusive guidelines, some of which
water. Lastly, climate change affects human can be applied to a wide variety of contexts
health through complex interactions (168–170).
with the cultural, social, economic and
political milieux in which it takes effect. Policies in countries of origin, transit and
In some places, it may contribute to risks destination can promote health in a variety
of conflict and violence by intensifying of ways – for example, policies that provide
disputes over scarce resources, reducing adequate housing, food, medical care,
economic opportunities, and straining public education, work conditions; equitable
institutions and infrastructure (163). At this treatment; and economic opportunities (171).
level, climate change acts as a risk multiplier Conversely, policies and programmes that
by compounding the effects of pre-existing separate families, limit access to medical
social and political determinants of or social services, or condone or promote
health (164). violence, discrimination, prolonged detention
or illicit trafficking yield poor health (109). For
Quantifying the impact of climate change example, political stability is associated with
on human mobility is difficult for several improved health for populations (172,173).
reasons. The key challenge is that
climate change acts as a direct driver of Optimizing the policies that are put in
migration, and it also influences a range place to improve the health of refugees and
of additional environmental, economic, migrants and host populations requires
social, demographic and political drivers of engaging with the target communities
displacement and migration (165,166). Other themselves. Including refugees and migrants
challenges include logistic difficulties in in health policies is consistent with the
collecting reliable data and methodological universal values of the SDGs and the pledge
inconsistencies across jurisdictions; the fact to leave no one behind (174). Providing access
that, at least for now, most movements of to basic care and preventive treatment aligns
people happen over short distances and not with global standards for human rights.
across international borders; and the almost Access to services includes universal health
complete lack of quantitative information coverage (UHC) and a primary health care
about people displaced by slow-onset (PHC) approach, including services such as
processes (163,167). language translation services and culturally
sensitive case management.
24
1.8.1 Key international frameworks the needs of refugees and migrants. This could
Health and displacement and migration are promote better transparency, accountability
integrally linked to the three agendas of global and management of future public health
health, global development and migration emergencies (183).
governance. At the international level, these
global agendas have enshrined addressing At the heart of these efforts is ensuring the
the needs of displaced populations and mainstreaming of displacement and migration
migrants as strategic areas that are key to within the health agenda and of health within
achieving policy goals. Numerous frameworks, the displacement and migration agenda (184).
agreements and resolutions have been forged Implementing this vision requires a pragmatic
during the last decade within national, regional effort across the following three focus areas.
and multilateral platforms. The two global
compacts (the Global compact on refugees (175) Integrated health needs. The first is to
and the Global compact for safe, orderly and ensure that the health needs of refugees
regular migration (176)), multiple World Health and migrants are applied across the health
Assembly resolutions and decisions (2008, sector and are explicitly integrated into
2017 and 2018), two global consultations on national health systems and programmes. For
migration and health (2010 and 2017), the 2030 instance, the critical importance of migration
Agenda for Sustainable Development and the is recognized in the Global plan to end TB
United Nations Political Declaration of the High- 2018–2022 (185), while ensuring inclusive and
level Meeting on Universal Health Coverage sensitive care and prevention services for
(2019) provide the basis to advance the refugees and migrants is a key pillar of the
formulation of policy and promote multisectoral framework of the End TB Strategy (186).
action to include, protect and integrate refugees
and migrants (175–181). Beyond the health sector. Secondly,
similar to the general population, solutions
One of the key regulations relevant to the for improving the health of refugees and
context of displacement and migration is the migrants cannot be found within the health
International Health Regulations (182). While sector alone (187). To meaningfully address
the International Health Regulations are not the underlying determinants and inequities
specific to refugees and migrants, they are as part of the development agenda requires
legally binding and oblige Member States intersectoral action. There is a need to
to develop specific public health core improve migration health literacy within the
capacities, in particular at points of entry foreign affairs, labour migration, travel, trade
(i.e. international ports, airports and ground and immigration-control sectors. A positive
crossings) to prevent, protect against, control development has been the inclusion of the
and provide a public health response to the health and migration agenda at various high-
international spread of diseases, with level regional forums within regional and
a precautionary approach. subregional blocs. Health and migration have
emerged as a strategic focus for discussions
At the Special Session of the World Health around labour migration, trade and economic
Assembly, a decision was taken to negotiate cooperation. It is also becoming apparent
an international instrument on pandemic that regional and subregional initiatives on
preparedness and response that will take into cross-border travel, trade and economic
consideration the migratory phenomenon and cooperation can be important drivers of action
25
for the health of migrants. Examples of regional Formulating policies and programmes rooted
and subregional migration governance in emergency preparedness and response
initiatives that include health as a key priority remains essential. However, to build resilient,
are the African Union Migration and Health refugee- and migrant-sensitive health systems,
Programme (188); the 2018 Quito Process structural policies are needed that recognize
between countries in Latin America and the long-term displacement, regular migration and
Caribbean receiving Venezuelan refugees and mixed migration flows. Investment in research
migrants (189,190); the Colombo Process for needs to be linked to policy-making, and it is
labour-sending countries of origin in Asia (191); crucial to enhance capacities and mentorship
and the European Commission's migration among researchers in developing regions.
health programme (192). Translating knowledge to policy effectively
means both generating rigorous evidence and
Better information. Thirdly, there is a need ensuring that this evidence informs the policy-
for improving health information and research making process.
platforms to promote the development of
evidence-informed policy and practices. While the COVID-19 pandemic will likely
Health information systems (HIS), routine push health systems worldwide towards
health surveys and registries, and other a greater focus on public and population
platforms that guide health care decisions health, several governments have taken
often exclude refugees and migrants and proactive measures to promote a refugee- and
do not take account of human mobility. migrant-inclusive approach to their COVID-19
Therefore, it is essential to integrate such response and recovery. For example, Peru
modules within a rigorous ethical and data approved temporary health coverage for
protection framework (193). The challenges refugees and migrants suspected of having
of and potential for improving data collection or who test positive for COVID-19 (197).
and analysis are dealt with in greater detail in Portugal temporarily lifted all barriers and
Chapters 5 and 6. provided free access to their national health
service, including for irregular migrants (198).
During the last decade, there has been Singapore set up medical facilities and triage
growing recognition that the health needs clinics in dormitories for migrant workers and
of refugees and migrants are a global health provided them with food and other necessities
priority. However, a number of practical (199). In the United Kingdom, charges were
considerations must be taken into account. waived for the diagnosis and treatment of
These include identifying and then training COVID-19 for all non-nationals, regardless of
staff in key government programmes and their residency or migratory status (200).
structures to take action for refugee and
migrant health at the national, regional Despite these positive developments, many
and local levels. Investments are also countries have explicitly stated to international
needed to support technical cooperation human rights bodies that they cannot or
to address health in displacement and do not want to provide health protection,
migration, galvanize intersectoral action including essential health services, to migrants,
and build evidence platforms to guide and especially to irregular migrants (201).
action. The resources and knowledge of COVID-19 is providing a powerful impetus for
diaspora populations should also be engaged change: evidence prior to 2021 shows that,
whenever possible (194–196). until recently, few countries included refugees
26
and migrants in their national pandemic across organizations and exchange of

preparedness plans or in broader health information could yield improved outcomes
policies (202,203). The rhetoric of leaving no (177,206). Similarly, resolution WHA70.15
one behind is futile if populations of refugees (Promoting the health of refugees and
and migrants continue to be restricted in their migrants) urged Member States to "identify
abilities and rights to access affordable health and collect evidence-based information, best
and social protection services. practices and lessons learned in addressing
the health needs of refugees and migrants
1.8.2 WHO resolutions and in order to contribute to the development
action plans of a draft global action plan on promoting
Within the United Nations, WHO has primary the health of refugees and migrants" (207).
responsibility for promoting and achieving This was translated into a framework that
health for all and UHC and PHC within the encompasses the priorities and guiding
context of the 2030 Agenda for Sustainable principles necessary to promote the health of
Development and its associated SDGs (180). refugees and migrants. Accordingly, Member
WHO works with its Member States to achieve States took note of the WHO Global action
the highest level of health for all people plan on promoting the health of refugees and
by pursuing UHC. Since 2019, WHO's work migrants, 2019–2023 (GAP) (208), following
and activities have been carried out within from the United Nations’ 2016 New York
its Thirteenth General Programme of Work declaration for refugees and migrants (170),
2019–2023 (GPW13), which was approved by which acknowledges specific national
the Seventy-first World Health Assembly in commitments adopted by Member States, and
resolution WHA71.1 in 2018 (204). In May 2022 the priorities and guiding principles necessary
the Health Assembly agreed to extend the for promoting the health of refugees and
timeline of GPW13 to 2025 (205). migrants, which were adopted at the Seventy-
second World Health Assembly in 2019 (209).
GPW13 focuses on the Triple Billion Targets
to achieve measurable impacts on people's WHO's GAP is fully aligned with the framework
health at country level (204). The GPW13 of priorities and guiding principles to promote
framework prioritizes guiding principles that the health of refugees and migrants (207),
aim to promote health, keep the world safe the United Nations’ SDGs (180), the Global
and serve the vulnerable. The framework re- compact on refugees and the Global compact
emphasizes the pledges of the 2030 Agenda to for safe, orderly and regular migration
leave no one behind, including refugees and (175,176). Both the GAP and the framework
migrants (180). of priorities and guiding principles were
developed in close collaboration with the IOM,
More specifically, policies that refer to health the UNHCR and other relevant stakeholders. A
and displacement and migration have monitoring framework is being developed to
created awareness that these concepts are track progress on implementing the GAP.
interlinked. Resolution WHA61.17 (Health of
migrants) recognized that multiple dimensions WHO's Health and Migration Programme was
of migration can affect health, that some created as a strategic commitment to provide
groups of persons who migrate may have global leadership on health and migration
elevated health risks and that the timely issues, including helping to implement the
and sensitive tracking of data, coordination GAP at the global, regional and country
27
levels and to address all of its priorities.

These include implementing public health
interventions, promoting the continuity and
ensuring the quality of health care, engaging
in advocacy to mainstream health policies
that are sensitive to the needs of refugees
and migrants, and strengthening capacity to
tackle social determinants of health, as well
as monitoring trends, strengthening HIS and
developing an accountability framework and
indicators to monitor and report on progress
made in implementation and communication.
This report is a response to these priorities.
28
References 11. Connor P. More than nine-in-ten people worldwide live

in countries with travel restrictions amid COVID-19. In:
Pew Research Center [website]. Washington (DC): Pew
Research Center; 2020 (https://www.pewresearch.org/fact-
tank/2020/04/01/more-than-nine-in-ten-people-worldwide-
1. Zhunio MC, Vishwasrao S, Chiang EP. The influence of live-in-countries-with-travel-restrictions-amid-covid-19/,
remittances on education and health outcomes: a cross accessed 9 January 2022).
country study. Appl Econ. 2012;44(35):4605–16. doi:10.1080/
12. International migration 2020: highlights. New York: United
00036846.2011.593499.
Nations Department of Economic and Social Affairs; 2020
2. Amega K. Remittances, education and health in sub-Saharan (https://www.un.org/en/desa/international-migration-2020-
Africa. Cogent Econ Finance. 2018;6(1):1516488. doi:10.1080/ highlights, accessed 9 January 2022).
23322039.2018.1516488.
13. Global trends: forced displacement in 2020. Geneva: United
3. International Labour Organization, Organisation for Nations High Commissioner for Refugees; 2021 (https://www.
Economic Co-operation and Development. How immigrants unhcr.org/60b638e37/unhcr-global-trends-2020, accessed
contribute to developing countries' economies. Paris: 23 November 2021).
Organisation for Economic Co-operation and Development;
14. Dumont J-C, Liebig T. Is migration good for the economy?
2018 (https://www.oecd-ilibrary.org/development/
Paris: Organisation for Economic Co-operation and
how-immigrants-contribute-to-developing-countries-
Development; 2014 (https://www.oecd.org/migration/
economies_9789264288737-en, accessed 9 January 2022).
OECD%20Migration%20Policy%20Debates%20Numero%202.
4. Report on the health of refugees and migrants in the WHO pdf, accessed 6 September 2021).
European Region: no public health without refugees and
15. Goldin I, Cameron G, Balarajan M. Exceptional people: how
migrant health. Copenhagen: WHO Regional Office for Europe;
migration shaped our world and will define our future.
2018 (https://apps.who.int/iris/handle/10665/311347,
Princeton (NJ): Princeton University Press; 2012.
accessed 9 January 2022).
16. d'Albis H, Boubtane E, Coulibaly D. Macroeconomic evidence
5. Kumar C, Oommen E, Fragapane F, Foresti M. Beyond
suggests that asylum seekers are not a "burden" for Western
gratitude: lessons learned from migrants' contribution to the
European countries. Sci Adv. 2018;4(6):eaaq0883. doi:10.1126/
COVID-19 response. London: Overseas Development Institute;
sciadv.aaq0883.
2021 (https://cdn.odi.org/media/documents/hmi-migrant_
key_workers-working_paper-final.pdf, accessed 17. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return
9 January 2022). on investment of public health interventions: a systematic
review. J Epidemiol Community Health. 2017;71(8):827–34.
6. Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R,
doi:10.1136/jech-2016-208141.
Barreto ML et al. The UCL–Lancet commission on migration
and health: the health of a world on the move. Lancet. 18. Woetzel J, Madgavkar A, Rifai K, Mattern F, Bughin J, Manyika
2018;392:2606–54. doi:10.1016/S0140-6736(18)32114-7. J et al. People on the move: global migration's impact and
opportunity. New York: McKinsey Global Institute; 2016
7. Nielsen R, Akey JM, Jakobsson M, Pritchard JK, Tishkoff S,
(https://www.mckinsey.com/~/media/mckinsey/industries/
Willerslev E. Tracing the peopling of the world through
public%20and%20social%20sector/our%20insights/
genomics. Nature. 2017;541:302–10. doi:10.1038/nature21347.
global%20migrations%20impact%20and%20opportunity/
8. Esipova N, Ray J, Pugliese A. How the world views migration. mgi-people-on-the-move-full-report.pdf, accessed
Geneva: International Organization for Migration; 2015 9 January 2022).
(https://publications.iom.int/system/files/pdf/how_the_
19. Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P, Burns R
world_gallup.pdf, accessed 28 March 2022).
et al. Global patterns of mortality in international migrants: a
9. Markaki Y, Longhi S. What determines attitudes to immigration systematic review and meta-analysis. Lancet. 2018;392:2553–
in European countries? An analysis at the regional level. Migr 66. doi:10.1016/S0140-6736(18)32781-8.
Stud. 2013;1(3):311–37. doi:10.1093/migration/mnt015.
20. Fernández-Reino MF. The health of migrants in the UK.
10. Refugees and migrants in times of COVID-19: mapping trends Oxford: The Migration Observatory at the University of Oxford;
of public health and migration policies and practices. Geneva: 2020 (https://migrationobservatory.ox.ac.uk/wp-content/
World Health Organization; 2021 (https://apps.who.int/iris/ uploads/2020/08/Briefing-The-Health-of-Migrants-in-the-UK.
handle/10665/341843, accessed 9 January 2022). pdf, accessed 4 April 2022).
29
21. Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis 32. Ward M, Kristiansen M, Sørensen K. Migrant health literacy in
E, Garcés-Ferrer J et al. Migrants' and refugees' health status the European Union: a systematic literature review. Health
and healthcare in Europe: a scoping literature review. BMC Educ J. 2019;78(1):81–95. doi:10.1177/0017896918792700.
Public Health. 2020;20:1039. doi:10.1186/s12889-020-08749-8.
33. Anderson B, Blinder S. Who counts as a migrant? Definitions
22. Heslehurst N, Brown H, Pemu A, Coleman H, Rankin J. and their consequences. Oxford: The Migration Observatory at
Perinatal health outcomes and care among asylum seekers the University of Oxford; 2019 (https://migrationobservatory.
and refugees: a systematic review of systematic reviews. BMC ox.ac.uk/wp-content/uploads/2017/01/Briefing-Who-Counts-
Med. 2018;16:89. doi:10.1186/s12916-018-1064-0. as-a-Migrant-Definitions-and-their-Consequences.pdf,
23. Abbas M, Aloudat T, Bartolomei J, Carballo M, Durieux-Paillard
S, Gabus L et al. Migrant and refugee populations: a public 34. Glossary on migration. Geneva: International Organization
health and policy perspective on a continuing global crisis. for Migration; 2019 (https://publications.iom.int/system/files/
Antimicrob Resist Infect Control. 2018;7(1):113. doi:10.1186/ pdf/iml_34_glossary.pdf, accessed 6 November 2021).
s13756-018-0403-4.
35. International migration report 2017: highlights. New York:
24. Bozorgmehr K, Razum O. Effect of restricting access to United Nations Department of Economic and Social
health care on health expenditures among asylum-seekers Affairs; 2017 (https://www.un.org/en/development/desa/
and refugees: a quasi-experimental study in Germany, population/migration/publications/migrationreport/docs/
1994–2013. PLOS One. 2015;10:e0131483. doi:10.1371/journal. MigrationReport2017_Highlights.pdf, accessed
pone.0131483. 9 January 2022).
25. Gottlieb N, Trummer U, Davidovitch N, Krasnik A, Juárez 36. UNHCR master glossary of terms [online database]. Geneva:
SP, Rostila M et al. Economic arguments in migrant health United Nations High Commissioner for Refugees; 2021
policymaking: proposing a research agenda. Glob Health. (https://www.unhcr.org/glossary/, accessed 21 January 2022).
2020;16:113. doi:10.1186/s12992-020-00642-8.
37. ILO global estimates on international migrant workers: results
26. Trummer U, Novak-Zezula S, Renner A, Wilczewska I. Cost and methodology, second edition. Geneva: International
savings through timely treatment for irregular migrants and Labour Organization; 2021 (https://www.ilo.org/wcmsp5/
European Union citizens without insurance. Eur J Public groups/public/---dgreports/---dcomm/---publ/documents/
Health. 2018;28(suppl 1):cky048.061. doi:org/10.1093/eurpub/ publication/wcms_652001.pdf, accessed 16 January 2022).
cky048.061.
38. Cross-national comparisons of internal migration: an update
27. Convention and protocol relating to the status of refugees. on global patterns and trends. New York: United Nations
Geneva: United Nations High Commissioner for Refugees; Department of Economic and Social Affairs; 2013 (Technical
1951 (https://www.unhcr.org/3b66c2aa10, accessed Paper No. 2013/1; https://www.un.org/en/development/
9 January 2022). desa/population/publications/pdf/technical/TP2013-1.pdf,
28. Hannigan A, O'Donnell P, O'Keeffe M, MacFarlane A. How do
variations in definitions of "migrant" and their application 39. Lucas REB. Internal migration in developing economies:
influence the access of migrants to health care services? an overview of recent evidence. Geopolit Hist Int Relat.
Copenhagen: WHO Regional Office for Europe; 2016 (https:// 2016;8(2):159–91 (https://www.jstor.org/
apps.who.int/iris/handle/10665/326307, accessed stable/26805968?refreqid=excelsior%3A8f12f5f84e2197
9 January 2022). aacbf4cddcf79600d2, accessed 9 January 2022).
29. Statistical Commission: report on the fifty-second session (1–3 40. Road map for development of policy framework for the
and 5 March 2021). New York: United Nations Department inclusion of internal migrant workers in India. Geneva:
of Economic and Social Affairs; 2021 (Official records, International Labour Organization; 2020 (https://www.ilo.org/
2021, Supplement No. 4; https://unstats.un.org/unsd/ wcmsp5/groups/public/---asia/---ro-bangkok/---sro-new_
statcom/52nd-session/documents, accessed 9 January 2022). delhi/documents/publication/wcms_763352.pdf, accessed
22 November 2021).
30. Recommendations on statistics of international migration,
revision 1. New York: United Nations Department of Economic 41. Lagakos D. Urban–rural gaps in the developing world:
and Social Affairs; 1998 (https://unstats.un.org/unsd/ does internal migration offer opportunities? J Econ
publication/seriesm/seriesm_58rev1e.pdf, accessed Perspect. 2020;34(3):174–92 (https://pubs.aeaweb.org/doi/
9 January 2022). pdfplus/10.1257/jep.34.3.174, accessed 9 January 2022).
31. Wickramage K, Vearey J, Zwi AB, Robinson C, Knipper M. 42. Greenwood MJ. Internal migration in developed countries. In:
Migration and health: a global public health research priority. Rosenweig MR, Stark O, editors. Handbook of population and
BMC Public Health. 2018;18:987. doi:10.1186/s12889-018- family economics: volume 1b. Amsterdam: North Holland;
5932-5. 1997:647–720.
30
43. Progress on the Sustainable Development Goals: the gender 52. Disability, displacement and climate change. Geneva:
snapshot 2021. New York: UN Women; 2021 (https://www. Internal Displacement Monitoring Centre; 2021 (https://www.
unwomen.org/en/digital-library/publications/2021/09/ internal-displacement.org/sites/default/files/publications/
progress-on-the-sustainable-development-goals-the-gender- documents/Disability_Displacement_Climate%20Change.
snapshot-2021, accessed 26 December 2021). pdf, accessed 29 December 2021).
44. Vargas-Lundius R, Chowdhury A, Yi S, Seshan G, Yameogo 53. Impacts of displacement: displaced by violence, Jos, Nigeria.
ND. Synthesis report: internal migration and urbanization. Geneva: Internal Displacement Monitoring Centre; 2021
Washington (DC): KNOMAD, World Bank; 2018 (https:// (https://www.internal-displacement.org/publications/
www.knomad.org/sites/default/files/2018-01/Internal%20 impacts-of-displacement-displaced-by-violence-jos-nigeria,
Migration%20and%20Urbanization_Synthesis%20Report_1. accessed 9 January 2022).
pdf, accessed 9 January 2022).
54. Cazabat C. Durable solutions to displacement must include
45. Rajan SI, Bhagat RB. Internal migration in India: integrating mental health. In: Internal Displacement Monitoring Centre
migration with development and urbanization policies. [website]. Geneva: Internal Displacement Monitoring Centre;
Washington (DC): KNOMAD, World Bank; 2021 (Policy Brief 2019 (https://www.internal-displacement.org/expert-opinion/
12; https://www.knomad.org/sites/default/files/2021-02/ durable-solutions-to-displacement-must-include-mental-
Policy%20Brief%20-%20Internal%20Migrationand%20 health, accessed 9 January 2022).
Urbanization%20-%20India%20Policy%20Brief%2012%20
55. Uphoff E, Robertson L, Cabieses B, Villalón FJ, Purgato M,
Feb%202021.pdf, accessed 9 January 2022).
Churchill R et al. An overview of systematic reviews on
46. Chan KW. Internal migration in China: integrating migration mental health promotion, prevention, and treatment of
with urbanization policies and Hukou reform. Washington common mental disorders for refugees, asylum seekers, and
(DC): KNOMAD, World Bank; 2021 (https://www.knomad. internally displaced persons. Cochrane Database Syst Rev.
org/sites/default/files/2022-02/Policy%20Brief%20 2020;(9):CD013458. doi:org/10.1002/14651858.CD013458.
16_Internal%20Migration%20in%20China-Integrating%20 pub2.
Migration%20with%20Urbanization%20Policies%20and%20
56. Morina N, Akhtar A, Barth J, Schnyder U. Psychiatric
Hukou%20Reform-Nov_21.pdf, accessed 9 January 2022).
disorders in refugees and internally displaced persons after
47. GRID 2021: global report on internal displacement. Geneva: forced displacement: a systematic review. Front Psychiatry.
Internal Displacement Monitoring Centre; 2021 (https://www. 2018;9:33. doi:10.3389/fpsyt.2018.00433.
internal-displacement.org/global-report/grid2021/, accessed
57. Dhillon P. Expert opinion: 5 key findings on internal displace-
22 November 2021).
ment and mental health. In: Internal Displacement Monitoring
48. Challenges of IDP protection: research study on the protection Centre [website]. Geneva: Internal Displacement Monitoring
of internally displaced persons in Afghanistan. Geneva: Centre; 2021 (https://www.internal-displacement.org/expert-
Internal Displacement Monitoring Centre; 2012 (https://www. opinion/5-key-findings-on-internal-displacement-and-mental-
internal-displacement.org/sites/default/files/publications/ health, accessed 4 April 2022).
documents/201211-me-afghanistan-challenges-of-idp-
58. Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM,
protection-country-en.pdf, accessed 14 February 2022).
Fitzgerald G et al. The prevalence of mental illness in refugees
49. Mason JB, White JM, Heron L, Carter J, Wilkinson C, and asylum seekers: a systematic review and meta-analysis.
Spiegel P. Child acute malnutrition and mortality in PLOS Med. 2020;17(9):e1003337. doi:10.1371/journal.
populations affected by displacement in the Horn of Africa, pmed.1003337.
1997–2009. Int J Environ Res Public Health. 2012;9(3):791–806.
59. Ochiltree K, Toma IA. Gender analysis of the impact
doi:10.3390/ijerph9030791.
of recent humanitarian crises on women, men, girls, and
50. Cantor D, Swartz J, Roberts B, Abbara A, Ager A, Bhutta ZA et boys in Puntland State in Somalia. Oxford: Oxfam,
al. Understanding the health needs of internally displaced KAALO; 2021 (https://oxfamilibrary.openrepository.
persons: a scoping review. J Migr Health. 2021;4:100071. com/bitstream/handle/10546/621186/rr-puntland-
doi:10.1016/j.jmh.2021.100071. state-somalia-gender-analysis-290421-en.
pdf;jsessionid=7E5380371CE5E96E8BC362
51. Internal displacement's impacts on health in Yemen. Geneva:
CF330C370D?sequence=1, accessed 21 December 2021).
Internal Displacement Monitoring Centre; 2020 (https://www.
internal-displacement.org/sites/default/files/publications/ 60. Convention relating to the status of stateless persons. Geneva:
documents/IDMC_ImpactsonHealthinYemen.pdf, accessed United Nations High Commissioner for Refugees; 1954
29 December 2021). (https://www.unhcr.org/protection/statelessness/3bbb25729/
convention-relating-status-stateless-persons.html, accessed
29 December 2021).
31
61. Statelessness around the world. In: United Nations High 72. Idemudia E, Boehnke K. Patterns and current trends in African
Commissioner for Refugees [website]. Geneva: United Nations migration to Europe. In: Psychosocial experiences of African
High Commissioner for Refugees; 2022 (https://www.unhcr. migrants in six European countries: a mixed method study.
org/statelessness-around-the-world.html, accessed Cham: Springer; 2020:15–31.
9 January 2022).
73. World migration report 2022. Geneva: International
62. Albarazi Z, van Waas L. Statelessness and displacement. Organization for Migration; 2021 (https://publications.iom.int/
Oslo: Norwegian Refugee Council; 2016 (https://www.nrc.no/ system/files/pdf/WMR-2022.pdf, accessed 26 December 2021).
globalassets/pdf/reports/statelessness-and-displacement.
74. Tangcharoensathien V, Thwin AA, Patcharanarumol W.
pdf, accessed 29 December 2021).
Implementing health insurance for migrants, Thailand.
63. Statelessness in numbers: 2020. London: Institute on Bull World Health Organ. 2017;95(2):146–51. doi:10.2471/
Statelessness and Inclusion; 2020 (https://files.institutesi.org/ BLT.16.179606.
ISI_statistics_analysis_2020.pdf, accessed 29 December 2021).
75. Smith JL, Ghimire P, Rijal KR, Maglior A, Hollis S, Andrade-
64. Van Hout MC, Bigland C, Murray N. Situation assessment Pacheco R et al. Designing malaria surveillance strategies for
of statelessness, health, and COVID-19 in Europe. London: mobile and migrant populations in Nepal: a mixed-methods
European Network on Statelessness; 2021 (https://www. study. Malar J. 2019;18(1):158. doi:10.1186/s12936-019-2791-1.
statelessness.eu/sites/default/files/2021-04/ENS_Health_
76. International labour migration statistics in South Asia:
Situation_Assessment_Europe.pdf, accessed
establishing a subregional database and improving data
29 December 2021).
collection for evidence-based policy-making. Geneva:
65. Van Waas L, de Chickera A, Spearman O. Stateless in a global International Labour Organization; 2018 (https://www.ilo.org/
pandemic: impact report, 2020. Eindhoven: Institute on wcmsp5/groups/public/---asia/---ro-bangkok/---sro-new_
Statelessness and Inclusion; 2020 (https://files.institutesi.org/ delhi/documents/publication/wcms_645286.pdf, accessed
Covid19_Stateless_Impact_Report.pdf, accessed 7 June 2022).
9 January 2022).
77. Plewa P. Migration in Maldives: a country profile 2018. Geneva:
66. Together we can: the COVID-19 impact on stateless people International Organization for Migration; 2018 (https://
& a roadmap for change. London: Institute on Statelessness publications.iom.int/system/files/pdf/mp_maldives_2018.
and Inclusion; 2021 (https://files.institutesi.org/together_we_ pdf, accessed 29 December 2021).
can_report_2021.pdf, accessed 29 December 2021).
78. Kase P. The influence of social demographic factor on
67. International migrant stock 2020 [online database]. New York: individual decision to cross-border migration between
United Nations Department of Economic and Social Affairs, Timor Leste and Indonesia. In: Siahaan A, Sihombing T,
Population Division; 2020 (https://www.un.org/development/ Shaw R, Jakimow T, Sumintono B, editors. Proceedings
desa/pd/content/international-migrant-stock, accessed of the International Conference on Public Policy, Social
28 May 2021). Computing and Development 2017 (ICOPOSDev 2017). Paris:
Atlantis Press; 2017:227–32 (https://www.atlantis-press.com/
68. Child migration. In: UNICEF data [website]. New York: United
article/25889843.pdf, accessed 29 December 2021).
Nations Children's Fund; 2021 (https://data.unicef.org/topic/
child-migration-and-displacement/migration/, accessed 79. Islam MN, Inan TT, Islam AKMN. COVID-19 and the
8 January 2022). Rohingya refugees in Bangladesh: the challenges and
recommendations. Asia Pac J Public Health. 2020;32(5):283–4.
69. Defining and measuring circular migration. Geneva: United
doi:10.1177/1010539520932707.
Nations Economic Commission for Europe; 2016 (ECE/CES/
BUR/2016/OCT/18/Add.1; https://unece.org/fileadmin/ 80. Fellmeth G, Plugge EH, Nosten S, Oo MM, Fazel M,
DAM/stats/documents/ece/ces/bur/2016/October/18Add1- Charunwatthana P et al. Living with severe perinatal
CircularMigration_for_Bureau_final.pdf, accessed depression: a qualitative study of the experiences of labour
28 March 2022). migrant and refugee women on the Thai–Myanmar border.
BMC Psychiatry. 2018;18:229. doi:10.1186/s12888-018-1815-7.
70. Mid-year trends. New York: United Nations High
Commissioner for Refugees. 2021 (https://www.unhcr.org/ 81. Brown TM. Building resilience: the emergence of refugee-led
mid-year-trends.html, accessed 26 December 2021). education initiatives in Indonesia to address service gaps
faced in protracted transit. Austrian J South-East Asian Stud.
71. Flahaux M-L, De Haas H. African migration: trends, patterns,
2018;11:165–81. doi:10.14764/10.ASEAS-0001.
drivers. Comp Migr Stud. 2016;4(1):1–25. doi:10.1186/s40878-
015-0015-6. 82. Villa M, editor. The future of migration to Europe. Milan:
Institute for International Political Studies; 2020 (https://
www.ispionline.it/sites/default/files/pubblicazioni/ispi_
futureofmigration_web_1.pdf, accessed 29 December 2021).
32
83. Dearden K, Sánchez Dionis M. Support needed for families 92. Bollini P, Pampallona S, Wanner P, Kupelnick B. Pregnancy
of missing migrants: evidence from IOM's "Assessing the outcome of migrant women and integration policy: a
needs of families searching for relatives lost in the central systematic review of the international literature. Soc Sci Med.
and western Mediterranean" project. Geneva: International 2009;68(3):452–61. doi:10.1016/j.socscimed.2008.10.018.
Organization for Migration; 2021. (https://publications.iom.
93. Jeffers K, Tjaden J, Laczko F. A pilot study on disaggregating
int/system/files/pdf/Support-Needed-for-Missing-Migrants.
SDG indicators by migratory status. Geneva: International
pdf, accessed 9 January 2022).
Organization for Migration; 2018 (https://publications.iom.
84. The Gulf Cooperation Council (GCC) and health worker int/system/files/pdf/a_pilot_study_on_disaggregating_sdg_
migration. Washington (DC): Aspen Institute; 2008 (https:// indicators.pdf, accessed 16 January 2022).
www.aspeninstitute.org/wp-content/uploads/files/content/
94. Lindert J, von Ehrenstein OS, Priebe S, Mielck A, Brähler
images/GCC%20and%20HWM%20Policy%20Brief.pdf,
E. Depression and anxiety in labor migrants and refugees:
a systematic review and meta-analysis. Soc Sci Med.
85. Situation report on international migration 2019: the 2009;69(2):246–57. doi:10.1016/j.socscimed.2009.04.032.
Global Compact for Safe, Orderly and Regular Migration in
95. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental
the Context of the Arab Region. New York: United Nations
disorder in 7000 refugees resettled in western countries: a
Economic and Social Commission for Western Asia; 2020
systematic review. Lancet. 2005;365:1309–14. doi:10.1016/
(https://archive.unescwa.org/sites/www.unescwa.org/files/
S0140-6736(05)61027-6.
publications/files/situation-report-international-migration-
2019-english_1.pdf, accessed 23 November 2021). 96. Public health services survey: inclusion of refugees into
national health systems [website]. Geneva: Office of the
86. Global trends 2019: forced displacement in 2019. Geneva:
United Nations High Commissioner for Refugees; 2020
United Nations High Commissioner for Refugees; 2020
(https://app.powerbi.com/view?r=eyJrIjoiMWQ0OGM4YWEtN
(https://www.unhcr.org/5ee200e37.pdf, accessed
zYxZS00MTVlLTk4ZTItMjk4YzU5NTkwYjhhIiwidCI6ImU1YzM3O
23 November 2021).
TgxLTY2NjQtNDEzNC04YTBjLTY1NDNkMmFmODBiZSIsImMi
87. Global trends 2013. Geneva: United Nations High Ojh9&pageName=ReportSection, accessed 28 January 2022).
Commissioner for Refugees; 2014 (https://www.unhcr.org/ph/
97. Brandenberger J, Tylleskär T, Sontag K, Peterhans B, Ritz
wp-content/uploads/sites/28/2017/03/GlobalTrends2013.pdf,
N. A systematic literature review of reported challenges in
accessed 23 November 2021).
health care delivery to migrants and refugees in high-income
88. Health of refugees and migrants: regional situation analysis, countries: the 3C model. BMC Public Health. 2019;19:755.
practices, experiences, lessons learned and ways forward. doi:10.1186/s12889-019-7049-x.
Manila: WHO Regional Office for the Western Pacific;
98. Kocot E, Szetela A. Assessing health systems' preparedness
2018 (https://cdn.who.int/media/docs/default-source/
for providing care for refugees, asylum seekers and migrants:
documents/publications/health-of-refugees-and-migrants-
a scoping review. Eur J Public Health. 2020;30(6):1157–63.
wpro-2018165be999-c496-4779-9b7d-853111f371f9.
doi:10.1093/eurpub/ckaa135.
pdf?sfvrsn=ab7602b1_1&download=true, accessed
29 December 2021). 99. 2020 annual public health global review. Geneva: United
Nations High Commissioner for Refugees; 2021 (https://www.
89. Asia-Pacific migration report 2020: assessing implementation
unhcr.org/60dc89e24.pdf, accessed 25 November 2021).
of the global compact for migration. New Delhi: United
Nations Economic and Social Commission for Asia and the 100. Alderslade R. A collective WHO European framework for
Pacific; 2020 (https://www.unescap.org/sites/default/d8files/ action to support refugees and migrant health. Copenhagen:
knowledge-products/AP_Migration_R_2020.pdf, accessed WHO Regional Office for Europe; 2016 (https://apps.who.int/
9 January 2022). iris/handle/10665/325344, accessed 17 July 2021).
90. Redden K, Safarian J, Schoenborn C, Shortall C, Gagnon AJ. 101. Malta: assessing health-system capacity to manage sudden,
Interventions to support international migrant women's large influxes of migrants: joint report on a mission of the
reproductive health in western-receiving countries: a Ministry for Energy and Health of Malta, the International
systematic review and meta-analysis. Health Equity. Centre for Migration, Health and Development and the
2021;5(1):356–72. doi:10.1089/heq.2020.0115. WHO Regional Office for Europe. Copenhagen: WHO
Regional Office for Europe; 2015 (https://apps.who.int/iris/
91. Shorey S, Ng ED, Downe S. Cultural competence and
handle/10665/344402, accessed 28 March 2022).
experiences of maternity health care providers on care
for migrant women: a qualitative meta-synthesis. Birth.
2021;48(4):458–69. doi:10.1111/birt.12581.
33
102. Serbia: assessing health-system capacity to manage 113. Fix M, Papademetriou DG, Sumption M, editors. Immigrants
sudden large influxes of migrants: joint report on a in a changing labor market: responding to economic needs.
mission of the Ministry of Health of Serbia and the WHO Washington (DC): Migration Policy Institute; 2013 (https://
Regional Office for Europe with the collaboration of the www.migrationpolicy.org/sites/default/files/publications/
International Organization for Migration. Copenhagen: WHO mpi-immigrantschanginglabormarket-2012-final-webversion.
Regional Office for Europe; 2015 (https://apps.who.int/iris/ pdf, accessed 9 January 2022).
handle/10665/344452, accessed 25 November 2021).
114. Vollset SE, Goren E, Yuan C-W, Cao J, Smith AE, Hsiao T et al.
103. Castañeda H, Holmes SM, Madrigal DS, Young M-ED, Beyeler Fertility, mortality, migration, and population scenarios for
N, Quesada J. Immigration as a social determinant of health. 195 countries and territories from 2017 to 2100: a forecasting
Annu Rev Public Health. 2015;36(1):375–92. doi:10.1146/ analysis for the Global Burden of Disease Study. Lancet. 2020
annurev-publhealth-032013-182419. 17;396:1285–306. doi:10.1016/S0140-6736(20)30677-2.
104. Galea S, Ettman CK, Zaman M, editors. Migration and health. 115. Gushulak BD, MacPherson DW. The basic principles
Chicago: University of Chicago Press; 2022. of migration health: population mobility and gaps in
disease prevalence. Emerg Themes Epidemiol. 2006;3:3.
105. Kennedy S, Kidd MP, McDonald JT, Biddle N. The healthy
doi:10.1186/1742-7622-3-3.
immigrant effect: patterns and evidence from four countries.
J Int Migr Integr. 2015–16(2):317–32. doi:10.1007/s12134-014- 116. Helgesson M, Johansson B, Nordquist T, Vingård E,
0340-x. Svartengren M. Healthy migrant effect in the Swedish context:
a register-based, longitudinal cohort study. BMJ Open.
106. Moullan Y, Jusot F. Why is the "healthy immigrant effect"
2019;9(3):e026972. doi:10.1136/bmjopen-2018-026972.
different between European countries? Eur J Public Health.
2014;24(suppl 1):80–6. doi:10.1093/eurpub/cku112. 117. Vang Z, Sigouin J, Flenon A, Gagnon A. The healthy immigrant
effect in Canada: a systematic review. In: Population change
107. Puschmann P, Donrovich R, Matthijs K. Salmon bias or
and lifecourse strategic knowledge cluster discussion paper
red herring? Comparing adult mortality risks (ages 30–90)
series. Hamilton (ON): Canadian Research Data Centre
between natives and internal migrants: stayers, returnees and
Network; 2015 (https://ir.lib.uwo.ca/cgi/viewcontent.
movers in Rotterdam, the Netherlands, 1850–1940. Hum Nat.
cgi?article=1012&context=pclc, accessed 9 January 2022).
2017;28(4):481–99. doi:10.1007/s12110-017-9303-1.
118. Ikram UZ, Malmusi D, Juel K, Rey G, Kunst AE. Association
108. Migration health assessments and travel health assistance:
between integration policies and immigrants' mortality: an
2019 overview of pre-migration health activities. Geneva:
explorative study across three European countries. PLOS One.
International Organization for Migration; 2020 (https://
2015;10(6):e0129916. doi:10.1371/journal.pone.0129916.
publications.iom.int/system/files/pdf/migration-health-
assessments.pdf, accessed 25 November 2021). 119. Kaplan GA. What's wrong with social epidemiology, and
how can we make it better? Epidemiol Rev. 2004;26:124–35.
109. Juárez SP, Honkaniemi H, Dunlavy AC, Aldridge RW, Barreto
doi:10.1093/epirev/mxh010.
ML, Katikireddi SV et al. Effects of non-health-targeted policies
on migrant health: a systematic review and meta-analysis. 120. Kuruvilla S, Sadana R, Montesinos EV, Beard J, Vasdeki JF,
Lancet Glob Health. 2019;7(4):e420–35. doi:10.1016/S2214- Araujo de Carvalho I et al. A life-course approach to health:
109X(18)30560-6. synergy with sustainable development goals. Bull World
Health Organ. 2018;96(1):42–50. doi:10.2471/BLT.17.198358.
110. Dahlgren G, Whitehead M. Policies and strategies to promote
social equity in health: background document to WHO 121. Spallek J, Zeeb H, Razum O. What do we have to know from
strategy paper for Europe. Stockholm: Institute for Futures migrants' past exposures to understand their health status?
Studies; 1991 (https://core.ac.uk/download/pdf/6472456.pdf, A life course approach. Emerg Themes Epidemiol. 2011;8:6.
accessed 17 June 2022). doi:10.1186/1742-7622-8-6.
111. McAuliffe M, Khadria B, editors. World migration report 122. Gong F, Xu J, Fujishiro K, Takeuchi DT. A life course perspective
2020. Geneva: International Organization for Migration; 2019 on migration and mental health among Asian immigrants:
(https://publications.iom.int/system/files/pdf/wmr_2020.pdf, the role of human agency. Soc Sci Med. 2011;73(11):1618–26.
accessed 19 January 2022). doi:10.1016/j.socscimed.2011.09.014.
112. Parsons AJQ, Gilmour S. An evaluation of fertility- and 123. Montes de Oca V, García TR, Sáenz R, Guillén J. The linkage of
migration-based policy responses to Japan's ageing life course, migration, health, and aging: health in adults and
population. PLOS One. 2018;13(12):e0209285. doi:10.1371/ elderly Mexican migrants. J Aging Health. 2011;23(7):1116–40.
journal.pone.0209285. doi:10.1177/0898264311422099.
124. Migration and vulnerability: migration and health.
Geneva: International Organization for Migration; (http://
migrationdataportal.org/themes/migration-and-health,
accessed 28 May 2021).
34
125. World urbanization prospects 2018. In: United Nations 138. Hagan JM, Wassink J. New skills, new jobs: return migration,
Department of Economic and Social Affairs; 2021 (https:// skill transfers, and business formation in Mexico. Soc Probl.
population.un.org/wup/, accessed 17 July 2021). 2016;63(4):513–33. doi:10.1093/socpro/spw021.
126. Lerch M. International migration and city growth in the 139. Ratha D, Kim EJ, Plaza S, Seshan G, Riordan EJ, Chandra
Global South: an analysis of IPUMS data for seven countries, V. Recovery: COVID-19 crisis through a migration lens.
1992–2013. Popul Dev Rev. 2020;46(3):557–82. doi:10.1111/ Washington (DC): KNOMAD, World Bank; 2021 (Migration
padr.12344. and Development Brief 35; https://www.knomad.org/sites/
default/files/2021-11/Migration_Brief%2035_1.pdf, accessed
127. Adger WN, Crépin AS, Folke C, Ospina D, Chapin III FS,
23 December 2021).
Segerson K et al. Urbanization, migration, and adaptation to
climate change. One Earth. 2020;3(4):396–9. doi:10.1016/j. 140. Ratha D, Kim EJ, Plaza S, Seshan G. Resilience: COVID-19 crisis
oneear.2020.09.016. through a migration lens. Washington (DC): KNOMAD, World
Bank; 2021 (Migration and Development Brief 34; https://
128. Fuller B, Romer P. Urbanization as opportunity. Washington
www.knomad.org/sites/default/files/2021-05/Migration%20
(DC) World Bank; 2014 (https://elibrary.worldbank.org/doi/
and%20Development%20Brief%2034_1.pdf, accessed
abs/10.1596/1813-9450-6874, accessed 17 June 2022).
29 March 2022).
129. Kuddus MA, Tynan E, McBryde E. Urbanization: a problem
141. Health of families left behind. Geneva: International
for the rich and the poor? Public Health Rev. 2020;41:1.
Organization for Migration; 2018 (https://www.iom.int/health-
doi:10.1186/s40985-019-0116-0.
families-left-behind, accessed 18 July 2021).
130. Integrating migration into urban development programmes:
142. Schröder-Butterfill E. Emigration and the care of older people
a toolkit. Geneva: International Organization for Migration;
"left behind": the changing role of neighbourhood networks,
2021 (https://unhabitat.org/sites/default/files/2022/02/urban-
ethnicity and civil society. J Ethn Migr Stud. 2021;2021:1–19.
development-migration-toolkit.pdf, accessed
doi:10.1080/1369183X.2021.2009783.
25 November 2021).
143. Older people in situations of migration in Africa: the untold
131. Azcona G, Bhatt A, Ndugwa R. COVID-19 exposes the harsh
migration story. London: HelpAge International; 2017
realities of gender inequality in slums. New York: UN Women;
(Policy paper; https://reliefweb.int/sites/reliefweb.int/files/
2020 (https://data.unwomen.org/features/covid-19-exposes-
resources/older-persons-and-migration-policy-briefing-
harsh-realities-gender-inequality-slums, accessed
paper-22-feb-2017.pdf, accessed 4 April 2022).
27 December 2021).
144. Women on the move: migration, care work and health.
132. Sampson L, Ettman CK, Galea S. Urbanization, urbanicity,
Geneva: World Health Organization; 2017 (https://apps.who.
and depression: a review of the recent global literature.
int/iris/handle/10665/259463, accessed 4 April 2022).
Curr Opin Psychiatry. 2020;33(3):233–44. doi:10.1097/
YC0.0000000000000588. 145. Wickramage K, Siriwardhana C, Peiris S. Promoting the health
of left-behind children of Asian labour migrants: evidence
133. The world health report 2006: working together for health.
for policy and action. Geneva: International Organization
Geneva: World Health Organization; 2006 (https://apps.who.
for Migration, Washington (DC): Migration Policy Institute;
int/iris/handle/10665/43432, accessed 9 January 2022).
2015 (https://www.migrationpolicy.org/sites/default/files/
134. Cabieses B, Tunstall H. Immigrant health workers in publications/MPI%20Issue%20No%2014_10Sep2015_
Chile: is there a Latin American 'brain drain'? Rev Panam FINALweb.pdf, accessed 9 January 2022).
Salud Publica. 2012;32(2):161–7. doi:10.1590/s1020-
146. Fellmeth G, Rose-Clarke K, Zhao C, Busert LK, Zheng Y,
49892012000800012.
Massazza A et al. Health impacts of parental migration on
135. Dohlman L, DiMeglio M, Hajj J, Laudanski K. Global brain left-behind children and adolescents: a systematic review and
drain: how can the Maslow theory of motivation improve meta-analysis. Lancet. 2018;392:2567–82. doi:10.1016/S0140-
our understanding of physician migration? Int J Environ Res 6736(18)32558-3.
Public Health. 2019;16(7):E1182. doi:10.3390/ijerph16071182.
147. Children "left behind". New York: United Nations Children's
136. Garner SL, Conroy SF, Bader SG. Nurse migration from India: Fund; 2019 (UNICEF Working Paper; https://www.unicef.org/
a literature review. Int J Nurs Stud. 2015;52(12):1879–90. media/83581/file/Children-Left-Behind.pdf, accessed
doi:10.1016/j.ijnurstu.2015.07.003. 27 December 2021).
137. Bradby H. International medical migration: a critical 148. Suleman S, Garber KD, Rutkow L. Xenophobia as a
conceptual review of the global movements of doctors determinant of health: an integrative review. J Public Health
and nurses. Health (London). 2014;18(6):580–96. Policy. 2018;39(4):407–23. doi:10.1057/s41271-018-0140-1.
doi:10.1177/1363459314524803.
35
149. Grove NJ, Zwi AB. Our health and theirs: forced migration, 158. Key findings on the characteristics of migrant smuggling
othering, and public health. Soc Sci Med. 2006;62(8):1931–42. in west Africa, north Africa and the central Mediterranean.
doi:10.1016/j.socscimed.2005.08.061. Vienna: United Nations Office on Drugs and Crime,
Observatory on Smuggling of Migrants; 2021 (https://www.
150. Agudelo-Suárez AA, Ronda-Pérez E, Gil-González D, Vives-
unodc.org/res/som/docs/Observatory_Storymap_1_
Cases C, García AM, Ruiz-Frutos C et al. The effect of perceived
Final_2021.05.19.pdf, accessed 29 December 2021)
discrimination on the health of immigrant workers in Spain.
BMC Public Health. 2011;11:652. doi:10.1186/1471-2458- 159. Abused and neglected: a gender perspective on aggravated
11-652. migrant smuggling offences and response. Vienna: United
Nations Office on Drugs and Crime; 2021 (https://www.unodc.
151. Hall BJ, Pangan CAC, Chan EWW, Huang RL. The effect of
org/documents/human-trafficking/2021/Aggravated_SOM_
discrimination on depression and anxiety symptoms and
and_Gender.pdf, accessed 29 December 2021).
the buffering role of social capital among female domestic
workers in Macao, China. Psychiatry Res. 2019;271:200–7. 160. Rigaud KK, de Sherbinin A, Jones B, Bergmann J,
doi:10.1016/j.psychres.2018.11.050. Clement V, Ober K et al. Groundswell: preparing for internal
climate migration. Washington (DC): World Bank; 2018
152. Drewniak D, Krones T, Wild V. Do attitudes and behavior of
(https://openknowledge.worldbank.org/handle/10986/29461,
health care professionals exacerbate health care disparities
accessed 29 December 2021).
among immigrant and ethnic minority groups? An integrative
literature review. Int J Nurs Stud. 2017;70:89–98. doi:10.1016/j. 161. Clement V, Rigaud KK, de Sherbinin A, Jones B, Adamo S,
ijnurstu.2017.02.015. Schewe J et al. Groundswell part 2: acting on internal climate
migration. Washington (DC): World Bank; 2021 (https://
153. Protocol against the smuggling of migrants by land, sea and
openknowledge.worldbank.org/handle/10986/36248,
air, supplementing the United Nations Convention against
transnational organized crime. Geneva: United Nations
High Commissioner for Refugees; 2000 (https://www.unhcr. 162. Callaghan M, Schleussner C-F, Nath S, Lejeune Q, Knutson
org/protection/migration/496323791b/protocol-against- TR, Reichstein M et al. Machine-learning-based evidence and
smuggling-migrants-land-sea-air-supplementing-united- attribution mapping of 100 000 climate impact studies. Nat
nations.html, accessed 27 December 2021). Clim Chang. 2021;11(11):966–72. doi:10.1038/s41558-021-
01168-6.
154. Protocol to prevent, suppress and punish trafficking in
persons, especially women and children, supplementing the 163. Opitz-Stapleton S, Lovell E, Cao Y, Dupar M, Peters K. Climate
United Nations Convention against transnational organized change, conflict and fragility: an evidence review and
crime. New York: United Nations; 2000 (https://www.ohchr. recommendations for research and action. London: Overseas
org/sites/default/files/Documents/ProfessionalInterest/ Development Institute; 2020 (https://cdn.odi.org/media/
ProtocolonTrafficking.pdf, accessed 27 December 2021). documents/odi_climate_change_conflict_and_fragility.pdf,
155. Human rights of migrants: note by the Secretary-General.
In: Seventy-sixth session, United Nations General Assembly, 164. Butler CD. Climate change and global health. Boston (MA):
promotion and protection of human rights, 30 July 2021. New CABI; 2014.
York: United Nations; 2021 (A/76/257; https://daccess-ods.
165. Migration and global environmental change: future challenges
un.org/access.nsf/Get?OpenAgent&DS=A/76/257&Lang=E,
and opportunities. London: United Kingdom Government
Office for Science; 2011 (https://assets.publishing.service.gov.
156. González Morales F. Report on means to address the human uk/government/uploads/system/uploads/attachment_data/
rights impact of pushbacks of migrants on land and at sea: file/287717/11-1116-migration-and-global-environmental-
report of the Special Rapporteur on the human rights of change.pdf, accessed 9 January 2022).
migrants. New York: United Nations Human Rights Council;
166. IOM outlook on migration, environment and climate change.
2021 (A/HRC/47/30; https://reliefweb.int/report/world/report-
Geneva: International Organization for Migration; 2014
means-address-human-rights-impact-pushbacks-migrants-
(https://publications.iom.int/system/files/pdf/mecc_outlook.
land-and-sea-report-special, accessed 29 December 2021).
pdf, accessed 29 December 2021).
157. The 10-point plan in action, 2016 update. Geneva: United
167. Internal displacement in the context of the slow-onset
Nations High Commissioner for Refugees; 2016 (https://www.
adverse effects of climate change: submission by the
refworld.org/10pointplaninaction2016update.html, accessed
International Organization for Migration to the Special
23 November 2021).
Rapporteur on the Human Rights of Internally Displaced
Persons. Geneva: International Organization for Migration;
2020 (https://publications.iom.int/system/files/pdf/idp-
climate-change.pdf, accessed 29 December 2021).
36
168. Triggs GD, Wall PCJ. "The makings of a success": the Global 179. Health of migrants: resetting the agenda. Report of the 2nd
Compact on Refugees and the inaugural Global Refugee Global Consultation: Colombo, Sri Lanka, 21–23 February
Forum. Int J Refug Law. 2020;32(2):283–339. doi:10.1093/ 2017. Geneva: International Organization for Migration; 2017
ijrl/eeaa024. (https://publications.iom.int/system/files/pdf/gc2_srilanka_
report_2017.pdf, accessed 9 January 2022).
169. Crawford N, O'Callaghan S. The Comprehensive Refugee
Response Framework: responsibility-sharing and self-reliance 180. Transforming our world: the 2030 Agenda for Sustainable
in East Africa. London: Overseas Development Institute; 2019 Development. New York: United Nations; 2015
(https://cdn.odi.org/media/documents/12935.pdf, accessed (https://sustainabledevelopment.un.org/content/
29 December 2021). documents/21252030%20Agenda%20for%20Sustainable%20
Development%20web.pdf, accessed 9 January 2022).
170. New York declaration for refugees and migrants. In: Seventy-
first session, United Nations General Assembly, New 181. Political declaration of the high-level meeting on universal
York, 19 September 2016. New York: United Nations; 2016 health coverage. New York: United Nations; 2019 (https://
(Resolution A/71/L.1; https://www.un.org/en/development/ www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/
desa/population/migration/generalassembly/docs/ FINAL-draft-UHC-Political-Declaration.pdf, accessed
globalcompact/A_RES_71_1.pdf, accessed 16 June 2022). 7 June 2022).
171. Data, social determinants, and better decision-making 182. International Health Regulations (2005), third edition. Geneva:
for health: the report of the 3-D Commission. Boston: World Health Organization; 2016 (https://apps.who.int/iris/
3-D Commission; 2021 (https://static1.squarespace.com/ handle/10665/246107, accessed 26 April 2022).
static/5e2ca08b9fdf240fb1abb55b/t/617aae3927d4790b590a
183. World Health Assembly second special session. Geneva:
ef4e/1635429947691/3DCommission_Report_SDoH_Oct+12_
World Health Organization; 2021 (https://apps.who.int/gb/
final.pdf, accessed 9 January 2022).
ebwha/pdf_files/WHASS2-REC1/WHASS2_REC1-en.pdf,
172. Klomp J, de Haan J. Is the political system really related accessed 7 June 2022).
to health? Soc Sci Med. 2009;69(1):36–46. doi:10.1016/j.
184. Wickramage K, Annunziata G. Advancing health in migration
socscimed.2009.03.033.
governance, and migration in health governance. Lancet.
173. Kirigia JM, Kirigia DG. The essence of governance in health 2018;392:2528–30. doi:10.1016/S0140-6736(18)32855-1.
development. Int Arch Med. 2011;4:11. doi:10.1186/1755-
185. Global plan to end TB 2018–2022: the paradigm shift. Geneva:
7682-4-11.
Stop TB Partnership; 2019 (https://www.stoptb.org/sites/
174. World health statistics 2019: monitoring health for the default/files/GPR_2018-2022_Digital.pdf, accessed
SDGs, sustainable development goals. Geneva: World 21 January 2022).
Health Organization; 2019 (https://apps.who.int/iris/
186. Implementing the End TB strategy: the essentials. Geneva:
handle/10665/324835, accessed 9 January 2022).
World Health Organization; 2015 (https://apps.who.int/iris/
175. Global compact on refugees. New York: United Nations; 2018 handle/10665/206499, accessed 9 January 2022).
(https://www.unhcr.org/5c658aed4.pdf, accessed
187. Key learning on Health in All Policies implementation from
4 October 2021).
around the world. Geneva: World Health Organization; 2018
176. Global compact for safe, orderly and regular migration. In: (https://apps.who.int/iris/handle/10665/272711, accessed
Seventy-third session, United Nations General Assembly, 7 June 2022).
New York, 11 January 2019. New York: United Nations;
188. African Union launches a new program on migration and
2019 (A/RES/73/195; https://www.un.org/en/development/
health. Addis Ababa: African Union; 2020 (https://au.int/
desa/population/migration/generalassembly/docs/
en/pressreleases/20200723/african-union-launches-new-
globalcompact/A_RES_73_195.pdf, accessed 6 August 2021).
program-migration-and-health, accessed 29 December 2021).
177. Resolution WHA61.17: health of migrants. In: Sixty-first World
189. What we do? Origins of the Quito process. Panama City:
Health Assembly, Geneva, 19–24 May 2008. Geneva: World
Proceso de Quito; 2021 (https://www.procesodequito.org/en/
Health Organization; 2008:23–25 (WHA61/2008/REC/1; https://
what-we-do, accessed 29 December 2021).
apps.who.int/gb/ebwha/pdf_files/WHA61-REC1/A61_REC1-
en.pdf, accessed 17 November 2021). 190. International technical meeting on human mobility
of Venezuelan citizens in the region (Quito process).
178. Health of migrants: the way forward. Report of a global
International Organization for Migration; 2022 (https://www.
consultation, Madrid, Spain, 3–5 March 2010. Geneva:
iom.int/international-technical-meeting-human-mobility-
venezuelan-citizens-region-quito-process, accessed
25 March 2022).
37
191. Regional consultative process on overseas employment and 202. Wickramage K, Gostin LO, Friedman E, Prakongsai P,
contractual labor for countries of origin in Asia (Colombo Suphanchaimat R, Hui C et al. Missing: where are the migrants
Process). Geneva: International Organization for Migration; in pandemic influenza preparedness plans? Health Hum
2021 (https://www.iom.int/regional-consultative-process- Rights. 2018;20(1):251–8. PMCID: PMC6039731.
overseas-employment-and-contractual-labor-countries-
203. Seventieth Regional Committee for Europe: virtual session,
origin-asia-colombo-process, accessed 30 December 2021).
14–15 September 2020: progress report on implementation of
192. Migrants' health. Brussels: European Commission; 2016 the Strategy and Action Plan for Refugee and Migrant Health
(https://ec.europa.eu/health/social-determinants/migrants- in the WHO European Region. Copenhagen: WHO Regional
health_en, accessed 29 December 2021). Office for Europe; 2021 (EUR/RC70/8(K); https://apps.who.int/
iris/handle/10665/333536, accessed 23 November 2021).
193. Collection and integration of data on refugee and migrant
health in the WHO European Region: technical guidance. 204. Resolution WHA71.1. Thirteenth General Programme of Work,
Copenhagen: WHO Regional Office for Europe; 2020 2019–2023. In: Seventy-first World Health Assembly, Geneva,
(https://apps.who.int/iris/handle/10665/337694, accessed 21–26 May 2018. Resolutions and decisions, annexes. Geneva:
12 November 2020). World Health Organization; 2018:3 (A75/8; https://apps.who.
int/iris/handle/10665/326571, accessed 16 June 2022).
194. Abdalla FM, Omar MA, Badr EE. Contribution of Sudanese
medical diaspora to the healthcare delivery system in 205. Programme budget 2022–2023: revision. Extending the
Sudan: exploring options and barriers. Hum Resour Health. Thirteenth General Programme of Work, 2019–2023 to
2016;14(suppl 1):28. doi:10.1186/s12960-016-0123-x. 2025. In: Seventy-fifth World Health Assembly, Geneva,
22–28 May 2022. Geneva: World Health Organization; 2018:3
195. Taslakian EN, Garber K, Shekherdimian S. Diaspora
(WHA71/2018/REC/1; https://apps.who.int/gb/ebwha/pdf_
engagement: a scoping review of diaspora involvement with
files/WHA75/A75_8-en.pdf, accessed 16 June 2022).
strengthening health systems of their origin country. Glob
Health Action. 2022;15(1):2009165. doi:10.1080/16549716.202 206. Health of migrants: report by the Secretariat. In: Sixty-first
1.2009165. World Health Assembly, Geneva, 19–24 May 2008. Geneva:
World Health Organization; 2008 (A61/12; https://apps.
196. Towards 2035. Strategic foresight: making migration and
who.int/iris/bitstream/handle/10665/23467/A61_12-en.
integration policies future ready. Paris: Organisation for
pdf;sequence=1, accessed 10 May 2022).
Economic Co-operation and Development; 2020 (https://
www.oecd.org/migration/mig/migration-strategic-foresight. 207. Promoting the health of refugees and migrants. In: Seventieth
pdf, accessed 22 January 2022). World Health Assembly, Geneva, 22–31 May 2017. Geneva:
World Health Organization; 2017 (WHA70.15; https://apps.
197. Healthcare in Peru: "COVID-19 highlighted a great need
who.int/iris/handle/10665/275698, accessed 7 June 2022).
to expand capacities". Geneva: United Nations High
Commissioner for Refugees, Global Compact on Refugees; 208. Global action plan on promoting the health of refugees
2020 (https://globalcompactrefugees.org/article/healthcare- and migrants, 2019–2023. In: Seventy-second World Health
peru-covid-19-highlighted-great-need-expand-capacities, Assembly, Geneva, 20–28 May 2019. Resolutions and
accessed 29 December 2021). decisions, annexes. Geneva: World Health Organization;
2019: Annex 5 (WHA72/2019/REC/1; https://apps.who.int/
198. Raposo VL, Violante T. Access to health care by migrants with
gb/ebwha/pdf_files/WHA72-REC1/A72_2019_REC1-en.pdf,
precarious status during a health crisis: some insights from
accessed 17 June 2022).
Portugal. Hum Rights Rev. 2021;22(4):459–82. doi:10.1007/
s12142-021-00621-5. 209. Promoting the health of refugees and migrants. In: Seventy-
second World Health Assembly, Geneva, 20–28 May 2019.
199. Tackling transmissions in migrant worker clusters [website].
Geneva: World Health Organization; 2019: 53 (WHA72(14);
Singapore: Government of Singapore; 2020 (http://www.gov.
https://apps.who.int/iris/handle/10665/328432, accessed
sg/article/tackling-transmissions-in-migrant-worker-clusters,
17 June 2022).
200. Information on coronavirus (COVID-19) for non-UK nationals.
London: Greater London Authority; 2021 (https://www.
london.gov.uk//what-we-do/communities/european-
londoners-hub/information-coronavirus-covid-19-non-uk-
nationals, accessed 29 December 2021).
201. International migration, health and human rights. Geneva:
CHAPTER 2
Determinants
of refugee and
migrant health
40
A Syrian interpreter working at a polyclinic for refugees and migrants in Eskişehir, Türkiye. Refugees and migrants may have difficulty
navigating the health care system and communicating. Interpreters help to bridge such barriers. © WHO
Determinants of refugee and migrant health
41
2.1 Introduction
This chapter explores the determinants that emerged from a review of the
literature on the health of refugees and migrants within the six WHO regions.
Determinants of health include a variety of individual, social and environmental
factors that can cause poorer health outcomes among refugees and migrants
compared with host populations. The determinants are highly interconnected
and often interdependent. Many researchers consider the displacement and
migration process to be a determinant in itself (1–3).
Refugees and migrants are affected by the same determinants that affect the
rest of humanity. However, their migratory status can add a layer of complexity
that, when combined with other determinants, makes them particularly
vulnerable to specific health risks, thereby affecting their overall health. These
determinants are broadly grouped as:
• individual characteristics and behaviours – genetics, gender and personal

behaviour and age;
• s ocial and economic environment (Box 2.1) – education, health literacy,
income and social status, employment and working conditions, social
support networks, culture, and health services (4); and
• p
hysical environment – safe water and clean air, healthy workplaces, safe
houses, communities and roads, and food and nutrition.
The determinants described in this chapter affect refugees and migrants

differently at various stages of their displacement and migration. For example,
issues such as water, sanitation, housing and food tend to be of greatest
concern during the migration process, that is, as refugees and migrants make
their journeys or first arrive at their destinations. Other determinants, such as
income and level of education, may assume greater importance as resettlement
progresses; equally, these determinants may influence a person's decision to
move in the first place. Sex and gender have cross-cutting impacts throughout
migration as in all other areas of life, while migratory status may evolve during
the process.
42
Box 2.1.
Social determinants of health
The social determinants of health are nonmedical factors that influence health outcomes, in both
positive and negative ways, by shaping daily life. Social determinants disproportionately affect
populations that are most vulnerable. When exploring the health of refugees and migrants, it is the
social determinants of health (rather than diseases or medical conditions themselves) that explain
most of their poor health outcomes.
Key social determinants include income and social protection, level of education, unemployment and job
insecurity, working conditions, food insecurity, housing and basic amenities, early childhood development,
social inclusion and non-discrimination, conflict, and access to affordable health services of good quality.
Recognizing their importance, the World Health Assembly adopted resolutions on social determinants
of health in 2009 and again in 2012 following the World Conference on Social Determinants of Health in
Rio de Janeiro.
Since early 2020, however, the social and health inequalities exposed by the COVID-19 pandemic have
led to renewed interest by Member States in WHO's work on the social determinants of health. In 2021,
the World Health Assembly passed resolution WHA74.16, highlighting the need to strengthen efforts to
address the social determinants of health, calling such efforts "an integral part of the national, regional
and international response to the health and socioeconomic crises generated by the current pandemic
and to future public health emergencies" (4).
In the Colombian municipality of Arauquita local authorities and humanitarian partners set up shelters and provided aid to people who
had recently arrived from the Bolivarian Republic of Venezuela. © WHO / PAHO / Karen Gonzalez
43
2.2 Sex and gender unbalanced power relations between men

and women affect the risks, health-seeking
behaviour and health outcomes of men and
• Sex- and gender-defined roles, norms women in different age and social groups (5–7).
and behaviour shape many of the
challenges that refugees and migrants Sex and gender greatly influence displacement
of all ages are exposed to, ranging
and migration. To take only one example,
from physical, sexual and emotional
many women who are displaced or choose to
violence in the household to specific
sectors of employment. migrate do so in their prime childbearing years.
Their health needs in any given situation may
• Sex and gender influence access to
be very different from those of men, requiring
health services and how these services
additional medical services for prenatal,
respond to the particular needs of
refugees and migrants across the labour and delivery, and postpartum care
life course. (8,9). Violence and security are other issues
that frequently affect women and men very
• Women and girls face unique
differently, along with safe access to public
challenges and vulnerabilities, such
as unique privacy and security spaces and facilities. LGBTQI+ minorities face
challenges in accessing water, a multitude of challenges, ranging from social
sanitation and hygiene (WASH) stigma to provider discrimination and barriers
services and facilities, including for to accessing health care. Men are also affected
menstrual hygiene management. differently in a disaster context. Although
• The vulnerability of men and boys limited, the evidence indicates that migrant
to physical and sexual violence, men felt disempowered because they could
and their need for care and support, not provide for their families as they used to
is underrecognized. in their home country, or were perceived as
• Lesbian, gay, bisexual, transgender, causing unrest in their host countries (10,11).
queer and intersex (LGBTQI+)
refugees and migrants typically lack 2.2.1 Health of women and girls
social support, face discrimination Sex and gender is often an important
and experience unique challenges determinant of noncommunicable diseases
with local health services. Mental (NCDs). In the WHO European Region, the length
health burdens are high among
of stay in host countries was observed to have
this population.
an impact on the development of overweight/
obese conditions and to affect female refugees
and migrants, particularly those from Africa.
The roles, norms and behaviour associated This may have been the result of cultural
with sex and gender have an influence on how attitudes around physical activity and women's
people – women, men, girls, boys and people physical appearance (12,13). Syrian refugee
with diverse gender identities – access health women in Türkiye had significantly higher levels
services and how health systems respond to of overweight/obesity than men, although
their particular needs. Research clearly shows levels increased with age among both men and
that sex inequality contributes to heightened women (14). Sex also affected the prevalence
health risks for women and girls globally. At the of diabetes mellitus and cardiovascular
same time, examining health issues in terms disease (CVD). Some of these health outcomes
of sex and gender helps to determine how can be attributed to factors such as a lack
44
of female-only settings in which to perform poorer oral health, compared with their host
physical activities, a lack of knowledge and counterparts (26–28). Transnational marriages
limited exercise skills, as shown from research often demand that women quickly take on
in Australia (15,16). In addition, a survey- new roles in unfamiliar settings, which
based study among children from occupied raises stress levels and the risk of mental
Palestinian territory, including east Jerusalem, health issues.
found that girls reported restricted access to
public spaces compared with boys and feelings Across various employment sectors there is
of insecurity when outdoors, which limited their often a sex disparity that results in different
activities (17). In Thailand, a survey of migrant injury rates between men and women. Many
workers also found that being female was jobs in high-risk sectors, such as construction,
associated with a lack of exercise, highlighting are heavily dominated by men (29–31).
the need for inclusive and culturally appropriate International employment schemes also
health promotion strategies (18). Sexual and exhibit a sex imbalance, as evidenced by
genderbased violence (SGBV) against women Australia's Seasonal Worker Program and New
is a factor that can increase vulnerability to Zealand's Recognized Seasonal Employer
suicide and self-harm, as demonstrated among scheme. Both have low female participation
Rohingya refugee women in Bangladesh (19,20). rates (17% and 10%, respectively), leading
In several regions, female refugees and migrants to an overrepresentation of accident-related
faced high levels of SGBV, which is linked to injuries among men (30). In the household
trauma and poor mental health outcomes (21– service sector, where predominantly women
24). In addition, practices such as female genital are employed as migrant domestic workers,
mutilation (FGM) and early marriage can drive female workers are subsequently at higher
girls to migrate in order to seek safer conditions risk for musculoskeletal disorders, abusive
in other places (25). practices and poor mental health (32–34).
In the Republic of Korea, women migrating

for marriage experience poorer health 2.2.2 Health of men and boys
outcomes and multilevel social challenges, Refugee and migrant men face their own
including acculturative stress, depression and challenges along the migration journey.
Because men are not traditionally recognized
as a vulnerable subgroup in the same way as
women or children, the needs of men may be
overlooked or neglected along the migration
journey, particularly those relating to the
Cases of sexual violence among provision of health services (35).
refugee and migrant boys and Evidence indicates that refugee and migrant
men are often underreported as men experience physical violence, including
a result of social and cultural torture, beatings and imprisonment, during
different phases of migration, sometimes
stigma and the belief that men more than women (36–40). Such experiences
cannot be raped. result in a high burden of post-traumatic
physical and psychological morbidity, as well
as a poorer quality of life and social isolation.
45
Notably, regional differences occur a country in the WHO European Region, 28%
regarding the type of physical violence of sexual assault survivors were men; a high
experienced by refugee and migrant men. proportion of these men indicated that their
Men transiting through the countries of attack occurred during the migration period
the WHO African Region and WHO Eastern rather than in their country of origin (46).
Mediterranean Region frequently report A study in one country of refugee survivors of
imprisonment and torture, often as a result SGBV and torture, including rape, found that
of political violence or driven by state actors. none of the men sought treatment or
Studies have included refugees from and officially reported their injuries (40).
transiting through several countries from
the African continent bound for Europe Refugee and migrant men in a few high-
(40–42). In contrast, extortion and theft income countries in the WHO Region of the
were the most common forms of physical Americas reported feeling pressure to fulfil
violence experienced by migrant men typical masculine social roles, such as sending
during transit through Central American remittances back home, and to assert their
countries to the United States (43). A study masculinity by establishing themselves as
found that male migrants in transit through breadwinners (47,48). Being unable to do
a Central American country where they so, whether because of unemployment or
were not nationals experienced a greater other barriers, was linked to high levels of
burden of violence compared with their stress, emotional and behavioural problems,
female counterparts, although no significant and feelings of inadequacy, leading to a
difference was found between male and state of "depleted masculinity" (48). In the
female migrants who were nationals of case of male migrants from Bangladesh and
that same country (43). This disparity may Pakistan working in Greece, such feelings of
be a result of irregular migrant conditions emasculation have driven many to rework
and limited social support. High levels of their masculine status into self-exploitative
violence were also reported by transsexual, contests (e.g. fruit-picking competitions)
transgender and transvestite individuals. that serve the employers' interests while
undermining worker solidarity (49).
Cases of sexual violence among refugee and
migrant boys and men are often underreported 2.2.3 LGBTQI+ populations and
as a result of social and cultural stigma and sexual minorities
the belief that men cannot be raped (41,44,45). LGBTQI+ refugees and migrants face particular
Evidence from male survivors of sexual risks and vulnerabilities as a result of their
violence in three refugee-hosting countries sexual orientation, gender identity, gender
(Bangladesh, Italy and Kenya) identified expression and sex characteristics, similar to
key barriers and deterrents faced in seeking LGBTQI+ people among the host population
services after experiencing sexual violence (45). (50). However, migratory status adds an
Many met negative attitudes in health care additional layer of complexity. Evidence from
providers and staff, such as disbelief and lack the WHO African Region shows that these
of empathy, and were subjected to humiliating groups often lack social support, face stigma
comments from service providers with and discrimination, and experience limited
xenophobic and homophobic misconceptions access to and poor treatment from local
of male-on-male sexual violence. In a clinic health services, and these challenges may be
providing medical care to asylum seekers in compounded by their migratory and/or
46
HIV status (51–53). Stigma presents a major refugee status in another country from the
barrier to HIV prevention and care, particularly WHO Region of the Americas, some reported
for men who have sex with men (MSM). In a suffering negative psychological impacts
country from the WHO Region of the Americas, while completing the refugee claims process.
HIV-related stigma was among the most Reasons for this included re-traumatization
frequently reported barriers to consistent while recounting experiences of violence and
attendance at HIV clinics (54); in Europe, persecution, compressed service timelines
structural stigma towards sexual minorities leading to mental health and identity crises,
and immigrants has been associated with a and the additional burden of proving that they
lack of knowledge about HIV prevention and are members of a sexual or gender minority as
service coverage (55). In a study carried out part of the process (61).
in another high-income country, 40% of MSM
from several migrant originated countries In a qualitative study exploring integration
indicated that their reason for migration was to experiences, Muslim LGBTQI+ refugees living
affirm their sexual orientation. The study found in high-income countries reported challenges
that migration to avoid persecution because resulting from their intersecting identities;
of being gay was associated with an increased refugees can suffer homophobia, transphobia
risk of HIV infection after arrival in that country, and discrimination from other refugees while
whereas migrating to lead a gay life was not (56). simultaneously experiencing anti-migrant
sentiments and/or Islamophobia from host
LGBTQI+ refugees and migrants reported a communities (62). Harassment and threats
variety of mental health burdens, including of violence can also discourage LGBTQI+
mental distress, suicidal ideation and traumatic refugees from seeking the social services and
stress, with some indicating that their mental benefits that they are entitled to. The literature
well-being during the post-migration period indicates that culturally tailored social support
was either unimproved or worsened compared groups, participation in civil society and
with their pre-migration well-being (57–60). building trust with health care providers who
In a study among LGBTQI+ people seeking recognize their needs for social support may
all help to moderate the effects of the various
stressors experienced by LGBTQI+ refugees
LGBTQI+ refugees and migrants and migrants (63–65).
reported a variety of mental health Displaced MSM and transgender women

burdens, including mental distress, interviewed in a cross-sectional study
presented higher levels of psychiatric
suicidal ideation and traumatic comorbidities compared with their
stress, with some indicating that counterparts in the host population as a
result of experiencing both displacement- and
their mental well-being during the stigma-related stressors (66). To successfully
post-migration period was either implement HIV prevention and testing
programmes, health care providers must
unimproved or worsened compared have high levels of comfort with LGBTQI+
with their pre-migration well-being. issues and also consider how MSM view their
sexual behaviour and relationships (67–69).
Further research is needed on sexual and
47
Rohingya women and girls using the water facility beside a women’s hygiene centre in Cox's Bazar, Bangladesh. The facility was designed
for refugee women by refugee women. © UNHCR / Hasib Zuberi
gender minorities such as transgender 2.2.4 Menstrual hygiene

refugees and migrants. Transgender asylum management
seekers in a high-income country recounted Women and girls often face unique
experiencing pervasive violence from family challenges in accessing WASH services and
members, police and their communities, facilities, particularly for menstrual hygiene
which led to persistent mental health management (note that WASH is discussed
problems (70,71). Compared with male and as a separate determinant in section 2.10). In
female migrants, transgender migrants Cox's Bazar, Bangladesh, Rohingya refugees
transiting from a middle-income country reported challenges around access, safety,
to a high-income country experienced a privacy and dignity, such as the need for
significantly greater burden of violence, private washing spaces for menstrual hygiene
with psychological violence being reported materials. Male architects and engineers
most often (43). Transgender refugees living largely dominate WASH infrastructure
in a European country encountered similar planning and design, and often integrate
stressors and traumas both before and sex assumptions into their work. These
after migration, but also stated that religion assumptions range from determining how
could be a protective factor for gender much space is needed for women and girls
affirmation (72). Transgender women who to feel comfortable in WASH facilities to
have migrated to work from a south-east issues of privacy and safety. To counter this,
Asian country to a high-income country as the Women's Social Architecture Project
transpinay entertainers view their experiences included Rohingya women and girls and
as a positive part of their gender affirmation female architects in planning WASH facilities
process and sexual emancipation (73,74). to provide a different perspective on how
48
to approach the design of these facilities Although the impact of sudden displacement
and where to locate them (75). Among the on children is well documented and easily
suggestions included by women were to draws the attention of both the public and
provide a ramp instead of steps leading to a decision-makers (see section 3.4), less well
latrine (as this is easier for older or pregnant known or provided for are the needs of
women) and shelving and drying areas for older people pushed from their homes by
sanitary products, and the preferred optimal catastrophic events, ranging from earthquakes
configuration of privacy screens. and flooding to famine and violent conflict.
Other countries with large camp-based settings Ageing is an ever-increasing factor in global
experience the same challenges. In a study health, driven both by the growing longevity
among displaced Somali women in northern of the population and improved survival
Kenya, women were often excluded from the at younger ages (78,79). Recognizing this
design and implementation phases of sanitation demographic fact and its implications, the
initiatives, despite having reported concerns such United Nations General Assembly declared
as personal safety in areas of open defecation, 2021–2030 the Decade of Healthy Ageing
the need for private spaces for menstruation (80). WHO has the task of implementing this
management and problems related to FGM (76). initiative through working with governments,
civil society, international agencies, the private
Poverty can also affect the health of refugee sector and other partners for a decade of
and migrant women, who may lack menstrual concerted action to foster long, healthy lives.
hygiene products and access to safe, clean and
private toilets (77). A study among Venezuelan This work will necessarily include the health
migrant women living in Brazil determined that needs of older refugees and migrants (Box 2.2),
almost half of participants who menstruated with consideration of the different ways that
(46.4%) did not receive any hygiene kits, 61% these are manifest across regions and contexts,
were not able to wash their hands as often as diseases and conditions and their interaction
they would have liked and the majority did not with other determinants (81). For example,
feel safe using public toilets. older refugees and migrants are sometimes
categorized within two groups: those who have
2.3 Age departed their home countries and arrived at
their destination as older people, and those
who arrived at a younger age and aged in
• The number of older people the host country (82). Particularly vulnerable
displaced by humanitarian crises groups, including asylum seekers and
is growing rapidly. migrants in irregular situations, will require
• The impact and needs of children specific attention, as will those affected by
are relatively better studied; however humanitarian crises.
the impact and needs of older people
forcibly displaced by catastrophic 2.3.1 Unaccompanied or
events are little known, but evidence
separated children
shows older people are at particularly
Migrating without a parent or caretaker
high risk in such crises across a variety
of determinants. may create particular vulnerabilities for
unaccompanied or separated children
(UASC), including the risk of abuse, trafficking
49
or exploitation in transit and destination UASC from the WHO African Region and
countries. During transit, UASC, particularly WHO Eastern Mediterranean Region
girls, may join families or groups to which migrating to Europe often follow the
they are unrelated to for protection; however, Central Mediterranean Route or Eastern
such groups can also be linked to exploitation Mediterranean Route. However, the
and violence (83,84). UASC in Europe are Central Mediterranean Route is particularly
overwhelmingly boys: in 2020 almost 9 in dangerous for UASC as they are more likely
10 children seeking asylum were boys. While not only to travel alone but also to be
boys may be more likely than girls to travel exploited, spend more time in transit,
unaccompanied, this gender disparity may and have limited access to protective
also be explained by challenges in identifying systems (83).
unaccompanied girls because many may go
undetected by authorities, either voluntarily
or involuntarily, and subsequently fail to
receive essential services for health and
protection (25).
Box 2.2.
Older age and migration
The number of older people displaced by humanitarian crises is growing rapidly. The proportion of
people aged 50 years and older in fragile countries, where conflict and disasters are more likely to occur,
is projected to increase from 12.3% (219.9 million) in 2020 to 19.2% (586.3 million) in 2050.
A 2019 study based on interviews conducted during humanitarian crises in 11 countries (Ethiopia,
Jordan, Malawi, Mozambique, Pakistan, South Sudan, the Syrian Arab Republic, the United Republic
of Tanzania, the Bolivarian Republic of Venezuela, Yemen and Zimbabwe) found that 77% of the older
people interviewed lacked income, 64% did not have enough to eat and one quarter had no access to
clean water (81). Women seemed to be disproportionately affected and accounted for 58% of those living
alone, 56% of those caring for others, 56% of those with no access to health care, 58% of those with no
access to food and 58% of those with no income.
Older people often encounter exclusion and discrimination, the erosion of traditional and family support
systems, a lack of access to information and documentation, and limited access to basic services,
including housing, food, nutrition and health. Almost four fifths (77%) of those interviewed said that they
had not been asked by any other humanitarian agency about the services being provided to them.
The impact of these issues is exacerbated when older people have to take care of children or other
adults. Nearly two thirds of those interviewed (63%) said that they were caring for at least one child, and
44% were caring for another older person.
Source: adapted from McGivern et al. (81).

50
For example, just under half of adolescents compared with those placed in youth
and young people interviewed on their reception centres. Additional challenges for
migration experience on the Central UASC include detention, poor treatment from
Mediterranean Route reported they had border and reception officials, and difficulty
been forced to work. In the WHO Region of in accessing health care services because
the Americas, UASC transiting from Central of being unaware of or having difficulty in
American countries (Guatemala, El Salvador accessing child-friendly health services (92–95).
and Honduras) to the United States face
family separation, struggles with reunification The evidence shows that UASC have a
and deportation (85–87). significantly high risk of developing mental
health issues. Contributory factors include
In destination countries, UASC face specific forced separation from family, death of a
challenges upon reception and screening. close family member and lack of social
For example, they may need to undergo an support (96–101). Evidence from the
age assessment process, which holds its own Netherlands also indicates that the type of
risks: the processes are not consistent across care facility in which UASC reside influences
countries, may be invasive, and can pose their mental health: UASC refugees who
protection risks if not conducted properly lived in large reception centres had the
(88–90). In a longitudinal study among lowest quality of living environment and
UASC in Norway, 56% were not recognized highest mental health problems compared
as minors (91). At both 15 and 26 months with children living in all other types of
after arrival, those who had been placed accommodation, including in small living
in reception centres for adults had higher units or with foster families (102).
levels of psychological distress symptoms
2.4 Education
• B
oth higher and lower levels of
For refugees and migrants, schools education are associated with poor
health outcomes. A lower level of
often provide a service beyond their education is associated with poor
educational purpose by linking uptake of health care services and risk
of physical assault, whereas a higher
students with a range of social level of education is associated with a
lower level of physical activity.
capital resources; serving as sites • A
ccess to good-quality education
for immunization programmes; after migration is limited in many
settings, often affecting young girls
providing community-based disproportionately.
nutrition interventions; and • A
cross high-income settings,
fulfilling their material, practical highly skilled refugees and migrants
are often employed in jobs
and emotional needs. below their educational and
employment qualifications.
51
2.4.1 Health outcomes status, although this association was not found
Refugees and migrants with lower levels of for refugee men (111). An American study
education often experience poorer physical explored how education levels can mediate
or mental health outcomes than those with the association between age at migration and
higher levels of education (103,104). The cognitive impairment (112). It concluded that
prevalence of HIV among Mozambican miners migrant men who had migrated when they
working in South Africa was found to decline were older than 50 years had a significantly
with increasing levels of education (105). In a higher risk for cognitive impairment than
Canadian study, a higher level of education their counterparts born in the United States,
was found to be a protective factor in migrant although this risk was not significant after
women for physical assault and from poor adjusting for level of education. However,
mental health (106). A separate study found migrant women who had migrated when they
that refugees and migrants in Canada who were older than 50 years had a higher risk for
were educated to above high-school level cognitive impairment than women born in the
were 37% more likely to report excellent, United States, even after adjusting for level of
very good or good health compared with education. Evidence from Europe highlights
those educated to high-school level or lower that the prevalence of diabetes in Ghanaian
(104). In a study in Germany, a migration migrant men and women decreased as the
background and lower level of education level of education increased, although the
were both associated with lower uptake of prevalence increased with increasing level of
nonmedical antenatal care (ANC) (107). In a education among their counterparts in rural
case–control study in the Islamic Republic of Ghana (113).
Iran, Afghan women refugees and migrants
had a higher risk of maternal mortality than Studies present a more nuanced picture
Iranian women; the risk was concentrated regarding the educational attainment of
among women with lower levels of education refugees and migrants and their awareness
(108). In urban refugees and asylum seekers of cancer. According to a cross-sectional
in Thailand, a cross-sectional study revealed study, Nepalese migrants in Japan with higher
lower levels of education than in the host education levels were more likely to seek
population, and unmet needs for health cancer-related health information compared
services were positively associated with lower with migrants with only primary education
levels of education (109). A community-based (114). An American study of prostate cancer
cross-sectional study of primarily young male screening among migrant men, predominantly
migrant labourers in Ethiopia determined that of African descent, indicated that being
a lower level of education was significantly unaware of prostate-specific antigen testing
associated with the risk of malaria (110). was associated with a low level of formal
education (115). In a descriptive cross-sectional
Education level is often considered alongside study, both Syrian refugees and Lebanese
sex as a determinant of health, with studies citizens with higher education levels recognized
highlighting disparities that correspond to significantly more cancer symptoms and risk
these factors for different health outcomes. A factors than those with lower education levels
quantitative study on refugees in the United (116). Knowledge of the most common cancers
Kingdom found that the number of years of impacting males was also low among both
education was positively associated with groups. Studies from various high-income
refugee women's self-reported general health settings, including Australia, the United States
52
and countries in Europe, reveal conflicting providing community-based nutrition

evidence on the influence of education levels interventions; and fulfilling their material,
on refugee and migrant women's cancer practical and emotional needs (126–129).
screening practices (117–122). For example, a However, various barriers to education remain,
study in Australia found no correlation between many of which disproportionately affect
education level and participation in breast school-aged girls. In Thailand, the country's
cancer screening practices among migrant Education for All initiative aims to provide all
women, whereas a cross-sectional study in the children, regardless of legal status, the right to
United States indicated that Korean migrant an education; however, migrant children may
women with lower education levels were more be prevented from attending school by their
likely to use breast cancer screening services parents' fears of local authorities, the high
such as mammography and clinical breast costs of school supplies and language barriers
examination (119,120). (130). Despite efforts and policies in Rwanda
to encourage continuation of schooling,
Alternatively, some evidence indicates that a pregnant Burundian refugee girls reported
higher level of education is linked to poorer low attendance, largely a result of the stigma
health behaviour, specifically inadequate associated with teenage pregnancy (131). In
physical activity. Among Sahrawi refugees in Lebanon, adolescent Syrian refugee girls who
Algeria, having higher education levels was had lost educational opportunities as a result
associated with lower physical activity, as of displacement reported not attending school
many were employed in sedentary jobs (123). because of financial limitations and concerns
A higher level of education was also associated about SGBV in and around schools (132).
with physical inactivity among Ghanaian
migrants living in Europe (124,125). Ghanaians Parental influence and perceptions of
in Amsterdam with lower education levels education also affect children's enrolment and
reported having more physically demanding participation in schools. In a study in Chile,
jobs and higher levels of physical activity migrant parents of children aged 1–6 years
compared with Ghanaians in Berlin and who were not enrolled in school indicated this
London, who had higher education levels. The was because they considered it unnecessary
association between level of education and or did not trust the care provided by the
health outcomes underscores the critical and school system (133). Arabic-speaking migrant
far-reaching role of education as a determinant parents living in Sweden cited concerns about
of health for refugees and migrants. the sex education received by their children
in Swedish schools, which may accentuate
2.4.2 Access to education for intergenerational conflicts (134). In Bangladesh
refugee and migrant children and Jordan, refugee girls reported parental
Access to good-quality education and schools discouragement and cultural expectations of
for refugee and migrant children may be early marriage as reasons for dropping out of
inconsistent or limited along the migration school, as parents may not value education
pathway, and this often intersects with other for girls as much as they do for boys. However,
social determinants of health. For refugees some evidence indicates that early marriage
and migrants, schools often provide a service is not always imposed but might result from
beyond their educational purpose by linking the girls' or families' living situations, where
students with a range of social capital resources; economic hardship and insecurity play a big
serving as sites for immunization programmes; role in decisions about marriage (135–137).
53
This calls for further research to develop

interventions that address the root causes
of early marriage. In the case of Rohingya
Refugee and migrant women
refugees in Bangladesh, despite free education in many WHO regions report
in camps, teacher negligence (e.g. inconsistent
attendance and poor teaching practices)
low levels of health literacy and
driven by low incentives was an additional inadequate knowledge of sexual
barrier to education (137). and reproductive health topics,
2.4.3 Employment challenges such as human papillomavirus
associated with level vaccination, contraception, cancer
of education
Across high-income settings, such as Australia, screening and menstruation.
the United States and countries in Europe,
highly skilled refugees and migrants are
often employed in jobs that are below their
educational and employment qualifications.
This is especially the case among highly skilled
migrant workers who work in low-skilled jobs
and face obstacles to entering the labour 2.5 Health literacy
market (138–140). Refugees and migrants may
face significant delays in acquiring work visas
and having their professional qualifications • A
low level of health literacy, combined
verified, during which time they may take on with language barriers, hinders the
less-skilled work (141,142). Despite evidence seeking of health care services and
indicating that migrants in the United States adherence to treatment.
were relatively successful in finding work, • I n situations of mass displacement
their occupations did not always match their and certain types of labour migration,
training or skills, a factor that has affected their such as for agricultural work,
quality of life and mental health (143). Some refugees and migrants often have
countries have adopted policies in response lower levels of health literacy than the
to these challenges. Several countries have host population.
introduced policies that place highly skilled • V arious strategies can improve health
migrant workers in workplaces that match the literacy among, and communication
needs of employers, namely Australia; China, with, refugees and migrants,
Hong Kong Special Administrative Region; New including translating clinical and
health promotion materials, offering
Zealand; and Singapore (141). In Germany,
interpretation services within
policies for skilled migrant workers came
health services and sensitivity
into effect in early 2020, thereby expanding training for health staff in cultural
opportunities for qualified professionals from and age differences.
outside the EU to work in Germany (144).
Ensuring the recognition of educational and
professional qualifications was critical to WHO states that health literacy is an integral
integrating refugees and migrants into the component of PHC and a critical determinant
labour markets of host countries (145). of the well-being of individuals, communities
54
A migrant worker uses a tele-kiosk to speak to a doctor from his dormitory in Singapore. © WHO / Juliana Tan
and health systems (146,147). Many factors knowledge of sexual and reproductive health
relevant to refugees and migrants affect an (SRH) topics, such as human papillomavirus
individual's health literacy. A study of homeless (HPV) vaccination, contraception, cancer
people in Spain, both migrant and of the host screening and menstruation (150–157). Cultural
population, found no differences in health stigma, taboos and feelings of shame and
literacy between the groups (148). However, embarrassment often limit discussion of
homeless migrants tended to have more issues these topics. However, without critical SRH
related to health care access and utilization education and information, many women
and were often not insured when compared may remain vulnerable to problems such
to homeless people in the host population. as sexually transmitted infections (STIs) and
The study concluded that migratory status, unplanned pregnancies. Refugees in Cox's
language proficiency and socioeconomic Bazar, Bangladesh, and in Ethiopia reported
status (SES) all play key roles in health literacy limited knowledge of how to treat diarrhoea,
and health outcomes. despite this being a common illness in
such circumstances (158,159). In Canada, a
2.5.1 Influence on health outcomes study found that 75% of migrants lacked the
Refugees and migrants often report lower health literacy skills to maintain good health
levels of health literacy than their host compared with 55% of non-migrants. This
populations. This is of particular concern discrepancy remained even after adjusting for
since refugees and migrants may struggle to factors such as sex, age, household income
adhere to care practices or to seek preventive and employment status (160). In Germany,
health care services (149). Refugee and a migrant background was found to be
migrant women in many WHO regions report significantly associated with lower levels of
low levels of health literacy and inadequate health literacy (161).
55
Language barriers also hinder communication 2.5.2 Strategies to improve health

between health care providers and their literacy and communication
refugee and migrant patients, with both Various strategies have been adopted to improve
groups citing a need for interpreters during health literacy and communication among
medical consultations (162–166). Interpreters refugees and migrants. These should take
and mediators are especially important to interest, need and engagement into account,
facilitate complex registration processes (167). along with sociocultural context (173–180).
Research in Switzerland found that a lack Strategies may include trained cultural mediators
of interpreters led to migrants using family and digital approaches. The deployment of
members or minors as translators or even trained interpreters and cultural mediators has
resorting to using gestures to communicate proven to be useful in communicating with
(164). In Australia, Afghan women reported refugees and migrants, and in improving their
that few on-site interpreters were available health (181,182). In the United States, a study
during imaging and pathology screening conducted with primarily Hispanic migrant
appointments, and virtually none were present women revealed that most (71.3%) were quite
during labour and birth, leaving many women open to participating in HIV health education
to depend on their husbands for translation via the internet (173). Among migrant cancer
(168). Alternatively, health care providers survivors in Australia, evidence showed there was
caring for refugees in Australia, Canada, a need for specific written health information
Ireland and the United States reported that related to recovery time after treatment in the
the use of trained interpreters during medical language of the migrant and appropriate for their
consultations comes with its own challenges, culture and community (174). These findings
including poor professionalism by interpreters from Australia indicate that bilingual resources
and low confidence and trust in interpreted can be beneficial to cross-generational families
consultations (169). with varying levels of proficiency in English.
Evidence from the United States indicates that Research in Sweden suggested that to improve
health care providers may perceive refugee self-care adherence among migrant patients
and migrant parents as having low levels of with heart failure, nurses should become more
health literacy, which can have an impact on sensitive to cultural differences and adapt self-
the establishment of trust between the two care counselling to the patient's level of health
parties (170). Different perceptions of ill health literacy (175). For example, research exploring
and limited knowledge of traditional medicine the interaction between Australian health care
among health care providers further contribute practitioners and refugees from Myanmar
to these challenges (171). Both patient- and concluded that the use of metaphors in
provider-based health literacy difficulties were sexual health dialogue was more linguistically
identified in the provision of maternity care appropriate and culturally accepted than
to migrant women in Australia (172). Health verbatim or literal translations (183). As a
care providers have urged the use of technical result, awareness of the nuances in sexual
resources such as electronic health (e-health) health vocabulary made dialogue around
tools, digitalized patient portals and electronic sexual health more culturally appropriate and
reminders in conjunction with health provider allowed health care practitioners to develop
communications to support health literacy and a better rapport with their patients. Beyond
information needs. being culturally and linguistically appropriate
56
for refugee and migrant populations, health costs, including out-of-pocket payments, that
communication should also consider the are often a barrier to health care for refugees
needs of those who are illiterate or have and migrants. Evidence from refugee camps
learning disabilities. in occupied Palestinian territory, including
east Jerusalem, highlighted the link between
income and chronic diseases: the prevalence
2.6 Income of chronic diseases was found to be higher
among groups with a lower income (184).
Access to the labour market and income
• Direct and indirect costs of health care, generation significantly improved the mental
including out-of-pocket payments, health of refugees in Canada (185), while
are problematic for many host research in South Africa highlighted the role
populations, but can be an even
of reliable income and economic capital in
greater barrier to health care for
determining positive health outcomes among
refugees and migrants, particularly
irregular migrants and those in sub-Saharan African migrant women (186).
precarious employment. Similarly in Sri Lanka, belonging to temporary
migrant households with lower SES was
• Sending remittances home is
associated with an increased risk of suicidal
an essential motivator of labour
migration, but may cause migrants to behaviour (187).
deprive themselves of good nutrition
and hinder health-seeking behaviour. 2.6.2 Remittances and left-behind
• Remittances often benefit the health-
families
seeking behaviour of left-behind Migrants who move for economic or labour
families in the home country, but the reasons can face persistent or continued
association is not fully understood. poverty in the post-migration process,
However, family separation and particularly if they must send remittances to
long-distance relationships can have families in their home countries (section 1.7.4
negative impacts on the mental health discusses left-behind families). In recent years,
of left-behind children and older active immigration policies in countries such
people, such as grandparents.
as Australia and Singapore have contributed to
an increase in immigration in the WHO Western
Pacific Region (188), which contains 3 of the
Income is a key determinant of health 10 countries receiving the most remittances
outcomes and access to health services. In worldwide: China (which is also a top sender
addition to being a barrier to accessing health of remittances), the Philippines and
services, economic insecurity may worsen the Viet Nam (189).
physical and mental health of refugees and
migrants. In North and South America, migrants from
Colombia reported experiencing material
2.6.1 Health outcomes deprivation and deep poverty in host countries
Economic insecurity, poverty and low income because of a combination of low wages
are often associated with negative physical and and sending remittances to their families
mental health outcomes. Chapter 4 on health in Colombia (190). Similarly, in the United
systems includes the topic of health financing Arab Emirates, low wages made it difficult
(section 4.6) and of the direct and indirect for Bangladeshi migrants to balance daily
57
living expenses with sending money to their 2.7 Migratory status

families (191). In Pakistan, family members
left behind by migrant workers, particularly
the wives of migrating husbands, reported a • F ear of deportation and anti-migrant
high prevalence of depression and anxiety; discourse reduce the willingness of
however, having a son who had migrated migrants to access health services,
leading to late diagnosis and,
provided economic benefits and had a positive
consequently, poorer health outcomes.
effect on their use of health services (192–
194). In Chile and the United States, family • T
he impact is particularly high
separation and distance from the country of among irregular migrants who lack
official documents and work in
origin were reported to be among the major
marginalized industries and among
sources of stress (195,196).
asylum seekers whose status has not
yet been recognized.
Although remittances may help the families
of migrant workers to access health services
in their home countries, the impact on health
and well-being varies. In Togo, the families Migratory status, including legal status
of international migrants showed increased according to legislation in the transit or
use of health care services, specifically destination country, is another important
for maternal and child health (MCH). This determinant of the health of refugees and
increased use was the result not only of migrants. Lack of legal documentation, fear of
additional financial support from remittances deportation, and anti-refugee and anti-migrant
but also of exposure to new ideas and discourse often prevent refugees and migrants
practices (197). However, among sub-Saharan from accessing health services (162,188,202–
African migrants living in France, remitting 206). Studies conducted in Sabah, Malaysia,
money and having a child abroad were noted the role of citizenship and nationality
associated with poor health among migrant among migrant children of Philippine and
women, although not among migrant men Indonesian migrants and their access to key
(198,199). In Sudan, pressure for women to services. Some had reportedly faced delay as
accept unsolicited or unwanted advice about a result of their citizenship status (207,208).
childbearing or child-rearing from male In Australia, irregular migrants may not be
relatives who had migrated abroad was found entitled to free regular health services but
to cause stress and anxiety in the families left only to free emergency care (209). In the WHO
behind. (200). A study comparing the impact South-East Asia Region, fear of deportation
of parental migration on children who are because of migratory status as well as higher
left behind in Ethiopia, India, Peru and Viet costs for primary care were reported by
Nam found that the negative health effects irregular migrants as barriers to accessing
were greater for children whose parents had health care (210,211).
migrated for longer periods (201). The context
also matters: parental migration was not A 3-year cohort study in the United States
found to have a significant impact on children found that growing anti-migrant rhetoric
left behind in Ethiopia, whereas it led to during the study period was associated with
poorer health outcomes for the children left a 43.3% decrease in PHC visits by irregular
behind in the other three countries. migrant children and a 34.5% decrease by
irregular migrant adults (202). In North and
58
South America, irregular migrants were found of psychosocial support systems (20,217,218).
to often experience stress, anxiety, fear of In Sweden, for example, a high prevalence
administrative barriers, mobility restrictions of PTSD and depression was found in UASC
and constant uncertainty about immigration who had experienced family separation
enforcement (212–214). How health access and and displacement (219). In several other
outcomes are influenced by migratory status regions, displacement was also associated
is discussed in detail in Chapter 3. Section 4.7 with increased sexual risk behaviour for
presents clear examples of how policies based economic and psychosocial reasons (including
on migratory status limit access to various transactional or survival sex), loss of social
services for refugees and migrants. support and loneliness (220–222).
2.8.1 Acculturation
2.8 Social support In the WHO Region of the Americas, low levels
of acculturation were a barrier to accessing
health services and were linked to less-
• Stress from displacement and informed decision-making about medical
migration is itself a determinant treatment (214,223,224). The process may be
of health among refugees and described as acculturation stress, which is
migrants, but it can be alleviated by
induced by adaptation to a new culture and
interventions such as counselling and
exacerbated by discrimination and exclusion.
community outreach.
A study of Mexican migrants in the United
• The impact of stress is often States showed that acculturation stress can
compounded by leaving behind social
lead to poor health outcomes, including mental
support networks.
health issues (225). Conversely, acculturation
• Women, particularly mothers, face may also lead to the development of protective
particular forms of stress in the factors over time, related to both the
absence of social support.
strengthening of social networks and family
• Acculturation – how individuals and cohesion (226). However, there are gaps in the
groups adapt to the culture of a host literature on the impacts of migration- and
country – can be a source of stress and displacement-related stressors on health and
reduce health-seeking behaviour, but
on family support systems.
it can also be mitigated by health and
social system outreach.
2.8.2 Parenting
Women, particularly mothers, face
particular forms of stress in the absence of
The presence or absence of social support social support. A study conducted among
may also influence refugee and migrant Syrian refugees in Lebanon modelled the
health status, particularly their mental effects of war exposure and daily stress on
health. Stress resulting from displacement maternal mental health, parenting and child
and migration can be compounded by psychosocial adjustment (227). The results
the loss of social support networks and by suggested that both war exposure and daily
acculturation processes experienced in the stress can affect the general mental health
host country (215,216). Several studies showed of mothers and increase the risk of negative
that forced displacement and its impact on parenting behaviour, contributing to poorer
mental health was partly caused by the loss psychosocial outcomes for children. The study
59
concluded that psychosocial and parenting their countries of origin (232). The complex
support should be provided for war-affected interplay of social determinants also makes
caregivers, along with interventions to provide interventions difficult (233–235).
for basic survival needs, ensure access to
quality health and education services, and Acculturation was found to play a role in the
break down restrictions on movement and prevalence of substance use in various studies
employment. Among refugees living in the based in the WHO European Region (234,236).
United States, the documented effects of Cross-sectional data from the Finnish Migrant
maternal traumatic distress on children Health and Wellbeing Study demonstrated
included depressive symptoms, antisocial that having a younger age, higher level of
behaviour and delinquent behaviour (228). education, employment, longer duration of
residence in Finland and language proficiency
Research in the United Arab Emirates noted a were associated with binge drinking and daily
higher prevalence of symptoms of depression smoking, with varying patterns of association
among adolescent migrants (aged 12–18 depending on migrant group and sex. For
years) from southern Asia (33.3%) compared example, a lower level of education and poor
with adolescents from the host population language proficiency acted as protective
(22%) (229). Not receiving a monthly factors for Kurdish migrant women, given
allowance from parents and coming from a their adherence to traditional cultural norms
single-parent family or a household with low around substance use (232). The impact of
monthly income were predictors of a higher length of stay in the host country remained
score on a depression scale. Depressive a factor, although the correlation weakened
symptoms were associated with poor self- after adjusting for perceived risk of substance
esteem and with experiencing neglect and use and dependence (all substances) and for
verbal abuse in school. Conversely, refugees substance accessibility (illegal substances);
and migrants may find family and social
support in their host countries, which may
bring health benefits.
2.8.3 Substance use

Substance use and dependence pose a health
challenge to diverse populations worldwide
Improving energy access for refugee
and are associated with a wide variety of populations, such as through
social determinants, including for refugees
and migrants. Studies among refugee groups
improved cooking stoves, can
in several African countries indicated that reduce reliance on biomass and the
alcohol and substance use were associated
with a higher prevalence of mental health
accompanying challenges, such as
conditions, including a higher prevalence of high household energy expenditure
psychopathologies, as well as related to SGBV and poor indoor air quality. It can
or intimate partner violence (IPV) (230,231). At
the same time, certain refugees and migrants also reduce the risk of SGBV for
consume substances at lower rates than local women when seeking firewood.
populations for a variety of reasons that may
include sex, religion and cultural norms in
60
however, some migrants were protected from 2.9 Air quality

this phenomenon, presumably because of
factors related to their country of origin (234).
• A
ir quality is critical to the health of
Some studies in the United States indicated refugees and migrants, especially
varying patterns of association for young those living in camps and irregular
settlements, where the burning
migrants from Latin America at risk of being
of biomass is linked to poor
drawn into early substance use, but education
respiratory health.
was a protective factor (237,238). In the WHO
Region of the Americas, traumatic experiences • I n workplaces or dormitories, where
many migrant workers spend a great
during migration often led to a convergence of
deal of time, overcrowding and
mental health issues. Interventions targeting
inadequate ventilation have been
substance use in Latin American migrant found to contribute to the spread of
populations, although effective in improving communicable diseases.
mental health symptoms, failed to reduce their
substance use (239).
Ensuring proper environmental conditions

relating to ventilation, heating and cooling,
and indoor air quality is critical for supporting
the health, and especially the respiratory
health, of refugees and migrants. The
literature emphasizes health risks in two
settings: refugee settlements and camps; and
workplaces and work-related housing.
Access to handwashing facilities
is essential to reducing the Migrant workers report facing a variety of
hazards related to air quality, which ultimately
transmission of communicable affects their health and quality of life. A study
diseases and maintaining safe carried out among migrant farmworkers in
the American state of North Carolina found
hygiene practices but can be numerous health challenges in their living
limited. Maintaining hygiene conditions. These included limited ventilation,
extensive mould and dampness, pests such
in refugee camps is challenging as cockroaches, heating units emitting
as access to handwashing smoke and fumes overnight, and having to
facilities might be limited, eat and sleep near fields newly sprayed with
pesticides (240). Other evidence indicated
hygiene supplies scarce and that being a migrant in the United States is
conditions crowded, thereby significantly associated with experiencing
air of better-than-average quality, whereas
increasing the risk of outbreaks of being a member of the host population is
communicable diseases. strongly associated with experiencing air of
poorer-than-average quality. The literature
indicates that this disparity may be explained
61
by migrants' consumer and environmental (246). Such conditions increase airborne

behaviours, which can have a lesser impact on particulate matter pollution to levels beyond
air quality compared with the habits of their the guideline maximum values.
counterparts in the host population (241).
Burning solid fuels has been linked to poor
In a study of migrant workers in central respiratory health among refugees in Rwanda
Thailand, almost half reported never opening and the United Republic of Tanzania. However,
their bedroom or living room windows the use of energy-efficient cooking stoves
for ventilation and 45% reported never can significantly improve lung function and
cleaning their window screen, with many have a positive impact on respiratory health,
citing a lack of time for home hygiene as a including among individuals with pre-existing
result of long working hours (242). Notably, airway obstruction and chronic obstructive
43.8% of migrants in the study presented pulmonary disease. Among Congolese
symptoms that may be related to indoor air refugees with airway obstruction in Rwanda,
quality. Among Rohingya refugees living in a prospective cohort study showed that those
Cox's Bazar, Bangladesh, conditions such as who use an energy-efficient cooking stove
overcrowding, indoor cooking practices and experience a significant increase in forced
the use of air-impermeable plastic sheets to expiratory volume compared with baseline
build shelters can contribute to the spread of groups (247,248).
acute respiratory infections, which are
among the main causes of death for this Indeed, improving energy access for refugee
population (243). (The link between housing populations, such as through improved
and health outcomes is further discussed cooking stoves, can reduce reliance on
in section 2.11.1.) biomass and the accompanying challenges,
such as high household energy expenditure
The burning of biomass (wood is by far the and poor indoor air quality. It can also reduce
most common, but other types include the risk of SGBV for women when seeking
animal dung, crop residues and grass (244)) firewood (249,250). Additional efforts to
is of particular concern for the health of address poor air quality include the use of
refugees living in camps. A comparative turbine ventilators in refugee camps and
study found variable air quality in refugee recycled plastic bricks as construction material
camps across 10 countries. In shelters in to reduce the high carbon dioxide emissions;
Bangladeshi, Djibouti and Ethiopian camps, however, evidence of the impact of such efforts
where solid fuels are primarily used for is limited (251,252).
cooking, the levels of total volatile organic
compounds exceed the recommended safe
levels (245). This contrasted with camps in
Jordan, Peru and Türkiye, where gas bottles
are primarily used as cooking fuel and
detected levels of these compounds were
lower than the recommended maximum
concentrations. In the case of Rohingya
refugees in Bangladesh, many shelters lack
proper ventilation because their kitchen area
is often not separated from their living spaces
62
2.10 Water, sanitation and wells and equipment, improper water storage
hygiene and misperceptions about water quality.
Some evidence indicates an association

• Challenges to securing WASH services between a higher level of education and
in refugee and migrant settings include greater adherence to safe water-chain
scarce hygiene supplies, financial practices. In refugee camps in Ethiopia,
barriers, inadequate measures to
households where women (described in
counter waterborne diseases, and
the study as caregivers) have no formal
varying levels of knowledge of
hygiene and handwashing practices. education were significantly more likely to
have water contaminated with faecal coliform
• Refugee populations in camp
bacteria than households whose caregivers
settings face a variety of challenges
had completed secondary education (253).
to securing safe drinking-water,
especially – but not only – in Similarly, in the Pagirinya Refugee Settlement
places where water is scarce. of northern Uganda, individuals with formal
education were more likely to observe safe
• Some evidence indicates that a higher
water-chain practices than those with no
level of education is associated with
greater adherence to safe water-chain formal education (255). Additional barriers
practices across all stages between to safe drinking-water across refugee camps
the water source and consumption. include long distances between households
and water sources, water shortages in the
• Although some refugee and migrant
groups lack knowledge of hygiene previous month, improper storage and
practices, the evidence indicates that the unavailability of free residual chlorine
disease outbreaks can be prevented (255–258). Psychological stress caused by the
when WASH standards are applied absence of clean drinking-water was identified
(e.g. protecting a water source from as a risk factor for mental health among young
contamination, ensuring the (aged 18–32 years) Syrian male refugees living
proximity of the water source or in a refugee camp in Jordan (259).
limiting the number of people using
a particular latrine).
2.10.2 Access to safe sanitation
Innovative sanitation systems, such as
urine-diverting dry toilets (UDDTs), have
2.10.1 Access to safe drinking-water been introduced into some refugee settings,
Refugee populations face a variety of but with varying results. In the Dollo Ado
challenges in securing safe drinking-water, refugee camp in Ethiopia, research on the
particularly when facing water constraints acceptability of UDDTs found high use among
in camp-based settings. Refugees living in survey respondents (88.8% and 93.4% in
camps in the Gambella region of Ethiopia two surveys conducted 18 months apart)
and refugees from occupied Palestinian (260). Satisfaction levels were significantly
territory, including east Jerusalem, living in higher in the second survey, with 97% of
Lebanon's Shatila camp reported that their respondents indicating that they were mostly
drinking-water was contaminated with faecal or very satisfied with UDDTs. However,
coliform bacteria and parasites (253,254). UDDTs were not as widely accepted in the
Other challenges in securing safe drinking- Kakuma refugee camp in Kenya by users who
water included the lack of maintenance of perform anal washing (a cultural practice
63
in their home country) or by women who conditions crowded, thereby increasing the
had experienced FGM (261). These examples risk of outbreaks of communicable diseases.
illustrate the importance of sociocultural
context in assessing the acceptability of Among South Sudanese refugees in the
sanitation systems. Many settings may also Rhino Camp Settlement in north-western
require different interventions to account for Uganda, only 23.1% of households reported
the estimated length of stay and population having access to adequate handwashing
size. Box 2.3 describes the challenges faced by facilities, with many citing barriers such as
Rohingya refugees in Cox's Bazar, Bangladesh, the high cost or lack of soap (264). Despite
in accessing WASH services. some improvements in WASH activities,
many people in refugee camps across the
2.10.3 Hygiene WHO African Region and WHO European
WASH interventions are critical because Region continue to experience outbreaks of
they address basic and essential needs, cholera and typhoid fever, as well as the risk
including handwashing facilities and hygiene of parasitic infections (265–267). A study in the
practices. Access to handwashing facilities Borgop-Cameroon refugee camp found that
is essential to reducing the transmission of it had not experienced a waterborne disease
communicable diseases and maintaining outbreak in the previous 6 months, probably
safe hygiene practices but can be limited. as a result of conforming to numerous WASH
Maintaining hygiene in refugee camps is standards, such as ensuring the availability
challenging as access to handwashing facilities of a protected water source and of sufficient
might be limited, hygiene supplies scarce and distance between latrines and water sources,
Box 2.3.
Water, sanitation and hygiene in Cox's Bazar, Bangladesh
The rapid influx of Rohingya refugees into Cox's Bazar, Bangladesh, in 2017 resulted in the formation of
new temporary settlements.
These settlements faced many challenges related to water, sanitation and hygiene (WASH), including a
lack of WASH facilities and infrastructure; the risk of transmission of diseases such as cholera, diarrhoea
and typhoid; a shortage of land area and groundwater; and susceptibility to floods, landslides and soil
erosion. Areas of improvement included raising awareness among refugees of waste disposal and proper
washing of transport containers (262,263).
The COVID-19 pandemic exacerbated these WASH challenges in an already resource-limited setting. The
pandemic made frequent handwashing and maintaining basic hygiene more difficult, with a greater
need for new handwashing locations, an increased water supply and additional hygiene promoters (246).
Recommendations for addressing the WASH challenges include designing and implementing infrastructure
that ensures a long-term water supply, rainwater harvesting and alternative methods for sanitation, such as
urine-diverting dry toilets.
64
and providing the recommended average programmes as a result of communication

amount of water per person (268). challenges, language barriers and low levels of
education. Similarly, compared with the host
Evidence from widely separated camps population, Nepalese migrants living in China,
(in Rwanda and Thailand) on knowledge, Hong Kong Special Administrative Region,
attitudes and practices regarding waterborne displayed considerably poorer knowledge of
diseases and WASH practices revealed that hand hygiene, with many reporting low levels
many refugees possess poor knowledge of education (274).
of safe water practices. A long duration
of stay, unemployment and higher age
were significantly associated with poor 2.11 Housing and living
handwashing practices (267,269). environments
Migrants often work in occupations where

maintaining good hygiene and handwashing • F or refugees and migrants, poor living
practices is imperative, as a protective environments, of which housing is
measure for both the individual and the a major factor, are associated with
adverse physical and mental health
host community. Migrant farmworkers in the
outcomes, such as respiratory diseases
United States are at a heightened risk for
and depression.
additional environmental exposures, such as
pesticides, that make access to handwashing • R
efugee and migrant children living
in poor-quality, inadequate housing,
facilities even more critical; however, prevalent
particularly in informal settlements,
barriers remain, including a need to promote
are more likely to experience
consistent handwashing behaviours and health problems than children in
routine handwashing in migrants and to better-quality housing.
ensure the provision of hygiene supplies
• A
lthough immigration detention is
(270–272). In Malaysia, a study among migrant
increasing worldwide, information
food handlers reported poor-to-moderate about many detention facilities
knowledge of hygiene practices and food is restricted and comprehensive
safety (273). Migrants who demonstrated poor data are rare. The available studies
knowledge often struggled to understand have documented harmful physical
the information given during food training and mental health impacts due to
overcrowding, uncertainty around the
period and conditions of detention
(especially in countries with no
time limits), isolation, confusion,
limited health care and insanitary
The inhumane conditions and detention conditions.
legal uncertainty of immigration • A

ccess to safe and secure housing can
vary greatly depending on migratory
detention can have devastating status, which can determine whether
refugees and migrants are included
effects on the mental health and in national policies and programmes
well-being of detainees. or qualify for support from
international organizations.
65
Health can be influenced by living Overcrowded living spaces increased the

environments directly, through poor- risk of communicable disease transmission,
quality heating systems and overcrowding, especially in refugee camps and in common
or indirectly through social dormitories and labour camps for migrant
marginalization, lack of sense of dignity workers (280–284). In Algeria, overcrowding
and neighbourhood violence. among refugees from Niger created an ideal
environment for the spread of head lice
The inhumane conditions and legal and louse-borne pathogens (285). In Nyala,
uncertainty of immigration detention can Sudan, refugees living in overcrowded camps
have devastating effects on the mental health were affected by a variety of skin diseases
and well-being of detainees. Refugee and (286). In Costa Rica during 2012–2015, a
migrant populations experience several key factor in tuberculosis (TB) transmission
overlapping challenges related to housing, among migrants was the high prevalence of
which often exacerbate their already overcrowding, which was often driven by low
precarious circumstances. SES and limited geographical mobility (287).
2.11.1 Housing In addition to the risk of communicable

The physical state of housing can influence disease transmission, refugees and migrants
health outcomes. Refugees and migrants can may be exposed to various environmental
live in a wide variety of settings according and social risk factors in their living
to their migration context; for example, environment. Poor and insanitary living
those with greater means may live in conditions, such as mould, water damage
secure housing, while those in transit or in and indoor pesticide use, contributed to
protracted displacement may find themselves respiratory health problems among migrant
in informal settlements living in tented farmworkers in the United States (288). In the
structures for many years or in detention WHO Region of the Americas, migrants living
contexts. Poor living conditions and insecure in crowded housing conditions experienced
housing may be associated with adverse a poorer quality of life and increased risk
physical and mental health outcomes for of violence and felt less able to protect
refugee and migrant populations (275–277). themselves (289–292). Secure housing was
Such an association was observed in informal associated with better mental well-being and
settlements in Lebanon, where a considerable reduced risk of mental disorders for refugees
number of households had more than eight from occupied Palestinian territory, including
housing problems, including the presence east Jerusalem, living in Lebanon's Shatila
of mice, shared or no bathrooms, lack of refugee camp (293). Similarly, the absence of
natural light and exposed electric wiring (278). comfortable accommodation was a risk factor
Children in these households were more for poor mental health among young (aged
likely to have three or more health problems 18–32 years) Syrian male refugees in the
than children in households with fewer than Za'atari camp in Jordan (259).
six housing problems. Further evidence
from Syrian migrant agricultural workers In Italy, informal settlements, such as those
in Lebanon found links between a variety found in areas of seasonal agricultural work,
of health conditions and poor housing and can represent unsafe and insanitary housing
infrastructure (279). and living conditions (294,295).
66
Refugees and migrants may also lack An array of sites is used for immigration
residential stability and experience detention. In the EU, directives require
homelessness. In a study in Denmark, Member States to use specialized facilities
Romanian Roma migrants reported unsafe, – which might include structures that used
poorly managed and unaffordable housing, to be prisons – for confining people who are
in addition to discrimination and language in return procedures. However, in Canada,
and cultural barriers, which often led to Morocco, South Africa, Switzerland and the
homelessness (296). In Kirkuk, Iraq, the United States, among other countries, police
majority (58%) of street children (defined stations and prison systems are widely used
as children who experience homelessness in addition to dedicated centres. In many
and live on the street) were found to be countries, particularly those that do not have
refugees (297). well-developed migration laws or face surges
in arrivals, people may be confined in ad
2.11.2 Immigration detention hoc detention centres, such as abandoned
Immigration detention is a growing global hotels, shipping containers, open-air camps,
phenomenon that involves detaining foreign warehouses or other informal sites (303).
nationals as part of administrative, criminal or
ad hoc procedures for immigration- or asylum- The COVID-19 pandemic has underscored
related reasons. States typically impose these the importance of broadly defining migration
detention measures – which can last from a detention because it led to a rise in new,
few hours to several years – to ensure that a ad hoc detention situations (304). It also
person is deported; to verify identity or other led many states to release people from
documents while an application for protection immigration detention, impose moratoria
is being processed or migratory status is on immigration detention and scale-up the
being resolved; or to prevent absconding use of non-custodial alternatives.
during the adjudication process (298). In
the migration context, detention can be There are limited data on how many
defined as "deprivation of liberty decided by people are placed in immigration detention
the competent administrative authority of a worldwide. However, studies have shown that
State, whether it is subject to judicial review this practice is growing, both within countries
or not" (299). Detention is often imposed and across more states, as destination
without distinguishing between asylum countries seek to externalize migration
seekers, irregular migrants, stateless people or controls. In the EU, the number of people
refugees (300,301). Certain forms of detention placed in detention has increased in recent
occur at points of entry or along borders, years, with the annual number of detainees
which some countries do not consider to be more than doubling in some Member States
detention. However, these ad hoc and transit (305). Experts have also documented how key
detention practices are forms of deprivation countries have extended detention practices
of liberty according to the UNHCR Working across the globe, leading to the emergence
Group on Arbitrary Detention, which has of new migration detention systems that are
affirmed that detention includes all forms either offshore or situated in neighbouring
of "deprivation of freedom either before, countries (306–308). As part of a 2015 survey
during, or after the trial … as well as on the availability of detention data in 33
deprivation of freedom in the absence of countries in Europe and North America, a team
any kind of trial" (302). of investigators reported that only six countries
67
provided full responses to information Living conditions failed to meet

requests about basic detention data (309). minimum requirements. Health problems
diagnosed at [health care facility]
The harmful impact of immigration detention consultations reflect the living conditions
on people's physical and mental health is and consist largely of diseases related
well documented, although much of the to overcrowding, lack of water and
focus has been on mental health outcomes ventilation, and poor diet. Furthermore,
in administrative detention centres located every month that people stay in detention
in high-income countries. Data is lacking on increases their risk of malnutrition (316).
health indicators specific to countries and
regions across all income levels. However, Other areas of study of health indicators
experts agree on the need "to develop include the impact of detention on children
specialized models and practices of care for (Box 2.4), as well as on people with pre-existing
the increasing numbers of people across trauma, such as torture survivors and victims
the globe who are confined in detention of human trafficking; health impacts stemming
centres (which could be prisons) for reasons from the uncertainty inherent in migration
related to their migratory status" (310). detention; the need for improved health
Adding urgency to these calls are numerous screening for people entering detention;
reports detailing deaths, suicides and cases morbidity and mortality; and concerns about
of self-harming in immigration detention health care provision in privately operated
settings (311,312); these are often attributed detention centres.
to a failure to provide adequate health care
and to the inhumane conditions of detention The excruciating uncertainty migrant detainees
(313,314). often face as a result of the interminable lack
of resolution of their cases, bewilderment
The few studies of health outcomes comparing over why they appear to be locked in prisons
differing national systems indicate that and the lack of clarity over how long they may
the detrimental impacts of poor detention be detained can have a severe effect on their
conditions are endemic. For example, a 2020 mental health and well-being (320). Much has
study of European detention centres found been written about the deleterious effect of
that "living conditions in the immigration detention in countries that lack detention time
detention settings [were] detrimental to limits, including Australia, Canada, the United
health across all studies" and that the Kingdom and the United States (321).
"migrant health experience, consideration
of their health and well-being, and the Other studies have underscored the lack of
provision of appropriate, responsive health access that detainees have to the outside
care in immigration detention settings … world, including to family support networks,
appeared sub-standard" (315). and their subsequent sense of isolation (322);
confusion stemming from being detained
Inhumane conditions of detention are without being charged with a crime; limited
frequently cited as features of ad hoc health care provision, including failure
detention situations in transit countries to distribute sufficient medicines (323);
that are the focus of externalized migration insanitary detention conditions (322); and the
controls. A study of a detention centre in one unsuitability of migrant detention systems to
such country concluded: treat the specific needs of women (324).
68
Box 2.4.
Detention of refugee and migrant children
In preparation for drafting of first ever United Nations Global Study on Children Deprived of Liberty, the
Independent Expert on Children Deprived of Liberty issued questionnaires to all countries in 2020 asking
for data on children in all forms of detention. Based on evidence generated by the Independent Expert's
questionnaires and a review of the data, the study estimated that some 80 countries detain children for
migration purposes, with the annual number of detained children reaching a conservative estimate of
330 000 (317). In contrast, in a review of 12 countries, the Office of the United Nations High Commissioner
for Refugees found that in 2014 nearly 165 000 children were detained (300). However, immigration
detention of children is prohibited under international law (318).
Concerning children, there is now overwhelming consensus that even very brief detention can have lasting
detrimental impacts on a child's mental and physical health (317,319). Based on the body of evidence
in support of this conclusion, the Office of the United Nations High Commissioner for Human Rights
Committee on the Rights of the Child, which oversees implementation of the United Nations Convention
on the Rights of the Child, concluded in a 2018 general comment about the human rights of children in
immigration detention that there can be no justification for locking up children for immigration reasons
because, in all cases, it "conflicts with the principle of the best interests of the child", one of the cornerstone
principles of the global human rights framework established in Art. 3 of the Convention (318).
The growth of privately operated immigration 2.11.3 Housing barriers and

detention centres has led to concerns over solutions
the dual loyalties of health care providers, The barriers faced by refugee and migrant
which may affect trust and the delivery of populations to obtaining safe and secure
services (310,325). To mitigate mental and housing vary extensively, depending on their
physical harm in detention centres, there are residential settings. Syrian refugees in Tunisia
increasing calls to improve health screening. reported major obstacles to securing good-
However, cross-national studies found that quality housing including high prices and the
many countries fail to undertake adequate availability of only basic accommodation with
screening upon entry to and/or exit from poor hygiene (328,329). In Jordan, competition
detention (326). International law and for housing and jobs was a main source of
guidance state that alternatives to detention tension between Syrian refugees and local
should be pursued first, and that detention communities, as Syrians benefited from a
measures should be used only as a last housing subsidy that affected real estate prices
resort, used for the minimum time necessary, (329,330). Among migrant workers in Thailand,
and applied where they have a legitimate living far from work increased fear of both
purpose and have been determined to be thieves and the police, leading migrants to
both necessary and proportionate in each live closer to their workplaces and in social
individual case (311,327). networks with family and relatives (331).
69
Some host countries have instituted a variety 2.12 Food and nutrition
of housing programmes for refugee and
migrant populations that differ by region,
migratory status and scope. In the WHO • F ood insecurity is a major issue among
European Region, beneficiaries of international refugees and migrants, and successful
protection may have access to a range of interventions must take local and
cultural factors into account.
housing accommodation, including public
social housing and private accommodation. • W
hen faced with food insecurity,
Programmes such as the Welcome Home refugees and migrants adopt coping
programme in Warsaw, Poland, aim to improve strategies that include skipping meals,
borrowing money for food or changing
access to affordable accommodation by
their eating patterns.
offering rents below market prices. Others,
such as the Leverkusen Model of refugee
housing in Germany, include support
measures, such as information services Some countries and international
and assistance in finding accommodation, organizations have dealt with food insecurity
implemented by local public administrations with public health interventions, such as
or complemented by nongovernmental increasing food ration coverage, distributing
organization (NGO) initiatives. In some cases, fortified blended foods, or supporting local
cities have rehabilitated buildings, including home gardens or community kitchens. Food
vacant properties, and made them available insecurity is a major issue for refugee and
to refugees and migrants, as exemplified by migrant populations and may lead to negative
the Vilafranca Inclusion programme in physical and mental health outcomes. While
Spain (332). different types of migrants face varied food
and nutrition-related health impacts, the
In the WHO Western Pacific Region, thousands following section focuses on forcibly displaced
of low-skilled migrant workers employed in populations. Nutritional programmes and food
the construction and marine industries and in security interventions are crucial for mobile
various other low-wage sectors in Singapore, populations, but must take into account the
live in dormitories, the largest of which have local and cultural context if they are
common and shared areas (e.g. recreational to succeed.
facilities, grocery stores and other services).
However, such conditions have made migrant Refugee and migrant populations in several
workers more vulnerable to infectious WHO regions have experienced high levels
diseases, particularly COVID-19 (333). In the of food insecurity and adopted a variety
WHO South-East Asia Region, many Timorese of coping strategies in response, including
refugees in the East Nusa Tenggara province skipping meals and borrowing money for
of Indonesia continue to live in refugee camps food (335–337). Among female asylum seekers
despite various housing aid programmes, and refugees in Durban, South Africa, 92%
citing a better livelihood in the camps and were found to be food insecure, leading
a preference for remaining within their many to reduce their food intake or change
communities (334). the types of food they consumed (336). In
the WHO Eastern Mediterranean Region,
one fifth of refugees in Egypt could not meet
their basic food needs, citing unemployment
70
as a major barrier to food security, and one livelihood-based coping strategies to meet
in three migrants living in Libya reported basic food needs and limited access to food.
inadequate food consumption (338,339). Fluctuations in food security have occurred,
Afghan refugees were significantly affected: particularly among Syrian refugees. Food
88.7% of those living in Iran reported food security among registered Syrian refugees
insecurity, and many Afghan refugee families has declined in recent years: only 20% of
in Pakistan experienced food insecurity, households living outside camps were
regardless of the duration of their stay (340). reported as food secure in 2018 compared with
28% in 2016 (341). Despite food consumption
A comprehensive food security and scores remaining stable, food expenditure
vulnerability assessment conducted in Jordan shares and the use of livelihood-based coping
showed variation across refugee groups by strategies have both increased, contributing
nationality (341). Among the groups assessed, to the overall decline of food security among
24% of refugees from Sudan experienced Syrian refugees in Jordan from 2016 to 2018.
food insecurity, followed by 23% of Somalian Further studies in Lebanon, South Africa
refugees, 15% of Yemeni refugees and 9% of and Uganda highlighted the relationship
Iraqi refugees. Reasons for food insecurity between food insecurity and negative
among these groups included high food health outcomes, including disease-related
expenditure shares, the use of emergency disability, depression and anxiety (342–344).
A child is screened for malnutrition using a mid-upper arm circumference (MUAC) tape at a nutrition stabilization centre in Abu Shouk IDP
camp in North Darfur. © WHO / Lindsay Mackenzie
71
Even in high-income countries, refugees and

migrants may experience food insecurity.
In the WHO European Region, refugees and
Refugee and migrant populations
migrants with financial limitations may be less in several WHO regions have
able to acquire food and may face disruption experienced high levels of food
of food intake or eating patterns. They may
also face sociocultural challenges in the host insecurity and adopted a variety
country, including obstacles to cooking meals of coping strategies in response,
in a new setting (345–350). Among asylum
seekers in Norway, 93% were food insecure, including skipping meals and
with many reporting economic constraints borrowing money for food.
and limited resources (351). In the Republic of
Korea, refugees from the Democratic People's
Republic of Korea reported significantly lower
food security and skipped meals three times
more frequently than their host country
counterparts (352). likely to consume vegetables as the refugee
comparison group (355).
A study of migrants in transit through Mexico
found that 74% experienced some degree Community kitchens (also known as healthy
of food insecurity, ranging from having only kitchens) have been promoted as an
one meal to no food at all during one or intergenerational public health intervention
several consecutive 24-h periods (353). Factors in Lebanon for populations from occupied
associated with the severity of food insecurity Palestinian territory, including east Jerusalem.
included more days in active transit, more Adapted to the cultural context, women
severe illness affecting mobility or the illness prepare subsidized, healthy traditional food in
of a travel companion during the previous community kitchens for school-aged children
2 weeks. The study predicted illness by a attending UNRWA schools. Positive outcomes
pre-migration diagnosis of chronic disease. for participating families included increased
spending on food and clothing and reductions
2.12.1 Food assistance in food insecurity (356,357).
Some host countries and local and
international partner organizations have
introduced a variety of interventions to 2.13 Summary
address high levels of food insecurity among
refugees and migrants. In Cox's Bazar, It is now clear that many, often interconnected,
Bangladesh, increased coverage of food factors affect the health of refugees and
rations, the distribution of fortified blended migrants and the health of nearby
foods, access to micronutrient powders and communities, either by undermining or
other public health interventions improved improving it.
the nutritional status of Rohingya refugee
children (354). In northern Uganda, an income- Some of these individual characteristics, such
generating project involving home gardens as sex and gender, are cross-cutting and affect
and increased vegetable production showed many of the other challenges faced by refugees
that participating refugees were twice as and migrants. There is clear evidence that
72
gender inequality fuels health risks for women Environmental determinants that negatively
and girls around the world during different influence the health of refugees and migrants
phases of displacement and migration. include poor air quality, which can impair
Although less recognized, men and boys also respiratory health; WASH issues such as
face sexual violence as well as the additional contaminated water in camps, or situations
dangers of working in high-risk sectors. The in which hygiene is compromised; poor
vulnerabilities of LGBTQI+ and gender-diverse housing and living conditions, such as poor
refugees and migrants are exacerbated by heating or overcrowding, which can contribute
cultural taboos and discrimination. Finally, to the spread of communicable diseases, or
many older migrants and refugees face inhumane conditions and legal uncertainty
particular challenges and needs, but these during immigration detention; and food
are often underreported or ignored. insecurity, which may provoke unhealthy
coping strategies, such as missing meals.
The effects of social and economic
determinants are more specific. For example, Displacement and migration are major
lower levels of education are associated determinants of health for refugees and
with poorer health outcomes, while higher migrants. Given identical health conditions,
levels of education can improve livelihoods. a migrant will not only be more vulnerable to
A lack of health literacy can prevent refugees health issues than a non-migrant but will also
and migrants from seeking care or following face greater barriers to accessing health care.
health-related instructions, but appropriate
strategies – linguistic support, sensitivity to
cultural differences and consideration of
the needs of these populations – have been
proven to work. Income and social status
also play a role in migrant health, since a lack
of resources can affect when and if refugees
and migrants receive health care. Their
migratory status often excludes them from
social insurance schemes, while their legal
status or fear of deportation may increase
their vulnerability to health problems.
73
References 11. Scheibelhofer P. "It won't work without ugly pictures": images
of othered masculinities and the legitimisation of restrictive
refugee-politics in Austria. NORMA. 2017;12(2):96–111. doi:10.
1080/18902138.2017.1341222.
12. Qureshi SA, Straiton M, Gele AA. Associations of socio-
1. Davies A, Basten A, Frattini C. Migration: a social determinant
demographic factors with adiposity among immigrants
of the health of migrants. Geneva: International Organization
in Norway: a secondary data analysis. BMC Public Health.
for Migration; 2009 (https://migrationhealthresearch.iom.int/
2020;20(1):772. doi:10.1186/s12889-020-08918-9.
migration-social-determinant-health-migrants, accessed
5 April 2022). 13. Persson G, Mahmud AJ, Hansson EE, Strandberg EL. Somali
women's view of physical activity – a focus group study. BMC
2. Fleischman Y, Willen SS, Davidovitch N, Mor Z. Migration as
Womens Health. 2014;14:129. doi:10.1186/1472-6874-14-129.
a social determinant of health for irregular migrants: Israel
as case study. Soc Sci Med. 2015;147:89–97. doi:10.1016/j. 14. Balcilar M. Health status survey of Syrian refugees in Turkey:
socscimed.2015.10.046. non-communicable disease risk factor surveillance among
Syrian refugees living in Turkey. Ankara: Disaster and
3. Bircher J, Kuruvilla S. Defining health by addressing
Emergency Management (AFAD); 2016 (https://hsgm.saglik.
individual, social, and environmental determinants: new
gov.tr/depo/birimler/kronik-hastaliklar-engelli-db/hastaliklar/
opportunities for health care and public health. J Public
kronik_havayolu/raporlar/HEALT_STATUS_SURVEY_of_
Health Policy. 2014;35(3):363–86. doi:10.1057/jphp.2014.19.
SYRIAN_REFUGEES_in_TURKEY.pdf, accessed 5 April 2022).
4. Resolution WHA74.16. Social determinants of health. In:
15. Alzubaidi H, McNarmara K, Kilmartin GM, Kilmartin
Seventy-fourth World Health Assembly, Geneva, 24 May–1
JF, Marriott J. The relationships between illness and
June 2021. Resolutions and decisions, annexes. Geneva:
treatment perceptions with adherence to diabetes self-
World Health Organization; 2021:60–3 (WHA74/2021/REC/1;
care: a comparison between Arabic-speaking migrants and
https://apps.who.int/gb/ebwha/pdf_files/WHA74-REC1/
Caucasian English-speaking patients. Diabetes Res Clin Pract.
A74_REC1-en.pdf, accessed 2 July 2022).
2015;110(2):208–17. doi:10.1016/j.diabres.2015.08.006.
5. Strategy for integrating gender analysis and actions into
16. El Masri A, Kolt GS, George ES. The perceptions, barriers
the work of WHO. Geneva: World Health Organization; 2009
and enablers to physical activity and minimising sedentary
(https://apps.who.int/iris/handle/10665/69857, accessed
behaviour among Arab-Australian adults aged 35-64 years.
5 April 2022).
Health Promot J Aust. 2021;32(2):312–21. doi:10.1002/
6. Pega F, Veale JF. The case for the World Health Organization's hpja.345.
Commission on Social Determinants of Health to address
17. Cavazzoni F, Fiorini A, Shoman H, Diab M, Veronese G. The role
gender identity. Am J Public Health. 2015;105(3):e58–62.
of gender and living context in shaping Palestinian children's
doi:10.2105/AJPH.2014.302373.
agency and well-being. Gend Place Cult. 2022;29(2):222–47.
7. Stark L, Seff I, Weber A, Darmstadt GL. Applying a gender lens doi:10.1080/0966369X.2021.1882954.
to global health and well-being: framing a Journal of Global
18. Aung TNN, Shirayama Y, Moolphate S, Lorga T, Yuasa M, Aung
Health special collection. J Glob Health. 2020;10(1):010103.
MN. Acculturation and its effects on health risk behaviors
doi:10.7189/jogh.10.01013.
among Myanmar migrant workers: a cross-sectional survey
8. Redden K, Safarian J, Schoenborn C, Shortall C, Gagnon AJ. in Chiang Mai, northern Thailand. Int J Environ Res Public
Interventions to support international migrant women's Health. 2020;17(14):5108. doi:10.3390/ijerph17145108.
reproductive health in western-receiving countries: a
19. Rahman MT. Rohingya crisis in Bangladesh and health sector
systematic review and meta-analysis. Health Equity.
challenges. Anwer Khan Mod Med Coll J. 2018;9(1):3–4.
2021;5(1):356–72. doi:10.1089/heq.2020.0115.
doi:10.3329/akmmcj.v9i1.35814.
9. Shorey S, Ng ED, Downe S. Cultural competence and
20. Joarder T, Sutradhar I, Hasan MI, Bulbul MMI. A record review
experiences of maternity health care providers on care
on the health status of Rohingya refugees in Bangladesh.
for migrant women: a qualitative meta‐synthesis. Birth.
Cureus. 2020;12(8):e9753. doi:10.7759/cureus.9753.
2021;48(4).458–69. doi:10.1111/birt.12581.
21. Im H, Swan LE, Warsame AH, Isse MM. Risk and protective
10. Gender analysis: the situation of refugees and migrants in
factors for comorbidity of PTSD, depression, and anxiety
Greece. Oxford: Oxfam; 2016 (https://www-cdn.oxfam.org/
among Somali refugees in Kenya. Int J Soc Psychiatry.
s3fs-public/file_attachments/oxfam_gender_analysis_
2022;68(1):134–46. doi:10.1177/0020764020978685.
september2016_webpage.pdf, accessed 5 April 2022).
22. Usta J, Masterson AR, Farver JM. Violence against
displaced Syrian women in Lebanon. J Interpers Violence.
2019;34(18):3767–79. doi:10.1177/0886260516670881.
74
23. Nisrane BL, Ossewaarde R, Need A. The exploitation narratives 34. Mendoza NB, Mordeno IG, Latkin CA, Hall BJ. Evidence of
and coping strategies of Ethiopian women return migrants the paradoxical effect of social network support: a study
from the Arabian Gulf. Gend Place Cult. 2020;27(4):568–86. among Filipino domestic workers in China. Psychiatry Res.
doi:10.1080/0966369X.2019.1611545. 2017;255:263–71. doi:10.1016/j.psychres.2017.05.037.
24. Oliveira C, Keygnaert I, Martins MRO, Dias S. Assessing 35. Arsenijević J, Burtscher D, Ponthieu A, Severy N, Contenta
reported cases of sexual and gender-based violence, causes A, Moissaing S et al. "I feel like I am less than other people":
and preventive strategies, in European asylum reception health-related vulnerabilities of male migrants travelling
facilities. Glob Health. 2018;14(1):48. doi:10.1186/s12992-018- alone on their journey to Europe. Soc Sci Med. 2018;209:86–
0365-6. 94. doi:10.1016/j.socscimed.2018.05.038.
25. Allen R, Beise J, Blume S, Lindt N, Moussa N, Pandolfelli L et 36. Mundy SS, Foss SLW, Poulsen S, Hjorthøj C, Carlsson J. Sex
al. Uncertain pathways: how gender shapes the experiences differences in trauma exposure and symptomatology in
of children on the move. New York: United Nations Children’s trauma-affected refugees. Psychiatry Res. 2020;293:113445.
Fund; 2021 (https://data.unicef.org/resources/uncertain- doi:10.1016/j.psychres.2020.113445.
pathways-how-gender-shapes-the-experiences-of-children-
37. Nelson N, Portnoy PS, Kuppa JO, Rocroi I, Tatel E, Diaz A et
on-the-move/, accessed 5 April 2022).
al. Patterns of torture among forcibly displaced Eritreans in
26. Kim Y, Son I, Wie D, Muntaner C, Kim H, Kim S-S. Don't ask for California: a cross-sectional study. Torture. 2021;31(1):53–63.
fair treatment? A gender analysis of ethnic discrimination, doi:10.7146/torture.v31i1.121786.
response to discrimination, and self-rated health among
38. Garoff F, Tinghög P, Suvisaari J, Lilja E, Castaneda AE. Iranian
marriage migrants in South Korea. Int J Equity Health.
and Iraqi torture survivors in Finland and Sweden: findings
2016;15(1):112. doi:10.1186/s12939-016-0396-7.
from two population-based studies. Eur J Public Health.
27. Thao NTP. Different effects of acculturative stress and 2021;31(3):493–8. doi:10.1093/eurpub/ckab037.
family life stress on depressive symptoms among married
39. Clément R, Lebossé D, Barrios L, Rodat O. Asylum seekers
Vietnamese immigrant women in South Korea. Asian Soc
alleging torture in their countries: evaluation of a French
Work Policy Rev. 2016;10(2):225–36. doi:10.1111/aswp.12092.
center. J Forensic Leg Med. 2017;46:24–9. doi:10.1016/j.
28. Lee H, Seo S, Kang R, Kim Y, Hyun H-K. Increasing access to jflm.2016.12.011.
oral healthcare for marriage-immigrant women in South
40. Liebling H, Barrett H, Artz L. South Sudanese refugee survivors
Korea: programme design to policy recommendation. Int
of sexual and gender-based violence and torture: health
Dent J. 2019;69(5):354–60. doi:10.1111/idj.12479.
and justice service responses in northern Uganda. Int J
29. Adhikari P, Keen S, van Teijlingen E. Workplace accidents Environ Res Public Health. 2020;17(5):1685. doi:10.3390/
among Nepali male workers in the Middle East and Malaysia: ijerph17051685.
a qualitative study. J Immigr Minor Health. 2019;21(5):1115–
41. Reques L, Aranda-Fernandez E, Rolland C, Grippon A, Fallet
22. doi:10.1007/s10903-018-0801-y.
N, Reboul C et al. Episodes of violence suffered by migrants
30. Bailey R. Health care management in Australia's and New transiting through Libya: a cross-sectional study in "Médecins
Zealand's seasonal worker schemes. Canberra: Department du Monde's" reception and healthcare centre in Seine-Saint-
of Pacific Affairs (ANU); 2020 (DPA Working Paper no. 2020/2; Denis, France. Confl Health. 2020;14(1):12. doi:10.1186/
https://apo.org.au/node/302960, accessed 5 April 2022). s13031-020-0256-3.
31. Öztaş D, Kurt B, Koç A, Akbaba M. Living conditions, access 42. Deps P, Collin SM, Aborghetti HP, Charlier P. Evidence of
to healthcare services, and occupational health and safety physical violence and torture in refugees and migrants
conditions of migrant seasonal agricultural workers in the seeking asylum in France. J Forensic Leg Med. 2021;77:102104.
Çukurova region. J Agromedicine. 2018;23(3):262–9. doi:10. doi:10.1016/j.jflm.2020.102104.
1080/1059924X.2018.1470048.
43. Leyva-Flores R, Infante C, Gutierrez JP, Quintino-Perez F,
32. Labao HC, Faller EM, Bacayo MFD. "Aches and pains" of Gómez-Saldivar M, Torres-Robles C. Migrants in transit
Filipino migrant workers in Malaysia: a profile of work-related through Mexico to the US: experiences with violence and
musculoskeletal disorders. Ann Glob Health. 2018;84(3):474– related factors, 2009-2015. PLOS One. 2019;14(8):e0220775.
80. doi:10.29024/aogh.2331. doi:10.1371/journal.pone.0220775.
33. Ghaddar A, Khandaqji S, Ghattas J. Justifying abuse of 44. Chynoweth SK, Buscher D, Martin S, Zwi AB. Characteristics
women migrant domestic workers in Lebanon: the opinion and impacts of sexual violence against men and boys in
of recruitment agencies. Gac Sanit. 2020;34(5):493–9. conflict and displacement: a multicountry exploratory
doi:10.1016/j.gaceta.2018.11.001. study. J Interpers Violence. 2020;38(9-10):NP73470–501.
doi:10.1177/0886260520967132.
75
45. Chynoweth SK, Buscher D, Martin S, Zwi AB. A social 56. Nieves-Lugo K, Barnett A, Pinho V, Reisen C, Poppen P, Zea
ecological approach to understanding service utilization MC. Sexual migration and HIV risk in a sample of Brazilian,
barriers among male survivors of sexual violence in three Colombian and Dominican immigrant MSM living in New York
refugee settings: a qualitative exploratory study. Confl Health. City. J Immigr Minor Health. 2019;21(1):115–22. doi:10.1007/
2020;14(1):43. doi:10.1186/s13031-020-00288-8. s10903-018-0716-7.
46. Belanteri RA, Hinderaker SG, Wilkinson E, Episkopou M, Timire 57. Golembe J, Leyendecker B, Maalej N, Gundlach A, Busch J.
C, De Plecker E et al. Sexual violence against migrants and Experiences of minority stress and mental health burdens
asylum seekers. The experience of the MSF clinic on Lesvos of newly arrived LGBTQ* refugees in Germany. Sex Res Soc
Island, Greece. PLOS One. 2020;15(9):e0239187. doi:10.1371/ Policy. 2021;18(4):1049–59. doi:10.1007/s13178-020-00508-z.
journal.pone.0239187.
58. Kahn S, Alessi EJ, Kim H, Woolner L, Olivieri CJ. Facilitating
47. Negi NJ, Prickett JC, Overdorff AM, Roberts J, Furman R. mental health support for LGBT forced migrants: a qualitative
Return-migration to Mexico and the gendered transnational inquiry. J Couns Dev. 2018;96(3):316–26. doi:10.1002/
migration process. Psychol Men Masc. 2018;19(3):385–91. jcad.12205.
doi:10.1037/men0000106.
59. Fox SD, Griffin RH, Pachankis JE. Minority stress, social
48. Affleck W, Thamotharampillai U, Jeyakumar J, Whitley R. integration, and the mental health needs of LGBTQ asylum
"If one does not fulfil his duties, he must not be a man": seekers in North America. Soc Sci Med. 2020;246:112727.
masculinity, mental health and resilience amongst Sri doi:10.1016/j.socscimed.2019.112727.
Lankan Tamil refugee men in Canada. Cult Med Psychiatry.
60. Hopkinson RA, Keatley E, Glaeser E, Erickson-Schroth L, Fattal
2018;42(4):840–61. doi:10.1007/s11013-018-9592-9.
O, Nicholson Sullivan M. Persecution experiences and mental
49. Kukreja R. Recouping masculinity: understanding the health of LGBT asylum seekers. J Homosex. 2017;64(12):1650–
links between macho masculinity and self-exploitation 66. doi:10.1080/00918369.2016.1253392.
among undocumented South Asian male migrants in
61. Kahn S, Alessi EJ. Coming out under the gun: exploring
Greece. Geoforum. 2021;122(3):164–73. doi:10.1016/j.
the psychological dimensions of seeking refugee status for
geoforum.2021.04.009.
LGBT claimants in Canada. J Refug Stud. 2018;31(1):22–41.
50. Improving the health and well-being of LGBTQI+ people doi:10.1093/jrs/fex019.
[website]. Geneva: World Health Organization; 2021 (https://
62. Alessi EJ, Kahn S, Greenfield B, Woolner L, Manning D. A
www.who.int/activities/improving-the-health-and-well-being-
qualitative exploration of the integration experiences of
of-lgbtqi-people, accessed 5 April 2022).
LGBTQ refugees who fled from the Middle East, North Africa,
51. Broqua C, Laborde-Balen G, Menetrier A, Bangoura D. Queer and Central and South Asia to Austria and the Netherlands.
necropolitics of asylum: Senegalese refugees facing HIV in Sex Res Soc Policy. 2020;17(1):13–26. doi:10.1007/s13178-018-
Mauritania. Glob Public Health. 2021;16(5):746–62. doi:10.108 0364-7.
0/17441692.2020.1851744.
63. Kostenius C, Hertting K, Pelters P, Lindgren E-C. From hell to
52. Mudarikwa M, Gleckman-Krut M, Payne A-L, Camminga B, heaven? Lived experiences of LGBTQ migrants in relation to
Marnell J. LGBTI+ asylum seekers in South Africa: a review of health and their reflections on the future. Cult Health Sex.
refugee status denials involving sexual orientation & gender 2021;20:1–13. doi:10.1080/13691058.2021.1983020.
identity. Johannesburg: Legal Resources Centre; 2021 (https://
64. Logie CH, Lacombe-Duncan A, Lee-Foon N, Ryan S, Ramsay
lrc.org.za/wp-content/uploads/LGBTI-ASYLUM-REPORT-RFS.
H. "It's for us – newcomers, LGBTQ persons, and HIV-positive
pdf, accessed 5 April 2022).
persons. You feel free to be": a qualitative study exploring
53. Alessi EJ, Kahn S, Giwa S, Cheung S. "Those tablets, they are social support group participation among African and
finding an empty stomach": a qualitative investigation of HIV Caribbean lesbian, gay, bisexual and transgender newcomers
risk among sexual and gender minority migrants in Cape and refugees in Toronto, Canada. BMC Int Health Hum Rights.
Town, South Africa. Ethn Health. 2020;27(1):1–17. doi:10.1080/ 2016;16(1):18. doi:10.1186/s12914-016-0092-0.
13557858.2020.1817342.
65. Kahn S, Alessi E, Woolner L, Kim H, Olivieri C. Promoting the
54. Levison JH, Bogart LM, Khan IF, Mejia D, Amaro H, Alegría M wellbeing of lesbian, gay, bisexual and transgender forced
et al. "Where it falls apart": barriers to retention in HIV care migrants in Canada: providers' perspectives. Cult Health Sex.
in Latino immigrants and migrants. AIDS Patient Care STDS. 2017;19(10):1165–79. doi:10.1080/13691058.2017.1298843.
2017;31(9):394–405. doi:10.1089/apc.2017.0084.
66. Clark K, Pachankis J, Khoshnood K, Bränström R, Seal D,
55. Pachankis JE, Hatzenbuehler ML, Berg RC, Fernández-Dávila Khoury D et al. Stigma, displacement stressors and psychiatric
P, Mirandola M, Marcus U et al. Anti-LGBT and anti-immigrant morbidity among displaced Syrian men who have sex with
structural stigma: an intersectional analysis of sexual minority men (MSM) and transgender women: a cross-sectional study
men's HIV risk when migrating to or within Europe. J Acquir in Lebanon. BMJ Open. 2021;11(5):e046996. doi:10.1136/
Immune Defic Syndr. 2017;76(4):356–66. doi:10.1097/ bmjopen-2020-046996.
QAI.0000000000001519.
76
67. Tohme J, Egan JE, Friedman MR, Stall R. Psycho-social 79. Rudnicka E, Napierała P, Podfigurna A, Męczekalski B,
correlates of condom use and HIV testing among MSM Smolarczyk R, Grymowicz M. The World Health Organization
refugees in Beirut, Lebanon. AIDS Behav. 2016;20 (WHO) approach to healthy ageing. Maturitas. 2020;139:6–11.
(suppl 3):417–25. doi:10.1007/s10461-016-1498-3. doi:10.1016/j.maturitas.2020.05.018.
68. Tohme J, Egan JE, Stall R, Wagner G, Mokhbat J. HIV 80. Resolution A/RES/75/131. United Nations decade of healthy
prevalence and demographic determinants of unprotected ageing (2021–2030). In Seventy-fifth session, United Nations
anal sex and HIV testing among male refugees who have General Assembly, New York, 21 December 2020. New
sex with men in Beirut, Lebanon. AIDS Behav. 2016;20(suppl York: United Nations; 2020 (https://digitallibrary.un.org/
3):408–16. doi:10.1007/s10461-016-1484-9. record/3896348?ln=en, accessed 28 April 2022).
69. Mutchler MG, McDavitt BW, Tran TN, Khoury CE, Ballan E, 81. McGivern V, Bluestone K, Lilly D. If not now, when? Keeping
Tohme J et al. This is who we are: building community for promises to older people affected by humanitarian
HIV prevention with young gay and bisexual men in Beirut, crises. London: HelpAge International; 2020 (https://
Lebanon. Cult Health Sex. 2018;20(6):690–703. doi:10.1080/ www.ageinternational.org.uk/globalassets/documents/
13691058.2017.1371334. reports/2020/if-not-now-when-report.pdf, accessed
11 April 2022).
70. Gowin M, Taylor EL, Dunnington J, Alshuwaiyer G, Cheney
MK. Needs of a silent minority: Mexican transgender 82. Health of older refugees and migrants, 2018. Copenhagen:
asylum seekers. Health Promot Pract. 2017;18(3):332–40. WHO Regional Office for Europe; 2018 (https://www.euro.
doi:10.1177/1524839917692750. who.int/__data/assets/pdf_file/0003/386562/elderly-eng.pdf,
accessed 28 April 2022).
71. Cheney MK, Gowin MJ, Taylor EL, Frey M, Dunnington
J, Alshuwaiyer G et al. Living outside the gender box in 83. International Organization for Migration, United Nations
Mexico: testimony of transgender Mexican asylum seekers. Children's Fund. Harrowing journeys: children and youth on
Am J Public Health. 2017;107(10):1646–52. doi:10.2105/ the move across the Mediterranean Sea, at risk of trafficking
AJPH.2017.303961. and exploitation. Geneva: International Organization
for Migration; 2017 (https://publications.iom.int/books/
72. Rosati F, Coletta V, Pistella J, Scandurra C, Laghi F, Baiocco
harrowing-journeys-children-and-youth-move-across-
R. Experiences of life and intersectionality of transgender
mediterranean-sea-risk-trafficking-and, accessed
refugees living in Italy: a qualitative approach. Int J
21 June 2022).
Environ Res Public Health. 2021;18(23):12385. doi:10.3390/
ijerph182312385. 84. Making the invisible visible: the identification of
unaccompanied and separated girls in Bulgaria, Greece, Italy
73. Okada T. Gender performance and migration experience
and Serbia. New York: United Nations Children's Fund; 2020
of Filipino transgender women entertainers in Japan. Int J
(https://www.unicef.org/eca/media/10676/file/This%20
Transgender Health. 2022;23(1-2):24–35. doi:10.1080/
Analysis.pdf, accessed 21 June 2022).
26895269.2020.1838390.
85. Patel SG, Bouche V, Martinez W, Barajas K, Garcia A, Sztainer
74. Okada T. Negotiations in the gendered experiences of
M, Hawkins K. "Se extraña todo:" family separation and
transpinay entertainers in Japan. J Contemp East Asia. 2020
reunification experiences among unaccompanied adolescent
Dec 31;19(2):40–60. doi:10.17477/jcea.2020.19.2.040.
migrants from Central America. New Dir Child Adolesc Dev.
75. Farrington M. Social and feminist design in emergency 2021(176):227–44. doi:10.1002/cad.20404.
contexts: the Women's Social Architecture Project, Cox's
86. Doering-White J. The shifting boundaries of "best interest":
Bazar, Bangladesh. Gend Dev. 2019;27(2):295–315. doi:10.
sheltering unaccompanied Central American minors in
1080/13552074.2019.1626593.
transit through Mexico. Child Youth Serv Rev. 2018;92:39–47.
76. Thuita W, Conn C, Wilson K. The role of marginalised women doi:10.1016/j.childyouth.2018.01.009.
in sanitation initiatives: Somali women in northern Kenya.
87. Uprooted in Central America and Mexico: migrant and refugee
Dev Pract. 2017;27(1):16–25. doi:10.1080/09614524.
children face a vicious cycle of hardship and danger. New
2017.1256951.
York: United Nations Children's Fund 2018 (https://www.
77. Soeiro RE, Rocha L, Surita FG, Bahamondes L, Costa ML. unicef.org/lac/en/reports/uprooted-central-america-and-
Period poverty: menstrual health hygiene issues among mexico, accessed 21 June 2022).
adolescent and young Venezuelan migrant women at the
88. Age assessment for children in migration: a human rights-
northwestern border of Brazil. Reprod Health. 2021;18(1):238.
based approach. Brussels: Council of Europe; 2019 (https://
doi:10.1186/s12978-021-01285-7
rm.coe.int/ageassessmentchildrenmigration/168099529f,
78. World report on ageing and health. Geneva: World accessed 21 June 2022).
handle/10665/186463, accessed 28 April 2022).
77
89. Age assessment and fingerprinting of children in asylum 100. Bjerneld M, Ismail N, Puthoopparambil SJ. Experiences
procedures: minimum age requirements concerning and reflections of Somali unaccompanied girls on their
children's rights in the EU. Vienna: European Union Agency first years in Sweden: a follow-up study after two decades.
for Fundamental Rights; 2018. (https://fra.europa.eu/sites/ Int J Migr Health Soc Care. 2018;14(3):305–17. doi:10.1108/
default/files/fra_uploads/fra-2018-minimum-age-asylum- IJMHSC-03-2018-0018.
procedures_en.pdf, accessed 21 June 2022).
101. Bjerneld M, Puthoopparambil SJ. Companions to
90. EASO practical guide on age assessment, second edition. unaccompanied asylum-seeking children in Sweden–
Valletta: European Asylum Support Office; 2018 (https://euaa. experiences of Swedish families. International Journal
europa.eu/sites/default/files/easo-practical-guide-on-age- of Migration, Health and Social Care. 2022;18(2):179–91.
assesment-v3-2018.pdf, accessed 21 June 2022). doi:10.1108/IJMHSC-09-2021-0088.
91. Jakobsen M, DeMott MA, Wentzel-Larsen T, Heir T. The impact 102. Zijlstra AE, Menninga MC, Van Os EC, Rip JA, Knorth EJ,
of the asylum process on mental health: a longitudinal study Kalverboer ME. "There is no mother to take care of you".
of unaccompanied refugee minors in Norway. BMJ Open. Views of unaccompanied children on healthcare, their mental
2017;7(6):e015157. doi:10.1136/bmjopen-2016-015157. health and rearing environment. Resid Treat Child Youth.
2019;36(2):118–36. doi:10.1080/0886571X.2018.1559118.
92. Coulter K, Sabo S, Martínez D, Chisholm K, Gonzalez K,
Bass Zavala S et al. A study and analysis of the treatment 103. Been SK, van de Vijver DAMC, Nieuwkerk PT, Is B, Stutterheim
of Mexican unaccompanied minors by customs and SE, Bos AER et al. Risk factors for non-adherence to cART
border protection. J Migr Hum Secur. 2020;8(2):96–110. in immigrants with HIV living in the Netherlands: results
doi:10.1177/2331502420915898. from the ROtterdam ADherence (ROAD) project. PLOS One.
93. Ehntholt KA, Trickey D, Harris Hendriks J, Chambers H,
Scott M, Yule W. Mental health of unaccompanied asylum- 104. Chowdhury M, Serieux J. Education and the sustainability
seeking adolescents previously held in British detention of immigrant health: Canadian evidence. Can Public Policy.
centres. Clin Child Psychol Psychiatry.. 2018;23(2):238–57. 2018;44(3):226–40. doi:10.3138/cpp.2017-072.
doi:10.1177/1359104518758839.
105. Baltazar CS, DeLima YV, Ricardo H, Botão C, Langa DC,
94. Field handbook on unaccompanied and separated children. da Costa P et al. HIV prevalence and TB in migrant miners
Alliance for Child Protection in Humanitarian Action; 2016 communities of origin in Gaza Province, Mozambique: the
(https://www.alliancecpha.org/fr/node/2043, accessed need for increasing awareness and knowledge. PLOS One.
21 June 2022). 2020;15(4):e0231303. doi:10.1371/journal.pone.0231303.
95. Zijlstra AE, Menninga MC, Van Os EC, Kalverboer ME. They 106. Lebenbaum M, Stukel TA, Saunders NR, Lu H, Urquia M,
ask for protection: an exploratory study into experiences with Kurdyak P et al. Association of source country gender
violence among unaccompanied refugee children in Dutch inequality with experiencing assault and poor mental health
reception facilities. Child Abuse Neglect. 2020;103:104442. among young female immigrants to Ontario, Canada. BMC
doi:10.1016/j.chiabu.2020.104442. Public Health. 2021;21(1):739. doi:10.1186/s12889-021-
10720-0.
96. Arega NT. Posttraumatic stress among Eritrean
unaccompanied refugee minors in Ethiopia. Int J Migr Health 107. Ludwig A, Miani C, Breckenkamp J, Sauzet O, Borde T,
Soc Care. 2020;17(1):1–15. doi:10.1108/IJMHSC-02-2020-0016. Doyle I-M et al. Are social status and migration background
associated with utilization of non-medical antenatal care?
97. Badri A, Eltayeb S, Mohamed M, Verdeli H. Mental health and
Analyses from two German studies. Matern Child Health J.
resilience status of Eritrean unaccompanied refugee minors in
2020;24(7):943–52. doi:10.1007/s10995-020-02937-z.
Sudan. Child Youth Serv Rev. 2020;116:105088. doi:10.1016/j.
childyouth.2020.105088. 108. Amini-Rarani M, Mansouri A, Nosratabadi M. Decomposing
educational inequality in maternal mortality in Iran. Women
98. Emedo M, Habeeb S, Joyce M, Anderson S, Lorek A. P4
Health. 2021;61(3):244–53. doi:10.1080/03630242.
Adverse experiences of unaccompanied asylum seeking
2020.1856294.
children and the impact on their emotional wellbeing and
mental health needs. Arch Dis Child. 2018;103(suppl 1):A2. 109. Suphanchaimat R, Sinam P, Phaiyarom M, Pudpong N,
doi:10.1136/archdischild-2018-rcpch.4. Julchoo S, Kunpeuk W et al. A cross sectional study of unmet
need for health services amongst urban refugees and asylum
99. Solberg Ø, Nissen A, Vaez M, Cauley P, Eriksson AK, Saboonchi
seekers in Thailand in comparison with Thai population, 2019.
F. Children at risk: a nation-wide, cross-sectional study
Int J Equity Health. 2020;19(1):205. doi:10.1186/s12939-020-
examining post-traumatic stress symptoms in refugee minors
01316-y.
from Syria, Iraq and Afghanistan resettled in Sweden between
2014 and 2018. Confl Health. 2020;14(1):67. doi:10.1186/
s13031-020-00311-y.
78
110. Aschale Y, Mengist A, Bitew A, Kassie B, Talie A. Prevalence 121. Riza E, Karakosta A, Tsiampalis T, Lazarou D, Karachaliou A,
of malaria and associated risk factors among asymptomatic Ntelis S et al. Knowledge, attitudes and perceptions about
migrant laborers in West Armachiho District, Northwest cervical cancer risk, prevention and human papilloma virus
Ethiopia. Res Rep Trop Med. 2018;9:95–101. doi:10.2147/ (HPV) in vulnerable women in Greece. Int J Environ Res Public
RRTM.S165260. Health. 2020;17(18):6892. doi:10.3390/ijerph17186892.
111. Cheung SY, Phillimore J. Gender and refugee integration: 122. Poncet L, Panjo H, Ringa V, Andro A. Do vulnerable groups
a quantitative analysis of integration and social policy access prevention services? Cervical cancer screening
outcomes. J Soc Policy. 2017;46(2):211–30. doi:10.1017/ and HIV testing among homeless migrant women in the
S0047279416000775. Paris metropolitan area. PLOS One. 2021;16(8):e0255900.
doi:10.1371/journal.pone.0255900.
112. Downer B, Garcia MA, Saenz J, Markides KS, Wong R. The role
of education in the relationship between age of migration to 123. Andersen E, Kjellså I, Hjellset VT, Henjum S. Insufficient
the United States and risk of cognitive impairment among physical activity level among Sahrawi adults living in a
older Mexican Americans. Res Aging. 2018;40(5):411–31. protracted refugee setting. BMC Public Health. 2021;21(1):166.
doi:10.1177/0164027517701447. doi:10.1186/s12889-021-10217-w.
113. Addo J, Agyemang C, de-Graft Aikins A, Beune E, Schulze MB, 124. van Nieuwenhuizen B, Zafarmand MH, Beune E, Meeks K, de-
Danquah I et al. Association between socioeconomic position Graft Aikins A, Addo J et al. Ideal cardiovascular health among
and the prevalence of type 2 diabetes in Ghanaians in Ghanaian populations in three European countries and rural
different geographic locations: the RODAM study. J Epidemiol and urban Ghana: the RODAM study. Intern Emerg Med.
Community Health. 2017;71(7):633–9. doi:10.1136/jech 2018;13(6):845–56. doi:10.1007/s11739-018-1846-6.
-2016-208322.
125. Afrifa-Anane E, de-Graft Aikins A, Meeks KAC, Beune E, Addo J,
114. Bhandari D, Ozaki A, Kobashi Y, Higuchi A, Shakya P, Tanimoto Smeeth L et al. Physical inactivity among Ghanaians in Ghana
T. Cancer information seeking and scanning behavior and Ghanaian migrants in Europe. Med Sci Sports Exerc.
among Nepalese migrants in Japan and its association 2020;52(10):2152–61. doi:10.1249/MSS.0000000000002357.
with preventive behavior. PLOS ONE. 2020;15(6):e0235275.
126. Dryden-Peterson S, Dahya N, Adelman E. Pathways to
educational success among refugees: connecting locally and
115. Lepore SJ, Nair RG, Davis SN, Wolf RL, Basch CE, Thomas globally situated resources. Am Educ Res J. 2017;54(6):
N et al. Patient and physician factors associated with 1011–47. doi:10.3102/0002831217714321.
undisclosed prostate cancer screening in a sample of
127. Kaji A, Parker DM, Chu CS, Thayatkawin W, Suelaor J,
predominantly immigrant black men. J Immigr Minor Health.
Charatrueangrongkun R et al. Immunization coverage in
2017;19(6):1343–50. doi:10.1007/s10903-016-0468-1.
migrant school children along the Thailand-Myanmar border.
116. Alawa J, Hamade O, Alayleh A, Fayad L, Khoshnood K. Cancer J Immigr Minor Health. 2016;18(5):1038–45. doi:10.1007/
awareness and barriers to medical treatment among Syrian s10903-015-0294-x.
refugees and Lebanese citizens in Lebanon. J Cancer Educ.
128. Jamaluddine Z, Choufani J, Masterson AR, Hoteit R, Sahyoun
2020;35(4):709–17. doi:10.1007/s13187-019-01516-3.
NR, Ghattas H. A community-based school nutrition
117. Patel H, Sherman SM, Tincello D, Moss EL. Awareness of intervention improves diet diversity and school attendance in
and attitudes towards cervical cancer prevention among Palestinian refugee schoolchildren in Lebanon. Curr Dev Nutr.
migrant Eastern European women in England. J Med Screen. 2020;4(11):nzaa164. doi:10.1093/cdn/nzaa164.
2020;27(1):40–7. doi:10.1177/0969141319869957.
129. Heltne UM, Dybdahl R, Elkhalifa S, Breidlid A. Psychosocial
118. Berens E-M, Mohwinkel L-M, van Eckert S, Reder M, Kolip P, support and emergency education: an explorative study
Spallek J. Uptake of gynecological cancer screening and of perceptions among adult stakeholders in Sudan and
performance of breast self-examination among 50-year- South Sudan. Sustainability. 2020;12(4):1410. doi:10.3390/
old migrant and non-migrant women in Germany: results su12041410.
of a cross-sectional study (InEMa). J Immigr Minor Health.
130. Shaeffer S. Preschool and primary education: Thailand's
2019;21(3):674–7. doi:10.1007/s10903-018-0785-7.
progress in achieving education for all. In: Fry GW, editor.
119. Lam M, Kwok C, Lee M-J. Prevalence and sociodemographic Education in Thailand: education in the Asia-Pacific region:
correlates of routine breast cancer screening practices issues, concerns and prospects; vol. 42. Singapore: Springer
among migrant-Australian women. Aust N Z J Public Health. Singapore; 2018 (http://link.springer.com/10.1007/978-981-
2018;42(1):98–103. doi:10.1111/1753-6405.12752. 10-7857-6_5, accessed 5 April 2022).
120. Lee HY, Lee MH, Jang YJ, Lee DK. Breast cancer screening 131. Ruzibiza Y. "They are a shame to the community … "stigma,
disparity among Korean American immigrant women in school attendance, solitude and resilience among pregnant
Midwest. Asian Pac J Cancer Prev. 2017;18(10):2663–7. teenagers and teenage mothers in Mahama refugee camp,
doi:10.22034/APJCP.2017.18.10.2663. Rwanda. Glob Public Health. 2021;16(5):763–74. doi:10.1080/1
7441692.2020.1751230.
79
132. Garbern SC, Helal S, Michael S, Turgeon NJ, Bartels S. "It 143. Luthra RR. Temporary immigrants in a high-skilled labour
will be a weapon in my hand": the protective potential of market: a study of H-1Bs. J Ethn Migr Stud. 2009;35(2):227–50.
education for adolescent Syrian refugee girls in Lebanon. doi:10.1080/13691830802586237.
Refuge Can J Refug. 2020;36(1):3–13. doi:10.25071/1920-
144. Germany opens labour market for skilled workers from non-
7336.40609.
EU countries. Berlin: German Federal Foreign Office; 2021
133. Cabieses B, Chepo M, Oyarte M, Markkula N, Bustos P, (https://www.auswaertiges-amt.de/en/-/2248702, accessed
Pedrero V et al. Brechas de desigualdad en salud en 5 April 2022).
niños migrantes versus locales en Chile [Health inequality
145. Clemens M, Huang C, Graham J. The economic and fiscal
gap in immigrant versus local children in Chile]. Rev Chil
effects of granting refugees formal labor market access.
Pediatr. 2017;88(6):707–16 (in Spanish). doi:10.4067/S0370-
Washington (DC): Center for Global Development; 2018
41062017000600707.
(Working Paper no. 496; https://www.cgdev.org/sites/default/
134. Herzig van Wees S, Fried S, Larsson EC. Arabic speaking files/economic-and-fiscal-effects-granting-refugees-formal-
migrant parents' perceptions of sex education in Sweden: labor-market-access.pdf, accessed 5 April 2022).
a qualitative study. Sex Reprod Healthc. 2021;28:100596.
146. Declaration of Astana. Geneva: World Health Organization;
doi:10.1016/j.srhc.2021.100596.
New York: United Nations Children's Fund; 2018 (https://apps.
135. Hattar‐Pollara M. Barriers to education of Syrian refugee who.int/iris/handle/10665/328123, accessed 6 April 2022).
girls in Jordan: gender‐based threats and challenges. J Nurs
147. Promoting health in the SDGs: report on the 9th Global
Scholarsh. 2019;51(3):241–51. doi:10.1111/jnu.12480.
Conference for health Promotion: All for Health, Health
136. Knox SE. How they see it: young women's views on early for All, 21–24 November 2016, Shanghai, China. Geneva:
marriage in a post-conflict setting. Reprod Health Matters. World Health Organization; 2017 (https://apps.who.int/iris/
2017;25(suppl 1):96–106. doi:10.1080/09688080.2017.1383738. handle/10665/259183, accessed 5 April 2022).
137. Prodip MA. Health and educational status of Rohingya refugee 148. Gil-Salmeron A, Smith L, Yang L, Rieder A, Grabovac I.
children in Bangladesh. J Popul Soc Stud. 2017;25(2):135–46. Differences in health status, health behaviour and healthcare
doi:10.25133/JPSSv25n2.005. utilisation between immigrant and native homeless people
in Spain: an exploratory study. Health Soc Care Community.
138. Ro A, Goldberg RE. Post-migration employment changes and
2021;29(3):856–66. doi:10.1111/hsc.13313.
health: a dyadic spousal analysis. Soc Sci Med. 2017;191:
202–11. doi:10.1016/j.socscimed.2017.09.002. 149. Schaeffer D, Berens EM, Vogt D. Health literacy in the German
population. Dtsch Arztebl Int. 2017;114(4):53–60. doi:10.3238/
139. Liu X, Bowe SJ, Milner A, Li L, Too LS, LaMontagne AD. Job
arztebl.2017.0053.
insecurity: a comparative analysis between migrant and
native workers in Australia. Int J Environ Res Public Health. 150. Raynault M-F, Féthière C, Côté D. Social inequalities in breast
2019;16(21):4159. doi:10.3390/ijerph16214159. cancer screening: evaluating written communications with
immigrant Haitian women in Montreal. Int J Equity Health.
140. Biletta A, Weber T, Vanderleyden J, Brandsma N. How your
2020;19(1):209. doi:10.1186/s12939-020-01322-0.
birthplace affects your workplace [website]. Dublin: European
Foundation for the Improvement of Living and Working 151. Allen EM, Lee HY, Pratt R, Vang H, Desai JR, Dube A et al.
Conditions; 2019 (https://www.eurofound.europa.eu/ Facilitators and barriers of cervical cancer screening and
publications/policy-brief/2019/how-your-birthplace-affects- human papilloma virus vaccination among Somali refugee
your-workplace, accessed 5 April 2022). women in the United States: a qualitative analysis. J Transcult
Nurs. 2019;30(1):55–63. doi:10.1177/1043659618796909.
141. Human mobility, shared opportunities: a review of the 2009
human development report and the way ahead. New York: 152. Metusela C, Ussher J, Perz J, Hawkey A, Morrow M, Narchal
United Nations Development Programme; 2020 (https:// R et al. "In my culture, we don't know anything about that":
www.aidsdatahub.org/sites/default/files/resource/undp-iom- sexual and reproductive health of migrant and refugee
human-mobility-shared-opportunities-2021.pdf, accessed women. Int J Behav Med. 2017;24(6):836–45. doi:10.1007/
5 April 2022). s12529-017-9662-3.
142. Hvidtfeldt C, Schultz-Nielsen ML, Tekin E, Fosgerau M. An 153. Ilami A, Winter S. Iranian migrants' lived experiences of access
estimate of the effect of waiting time in the Danish asylum to sexual and reproductive healthcare services in Western
system on post-resettlement employment among refugees: Australia: a conventional content analysis. Sex Res Soc Policy.
separating the pure delay effect from the effects of the 2021;18(3):533–46. doi:10.1007/s13178-020-00478-2.
conditions under which refugees are waiting. PLOS One.
154. Dolan H, Li M, Bateson D, Thompson R, Tam CWM, Bonner
C et al. Healthcare providers' perceptions of the challenges
and opportunities to engage Chinese migrant women in
contraceptive counselling: a qualitative interview study. Sex
Health. 2020;17(5):405–13. doi:10.1071/SH19215.
80
155. Åkerman E, Larsson EC, Essén B, Westerling R. A missed 166. Nathenson RA, Saloner B, Richards MR, Rhodes KV. Spanish-
opportunity? Lack of knowledge about sexual and speaking immigrants' access to safety net providers and
reproductive health services among immigrant women in translation services across traditional and emerging US
Sweden. Sex Reprod Healthc. 2019;19:64–70. doi:10.1016/j. destinations. Milbank Q. 2016;94(4):768–99. doi:10.1111/1468-
srhc.2018.12.005. 0009.12231.
156. Gausman J, Othman A, Daas I, Hamad I, Dabobe M, Langer A. 167. Leaving no-one behind: access to social protection for all
How Jordanian and Syrian youth conceptualise their sexual migrant women. New York: UN Women; 2020 (https://www.
and reproductive health needs: a visual exploration using aidsdatahub.org/sites/default/files/resource/unwomen-
concept mapping. Cult Health Sex. 2021;23(2):176–91. doi: policy-brief-migration-and-social-protection-2020.pdf,
10.1080/13691058.2019.1698769. accessed 5 April 2022).
157. El Ayoubi LL, Abdulrahim S, Sieverding M. Sexual and 168. Yelland J, Riggs E, Szwarc J, Casey S, Duell-Piening
reproductive health information and experiences among P, Chesters D et al. Compromised communication: a
Syrian refugee adolescent girls in Lebanon. Qual Health Res. qualitative study exploring Afghan families and health
2021;31(5):983–98. doi:10.1177/1049732321989685. professionals' experience of interpreting support in Australian
maternity care. BMJ Qual Saf. 2016;25(4):e1. doi:10.1136/
158. Mekonnen GK, Mengistie B, Sahilu G, Mulat W, Kloos H.
bmjqs-2014-003837.
Caregivers' knowledge and attitudes about childhood
diarrhea among refugee and host communities in Gambella 169. MacFarlane A, Huschke S, Pottie K, Hauck FR, Griswold
Region, Ethiopia. J Health Popul Nutr. 2018;37(1):24. K, Harris MF. Barriers to the use of trained interpreters in
doi:10.1186/s41043-018-0156-y. consultations with refugees in four resettlement countries: a
qualitative analysis using normalisation process theory. BMC
159. Rahman MR, Faiz MA, Nu MY, Hassan MR, Chakrabarty AK,
Fam Pract. 2020;21(1):259. doi:10.1186/s12875-020-01314-7.
Kabir I et al. A rapid assessment of health literacy and
health status of Rohingya refugees living in Cox's Bazar, 170. Khuu BP, Lee HY, Zhou AQ, Shin J, Lee RM. Healthcare
Bangladesh following the August 2017 exodus from Myanmar: providers' perspectives on parental health literacy and
a cross-sectional study. Trop Med Infect Dis. 2020;5(3):110. child health outcomes among Southeast Asian American
doi:10.3390/tropicalmed5030110. immigrants and refugees. Child Youth Serv Rev. 2016;67:220–
9. doi:10.1016/j.childyouth.2016.06.006.
160. Ng E, Omariba W. Health literacy and immigrants in Canada:
determinants and effects on health outcomes. Canadian 171. Health of refugees and migrants: regional situation analysis,
Council on Learning; 2010 (http://en.copian.ca/library/ practices, experiences, lessons learned and ways forward.
research/ccl/health_lit_immigrants_canada/health_lit_ Manila: WHO Regional Office for the Western Pacific; 2018
immigrants_canada.pdf, accessed 5 April 2022). (https://www.who.int/docs/default-source/documents/
publications/health-of-refugees-and-migrants-wpro-2018.
161. Berens EM, Pelikan JM, Schaeffer D. The effect of self-efficacy
pdf?sfvrsn=ab7602b1_1, accessed 5 April 2022).
on health literacy in the German population. Health Promot
Int. 2022;37(1):daab085. doi:10.1093/heapro/daab085. 172. Hughson J, Marshall F, Daly JO, Woodward-Kron R, Hajek J,
Story D. Health professionals' views on health literacy issues
162. Qiu J, Song D, Nie J, Su M, Hao C, Gu J et al. Utilization of
for culturally and linguistically diverse women in maternity
healthcare services among Chinese migrants in Kenya: a
care: barriers, enablers and the need for an integrated
qualitative study. BMC Health Serv Res. 2019;19(1):995.
approach. Aust Health Rev. 2018;42(1):10. doi:10.
doi:10.1186/s12913-019-4846-y.
1071/AH17067.
163. Gikonyo BM, Kiruthu F. Determinants of provision of public
173. Villegas N, Cianelli R, de Tantillo L, Warheit M, Montano
health care services to asylum seekers in Nairobi City County,
NP, Ferrer L et al. Assessment of technology use and
Kenya. Int Acad J Arts Humanit. 2021;1(2):210–38 (https://ir-
technology preferences for HIV prevention among
library.ku.ac.ke/handle/123456789/22369, accessed
Hispanic women. Hisp Health Care Int. 2018;16(4):197–203.
5 April 2022).
doi:10.1177/1540415318808828.
164. Jaeger FN, Pellaud N, Laville B, Klauser P. The migration-
174. Wiley G, Piper A, Butow AMP, Schofield P, Douglas F, Roy J et
related language barrier and professional interpreter use in
al. Developing written information for cancer survivors from
primary health care in Switzerland. BMC Health Serv Res.
culturally and linguistically diverse backgrounds: lessons
2019;19(1):429. doi:10.1186/s12913-019-4164-4.
learnt. Asia Pac J Oncol Nurs. 2018;5(1):121–6. doi:10.4103/
165. Soneta M, Kondo A, Abuliezi R, Kimura A. International apjon.apjon_63_17.
students' experience with health care in Japan. SAGE Open.
175. Patel H, Szkinc-Olsson G, Al Liddawi ML. A qualitative study
2021;11(2). doi:10.1177/21582440211009211.
of nurses' experiences of self-care counseling in migrant
patients with heart failure. Int J Nurs Sci. 2021;8(3):279–88.
doi:10.1016/j.ijnss.2021.05.004.
81
176. Ghahari S, Burnett S, Alexander L. Development and pilot 186. Ncube A, Bahta Y, Jordaan A. Coping and adaptation
testing of a health education program to improve immigrants' mechanisms employed by sub-Saharan African migrant
access to Canadian health services. BMC Health Serv Res. women in South Africa. Jamba. 2019;11(1):645. doi:10.4102/
2020;20(1):321. doi:10.1186/s12913-020-05180-y. jamba.v11i1.645.
177. DeCamp LR, Godage SK, Valenzuela Araujo D, Dominguez 187. Knipe DW, Gunnell D, Pieris R, Priyadarshana C, Weerasinghe
Cortez J, Wu L, Psoter KJ et al. A texting intervention in Latino M, Pearson M et al. Socioeconomic position and suicidal
families to reduce ED use: a randomized trial. Pediatrics. behaviour in rural Sri Lanka: a prospective cohort study
2020;145(1):e20191405. doi:10.1542/peds.2019-1405. of 168,000+ people. Soc Psychiatry Psychiatr Epidemiol.
2019;54(7):843–55. doi:10.1007/s00127-019-01672-3.
178. Mas FS, Schmitt CL, Jacobsen HE, Myers OB. A cardiovascular
health intervention for Spanish speakers: the health literacy 188. Asia‐Pacific migration report 2020: assessing implementation
and ESL curriculum. J Community Health. 2018;43(4):717–24. of the global compact for migration. Bangkok: United Nations
doi:10.1007/s10900-018-0475-3. Economic and Social Commission for Asia and the Pacific;
2020 (https://www.aidsdatahub.org/sites/default/files/
179. Kosiyaporn H, Julchoo S, Phaiyarom M, Sinam P, Kunpeuk
resource/escap-asia-pacific-migration-repport-2020.pdf,
W, Pudpong N et al. Strengthening the migrant-friendliness
of Thai health services through interpretation and cultural
mediation: a system analysis. Glob Health Res Policy. 189. World migration report 2020. Geneva: International
2020;5(1):53. doi:10.1186/s41256-020-00181-0. Organization for Migration; 2021 (https://publications.iom.int/
system/files/pdf/wmr_2020.pdf, accessed 5 April 2022).
180. Pocock NS, Chan Z, Loganathan T, Suphanchaimat R,
Kosiyaporn H, Allotey P et al. Moving towards culturally 190. Castro A. Pobreza y migraciones [Poverty and migration]. Rev
competent health systems for migrants? Applying systems Derecho Estado. 2010;24:65–80 (in Spanish; https://revistas.
thinking in a qualitative study in Malaysia and Thailand. PLOS uexternado.edu.co/index.php/derest/article/view/420,
One. 2020;15(4):e0231154. doi:10.1371/journal.pone.0231154. accessed 5 April 2022).
181. Verrept H. What are the roles of intercultural mediators in 191. Jamil R, Kumar R. Culture, structure, and health: narratives
health care and what is the evidence on their contributions of low-income Bangladeshi migrant workers from the United
and effectiveness in improving accessibility and quality of Arab Emirates. Health Commun. 2021;36(11):1297–308. doi:
care for refugees and migrants in the WHO European Region? 10.1080/10410236.2020.1750773.
Copenhagen: WHO Regional Office for Europe; 2019 (Health
192. Gul A, Naz A, Nadeemullah M. Migration and women left
Evidence Network synthesis report no. 64; https://apps.who.
behind: challenges and constraints. Clin Soc Work Health
int/iris/handle/10665/327321, accessed 11 April 2022).
Interv. 2018;9(4):30–5. doi:10.22359/cswhi_9_4_05.
182. McGarry O, Hannigan A, De Almeida MM, Severoni S,
193. Ariadi S, Saud M, Ashfaq A. Analyzing the effect of remittance
Puthoopparambil SJ, MacFarlane A. What strategies to
transfer on socioeconomic well-being of left-behind parents:
address communication barriers for refugees and migrants
a study of Pakistan and Azad Jammu and Kashmir (AJK). J Int
in health care settings have been implemented and
Migr Integr. 2019;20(3):809–21. doi:10.1007/s12134-018-
evaluated across the WHO European Region? Copenhagen:
0632-7.
WHO Regional Office for Europe; 2018 (Health Evidence
Network synthesis report no. 62; https://apps.who.int/iris/ 194. Mushtaq R, Khalily MT, Gul S. Determinants of depression
handle/10665/326238, accessed 11 April 2022). anxiety stress among left behind families in Azad Jammu &
Kashmir. Pak Armed Forces Med J. 2017;67(3):472–7 (https://
183. Tuteja A, Sanci L, Mascarenhas L, Riggs E, Dwyer LO, Villet
www.pafmj.org/index.php/PAFMJ/article/view/574, accessed
DV et al. Understanding sexual health language: community
6 April 2022).
engagement with refugees from Burma, post settlement
in Australia. Sex Transm Infect. 2017;93(suppl 2):A5–6. 195. McCabe BE, Mitchell EM, Gonzalez-Guarda RM, Peragallo
doi:10.1136/sextrans-2017-053264.13. N, Mitrani VB. Transnational motherhood: health of
Hispanic mothers in the United States who are separated
184. Jonassen M, Shaheen A, Duraidi M, Qalalwa K, Jeune B,
from children. J Transcult Nurs. 2017;28(3):243–50.
Brønnum-Hansen H. Socio-economic status and chronic
doi:10.1177/1043659616644960.
disease in the West Bank and the Gaza Strip: in and outside
refugee camps. Int J Public Health. 2018;63(7):875–82. 196. Urzúa A, Heredia O, Caqueo-Urízar A. Salud mental y estrés
doi:10.1007/s00038-018-1122-6. por aculturación en inmigrantes sudamericanos en el norte
de Chile [Mental health and stress caused by acculturation in
185. Beiser M, Hou F. Language acquisition, unemployment and
immigrants from South America in northern Chili]. Rev Med
depressive disorder among Southeast Asian refugees: a 10-
Chil. 2016;144(5):563–70 (in Spanish). doi:10.4067/S0034-
year study. Soc Sci Med. 2001;53(10):1321–34. doi:10.1016/
98872016000500002.
s0277-9536(00)00412-3.
82
197. Atake EH. The impacts of migration on maternal and child 208. Lasimbang HB, Tong WT, Low WY. Migrant workers in Sabah,
health services utilisation in sub-Saharan Africa: evidence East Malaysia: the importance of legislation and policy
from Togo. Public Health. 2018;162:16–24. doi:10.1016/j. to uphold equity on sexual and reproductive health and
puhe.2018.05.010. rights. Best Pract Res Clin Obstet Gynaecol. 2016;32:113–23.
doi:10.1016/j.bpobgyn.2015.08.015.
198. Afulani PA, Torres JM, Sudhinaraset M, Asunka J.
Transnational ties and the health of sub-Saharan African 209. Stubbe Østergaard L, Norredam M, Mock-Munoz de Luna
migrants: the moderating role of gender and family C, Blair M, Goldfeld S, Hjern A. Restricted health care
separation. Soc Sci Med. 2016;168:63–71. doi:10.1016/j. entitlements for child migrants in Europe and Australia. Eur J
socscimed.2016.09.009. Public Health. 2017;27(5):869–73. doi:10.1093/eurpub/ckx083.
199. Pannetier J, Lert F, Jauffret Roustide M, du Loû AD. Mental 210. Boonchutima S, Sukonthasab S, Sthapitanonda P.
health of sub-Saharan African migrants: the gendered role of Myanmar migrants' access to information on HIV/AIDS in
migration paths and transnational ties. SSM – Popul Health. Thailand. J Sport Sci Health. 2020;21(1):111–24 (https://
2017;3:549–57. doi:10.1016/j.ssmph.2017.06.003. he02.tci-thaijo.org/index.php/spsc_journal/article/
download/241521/164472/, accessed 5 April 2022).
200. Mingot ES. The gendered burden of transnational care-
receiving: Sudanese families across the Netherlands, the UK 211. Regmi PR, van Teijlingen E, Mahato P, Aryal N, Jadhav N,
and Sudan. Gend Place Cult. 2020;27(4):546–67. doi:10.1080/ Simkhada P et al. The health of Nepali migrants in India:
0966369X.2019.1611546. a qualitative study of lifestyles and risks. Int J Environ Res
Public Health. 2019;16(19):3655. doi:10.3390/ijerph16193655.
201. Nguyen CV. Does parental migration really benefit left-behind
children? Comparative evidence from Ethiopia, India, Peru 212. Wang JS-H, Kaushal N. Health and mental health effects of
and Vietnam. Soc Sci Med. 2016;153:230–9. doi:10.1016/j. local immigration enforcement. Int Migr Rev. 2019;53(4):970–
socscimed.2016.02.021. 1001. doi:10.1177/0197918318791978.
202. Nwadiuko J, German J, Chapla K, Wang F, Venkataramani 213. Kammogne CL, Marchand A. Ethnicité et statut d'immigrant :
M, Vaidya D et al. Changes in health care use among quelle association avec le travail et les symptômes
undocumented patients, 2014–2018. JAMA Netw Open. dépressifs? [Ethnicity and immigration status: how are they
2021;4(3):e210763. doi:10.1001/jamanetworkopen.2021.0763. associated with work and depressive symptoms?]. Rev
Epidemiol Sante Publique. 2021;69(3):145–53 (in French).
203. Müllerschön J, Koschollek C, Santos-Hövener C, Kuehne A,
doi:10.1016/j.respe.2021.01.009.
Müller-Nordhorn J, Bremer V. Impact of health insurance
status among migrants from sub-Saharan Africa on access to 214. Mera-Lemp MJ, Martínez-Zelaya G, Orellana A, Smith-Castro
health care and HIV testing in Germany: a participatory cross- V. Acculturation orientations, acculturative stress and
sectional survey. BMC Int Health Hum Rights. 2019;19(1):10. psychological well-being on Latin American immigrants
doi:10.1186/s12914-019-0189-3. settled in Santiago, Chile. Acta Colomb Psicol. 2020;23(1):231–
44. doi:10.14718/ACP.2020.23.1.11.
204. Nkulu Kalengayi FK, Hurtig A-K, Ahlm C, Krantz I. Fear of
deportation may limit legal immigrants' access to HIV/AIDS- 215. Suhaiban A, Grasser J, Javanbakht A. Mental health of
related care: a survey of Swedish language school students in refugees and torture survivors: a critical review of prevalence,
northern Sweden. J Immigr Minor Health. 2012;14(1):39–47. predictors, and integrated care. Int J Environ Res Public
doi:10.1007/s10903-011-9509-y. Health. 2019;16(13):2309. doi:10.3390/ijerph16132309.
205. Yu M, Kelley AT, Morgan AU, Duong A, Mahajan A, Gipson JD. 216. Novella AC, Monroy AMV, Wharton T. Migración de
Challenges for adult undocumented immigrants in accessing venezolanos a Florida Central, Estados Unidos: aspectos
primary care: a qualitative study of health care workers in Los relacionados con la percepción de condiciones y necesidades
Angeles County. Health Equity. 2020;4(1):366–74. doi:10.1089/ de salud mental en 2019 [Migration of Venezuelans to Central
heq.2020.0036. Florida, United States: aspects related to the perception of
mental health conditions and needs in 2019]. Gerenc Políticas
206. Rajaraman N, Yip T-W, Kuan BYH, Lim JFY. Exclusion of
Salud. 2020;19:1–18 (in Spanish). doi:10.11144/Javeriana.
migrant workers from national UHC systems—perspectives
rgps19.mvfc.
from HealthServe, a non-profit organisation in Singapore.
Asian Bioeth Rev. 2020;12(3):363–74. doi:10.1007/s41649 217. Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM,
-020-00138-y. Fitzgerald G et al. The prevalence of mental illness in refugees
and asylum seekers: a systematic review and meta-analysis.
207. Allerton C. Statelessness and the lives of the children of
PLOS Med. 2020;17(9):e1003337. doi:10.1371/journal.
migrants in Sabah, East Malaysia. Tilburg Law Rev. 2014;19
pmed.1003337.
(1–2):26–34. doi:10.1163/22112596-01902004.
218. Swan LET, Im H. Risk and protective factors for common
mental disorders among urban Somali refugee youth. J Child
Adolesc Trauma. 2020;14(3):321–33. doi:10.1007/s40653-020-
00325-x.
83
219. Sarkadi A, Ådahl K, Stenvall E, Ssegonja R, Batti H, Gavra P 230. Chiumento A, Rutayisire T, Sarabwe E, Hasan MT, Kasujja
et al. Teaching recovery techniques: evaluation of a group R, Nabirinde R et al. Exploring the mental health and
intervention for unaccompanied refugee minors with psychosocial problems of Congolese refugees living in
symptoms of PTSD in Sweden. Eur Child Adolesc Psychiatry. refugee settings in Rwanda and Uganda: a rapid qualitative
2018;27(4):467–79. doi:10.1007/s00787-017-1093-9. study. Confl Health. 2020;14(1):77. doi:10.1186/s13031-
020-00323-8.
220. Michalopoulos LM, Ncube N, Simona SJ, Kansankala B,
Sinkala E, Raidoo J. A qualitative study of migrant-related 231. Sharma V, Papaefstathiou S, Tewolde S, Amobi A, Deyessa
stressors, psychosocial outcomes and HIV risk behaviour N, Relyea B et al. Khat use and intimate partner violence in a
among truck drivers in Zambia. Afr J AIDS Res. 2016;15(3): refugee population: a qualitative study in Dollo Ado, Ethiopia.
219–26. doi:10.2989/16085906.2016.1179653. BMC Public Health. 2020;20(1):670. doi:10.1186/s12889-020-
08837-9.
221. Jirattikorn A, Tangmunkongvorakul A, Musumari PM,
Ayuttacorn A, Srithanaviboonchai K, Banwell C et al. Sexual 232. Salama E, Niemelä S, Suvisaari J, Laatikainen T, Koponen
risk behaviours and HIV knowledge and beliefs of Shan P, Castaneda AE. The prevalence of substance use among
migrants from Myanmar living with HIV in Chiang Mai, Russian, Somali and Kurdish migrants in Finland: a
Thailand. Int J Migr Health Soc Care. 2020;16(4):543–56. population-based study. BMC Public Health. 2018;18(1):651.
doi:10.1108/IJMHSC-09-2019-0080. doi:10.1186/s12889-018-5564-9.
222. Selvey LA, Lobo RC, McCausland KL, Donovan B, Bates J, 233. Kane JC, Greene MC. Addressing alcohol and substance use
Hallett J. Challenges facing Asian sex workers in Western disorders among refugees: a desk review of intervention
Australia: implications for health promotion and support approaches. Geneva: United Nations High Commissioner
services. Front Public Health. 2018;6:171. doi:10.3389/ for Refugees; 2018 (https://www.unhcr.org/uk/protection/
fpubh.2018.00171. health/5c064a8d4/addressing-alcohol-substance-use-
disorders-among-refugees-desk-review-intervention.html,
223. Zibrik L, Huang A, Wong V, Lauscher HN, Choo Q, Yoshida
EM et al. Let's talk about B: barriers to hepatitis B screening
and vaccination among Asian and South Asian immigrants 234. Sordo L, Indave BI, Vallejo F, Belza MJ, Sanz-Barbero B,
in British Columbia. J Racial Ethn Health Disparities. Rosales-Statkus M et al. Effect of country-of-origin contextual
2018;5(6):1337–45. doi:10.1007/s40615-018-0483-0. factors and length of stay on immigrants' substance use in
Spain. Eur J Public Health. 2015;25(6):930–6. doi:10.1093/
224. Katz SJ, Wallner LP, Abrahamse PH, Janz NK, Martinez
eurpub/ckv144.
KA, Shumway DA. Treatment experiences of Latinas after
diagnosis of breast cancer. Cancer. 2017;123(16):3022–30. 235. Widmann M, Apondi B, Musau A, Warsame AH, Isse M,
doi:10.1002/cncr.30702. Mutiso V et al. Comorbid psychopathology and everyday
functioning in a brief intervention study to reduce khat
225. Finch BK, Frank R, Vega WA. Acculturation and acculturation
use among Somalis living in Kenya: description of baseline
stress: a social-epidemiological approach to Mexican
multimorbidity, its effects of intervention and its moderation
migrant farmworkers' health. Int Migr Rev. 2004;38(1):236–62.
effects on substance use. Soc Psychiatry Psychiatr Epidemiol.
doi:10.1111/j.1747-7379.2004.tb00195.x.
2017;52(11):1425–34. doi:10.1007/s00127-017-1368-y.
226. Markides KS, Rote S. The healthy immigrant effect and
236. Addo J, Cook S, Galbete C, Agyemang C, Klipstein-Grobusch
aging in the United States and other western countries.
K, Nicolaou M et al. Differences in alcohol consumption and
Gerontologist. 2019;59(2):205–14. doi:10.1093/geront/gny136.
drinking patterns in Ghanaians in Europe and Africa: the
227. Sim A, Bowes L, Gardner F. Modeling the effects of war RODAM study. PLOS One. 2018;13(11):e0206286. doi:10.1371/
exposure and daily stressors on maternal mental health, journal.pone.0206286.
parenting, and child psychosocial adjustment: a cross-
237. Riosmena F, Wong R, Palloni A. Migration selection,
sectional study with Syrian refugees in Lebanon. Glob Ment
protection, and acculturation in health: a binational
Health. 2018;5:e40. doi:10.1017/gmh.2018.33.
perspective on older adults. Demography. 2013;50(3):1039–
228. Sangalang CC, Jager J, Harachi TW. Effects of maternal 64. doi:10.1007/s13524-012-0178-9.
traumatic distress on family functioning and child mental
238. Luo T, Escalante CL. Stringent immigration enforcement
health: an examination of Southeast Asian refugee families
and the mental health and health‐risk behaviors of Hispanic
in the US. Soc Sci Med. 2017;184:178–86. doi:10.1016/j.
adolescent students in Arizona. Health Econ. 2021;30(1):86–
socscimed.2017.04.032.
103. doi:10.1002/hec.4178.
229. Shah SM, Al Dhaheri F, Albanna A, Al Jaberi N, Al Eissaee S,
Alshehhi NA et al. Self-esteem and other risk factors for
depressive symptoms among adolescents in United Arab
Emirates. PLOS One. 2020;15(1):e0227483. doi:10.1371/
84
239. Alegría M, Falgas-Bague I, Collazos F, Carmona Camacho R, 249. Lehne J, Blyth W, Lahn G, Bazilian M, Grafham O. Energy
Lapatin Markle S, Wang Y et al. Evaluation of the integrated services for refugees and displaced people. Energy Strategy
intervention for dual problems and early action among Rev. 2016;13–14:134–46. doi:10.1016/j.esr.2016.08.008.
Latino immigrants with co-occurring mental health and
250. Benka-Coker ML, Tadele W, Milano A, Getaneh D, Stokes H.
substance misuse symptoms: a randomized clinical
A case study of the ethanol CleanCook stove intervention
trial. JAMA Netw Open. 2019;2(1):e186927. doi:10.1001/
and potential scale-up in Ethiopia. Energy Sustain Dev.
jamanetworkopen.2018.6927.
2018;46:53–64. doi:10.1016/j.esd.2018.06.009.
240. Keim-Malpass J, Spears Johnson CR, Quandt SA, Arcury
251. Ma'arof MIN, Chala GT, Nair SR. Performance analysis of
TA. Perceptions of housing conditions among migrant
turbine ventilators for refugee camps usage. Int J Mech Eng
farmworkers and their families: implications for health,
Tech. 2019;10(3):1373–83 (https://papers.ssrn.com/sol3/
safety and social policy. Rural Remote Health. 2015;15:3076.
papers.cfm?abstract_id=3453033, accessed 5 April 2022).
doi:10.22605/RRH3076.
252. Haque MS. Sustainable use of plastic brick from waste PET
241. Ma G, Hofmann E. Immigration and environment in the US:
plastic bottle as building block in Rohingya refugee camp:
a spatial study of air quality. Soc Sci J. 2018;56(1):94–106.
a review. Environ Sci Pollut Res. 2019;26(36):36163–83.
doi:10.1016/j.soscij.2018.08.007.
doi:10.1007/s11356-019-06843-y.
242. Luksamijarulkul P, Suknongbung S, Vatanasomboon P,
253. Mekonnen GK, Mengistie B, Sahilu G, Mulat W, Kloos H.
Sujirarut D. Health status, environmental living conditions
Determinants of microbiological quality of drinking water
and microbial indoor air quality among migrant worker
in refugee camps and host communities in Gambella
households in Thailand. Southeast Asian J Trop Med Public
Region, Ethiopia. J Water Sanit Hyg Dev. 2019;9(4):671–82.
Health. 2017;48(2):396–406. PMID:29642302.
doi:10.2166/washdev.2019.148.
243. Chan EYY, Chiu CP, Chan GKW. Medical and health risks
254. Khoury S, Graczyk T, Burnham G, Jurdi M, Goldman L. Drinking
associated with communicable diseases of Rohingya
water system treatment and contamination in Shatila
refugees in Bangladesh 2017. Int J Infect Dis. 2018;68:39–43.
Refugee Camp in Beirut, Lebanon. East Mediterr Health J.
doi:10.1016/j.ijid.2018.01.001.
2016;22(8):568–78. doi:10.26719/2016.22.8.568.
244. Torres-Duque C, Maldonado D, Pérez-Padilla R, Ezzati M, Viegi
255. Mugumya T, Isunju JB, Ssekamatte T, Wafula ST, Mugambe
G. Biomass fuels and respiratory diseases: a review of the
RK. Factors associated with adherence to safe water chain
evidence. Proc Am Thorac Soc. 2008;5(5):577–90. doi:10.1513/
practices among refugees in Pagirinya refugee settlement,
pats.200707-100RP.
northern Uganda. J Water Health. 2020;18(3):398–408.
245. Albadra D, Kuchai N, Acevedo De Los Ríos A, Rondinel- doi:10.2166/wh.2020.230.
Oviedo D, Coley D, da Silva CF et al. Measurement and
256. Ali SI, Arnold M, Liesner F, Fesselet J-F. Characterisation of
analysis of air quality in temporary shelters on three
disinfection by-products levels at an emergency surface water
continents. Build Environ. 2020;185:107259. doi:10.1016/j.
treatment plant in a refugee settlement in northern Uganda.
buildenv.2020.107259.
Water. 2019;11(4):647. doi:10.3390/w11040647.
246. Shammi M, Robi MR, Tareq SM. COVID-19: socio-
257. Hsan K, Naher S, Griffiths MD, Shamol HH, Rahman MA.
environmental challenges of Rohingya refugees in
Factors associated with the practice of water, sanitation, and
Bangladesh. J Environ Health Sci Eng. 2020;18(2):1709–11.
hygiene (WASH) among the Rohingya refugees in Bangladesh.
doi:10.1007/s40201-020-00489-6.
J Water Sanit Hyg Dev. 2019;9(4):794–800. doi:10.2166/
247. Rivoal M, Haselip JA. The true cost of using traditional fuels in washdev.2019.038.
a humanitarian setting. Case study of the Nyarugusu refugee
258. Ali SI, Ali SS, Fesselet JF. Evidence-based chlorination
camp, Kigoma region, Tanzania. Nairobi: United Nations
targets for household water safety in humanitarian settings:
Environment Programme; Copenhagen: Denmark Technical
recommendations from a multi-site study in refugee
University; 2017 (UNEP DTU Partnership Working Paper no.
camps in South Sudan, Jordan, and Rwanda. Water Res.
3; https://unepdtu.org/publications/the-true-cost-of-using-
2021;189:116642. doi:10.1016/j.watres.2020.116642.
traditional-fuels-in-a-humanitarian-setting-case-study-of-the-
nyarugusu-refugee-camp-kigoma-region-tanzania/, accessed 259. Al-Hourani MAK, Azzam AB, Jaber R. Manifestations of
5 April 2022). lifeworld crisis among Syrian male youth in Jordanian
refugee camps. Int J Child Youth Fam Stud. 2019;10(4):3–23.
248. Wolff F, Kothe H, Mubiru A, Gashirabake J, Uwimana I,
doi:10.18357/ijcyfs104.1201919284.
Dalhoff K. Positive impact of improved cookstove usage on
respiratory health in Congolese refugees: a prospective cohort 260. Patrick M, Tsige Y, Adow A, Abdirashid M, Yunis H, Githiri
study. Environ Sci Pollut Res. 2020;27(4):4509–12. doi:10.1007/ D et al. Acceptability of urine diversion dry toilets in Dollo
s11356-019-06816-1. Ado refugee camp, Ethiopia. Int J Hyg Environ Health.
2021;234:113745. doi:10.1016/j.ijheh.2021.113745.
85
261. Nyoka R, Foote AD, Woods E, Lokey H, O'Reilly CE, Magumba 272. Walton AL, LePrevost C, Wong B, Linnan L, Sanchez-
F et al. Sanitation practices and perceptions in Kakuma Birkhead A, Mooney K. Observed and self-reported pesticide
refugee camp, Kenya: comparing the status quo with a novel protective behaviors of Latino migrant and seasonal
service-based approach. PLOS One. 2017;12(7):e0180864. farmworkers. Environ Res. 2016;147:275–83. doi:10.1016/j.
doi:10.1371/journal.pone.0180864. envres.2016.02.020.
262. Akhter M, Uddin SMN, Rafa N, Hridi SM, Staddon C, Powell W. 273. Woh PY, Thong KL, Behnke JM, Lewis JW, Mohd Zain
Drinking water security challenges in Rohingya refugee camps SN. Evaluation of basic knowledge on food safety and
of Cox's Bazar, Bangladesh. Sustainability. 2020;12(18):7325. food handling practices amongst migrant food handlers
doi:10.3390/su12187325. in Peninsular Malaysia. Food Control. 2016;70:64–73.
doi:10.1016/j.foodcont.2016.05.033.
263. Rahman MR. Rohingya crisis – health issues. Delta Med Coll J.
2018;6(1):1–3. doi:10.3329/dmcj.v6i1.35960. 274. Suen LKP, Rana T. Knowledge level and hand hygiene practice
of Nepalese immigrants and their host country population:
264. Namara F, Mendoza H, Tumukunde G, Wafula ST. Access
a comparative study. Int J Environ Res Public Health.
to functional handwashing facilities and associated
2020;17(11):4019. doi:10.3390/ijerph17114019.
factors among South Sudanese refugees in Rhino Camp
Settlement, northwestern Uganda. J Environ Public Health. 275. Carta MG, Moro D, Oumar FW, Moro MF, Pintus M, Pintus E et
2020;2020:3089063. doi:10.1155/2020/3089063. al. A follow-up on psychiatric symptoms and post-traumatic
stress disorders in Tuareg refugees in Burkina Faso. Front
265. Kisera N, Luxemburger C, Tornieporth N, Otieno G, Inda J.
Psychiatry. 2018;9:127. doi:10.3389/fpsyt.2018.00127.
A descriptive cross-sectional study of cholera at Kakuma
and Kalobeyei refugee camps, Kenya in 2018. Pan Afr Med J. 276. Allen J, Balfour R, Bell R, Marmot M. Social determinants of
2020;37:197. doi:10.11604/pamj.2020.37.197.24798. mental health. Int Rev Psychiatry. 2014;26(4):392–407. doi:
10.3109/09540261.2014.928270.
266. Claus P-E, Ceuppens A-S, Cool M, Alliet G. Ascaris
lumbricoides: challenges in diagnosis, treatment and 277. Arega NT. The plights of Eritrean refugees in the Shimelba
prevention strategies in a European refugee camp. Acta Clin Refugee Camp, Ethiopia. Int J Migr Health Soc Care.
Belg. 2018;73(6):431–4. doi:10.1080/17843286.2018.1436956. 2017;13(1):93–105. doi:10.1108/IJMHSC-02-2016-0007.
267. Nahimana M-R, Ngoc CT, Olu O, Nyamusore J, Isiaka A, 278. Habib RR, Ziadee M, Younes EA, Asmar KE, Jawad M. The
Ndahindwa V et al. Knowledge, attitude and practice of association between living conditions and health among
hygiene and sanitation in a Burundian refugee camp: Syrian refugee children in informal tented settlements in
implications for control of a Salmonella typhi outbreak. Pan Lebanon. J Public Health. 2020;42(3):e323–33. doi:10.1093/
Afr Med J. 2017;28:54. doi:10.11604/pamj.2017.28.54.12265. pubmed/fdz108.
268. Arétouyap Z, Osang Liku E, Bernard Nka L, Bagnem JE, Zambo 279. Habib RR, Mikati D, Hojeij S, Asmar KE, Chaaya M, Zurayk
EA. Water and hygiene quality in the Borgop-Cameroon R. Associations between poor living conditions and multi-
Refugee Camp and its potential adverse impacts on morbidity among Syrian migrant agricultural workers
environment and public health. J Environ Sci Public Health. in Lebanon. Eur J Public Health. 2016;26(6):1039–44.
2017;1(3):139–50. doi:10.26502/jesph.96120014. doi:10.1093/eurpub/ckw096.
269. Scobie HM, Phares CR, Wannemuehler KA, Nyangoma E, 280. Wu X, Lu X, Schneider E, Ahmed JA, Njenga MK, Breiman RF
Taylor EM, Fulton A et al. Use of oral cholera vaccine and et al. Reassessment of high prevalence human adenovirus
knowledge, attitudes, and practices regarding safe water, detections among residents of two refugee centers in Kenya
sanitation and hygiene in a long-standing refugee camp, under surveillance for acute respiratory infections. J Med
Thailand, 2012–2014. Vinetz JM, editor. PLOS Negl Trop Dis. Virol. 2019;91(3):385–91. doi:10.1002/jmv.25320.
2016;10(12):e0005210. doi:10.1371/journal.pntd.0005210.
281. Saikal SL, Ge L, Mir A, Pace J, Abdulla H, Leong KF et al. Skin
270. Castillo F, Mora AM, Kayser GL, Vanos J, Hyland C, Yang disease profile of Syrian refugees in Jordan: a field-mission
AR et al. Environmental health threats to Latino migrant assessment. J Eur Acad Dermatol Venereol. 2020;34(2):
farmworkers. Annu Rev Public Health. 2021;42(1):257–76. 419–25. doi:10.1111/jdv.15909.
doi:10.1146/annurev-publhealth-012420-105014.
282. Impact of the COVID-19 crisis in the Maldives. Malé:
271. Walton AL, LePrevost C, Wong B, Linnan L, Sanchez-Birkhead Ministry of Economic Development, Government of
A, Mooney K. Pesticides: perceived threat and protective Maldives; 2020 (https://maldives.un.org/sites/default/
behaviors among Latino farmworkers. J Agromedicine. files/2021-03/1598369482.pdf, accessed 6 April 2022).
2017;22(2):140–7. doi:10.1080/1059924X.2017.1283278.
283. Sadarangani SP, Lim PL, Vasoo S. Infectious diseases and
migrant worker health in Singapore: a receiving country's
perspective. J Travel Med. 2017;24(4). doi:10.1093/jtm/tax014.
86
284. ApartTogether survey: preliminary overview of refugees 295. Fuori campo 2018: insediamenti informali: marginalità
and migrants self-reported impact of COVID-19. Geneva: sociale, ostacoli all'accesso alle cure e ai beni essenziali per
World Health Organization; 2020 (https://apps.who.int/iris/ migranti e rifugiati [Out-of-field 2018: informal settlements:
handle/10665/337931, accessed 6 April 2022). social marginalisation, barriers to access to care and essential
goods for migrants and refugees]. Rome: Médecins Sans
285. Louni M, Amanzougaghene N, Mana N, Fenollar F, Raoult D,
Frontières; 2018 (in Italian; https://www.medicisenzafrontiere.
Bitam I et al. Detection of bacterial pathogens in clade E head
it/wp-content/uploads/2019/04/Fuoricampo2018.pdf,
lice collected from Niger's refugees in Algeria. Parasit Vectors.
2018;11(1):348. doi:10.1186/s13071-018-2930-5.
296. Ravnbøl CI. Doubling syndemics: ethnographic accounts
286. Öztürk MK. Skin diseases in rural Nyala, Sudan (in a rural
of the health situation of homeless Romanian Roma
hospital, in 12 orphanages, and in two refugee camps). Int J
in Copenhagen. Health Hum Rights. 2017;19(2):73–88.
Dermatol. 2019;58(11):1341–9. doi:10.1111/ijd.14619.
PMID:29302164.
287. Fernández-Villalobos NV, Arbeláez-Montoya MP. Factores
297. Ahmed N, Kumait AS, Othman S, Al-Tawil N. Assessment
relacionados con los casos de tuberculosis en Costa Rica,
of certain aspects and health issues that encountered by
2012–2015 [Factors related to tuberculosis cases in Costa
street children and adolescents in Kirkuk city. Indian J
Rica, 2012–2015]. Rev Cuba Salud Pública. 2020;46(3) (in
Forensic Med Toxicol. 2019;13(3):298–304. doi:10.5958/0973-
Spanish; http://www.revsaludpublica.sld.cu/index.php/spu/
9130.2019.00213.5.
article/view/1455, accessed 6 April 2022).
298. There are alternatives: a handbook for preventing
288. Kearney GD, Chatterjee AB, Talton J, Chen H, Quandt SA,
unnecessary immigration detention (revised edition).
Summers P et al. The association of respiratory symptoms
Melbourne: International Detention Coalition; 2015 (https://
and indoor housing conditions among migrant farmworkers
idcoalition.org/wp-content/uploads/2015/10/There-Are-
in eastern North Carolina. J Agromedicine. 2014;19(4):395–
Alternatives-2015.pdf, accessed 6 April 2022).
405. doi:10.1080/1059924X.2014.947458.
299. Glossary on migration. Geneva: International Organization
289. Hernández-Vásquez A, Vargas-Fernández R, Rojas-Roque C,
for Migration; 2019 (https://publications.iom.int/system/files/
Bendezu-Quispe G. Factores asociados a la no utilización
pdf/iml_34_glossary.pdf, accessed 6 April 2022).
de servicios de salud en inmigrantes venezolanos en Perú
[Factors associated with the non-utilization of healthcare 300. Beyond detention: a global strategy to support governments
services among Venezuelan migrants in Peru]. Rev Peru to end the detention of asylum-seekers and refugees. Geneva:
Med Exp Salud Publica. 2019;36(4):583–91 (in Spanish). United Nations High Commissioner for Refugees; 2014
doi:10.17843/rpmesp.2019.360.4654. (https://www.unhcr.org/protection/detention/53aa929f6/
beyond-detention-global-strategy-support-governments-end-
290. Quandt SA, Brooke C, Fagan K, Howe A, Thornburg TK,
detention-asylum.html, accessed 6 April 2022).
McCurdy SA. Farmworker housing in the United States
and its impact on health. New Solut. 2015;25(3):263–86. 301. Flynn M. Who must be detained? Proportionality as a tool
doi:10.1177/1048291115601053. for critiquing immigration detention policy. Refug Surv Q.
2012;3(3):40–68. doi:10.1093/rsq/hds008.
291. Hanley J, Ives N, Lenet J, Hordyk S-R, Walsh C, Ben Soltane
S et al. Migrant women's health and housing insecurity: 302. Fact sheet no. 26, the Working Group on Arbitrary Detention.
an intersectional analysis. Int J Migr Health Soc Care. Geneva: United Nations Office of the High Commissioner
2019;15(1):90–106. doi:10.1108/IJMHSC-05-2018-0027. for Human Rights; 2000 (https://www.refworld.org/
docid/479477440.html, accessed 6 April 2022).
292. Chepo M, Astorga-Pinto S, Cabieses B. Atenção inicial a
populações migrantes no Chile: iniciativa em atenção 303. Immigration detention centres [website]. Geneva: Global
primária à saúde após um ano da sua implementação [Initial Detention Project; 2022 (https://www.globaldetentionproject.
care for migrants in Chile: status of a primary health care org/detention-centres/list-view, accessed 6 April 2022).
initiative after one year of implementation]. Rev Panam Salud
304. COVID-19 & immigration detention: what can governments
Publica. 2019;43:e71 (in Spanish). doi:10.26633/RPSP.2019.71.
and other stakeholders do? Geneva: United Nations
293. Segal SP, Khoury VC, Salah R, Ghannam J. Contributors to Network on Migration; 2020 (https://www.refworld.org/
screening positive for mental illness in Lebanon's Shatila docid/5eac26514.html, accessed 6 April 2022).
Palestinian refugee camp. J Nerv Ment Dis. 2018;206(1):46–51.
305. Majcher I, Flynn M, Grange M. Immigration detention in the
doi:10.1097/NMD.0000000000000751.
European Union: in the shadow of the "crisis", first edition.
294. Corrado A. Is Italian agriculture a "pull factor" for irregular New York: Springer; 2020 (European Studies of Population
migration – and, if so, why? New York: Open Society no. 22; https://www.globaldetentionproject.org/immigration-
Foundations; 2018 (https://www.opensocietyfoundations. detention-in-the-european-union-in-the-shadow-of-the-crisis,
org/publications/italian-agriculture-pull-factor-irregular- accessed 6 April 2022).
migration-and-if-so-why, accessed 6 April 2022).
87
306. Ghezelbash D. Refuge lost: asylum law in an interdependent 318. Joint general comment No. 4 (2017) of the Committee on the
world. Cambridge: Cambridge University Press; 2018. Protection of the Rights of All Migrant Workers and Members
of Their Families and No. 23 (2017) of the Committee on the
307. FitzGerald DS. Refuge beyond reach: how rich democracies
Rights of the Child on state obligations regarding the human
repel asylum seekers. Oxford, New York: Oxford University
rights of children in the context of international migration
Press; 2019.
in countries of origin, transit, destination and return.
308. Flynn M. There and back again: on the diffusion of Geneva: Office of the United Nations High Commissioner
immigration detention. J Migr Hum Secur. 2018;2(3):165–97. for Human Rights; 2017 (https://digitallibrary.un.org/
doi:10.1177/233150241400200302. record/1323015?ln=en, accessed 6 April 2022).
309. The uncounted: detention of migrants and asylum seekers in 319. Ehntholt KA, Trickey D, Harris Hendriks J, Chambers H,
Europe. Geneva: Global Detention Project; 2015 (https://www. Scott M, Yule W. Mental health of unaccompanied asylum-
globaldetentionproject.org/wp-content/uploads/2015/12/ seeking adolescents previously held in British detention
The-Uncounted.pdf, accessed 6 April 2022). centres. Clin Child Psychol Psychiatry. 2018;23(2):238–57.
doi:10.1177/1359104518758839.
310. Brooker S, Albert S, Young P, Steel Z. Mental health care in an
invalidating environment: the case of immigration detention 320. Durcan G, Stubbs J, Boardman J. Immigration removal
in Australia. In: Flynn MJ, Flynn MB, editors. Challenging centres in England: a mental health needs analysis. London:
immigration detention. Cheltenham: Edward Elgar Centre for Mental Health; 2017 (https://www.basw.co.uk/
Publishing; 2017. system/files/resources/basw_71119-7_0.pdf, accessed
6 April 2022).
311. Takei C, Small M, Wu C, Chan J. Fatal neglect: how ICE ignores
deaths in detention. New York: American Civil Liberties 321. Mental health in detention: written evidence submitted
Union. 2016; (https://www.aclu.org/sites/default/files/field_ by Medical Justice to the Shaw Review. London: Medical
document/fatal_neglect_acludwnnijc.pdf, accessed Justice; 2015 (http://www.medicaljustice.org.uk/wp-content/
6 April 2022). uploads/2016/04/alHealthinDetention-SummarybyMedicalJu
sticeforShawReview.pdf, accessed 6 April 2022).
312. Failures and cover-ups: suicide in UK detention centres
[website]. London: Bail for Immigration Detainees; 2019 322. Puthoopparambil SJ, Ahlberg BM, Bjerneld M. "A prison
(https://www.biduk.org/articles/532-failures-and-cover-ups- with extra flavours": experiences of immigrants in Swedish
suicide-in-uk-detention-centres, accessed 6 April 2022). immigration detention centres. Int J Migr Health Soc Care.
2015;11:73–85. doi:10.1108/IJMHSC-10-2014-0042.
313. Blunt M. Systemic indifference: dangerous & substandard
medical care in US immigration detention. New York: Human 323. Venters HD, McNeely J, Keller AS. HIV screening and care for
Rights Watch; 2017 (https://www.hrw.org/sites/default/files/ immigration detainees. Health Hum Rights. 2009;11(2):89–
report_pdf/usimmigration0517_web_0.pdf, accessed 100. PMID:20845844.
6 April 2022).
324. Van Hout MC. Human rights violations, detention conditions
314. Kellezi B, Wakefield J, Bowe M. The impact of poor healthcare and the invisible nature of women in European immigration
provision in UK immigration removal centres [website]. detention: a legal realist account. Int J Prison Health. 2021;5.
London: The Conversation; 2021 (http://theconversation. doi:10.1108/IJPH-03-2021-0023.
com/the-impact-of-poor-healthcare-provision-in-uk-
325. Essex R. Human rights, dual loyalties, and clinical
immigration-removal-centres-161525, accessed 6 April 2022).
independence: challenges facing mental health professionals
315. van Hout MC, Lungu-Byrne C, Germain J. Migrant health working in Australia's immigration detention network. J
situation when detained in European immigration detention Bioeth Inq. 2014;11:75–83. doi:10.1007/s11673-013-9493-0.
centres: a synthesis of extant qualitative literature. Int J Prison
326. Puthoopparambil SJ, Bjerneld M. Detainees, staff, and health
Health. 2020;16(3):221–36. doi:10.1108/IJPH-12-2019-0074.
care services in immigration detention centres: a descriptive
316. Kuehne A, van Boetzelaer E, Alfani P, Fotso A, Elhammali H, comparison of detention systems in Sweden and in the
Khamala T et al. Health of migrants, refugees and asylum Benelux countries. Glob Health Action. 2016;9(1):30358.
seekers in detention in Tripoli, Libya, 2018–2019: retrospective doi:10.3402/gha.v9.30358.
analysis of routine medical programme data. PLOS One.
327. Addressing the health challenges in immigration and
detention, and alternatives to detention: a country
317. Nowak M, Krishan M. The UN global study on children implementation guide. Copenhagen: WHO Regional Office for
deprived of liberty: the role of academia in "making the Europe; 2022 (https://apps.who.int/iris/handle/10665/353569,
invisible and forgotten visible". In: Kury H, Redo S, editors. accessed 9 May 2022).
Crime prevention and justice in 2030. New York:
328. Araissia H. Syrian women refugees in Tunisia: difficulties
Springer; 2021.
accessing economic and social rights. Collect Rev Cienc Soc.
2019;6(2):91–103. doi:10.15648/Coll.2.2019.6.
88
329. Chandler H, Boothby N, McNatt Z, Berrigan M, Zebib L, 340. Khakpour M, Iqbal R, GhulamHussain N, Engler-Stringer R, Koc
Freels PE et al. Causes of family separation and barriers M, Garcea J et al. Facilitators and barriers toward food security
to reunification: Syrian refugees in Jordan. J Refug Stud. of Afghan refugees residing in Karachi, Pakistan. Ecol Food
2020;33(2):371–89. doi:10.1093/jrs/feaa033. Nutr. 2019;58(4):317–34. doi:10.1080/03670244.2019.1598982.
330. Alsoudi A. The socio-economic impact of Syrian refugees 341. Carey E, Lindow O, Al Jawamees M, Al Refaay R, Teo Ficcarelli
on labor in Jordan: a case study on local communities in F. Jordan: comprehensive food security and vulnerability
Mafraq governorate. J Islam Thought Civiliz. 2020;10(1):1–23. assessment 2018. Rome: World Food Programme;
doi:10.32350/jitc.101.01. 2019 (https://reliefweb.int/sites/reliefweb.int/files/
resources/70245.pdf, accessed 6 April 2022).
331. Kusakabe K, Khuenta K, Hemsakul T, Veena N. Building a
home away from home: housing choices of labor migrants in 342. Salti N, Ghattas H. Food insufficiency and food insecurity as
Thailand. Migr Dev. 2019;8(2):176–91. doi:10.1080/21632324. risk factors for physical disability among Palestinian refugees
2018.1498255. in Lebanon: evidence from an observational study. Disabil
Health J. 2016;9(4):655–62. doi:10.1016/j.dhjo.2016.03.003.
332. Good practices for migrant and refugee housing in Europe.
Geneva: United Nations High Commissioner for Refugees; 343. Logie CH, Okumu M, Mwima S, Hakiza R, Chemutai D,
2020 (https://www.unhcr.org/bg/wp-content/uploads/ Kyambadde P. Contextual factors associated with depression
sites/18/2020/10/Good-practices-housing-FINAL-EN.pdf, among urban refugee and displaced youth in Kampala,
accessed 6 April 2022). Uganda: findings from a cross-sectional study. Confl Health.
2020;14(1):45. doi:10.1186/s13031-020-00289-7.
333. Koh D. Migrant workers and COVID-19. Occup Environ Med.
2020 Sep;77(9):634–6. doi:10.1136/oemed-2020-106626. 344. Maharaj V, Tomita A, Thela L, Mhlongo M, Burns JK.
Food insecurity and risk of depression among refugees
334. Sianipar KD. Resettlement of former East Timorese refugees
and immigrants in South Africa. J Immigr Minor Health.
in East Nusa Tenggara. In: Friedberg E, Hilderbrand
2017;19(3):631–7. doi:10.1007/s10903-016-0370-x.
ME, editors. Observing policy-making in Indonesia.
Singapore: Springer; 2017 (https://link.springer.com/ 345. Henjum S, Caswell BL, Terragni L. "I feel like I'm eating rice
chapter/10.1007/978-981-10-2242-5_5, accessed 6 April 2022). 24 hours a day, 7 days a week": dietary diversity among
asylum seekers living in Norway. Nutrients. 2019;11(10):2293.
335. Jamaluddine Z, Sahyoun NR, Choufani J, Sassine AJ, Ghattas
doi:10.3390/nu11102293.
H. Child-reported food insecurity is negatively associated with
household food security, socioeconomic status, diet diversity, 346. Terragni L, Arnold CD, Henjum S. Food skills and their
and school performance among children attending UN relief relationship with food security and dietary diversity among
and works agency for Palestine refugees schools in Lebanon. asylum seekers living in Norway. J Nutr Educ Behav.
J Nutr. 2019;149(12):2228–35. doi:10.1093/jn/nxz189. 2020;52(11):1026–34. doi:10.1016/j.jneb.2020.05.009.
336. Napier C, Oldewage-Theron W, Makhaye B. Predictors of food 347. Sauter A, Kikhia S, Sommoggy J, Loss J. Factors influencing
insecurity and coping strategies of women asylum seekers the nutritional behavior of Syrian migrants in Germany
and refugees in Durban, South Africa. Agric Food Secur. – results of a qualitative study. BMC Public Health.
2018;7:67. doi:10.1186/s40066-018-0220-2. 2021;21(1):1334. doi:10.1186/s12889-021-11268-9.
337. VASyR 2020: Vulnerability assessment of Syrian refugees in 348. Steinhilber A, Dohnke B. Adolescent Turkish migrants' eating
Lebanon. Geneva: United Nations High Commissioner for behavior in Germany: a comparison to nonmigrants in the
Refugees; New York: United Nations Children's Fund; Rome: home and host countries based on the prototype-willingness
World Food Programme; 2020 (https://reliefweb.int/sites/ model. Cultur Divers Ethnic Minor Psychol. 2016;22(1):114–25.
reliefweb.int/files/resources/VASyR%202020.pdf, accessed doi:10.1037/cdp0000042.
6 April 2022).
349. Topalovic T, Episkopou M, Schillberg E, Brcanski J, Jocic M.
338. Laithy HE, Armanious D. Vulnerability assessment of refugees Migrant children in transit: health profile and social needs
in Egypt: risks and coping strategies. Geneva: United Nations of unaccompanied and accompanied children visiting the
High Commissioner for Refugees; 2019 (https://www.unhcr. MSF clinic in Belgrade, Serbia. Confl Health. 2021;15(1):32.
org/eg/wp-content/uploads/sites/36/2021/01/Vulnerability- doi:10.1186/s13031-021-00366-5.
Assessment-of-Refugees-in-Egypt-Risks-and-Coping-
350. Angeletti S, Ceccarelli G, Bazzardi R, Fogolari M, Vita S,
Strategies-April-2019.pdf, accessed 6 April 2022).
Antonelli F et al. Migrants rescued on the Mediterranean Sea
339. Migrant emergency food security report: Libya. Geneva: route: nutritional, psychological status and infectious disease
International Organization for Migration; 2020 (https:// control. J Infect Dev Ctries. 2020;14(5):454–62. doi:10.3855/
migration.iom.int/sites/default/files/public/reports/ jidc.11918.
DTMLibya_MigrantFS_May2020_0.pdf, accessed 6 April 2022).
89
351. Henjum S, Morseth MS, Arnold CD, Mauno D, Terragni L. "I 355. Glaser J, Pittore K, Roefs M. Evaluation of nutrition and
worry if I will have food tomorrow": a study on food insecurity income generation intervention (NIGI) Uganda: evaluation
among asylum seekers living in Norway. BMC Public Health. on the effect of NIGI on the refugee community in the
2019;19(1):592. doi:10.1186/s12889-019-6827-9. Omugo refugee settlement in northern Uganda. Wageningen:
Wageningen Centre for Development Innovation; 2021
352. Kim J, Lee S, Kim S. Comparisons of food security, dietary
(https://edepot.wur.nl/546245, accessed 6 April 2022).
behaviors and nutrient intakes between adult North Korean
refugees in South Korea and South Koreans. Nutr Res Pract. 356. Ghattas H, Choufani J, Jamaluddine Z, Masterson AR,
2020;14(2):134–42. doi:10.4162/nrp.2020.14.2.134. Sahyoun NR. Linking women-led community kitchens to
school food programmes: lessons learned from the Healthy
353. Aragón Gama AC, Infante Xibille C, Mundo Rosas V, Liu X,
Kitchens, Healthy Children intervention in Palestinian
Orjuela-Grimm M. Relative severity of food insecurity during
refugees in Lebanon. Public Health Nutr. 2020;23(5):914–23.
overland migration in transit through Mexico. J Immigr Minor
doi:10.1017/S1368980019003161.
Health. 2020;22(6):1118–25. doi:10.1007/s10903-020-01063-w.
357. Sahyoun NR, Jamaluddine Z, Choufani J, Mesmar S, Reese-
354. Leidman E, Humphreys A, Cramer BG, Mil LT-V, Wilkinson
Masterson A, Ghattas H. A mixed-methods evaluation of
C, Narayan A et al. Acute malnutrition and anemia among
community-based healthy kitchens as social enterprises
Rohingya children in Kutupalong Camp, Bangladesh. JAMA.
for refugee women. BMC Public Health. 2019;19(1):1590.
2018;319(14):1505–6. doi:10.1001/jama.2018.2405.
doi:10.1186/s12889-019-7950-3.
CHAPTER 3
Health status
of refugees
and migrants:
a global
perspective
92
A Venezuelan living in Peru is working 12–13 hours per day to pay a high price for braving the COVID-19 crisis far from his home country,
with challenges finding jobs and limited access to health services. © PAHO / WHO
Health status of refugees and migrants: a global perspective
93
3.1 Introduction
This chapter explores recent evidence from the six WHO regions to provide a
global overview of the health status of refugees and migrants. A comprehensive
review of the available literature globally has been conducted, and the results are
presented in this report. A main finding of the review was the absence of studies
presenting a global or regional synthesis. Comparing individual studies to reach
regional or global conclusions also proved to be challenging, mainly because of
the use of different indicators and population groups, which were often not clearly
defined. The Annex summarizes the methodology and the types of study, disease
categories and population groups included in the literature review. With these
limitations, this chapter presents global patterns and trends in the health status of
refugees and migrants. Wherever possible, it also presents examples from different
countries and regions to highlight the global variation for each health challenge.
In spite of some limitations, some compelling conclusions can be made. At the

broadest level of overview, being a refugee or migrant clearly carries significant
health risks, to the extent that displacement or migration must itself be
considered a determinant of health (Box 3.1), as shown in Chapter 2.
This report aims to support and promote the health of refugees and migrants in
all of the known contexts in which they may find themselves. It focuses on the
The remains of a boat carrying migrants and asylum seekers that departed Libya but capsized on a sandbar north of the Tunisian islands of
Kerkennah. Authorities estimated that 250 people tragically drowned in the incident. © Lindsay Mackenzie
94
human right to health, and highlights health- and migrant population. Information is also
promoting public health interventions that needed both on the health needs of refugees
will help to achieve this goal. and migrants and on current and potential
policies and responses. More research is
A major conclusion is that more and better- also required to facilitate the creation and
quality evidence is needed, with clearly promotion of health among refugees and
defined study populations and outcomes and migrants, as indicated in the Ottawa charter
comparable data that reflect the global refugee for health promotion (1).
Box 3.1.
Death and disappearance: the Missing Migrants Project
Based on a variety of sources (e.g. from coastguards and medical examiners, media reports,
nongovernmental organizations, and surveys and interviews of migrants), the International
Organization for Migration (IOM) Missing Migrants Project estimates (as of 6 February 2022) that
more than 47 296 people died on migration journeys worldwide between 2014 and 2021 (2).
Given the difficulties of data collection, these figures are best understood as a minimum estimate of
the true number of deaths during migration.
IOM reports that more than 20 000 individuals disappeared during sea crossings and their remains
have not been recovered, with more deaths likely to have gone undocumented. Nearly 8000 fatalities
during migration have an unknown or mixed cause of death or disappearance, indicating the scarcity of
robust, disaggregated data as well as the lack of official investigation into thousands of deaths.
Fatalities during migration occur across the world when people lack access to safe and legal mobility
pathways. However, certain routes are known to be especially deadly for those on the move. For
the 2014–2022 period, the largest proportion (23 485 out of 47 296) of deaths and disappearances
documented during migration was recorded in the Mediterranean Sea: 80% of these deaths were
recorded on the Central Mediterranean Route to Italy and Malta and involved the attempted sea
crossing from Algeria, Libya and Tunisia and, to a lesser degree, from Egypt. An additional 5226 deaths
were recorded during migration across the Sahara Desert, although the challenges of monitoring this
vast area mean that it is extremely likely that far more deaths occurred than have been recorded. At
least another 3661 people died attempting to cross the southern border of the United States from
Mexico, with most deaths being linked to harsh conditions in the desert regions or to the hazardous
Rio Grande river crossing. At least 2664 deaths occurred (of which 1176 were recorded in 2021 alone) on
the overseas migration route to the Spanish Canary Islands, a destination for migrants from southern
Morocco or western African countries.
A vast amount of work is needed to properly identify those who die during migration. No information
is available on the country of origin or identity of more than 21 000 individuals recorded in the Missing
Migrants Project database during 2015–2020.
95
Despite focusing on various diseases and

health conditions, this chapter clearly shows
that, as a population, refugees and migrants
A significant number of migrant
are innately healthy, and in some cases workers are engaged in so-called
even healthier than the host populations.
Some of the evidence indicates that refugees
3D jobs – dirty, dangerous and
and migrants have an overall mortality demanding – and are at greater
advantage (i.e. lower death rates) for the
most common diseases compared with the
risk of occupational accidents,
general population. However, as in the general injuries and work-related
population, there are certain subgroups health problems than their
among refugees and migrants whose high risk
of poor health outcomes – and even of death non-migrant counterparts.
and disappearance during migration (Box 3.1) –
is certainly exacerbated by conditions during
displacement and migration.
3.2 Occupational health
ILO estimated that there were 169 million

• M
ale migrant workers appear to be at international migrant workers worldwide
a higher risk of occupational injuries, in 2019, representing around 5% of the
mainly because of their employment global labour force (3). Although labour
in high-risk industries, such as mining
migration can be beneficial for workers by
and construction.
broadening their employment opportunities,
• As well as workplace injury and migrant workers can also face hardship and
death, occupational health problems increased vulnerability in their country
most often include musculoskeletal,
of destination.
respiratory and mental health
conditions, as well as other industry-
specific hazards. Migrant workers can frequently face
negative health outcomes, resulting
• Migrant workers are found to have less
from workplace hazards, exposure,
ability to exercise workers' rights to safe
discrimination, lack of insurance (or loss
and healthy working conditions.
of insurance when it is not portable), an
• Major data gaps are known to exist absence of safety measures, or abuse in
because of the informal nature of the
jobs in which they face higher risks to their
sectors in which many migrant workers
safety and well-being (4–10). Compared
are more likely to work and because
information on migratory status is often with non-migrant workers, migrant workers
missing from relevant surveys. rarely benefit from equal access to social
security systems (11); low-skilled migrant
• In data collected through various
surveys where migrant workers might workers, irregular migrants, refugees and
be included, information on migratory asylum seekers face even greater barriers
status is often missing. in accessing social protection (12).
96
Studies suggest that a significant number A study in Saudi Arabia comparing

of migrant workers are engaged in so-called occupational injuries among insured Saudi
3D jobs – dirty, dangerous and demanding Arabian labourers with those among insured
(sometimes degrading or demeaning) – and migrant labourers, using data from a health
are at greater risk of occupational accidents, insurance database, concluded that 93.5%
injuries and work-related health problems than of the injured were migrant workers and
their non-migrant counterparts (13). Particularly only 6.5% were from the host population;
if they come from low- and middle-income however, a notable limitation of this study
countries, they are often employed in low-wage is that migrant workers without health
or low-skilled occupations. Their jobs may be insurance, who may have experienced even
more dangerous than those of non-migrants, higher rates of injury, were excluded (5).
with higher physical demands and poorer
environmental working conditions (14). Numerous other studies among migrant
workers from China, Hong Kong Special
Additional concerns include the wide variation Administrative Region, and the United States
in conditions regarding social protection and have shown more occupational fatalities
legal status, such as temporary, permanent among migrant workers compared with
or sector-specific work, or no legal right to workers from host populations (6,10,17). For
work (15). It is, therefore, essential to promote example, a study in China, Hong Kong Special
global frameworks such as the WHO global Administrative Region, among migrant workers
plan of action on workers' health (2008–2017) from Nepal reported cases of serious injury
and to develop national policies to ensure the (including paraplegia) and workplace death,
protection of migrant workers (16). but postmortem documentation incorrectly
attributed the deaths to natural causes (10).
A recent meta-analysis of more than 17 million
participants in 16 countries across five WHO A study conducted among Nepalese migrant
regions (WHO African Region, WHO Region of workers in Malaysia, Qatar and Saudi
the Americas, WHO European Region, WHO Arabia reported poor health and safety
Eastern Mediterranean Region and WHO regulations, intense productivity pressure
Western Pacific Region) investigated the use and risky practices, such as working without
of health services by migrant workers (9). safety equipment. These have led to severe
Compared with non-migrant workers, migrant injuries including lost fingers and permanent
workers were less likely to use health services disabilities (7).
and more likely to have had an occupational
injury. Another study concluded that migrant Research in the WHO European Region revealed
workers faced substantial risk around work- mixed results: one study within the agriculture
related illness and injury, which is "critically sector in Türkiye showed that male migrant
overlooked in research and policy" (13). workers have similar rates of work-related injury
as the host population (18), whereas a study in
The most commonly reported work-related Denmark reported a greater risk of occupational
health problems among refugee and migrant injuries for migrant workers compared with the
workers relate to musculoskeletal, respiratory host population (19).
and mental health, according to a study based in
the WHO European Region (4). (Other industry- Male migrant workers tend to have higher
specific hazards are discussed in section 3.2.1.) rates of workplace physical injury than female
97
migrant workers, reflecting traditional domains In a study conducted in Sweden, migrants

of work in which men tend to work in sectors who were temporarily employed were at
with higher physical risk (20). A meta-analysis increased risk of psychological distress
across 13 countries and territories of the WHO compared with those who had permanent
European Region included occupational jobs or were self-employed (28).
health outcomes for 12 168 migrant workers
(representing 25 low- and middle-income Similarly, differences in exposures to
countries) employed in mostly unskilled workplace hazards depending on the country
manual labour (13). It found the pooled of origin are apparent in Australia: workers
prevalence of having at least one occupational born in New Zealand were less likely to be
morbidity to be 47%, with most related to exposed to any psychosocial hazard – for
respiratory function, general health problems, example, discrimination (Box 3.2), job strain,
mental health and injuries requiring vulnerability and insecurity – but were more
medical care. likely to be exposed to diesel exhaust and at
least one carcinogen compared with migrants
Enduring difficult or insecure work conditions, born in India and the Philippines (39).
including exploitative treatment and unsafe
situations, is related to poor psychosocial and In Chile, Bolivian migrant women in
mental health outcomes in studies across domestic work reported poor working
multiple regions (8,21–23). For example, some conditions and long working hours, which
countries follow the approach of legally increased their fatigue and feelings of
binding the migrant worker's visa or work hopelessness and may, in turn, increase the
permit to the employer or sponsor, which risk of mental health conditions (40). Returning
prevents the migrant from taking other to the home country may bring financial
employment or even from leaving the country disadvantages and additional psychosocial
without the employer's permission. Reports stressors or rejection, or pressure to travel
indicate that misuse of this system is putting again to seek employment abroad (8,41,42).
the migrant workers in a vulnerable situation
through practices such as withholding the 3.2.1 High-risk and physically
migrant worker's passport or through the demanding sectors of industry
worker facing negative consequences for The high risk and physically demanding
reporting abuse by the employer (24). economic sectors of agriculture, construction
and mining are major employers of refugees
Evidence based on Canada's Temporary and migrants globally.
Foreign Worker Program has shown the impact
of precarious employment and legal status Evidence from the WHO European Region
on mental health: migrants living away from and WHO Western Pacific Region has shown
their families on temporary visas as part of that refugees and migrants, including
the Canadian programme, especially those seasonal workers, are likely to lack awareness
on agricultural visas, experience a higher of workplace hazards and to be exposed to
prevalence of stressors that can affect mental pesticides, chemicals and workplace abuse
health (25,26). Domestic care workers also (43,44). Farmworkers across the WHO Region
experience deteriorating mental health and of the Americas face various forms of pain and
report that long working hours and housing musculoskeletal disorders, as well as exposure
conditions are the major contributors (27). to agricultural chemicals that cause respiratory
98
Box 3.2.
Workplace discrimination and marginalization
Refugees and migrants often report experiencing discrimination, isolation and marginalization in their
workplaces. Migrant workers in Italy consistently reported self-perceived workplace discrimination
(29,30). In Australia, a report described how migrants of Māori or Pasifika background were more likely
to experience ethnic discrimination, bullying, and fair or poor current health compared with their
Caucasian counterparts from New Zealand (31). In Saudi Arabia, workplace bullying in health care
settings is 25% more prevalent towards migrant workers than towards their non-migrant counterparts
(32). Migrants indicated numerous reasons why they may not make a formal complaint about their
workplace treatment, with fear of losing employment and risk of deportation the primary concerns
(23,33–37). Irregular migrants in Canada and the United States are often not formally employed and,
therefore, lack written contracts and social protection. As a result, employers may use the threat of
deportation as a disciplinary technique to ensure that migrants accept detrimental working conditions
(33–37). Similarly, migrant workers in the Maldives reported the constant threat of deportation and made
no formal complaints because of concerns over the precarious nature of their visa status, leading to
harmful impacts on their physical and mental health (36). Official complaints mechanisms are essential
because migrant workers, such as women in the WHO South-East Asia Region, have been provided
false contracts, had their identity documents withheld and had difficulty accessing legal aid (38).
and dermatological problems, cancer and workers in China (4). Studies of migrant
allergies, among other issues (45–47). In farmworkers in South Africa link an increased
Mexico, agricultural labour migrants described risk of HIV acquisition to factors including
poor diets and increased chronic diseases poorly implemented labour legislation,
(cardiovascular and metabolic) related to perceptions of anti-migrant sentiment, poor
long-term residence in isolated farming living conditions, inability to take time off
environments with poor living and sanitary to access health care, and psychosocial
conditions, and to a heavy workload (48). and behavioural determinants (50,51).
Migrants in the Republic of Korea working in Construction is another sector that has many
the agriculture, livestock and fisheries sectors, safety issues and often employs a refugee
among the most physically demanding or migrant workforce. In an ILO study, Syrian
industries, have reported being unable to refugee construction workers reported a lack
claim workers' compensation unless they of enforcement mechanisms or sanctions
were severely injured (49). A study on the risk for violations of safety procedures (52). In
factors for occupational injuries found that Singapore, migrant workers in the construction,
Chinese migrant workers in the Republic of shipyard and process (manufacturing)
Korea working in these industries reported industries reported trauma-related injuries and
a higher fatality rate from occupational sometimes being discharged against medical
injuries compared with Korean migrant advice (53). Another sector with a poor record
99
on health and safety is transportation; according Although not traditionally regarded as high-risk
to studies based in South Africa and Zambia, industries, the service and care sectors –including
truck drivers face sleep disorders, unsafe roads, domestic workers and health care staff, of whom
exposure to criminal activity and violence (both the great majority are women – frequently expose
during their journeys and at border crossings), individuals to long hours and considerable
and other poor psychosocial outcomes (54,55). hardship. Female labour migrants often work in
domestic services and caregiving, areas in which
The risks for refugee and migrant workers in the musculoskeletal diseases and stress-related
mining sector are highlighted in literature from conditions persist, with evidence reported from
the WHO African Region, in particular. Trends China, Israel and Malaysia (61–65).
in mining employment have shifted in South
Africa during the past 50 years: for example, Refugees and migrants in the health sector
there is increased employment of women and often face discrimination both from other
acknowledgement of the need to consider staff and patients. A cross-sectional study on
the risks of HIV, TB and silicosis in areas where workplace bullying in a hospital in Saudi Arabia
mineworkers are recruited from and return to (56). found that bullying was more prevalent among
expatriate workers such as migrant nurses
HIV prevalence was found to be high among (66.4%) than in national comparison groups
mineworkers in Mozambique who had worked (56.5%) (32). Harassment and discrimination
in mines in South Africa, and among their among nursing teams in the United Kingdom's
families; however, the study found that HIV National Health Service were explored in a
prevalence was lower in households with higher number of studies (66), with research revealing
levels of education (57). Another study into the that migrant nurses in the United Kingdom face
feasibility and acceptability of, and adherence prejudice and discrimination when patients
to, daily oral short-term pre-exposure HIV (or their family members) refuse to receive
prophylaxis combined with access to HIV testing care from them or request a non-minority
as a preventive intervention for partners of home-care nurse (67). Migrant health workers
mineworkers reported positive results overall in Oman faced job security stressors related
(58). Additional analysis in the Region has also to the government's preference for employing
shown that mineworkers have a significantly health workers from the host population (68).
higher lifetime risk of developing and potentially
transmitting TB after returning to their home Across most regions, migrant sex workers
communities, and face systemic barriers to face a range of abuses. Resulting from
accessing their rightful compensation for a marginalization at the intersection of sex and
lung disease claim linked to occupational risk gender, legal status and working in an often-
factors (59). criminalized industry, these abuses have
repercussions for SRH, among other health
Challenges remain relating to continuity of care areas (69–75). A qualitative study among male
for migrant workers who live with TB and/or HIV migrant sex workers in London reported high
because moving for work, and the seasonality of exposure to discrimination, social exclusion
work, impacts their ability to access appropriate and inequalities in accessing health care (76).
medications in a sustained manner. Additional Social marginalization was linked to low levels
challenges include the accurate calculation of of health literacy or use of health screening
compensation, which requires documentation in migrant sex workers near the Guatemala–
and identification verification processes (60). Mexico border (77).
100
3.2.2 Data challenges Administrative sources. Most of the data

Data on the occupational health outcomes about occupational injuries are acquired from
of migrant workers remain scarce. administrative sources, including insurance
records, labour inspectorate records or
Migrants are more likely to work for small records of employers' organizations, and
businesses, in the informal economy or other registers. Administrative sources are
as temporary or part-time workers. As subject to undercoverage as in most cases
such, they are often excluded from the they only cover injuries of workers who are
legal frameworks of most countries that employed in the formal sector. They are
require notification and recording of also subject to important underreporting
occupational accidents and diseases (78). as a result of workers fearing job loss, not
These circumstances reduce their inclusion being able to afford time away from work,
in standard data collection systems, such and having limited or no access to social
as administrative records, as well as in protection, or of the failure of employers to
establishment and household surveys. provide recording mechanisms, among other
reasons (80). Migrant workers in precarious
Unless a household survey seeking to acquire employment may also be more likely to
occupational health data has been specifically experience those barriers to reporting.
designed to cover migrants living in different
types of accommodation, information Of the few (six) countries with data from
on migratory status may be missing, not administrative sources (Fig. 3.1), the
appropriately captured or not captured from a incidence of non-fatal occupational injuries
sufficiently large sample of migrants to support (i.e. new cases of non-fatal occupational
separate estimates by migratory status. injuries during a reference period per 100 000
workers in the reference group) was higher
These issues limit the possibility of among migrant workers in four of the six
analysing the situation of migrant workers (79). In the two other countries, fewer cases
without introducing biases resulting from of non-fatal occupational injuries were
non-coverage or a lack of precision. reported by migrant workers compared with
their non-migrant counterparts. A possible
As an illustration, the 2021 ILO occupational explanation for this inconsistency is that, in
safety and health statistics database some countries, migrants tend to report work-
presents information – mainly based on related illness or injuries less often than their
administrative records from 79 countries and non-migrant counterparts (81). Another factor
for a specific indicator, namely cases of non- affecting these contradictory findings may be
fatal occupational injury – disaggregated by that migrants are insufficiently captured in
two commonly available variables: sex and standard administrative data collection and
economic activity (79). The same indicator reporting systems. That could be the case for
from the same sources but disaggregated by irregular migrants or migrants in low-skilled
migratory status is available only for jobs or the informal sector, who are often
13 countries. As a result, there is insufficient excluded from social protection frameworks,
evidence to inform policy-makers or to tailor not registered in the national system or
health and social protection services to meet worried about their precarious migratory
the needs of those vulnerable workers. status (12,19,82).
101
Migrant workers may also often avoid seeking concentrated in selected areas that are not
medical care for fear of being dismissed from sufficiently covered by household surveys
work due to injury or absence and many do not or when migrant workers live in collective
want to give information to the authorities for households and institutions, such as boarding
fear of repercussion. This reluctance to access houses, dormitories or worker camps.
health services or be included in surveys also Additionally, relying on proxy respondents
poses challenges to collecting data and points may not be adequate for collecting data on
to broader structural health issues. the injuries, accidents and other adverse
health outcomes experienced by migrant
Household surveys. Household surveys may workers. These issues limit the analysis of
contain relevant/disaggregated data, allowing the situation of migrant workers: bias may
comparison among various types of worker, be introduced because of non-coverage by
including migrant workers, and providing or a lack of precision from household
information on work-related illnesses or surveys (Fig. 3.2).
injuries. However, unless the survey has been
specifically designed to ensure adequate Sex and migratory status. In the majority
coverage of migrants, standard household of countries, cases of non-fatal occupational
surveys may also suffer from problems injuries are not disaggregated by migratory
of misrepresentation and underreporting status (Fig. 3.1, Fig. 3.2). Since the number of
(covered in more detail in Chapter 5). migrant workers or employed migrants for
those countries is not available, the working-
This issue can be particularly important in age population was used to calculate the
countries where migrant workers may be number of non-fatal occupational injuries
Fig. 3.1. Incidence of non-fatal occupational injuries by international migratory status
6000
No. occupational injuries /100 000 workers
International migrants
5000 Non-migrants
4000
3000
2000
1000
0
Argentina Bahrain Belize Pakistan Spain Türkiye
(2018) (2020) (2017) (2018) (2016) (2016)
Country (latest year)
Source: ILO Department of Statistics (79).

102
Fig. 3.2. Cases of non-fatal occupational injuries in working-age men
25 000
No. occupational injuries/100 000 working-age
Ghana 2017
20 000
Chile 2017
migrant men
15 000 Zimbabwe 2019 Gambia 2012

United Republic of Tanzania 2014
Afghanistan 2014
10 000 Côte d’Ivoire 2017
Malawi 2013
Bangladesh 2017
5000
Liberia 2010
Cambodia 2012
0
5000 10 000 15 000 20 000 25 000
No. occupational injuries/100 000 working-age non-migrant men
per 100 000 people of working age by sex refugees and migrants, may work in safer
and migratory status. In more than half of industries and occupations and may,
the reporting countries, migrant men are less therefore, be at a lower risk of occupational
likely to have reported non-fatal occupational accidents (80). At global level, the latest ILO
injuries compared with non-migrant men. estimates show that a large majority of female
migrants (80%) work in services, whereas
Household survey data show the same 37% of their male counterparts work in
results as some administrative sources industrial sectors, such as construction and
and, as indicated in the literature, do mining, two sectors generally recognized
not systematically indicate a higher as highly hazardous for workers (84–86).
prevalence of occupational injuries among
male migrants compared with their non- A detailed comparison of the data for both
migrant counterparts (83). It is important sexes shows that, regardless of migratory
to note that the number of countries with status, fewer women have experienced
available household survey data is small, occupational injuries or accidents compared
and that these findings based on a few with men in all countries for which data
selected developing countries may not be are available (Fig. 3.4). Additionally, some
representative for the rest of the world. higher-risk male-dominated industries are
Among women, there is little difference also sectors where migrant workers reside
between migrants and non-migrants in in camps, workers' dormitories or hotels.
reporting non-fatal occupational injuries For example, this is common in agriculture,
(Fig. 3.3) (79). A possible explanation for this construction, fishing, long-distance
could be that women in general, including transportation and mining (84,86,87),
103
Fig. 3.3. Cases of non-fatal occupational injuries in working-age women

No. occupational injuries/100 000 working-age
20 000
Ghana 2017
15 000
migrant women
Zimbabwe 2019 Gambia 2012

United Republic of Tanzania 2014
10 000
Chile 2017
Afghanistan 2014
5000
Côte d’Ivoire 2017 Liberia 2010
0
Malawi 2013
5000 10 000 15 000 20 000
No. occupational injuries/100 000 working-age non-migrant women
Fig. 3.4. Cases of non-fatal occupational injuries in people of working age
25 000
No. occupational injuries/100 000 persons of
20 000
working age
15 000
10 000
5000
0
Afghanistan Chile Côte d’Ivoire Gambia Ghana Liberia Malawi Zimbabwe
(2014) (2017) (2017) (2012) (2017) (2010) (2013) (2019)
Country (latest year)
Male International migrants Non-migrants Female International migrants Non-migrants

104
sectors in which many male migrants are 3.3 Sexual and reproductive
often excluded from the scope of surveys. health
Exploring the occupational health outcomes

of migrants is challenging because relatively • A
wareness and use of SRH services
small-scale studies report a higher prevalence (including contraception and general
of occupational injuries among migrants than sexual education) by some refugees and
migrants are low compared with the
non-migrants, whereas larger surveys do not
host population.
always show the same results (19,80,83). This
raises questions about the data quality and • R
efugees and migrants, especially
reliability of surveys that are not specifically women but also men, frequently
experience sexual and gender-based
tailored to gathering data about occupational
violence during displacement and
health outcomes for migrant workers.
after arrival.
Mainstreaming occupational health and • S

ome refugee and migrant groups
continue to practice FGM and some
safety questions in surveys of migrants could
evidence shows acceptability of the
help to improve the availability of data. The
practice decreases over time in
same questions could also be integrated host countries.
into labour force surveys or other household
• L ower levels of knowledge of STIs
or individual surveys with a strong labour
and increased risks among some
component that are implemented on a more
groups of refugees and migrants are
regular basis. However, the primary challenge often associated with limited access
is to ensure proper coverage of the migrant to information.
population in the sample, according to
national specificities. Finally, strengthening
legal and statistical frameworks at the
national and international levels to improve 3.3.1 Contraception and family
the overall quality of administrative data planning
could also contribute to providing more and Family planning allows people to have their
better-quality statistical evidence about the desired number of children (which may be
occupational health of migrants. none) or control the spacing of pregnancies.
It is achieved through the use of contraceptive
methods and the treatment of infertility (88).
Fertility and childbearing are considered

central to the identity of migrant women; their
perspectives on contraceptives, often shaped
by religion, culture and education, influence the
type of contraceptive used or whether they are
used at all. However, as shown in this section, in
some settings awareness and utilization of SRH
services are low among refugees and migrants
compared with host populations, often due to
a lack of health literacy and awareness, legal
status issues and language barriers.
105
Low levels of awareness and use of

contraceptives are reported for refugee and
migrant groups across all WHO regions (89–94).
Sexual violence against refugee
Research from the WHO African Region (95–97), and migrant women can also be
WHO South-East Asia Region (90,98,99) and
the WHO Western Pacific Region (100,101)
linked to both their arrival and
highlights the need for early, comprehensive their post-migration experience.
sexual education about various topics,
including contraception and family
Exposure to sexual violence among
planning, for refugee and migrant groups. male refugees and migrants is a
potentially understudied issue.
The literature emphasizes that education
(from peer educators) should be offered to
all age groups but particularly to adolescents
and their parents and, where possible, be
accompanied by free SRH services. A study
of refugees and migrants aged 10–16 years
in Thailand explored how the impacts of adolescent refugees, although awareness
displacement have shaped their perspectives was relatively higher (65%); this indicates
on SRH and their awareness of puberty or a gap between awareness and use (104).
family planning. The results highlight a need
for the involvement of peers and key influential A cross-sectional study in Eritrean refugee
adults as the most effective way to reach camps in Ethiopia recommended improving
these vulnerable adolescent groups (102). awareness and use through increasing access
to contraceptives in refugee-hosting settings to
In a cross-sectional study conducted among allow refugee women to make informed choices
a sample of 260 refugee adolescent girls in (105). In the WHO European Region, female
Uganda (mostly from the Democratic Republic refugees and migrants are reported to be at
of the Congo), 31.2% reported ever having a high risk of reproductive health problems
used an SRH service, mostly to test for HIV and unmet contraceptive needs than women
or to seek help for menstruation; this was a in the host population, according to studies
much lower proportion than for adult refugee in Germany and the Netherlands (106,107).
women in the same settlement (58%) (89).
A lack of knowledge or information about
In Australia, refugees and migrants from Eritrea where to receive contraception counselling
and Sudan acknowledged that social and (and HIV testing) among refugee and migrant
cultural influences are a barrier to discussing women reflects a missed opportunity, as
issues around SRH and contraception; however, several WHO European Region countries have
women across different age groups reported an free access to contraception and other SRH
openness to shifting away from the traditional services (94,106–109). In the Region, the use of
attitude of avoiding discussion of various SRH modern contraception is increasing among
topics within familial environments (103). the host population (110); however, based on
the most recent data, unmet family planning
A survey in Ghana showed low levels of needs continue to be an issue for migrant
contraceptive use (12%) among female women (94,109).
106
In the United States, data show that refugee 2015 to 2020, while the use of traditional
and migrant women are less likely to use methods increased considerably during this
the most effective contraceptive methods, period. With regards to contraceptive pills,
including oral contraceptives, injectables, households reported a steep decline in use
patches and vaginal rings, compared between 2019 and 2020, following years of
with the host population (93). In Jordan, steady increase. Overall, the proportion
Syrian women were less likely to use of Syrian refugee households in Lebanon
modern contraceptive methods (which are reporting the use of any type of contraception
more effective than traditional methods) increased from 38% in 2015 to 55% in 2020.
compared with Jordanian women (111,112).
A cross-sectional study conducted in the
Fig. 3.5 demonstrates the low but increasing United Arab Emirates reported a higher
levels of use of some contraceptive methods prevalence of contraception use among
by Syrian refugees in Lebanon, with traditional migrants (77.3%) compared with the host
methods (rhythm/calendar and withdrawal) population (54.3%) (119). This highlights
being the most common as of 2020 (113–118). the need to interpret study results in
The proportion of households reporting relation to the research context, that is,
condom use remained relatively stable from cultural context and type of migrants.
Fig. 3.5. Proportion of Syrian refugee households in Lebanon reporting the use of various types of contraceptive
method, 2015–2020
60 57 57
55
50 48
% of Syrian refugee households
40 38 38 38 38 38
31 31 31
34
30
25 25 25
20 20
20 23
16 16
13 13
12 12 11 11
10
0
2015 2016 2017 2018 2019 2020
Year
Using any Using traditional Using the Using an intrauterine Using

contraception contraceptive contraceptive pill device condoms
methods
Source: UNHCR (112–117).

107
Similarly, levels of use of modern contraceptive WHO Western Pacific Region (133) – have
methods are low among refugee and migrant documented how the number of unintended
women in the WHO Western Pacific Region; or unwanted pregnancies may increase during
many opt for more traditional methods displacement or migration circumstances for
because of concerns about the potential side- various reasons, including a lack of access
effects of modern methods such as hormones, to services and increased sexual violence
limited knowledge of contraceptive options (section 3.3.3), leading to unsafe or self-induced
and unsupportive sexual partners (120–124). abortions among some refugees and migrants.
A survey in Australia noted that Sri Lankan A study from eastern Myanmar concluded
migrants were less likely to use long-acting that the need for SRH services in complex
reversible contraception (8.5%) and permanent and fragile displacement settings is greater
contraceptive methods (2.9%) compared than in the more stable settings in the
with the host population (14.9% and 28.7%, country because of the link between conflict
respectively) (122). Numerous studies across or political violence and increased risks of
the WHO Region of the Americas (e.g. in SGBV, particularly for women and girls (134).
Canada (125), Costa Rica (126) and Uruguay (127)) The study showed that migrant women
demonstrated the importance of culturally in these fragile contexts experience SRH
tailored family planning programmes, as well challenges, especially along border regions,
as the provision of contraceptive options such as the risk of trafficking along the
according to the preferences and decision- Myanmar–China border, limited services
making capacities of refugees or migrant groups (particularly for trafficked women) and the
of different ethnicities or countries of origin. risk of sexual violence in remote, peri-urban
In Uruguay, African–Caribbean migrants may areas in Thailand. Economic push-and-
encounter methods of contraception not widely pull factors are reported to influence the
used in their country of origin (127); in the study migration of women in the region, despite the
in Canada, some migrant women viewed the precarious context of political transition.
use of contraceptives as forbidden or
dangerous (125). 3.3.2 Sexually transmitted infections
Reviews of the available data on STI
The literature on early childbearing after screening in refugees and migrants highlight
marriage at a young age among some refugee huge differences between nationalities and
and migrant groups was reviewed. In Jordan, across regions and subregions globally (see
a recent survey of women and girls aged section 3.7.1 for more detailed information
15–29 years found that 28% of those from on HIV/AIDS).
the Syrian Arab Republic and 12% of those of
other nationalities had begun childbearing, According to one study, Mexican migrant
compared with 3% of Jordanian women and women in the United States are less likely to
girls (112). However, this might represent a have an STI overall than non-Hispanic white
continuation of practices that existed prior and Black women, as measured at the time
to displacement (128). of giving birth (135). In studies conducted
among migrants in Thailand (136) and refugees
Several WHO regions – WHO Region the in Uganda (95), the findings indicated lack of
Americas (129), WHO South-East Asia Region awareness of STI risk, transmission and clinical
(130), WHO European Region (131,132) and symptoms, as well as the need to address
108
stigma and improve access to testing for Literature from the WHO Eastern
refugee and migrant groups. Compared with Mediterranean Region describes increases in
Nepalese women in the same geographical both generalized SGBV and marriage violence
area, Bhutanese refugees in Nepal had during times of war or conflict, with a link
overall low levels of awareness of STIs (137). between early marriage and IPV (146,147).
In addition, the same study concluded that SGBV and IPV are also experienced by migrant
refugee women were less likely to know that women from Latin America in the United
HPV infection, a known STI, is the cause of States, linked to cultural patterns in relation
cervical cancer. to the country of origin as well as to changing
power dynamics within the relationship related
Risk factors for poor SRH (e.g. lower levels to migration and acculturation (142,148).
of condom use, fewer sexual health check-
ups and less access to information about Sexual violence against refugee and migrant
safe sex) are associated with displacement women can also be linked to both their
or migration for various reasons related to arrival and their post-migration experience.
economic and psychosocial stressors (e.g. This includes abuse and sexual assault
selling or exchanging sex for assistance, or exploitation experienced by migrant
loss of social support and loneliness). women workers or domestic workers, as
Such risk factors have been documented cited in studies in the WHO Region of the
among all sexes and genders in Australia Americas (139,149), WHO European Region
(75), Thailand (138) and Zambia (55). (150,151) and WHO Eastern Mediterranean
Region (152). The migrant women often have
Evidence from reports on migration and increased vulnerabilities because of their
health in border areas across Central and legal status, SES or housing insecurity.
South America highlights the influence
of the migration process on exposure In the WHO Region of the Americas, migrant
to STIs, including risk factors related to women in particular experience SGBV as
discrimination, sex work, violence and well as physical violence and IPV during
human trafficking, mainly for women transit through Mexico to the United States
(139,140). (See Chapter 2 for a discussion of (153–155). These findings indicate that female
these and other determinants of risk.) migrants from Central America are at a
higher risk of violence compared with their
3.3.30 Sexual and gender-based male and Mexican migrant counterparts.
violence
The research evidence indicates that high In a context in which the risk for migrant
levels of SGBV are experienced by refugees women of sexual violence, rape and
and migrants, particularly women and people transactional sex is high, it is widely
in vulnerable situations such as migrant assumed that there is major underreporting
workers with low income (130,141–143). Studies of SGBV, particularly in a social context
among refugees in eastern African countries marked by impunity (154), stigma and
and in the WHO Eastern Mediterranean the normalization of violence (156).
Region report increased IPV and forced
pregnancy related to life stressors in host Migrants in transit through Mexico to the
country settings, as well as high rates of SGBV United States are at risk of violence, including
related to escaping armed conflict (143–145). SGBV, and the dynamics of undocumented
109
migration provide multiple opportunities 3.3.4 Female genital mutilation

for this. A study of Central American migrant In 2021 UNICEF estimated that at least
women in transit, many of whom cited violence 200 million girls and women had undergone
as their cause for migration, indicated that FGM in more than 30 countries (161). FGM has
social support from institutions (e.g. migrant no health benefits and can lead to various
shelters), people (so-called Good Samaritans) health complications, including pain during
and their families was key to supporting their intercourse or the birth process, postpartum
journey to the United States border (157). It also complications and pelvic floor symptoms
found that these women possessed significant that affect the daily life of women (162).
internal strengths, including religious beliefs, Although FGM is illegal in several countries,
courage, endurance and goal setting that including many in the WHO European Region
helped them in their successful journeys. (163), refugee and migrant groups whose
countries of origin still widely practice
There is a high risk of all forms of sexual FGM may continue to practice it in their
violence for men and women during forced host country, for example as indicated in
displacement and on dangerous migration a study conducted in Saudi Arabia (164).
routes. The Central Mediterranean Route
through Libya to Europe is known to have In high-income host countries, refugee
a high risk of physical and sexual violence and migrant women may not seek various
committed by smugglers, local authorities SRH services because of feelings of shame
and police, as well as by other people or stigma around FGM and discrimination
unknown to the survivors (158,159). from providers (163). Some evidence from
Norway and Sweden indicates that refugee
A United Nations Children's Fund (UNICEF) and migrant women with a longer period
report of 2017 noted that 72% of detected of residence in a host country where the
female victims of trafficking reported sexual practice is not legal or culturally accepted
exploitation on the Central Mediterranean and those with greater exposure to
Route (159). A cross-sectional study conducted awareness campaigns and counselling are
in a reception centre in France in 2017 surveyed more likely to reject the practice (165,166).
adults older than 18 years; it found that more
than half of the women (53%) and 18% of the
men reported sexual violence along the
route (141).
Exposure to sexual violence among male

refugees and migrants is a potentially
understudied issue. Sexual violence against
men and boys was reported in research in
the WHO South-East Asia Region, especially
in refugee camp settings, and included
violence inflicted on genitals, forced
witnessing of sexual violence, and rape (160).
110
3.4 Maternal and child health and children under 5 years of age, with all
countries aiming to reduce neonatal mortality
to at least as low as 12 per 1000 live births and
• Access to MCH services among refugees under-5 mortality to at least as low as 25 per
and migrants is often difficult compared 1000 live births).
with access for women of the host
country, due to barriers such as clinic
Although important progress has been made
fees, lack of awareness, education and
over the last two decades, the numbers
cultural beliefs. This includes low levels
of attendance for antenatal care (ANC). of women and children dying remains
Refugee and migrant women are at a unacceptably high. Addressing inequalities
higher risk of negative outcomes that affect health outcomes, especially sexual
during pregnancy and delivery, and reproductive health and rights and
including mortality. gender issues, is fundamental to ensuring
• Refugee and migrant women and all women, including refugee and migrant
children have higher rates of anaemia, women, have access to respectful
and there is an increased risk of both and high-quality maternity care.
anaemia and malnutrition in some
camp-based settings. Available evidence from this review indicates
• Refugee and migrant women face various relatively poorer knowledge of, and access to,
challenges with infant-feeding practices, MCH services on behalf of refugee and migrant
including exposure to poor-quality mothers and children and a higher risk of
substitutes for breast milk. poor outcomes.
3.4.1 Access to antenatal care

MCH refers to the health of women during In the WHO Eastern Mediterranean Region,
pregnancy, childbirth and the postnatal period, refugee and migrant women reported attending
and the promotion of the full potential for fewer ANC appointments compared with
health and well-being for mothers and children. women of the host country. For example, in a
Improvements in MCH remain an important study among refugee women in Jordan from
goal, as included in the SDGs as Targets 3.1 (by the occupied Palestinian territory, including
2030, reduce the global maternal mortality ratio east Jerusalem, almost 30% attended fewer
to less than 70 per 100 000 live births) and 3.2 than four ANC appointments; younger age,
(by 2030, end preventable deaths of newborns high pregnancy-risk status and a lower number
of gynaecological consultations were reported
as significant predictors associated with
inadequate access to ANC (167). Similarly,
a representative survey conducted in the
occupied Palestinian territory, including east
Refugee and migrant children Jerusalem, found that ANC coverage was
are particularly vulnerable to lower for refugees (88.2%) compared with
non-refugees (95.9%) (168). A study focusing on
underweight issues, undernutrition Syrian women in Jordan reported that 82% of
and wasting. Jordanian women attended at least seven ANC
appointments compared with only 62%
of Syrian women (112).
111
Data collected among Syrian refugees in refugee and host community mothers, refugee
Lebanon showed that the most common mothers felt less satisfied with how they were
reasons for not accessing ANC were primarily treated during ANC and were more likely to
related to payment of the clinic fee, followed by report discrimination by health care staff (170).
the belief that such services were not necessary In Italy, pregnant migrant women were more
(113–118). Fig. 3.6 shows these and other likely than local women to receive fewer than
common barriers to accessing ANC services. five gynaecological examinations (16.3% versus
8.5%), have their first examination after the
Failing or deciding not to attend ANC services 12th gestational week (12.5% versus 3.8%) and
has also been reported among migrant receive fewer than two obstetric ultrasounds
populations; research from the WHO African (3.8% versus 1.0%) (171).
Region suggested that low ANC attendance in
Johannesburg, South Africa, may be related to In the WHO European Region, migratory
the predominantly migrant population in the status and level of education were found to be
city (169). A study in northern Uganda found associated with ANC uptake; a study in Germany
that, although there appears to be equal access determined that being a first-generation
to and quality of maternal health care for migrant and having a lower level of education
Fig. 3.6. Most common reasons (%) for not accessing ANC services reported by Syrian refugees in Lebanon,
2015–2020
10 70 32
28
2015 2016 2017

30
21
62 47
17 18 26
19 44
2018 2019 30 2020
38 38
26
44
Not being able to Believing ANC not Long waiting Not knowing where No data
pay clinic fees necessary times ANC provided

112
were associated with a lower uptake of ANC or postpartum complications (181–183).

services (172). Whether ANC is accessed is also Studies of asylum seekers in the Netherlands
associated with the level of awareness of SRH; revealed a statistically significant higher rate
women in the WHO European Region with of perinatal mortality (3.2%) compared with
experience of post-migration ANC are more the host population (0.6%), independent
likely to have been tested for HIV (173). of parity, birth weight or gestational age at
birth, as well as a higher rate of intrauterine
In the WHO Region of the Americas, studies fetal death (2.3% versus 0.2%) (184).
from Canada and the United States show both
delayed and suboptimal ANC among refugees In the WHO Western Pacific Region, a study
and migrants: in the United States, refugees and of refugee and migrant women in Australia
migrants have a prevalence of delayed ANC of found higher rates of stillbirth, perinatal
20.6% and 15.0%, respectively (174–176). mortality and repeat abortion compared with
the host population (185); these differences
3.4.2 Obstetric, postpartum and were attributed to delays in accessing PHC
postnatal health and access and hospital-based care, important to the
to care optimization of MCH outcomes. Another study
Among refugee and migrant women, there in Australia found that late commencement of
is some evidence that migratory status ANC, underutilization of interpreting services and
may improve their access to postnatal care midwife-only intrapartum care were associated
compared with host country women (174). with an increased risk of stillbirth among
However, postpartum and postnatal health care migrant women from Africa and India (186).
received by the refugee and migrant mothers
and their children and the health outcomes are A further study from Australia linked migration
not consistently better than the care received to birth outcomes, as refugee and migrant
by their peers in the host population. For women were more likely to give birth to children
example, Afghan refugee and migrant women who were small for their gestational age (11.3%)
are reported to receive little information than local host country women (7.3%); this
about postnatal problems and the need for difference was attributed to factors also noted
routine care (177). Other child health problems in WHO South-East Asia Region literature, such
highlighted for refugee children include low as pre-migration well-being and maternal
birth weight; low levels of vitamins A and D; stature, the context of the migration journey,
low AGPAR score (appearance, pulse, grimace, settlement conditions, including pregnancy
activity and respiration); and congenital heart weight gain, and the social environment post-
disease (178,179). migration (187,188).
A meta-analysis of 13 studies demonstrated 3.4.3 Malnutrition and anaemia

that refugee and migrant women in western Malnutrition and anaemia in both mothers and
European countries have double the risk of children have been observed in most WHO
dying during or after pregnancy compared regions, although the settings in which these
with host country women (180). Various studies conditions occur vary widely; for example,
from the WHO Region of the Americas show some refugee camps provide monthly food
that refugee and migrant women are more assistance, free PHC services, nearby health
likely to undergo an unplanned caesarean centres and water collection points, and the
section, among other adverse birth outcomes free distribution of mosquito nets. However,
113
compared with refugees and migrants in other blankets and clothes, and the selling or sharing
settings, camp-based refugees may have limited of food rations (193). In the WHO European
access to diversified food sources other than Region, nutritional anaemia is relatively
the general food ration and few ways of earning common among refugee and migrant children
money to purchase these (189). (194,195), with one study in particular showing
that one out of four children in German refugee
In the WHO Eastern Mediterranean Region, centres was anaemic (195).
higher rates of anaemia were reported in Syrian
refugee mothers compared with Jordanian and The impact of acculturation on infant-feeding
Lebanese mothers (178,190,191). In the WHO practices was investigated in a meta-synthesis
African Region, a study in Sudan found that from Australia; this demonstrated that hospital
being a camp-based refugee is a determinant policies in Western Australia (including not
of anaemia among women of reproductive age allowing the birthing woman's mother or
(192). The same trend was observed among other family members to be present) are seen
children, and a study of refugee preschool as a deterrent to lactation. Unfamiliarity with
children in camp settings in Ethiopia reported a the health system and societal norms often
link between high levels of anaemia in children undermined maternal confidence about infant
and inadequate food rations, insufficient feeding (196,197). In the WHO South-East Asia
micronutrients, lack of non-food items, such as Region, a higher prevalence of both moderate-
A family from Honduras, part of a "Migrant Caravan", walks on a road in Guatemala. © UNICEF / Daniele Volpe
114
acute undernutrition and severe-acute Republic of Korea in the Republic of Korea and
undernutrition in Rohingya refugee children on children enrolled in UNRWA schools in the
compared with local children in Bangladesh occupied Palestinian territory, including east
was observed (198–200). Jerusalem, highlight how children experience
the double burden of undernutrition/
Further studies in the Region showed that malnutrition and obesity (210,211).
religion, birth weight, disease history, stunting,
exclusive breastfeeding, time of initiation of 3.4.4 Other child health issues
breastfeeding and lack of knowledge about Child health (with children defined by UNICEF
anaemia among parents were all associated as any person younger than 18 years) is a broad
with the prevalence of anaemia among migrant field, with various issues being of interest in
children (201,202). Overweight/obesity among distinct regions (Chapter 4 discusses childhood
children is discussed in section 3.5.6. Refugee vaccination rates and uptake).
and migrant children are particularly vulnerable
to underweight issues, undernutrition and For example, among Syrian refugees in the WHO
wasting (203–207). A cross-sectional study Eastern Mediterranean Region, data indicate
in two refugee reception centres in Greece that mortality rates are higher among children
concluded that the prevalence of underweight born to Syrian refugee women than in those of
for refugee children was 7.8%; the proportion the host population (179).
of underweight boys in one reception centre
and girls in the other was found to be very high, The mortality of children under 5 years of age
according to WHO trigger levels (208). was explored in a retrospective cross-sectional
survey in the Meheba refugee camp in Zambia,
Inadequate infant-feeding practices and which found that malaria and respiratory
chronic infant undernutrition were explored in infections accounted for 81% of child deaths
a mixed-methods study along the Thailand– and diarrhoea for 10%; an increased frequency
Myanmar border, finding increased odds of of visits to the health care facility significantly
underweight among migrants (209). Studies of reduced mortality in children (212).
refugee children from the Democratic People's
In the WHO European Region, it was reported
that the overall health of refugee and migrant
children is often contingent on the child's
particular experiences in the home country,
during travel and after arrival at the destination
Compared with refugees and country, as well as being linked to the health
migrants in other settings, camp- of their mother (213,214). Because of the
based refugees may have limited disruption of health care in the conflict zones
from where the children may have come, they
access to diversified food sources may be more vulnerable to vaccine-preventable
other than the general food ration diseases (VPDs) such as latent TB infection
(LTBI) and hepatitis B virus (HBV) infection (215).
and few ways of earning money to Also reported within the WHO European Region
purchase these. are nutritional deficiencies, poor oral health,
skin conditions, and airway and gastrointestinal
infections (216).
115
Studies conducted across the WHO European Across WHO regions, NCDs constitute the major
and Eastern Mediterranean Region show that part of the burden of disease for all populations,
oral health is poor among refugee and migrant including refugees and migrants. The increased
children, with dental care considered a key prevalence is associated with factors such as
problem in populations such as UASC in Spain the social and environmental determinants
and Syrian refugees in Jordan (217–220). In Italy, of health, changing lifestyles and the impact
a study among a sample of 553 children found of behavioural determinants such as use of
caries prevalence of 77.5% in the migrant group tobacco and alcohol, unhealthy diet and lack of
compared with 55.9% in the non-migrant group, exercise, ageing, social exclusion, low levels of
with the unmet restorative treatment needs index health literacy and limited access to health care.
being higher among migrant children (221).
Box 3.3 gives more information on how the The most prevalent NCDs are CVDs (particularly
migration process affects the health of children. coronary artery disease), cancer, respiratory
disease and diabetes. In particular, diabetes,
cancer and CVDs, and the linked risk factors
3.5 Noncommunicable diseases of obesity, and substance use, have been
and major risk factors discussed in regional literature, providing
the framework for this report. Obesity is also
considered in this section, together (briefly)
• N
CDs are an increasing health burden with undernutrition.
among refugee and migrant populations,
often linked to longer residence in the Interestingly, a study among Syrian refugees
host country, particularly high- and
and host communities found that 50.4%
middle-income countries.
of refugee households and 60.2% of host
• D
iabetes mellitus and hypertension are left community households reported that
undiagnosed and uncontrolled for some a member of their household had been
refugees and migrants, who have a higher
diagnosed with one of the five NCDs under
prevalence than the host population,
investigation (i.e. hypertension, CVDs,
leading to a higher risk of CVDs.
diabetes, chronic respiratory disease and
• C
ancer is often diagnosed at later stages arthritis). Host community prevalence was
among refugees and migrants, who
higher than that of refugees for all conditions
often have lower uptake of or access to
except for chronic respiratory disease.
preventive measures.
Care-seeking for NCDs was high for all five
• E
vidence suggests that mental conditions, with 82.9% of refugees and
health problems, the stress of adapting
97.8% of host respondents having sought
to a new environment, unemployment
and previous experience of war
care in Lebanon for their condition (232).
can contribute to an increase in
substance use. A higher risk of type 2 diabetes mellitus,
hypertension and CVDs was observed among
• Refugees and migrants may experience
issues related to underweight and weight refugees and migrants in the WHO Western
loss, even in their host country, and Pacific Region, associated with socioeconomic
others may also experience increased factors such as perceived ethnic discrimination,
risk of high body mass index (BMI) once and low levels of health literacy with regards
they reside in host countries. to NCD prevention (233,234). As observed for
other NCDs, the length of stay and acculturation
116
Box 3.3.
Children on the move and unaccompanied or separated children
Of the approximately 281 million migrants in 2020, it is estimated that 36 million (close to 13%) were children
(222). Close to 14 million live in Asia, 11 million in Europe and North America and 6.2 million in Africa.
Among those forcibly displaced, children are drastically overrepresented.
Worldwide, more than 4 out of 10 forcibly displaced people are younger than 18 years, with 33 million
children living in forced displacement – either internally displaced within their country or as refugees or
asylum seekers abroad – at the end of 2020 (223).
Characterizing the health status of children on the move is a challenge because of the diverse
backgrounds and experiences of refugee, migrant and internally displaced children, as well as the lack
of comprehensive, disaggregated and comparable data. However, findings generally show that children
on the move tend to have a higher exposure to risk factors than children in host communities because
of poor living conditions or limited access to hygiene, and because health care is routinely disrupted
or halted when children and families move or are displaced (224). Exposure to risk factors can be even
higher when other factors are considered, such as disability status, sex and gender, or being a member of
a minority group.
Other social and environmental determinants of health influencing the well-being of children on the move
include health literacy, which can be affected by the limited language proficiency of their parents, their
level of education and income (i.e. socioeconomic status), migratory status and food insecurity (225).
The journey is often the most dangerous stage for many children, particularly for unaccompanied or
separated children (UASC). During the journey, children may be exposed to the risk of injuries, extreme
weather conditions or acute infectious disorders. UASC are at particular risk of physical and sexual violence
(213). An analysis of the journey of some 11 000 migrant and refugee adolescents (aged 14–17 years) and
young people (aged 18–24 years) along the Mediterranean routes found that 8 out of 10 adolescents
reported exploitation (159).
Children on the move are also at greater risk of psychosocial and mental health problems (226). They may
feel overwhelmed, confused or distressed, frightened and anxious, as well as experience sleep problems,
and outbursts of anger and sadness (227). This is particularly the case for forcibly displaced and refugee
children, who commonly experience mental health problems, such as post-traumatic stress disorder or
depression (228).
Children on the move are faced with legal, procedural, financial, cultural and social barriers that can
exclude them from accessing health services, including routine immunization, nutrition and child
health services, and mental health services. Common exclusion barriers include discrimination and
stigmatization by health care providers and host community members, language barriers, lack of access to
information, prohibitive costs, the inaccessibility of health insurance and other social protection schemes,
and legal status (229). A lack of firewalls between service providers and immigration authorities may deter
undocumented migrants from seeking health services for fear of arrest, detention and deportation (230).
Finally, children at the greatest risk of hunger and disease have also seen their already fragile health and
food systems buckle under the strain of the COVID-19 pandemic. Around 50% of countries in which UNICEF
has active humanitarian operations reported a reduction in access to health care among displaced and
refugee populations as a direct consequence of the pandemic (231).
117
were associated with CVD risk factors, such as Studies among Syrian refugees residing
diabetes and obesity, with those who migrate at in Jordan and Lebanon reported a CVD
younger ages being more susceptible (235–237). prevalence of 8.2–20.9% (254,255).
Other NCDs to note from the literature reviewed 3.5.2 Cancer

include nutrition-related health issues, such as Evidence from WHO regions in relation to
scurvy and anaemia in the WHO African Region cancer among refugees and migrants is not
(238,239); inflammatory diseases in the WHO uniform and there is no clear pattern. There
Region of the Americas, such as inflammatory is little consistency within and between
bowel disease, Crohn's disease and ulcerative WHO regions regarding factors linked to
colitis (240–242); and renal diseases in the WHO cancer among refugees and migrants and
European Region (243,244). limited information regarding cancer among
refugee and migrant children. For these
3.5.1 Cardiovascular diseases reasons it is difficult to draw conclusions
The prevalence of CVDs varies widely across the at national, regional and global levels.
WHO regions. CVDs are known to affect refugee
and migrant populations disproportionately in In Canada, migrants diagnosed with cancer
the WHO European Region, as multiple studies were found to have a mortality advantage
have demonstrated that factors such as the over non-migrant populations, and studies
social determinants of health and ethnicity from Chile and the United States pointed to
often negatively affect the prevalence and types the country of origin as a potential protective
of disease among these populations (245–247). factor (256–258). This aligns with global analyses
In Italy, refugees and migrants from sub- showing a mortality advantage for refugees
Saharan African and south Asian countries were and migrants across most categories in the
found to have a higher risk of CVDs than native International Statistical Classification of Diseases
host country populations (248–250). and Related Health Problems, tenth revision,
compared with the general population (259).
However, data from the United States show
a lower prevalence of cardiovascular events Similar results were observed in the WHO
such as heart attack and stroke in individuals Western Pacific Region, with the literature
born in other countries (e.g. naturalized suggesting that foreign country of origin was
citizens, refugees and migrants) compared associated with lower cancer morbidity and
with the host population; in particular, a lower mortality (260,261). In contrast, in the WHO
prevalence was observed among those from European Region, studies in Norway and Italy
Mexico as well as Asian, Caribbean and Central suggested that cancer among refugee and
American countries (251). migrant populations tends to be diagnosed
at an advanced stage, leading to poorer
In Goiás State, Brazil, a 2020 report indicated health outcomes compared with the host
that CVDs were one of the main reasons population (262,263).
for migrants to seek medical attention,
representing 32.7% of cases of CVD within In Lebanon and Jordan, there is a need
the State (252). Medical consultations for for increased funding and use of standard
circulatory system diseases among Venezuelan operating procedures across the countries
refugees and migrants in Colombia increased and for humanitarian responses to ensure that
by 93.4% in 2019 from 2018 figures (253). patients with cancer have equitable access
118
to care; for example, data from the UNHCR vaccine, several did not know the optimal age
on Syrian and Iraqi refugees seeking cancer of vaccination (279). Evidence from Australia
treatment or investigation during 2016–2017 highlighted how parents of adolescents from
showed that one third were for breast cancer, Arabic-speaking countries play a significant role
followed by leukaemia or other blood cancers in shaping attitudes towards HPV vaccination
(12%) and then colorectal cancer (11%), and its acceptability (280).
among others (264,265).
Studies from the United States highlighted
In the WHO African Region, several studies the various barriers faced by refugee and
on refugee and migrant women in Ethiopia, migrant women with regards to accessing the
South Africa and Uganda demonstrated a lack vaccine, including long clinic waiting times,
of knowledge and awareness with regards employment inflexibility, lack of vaccine
to cervical cancer, emphasizing the need for coverage for non-citizens and a lack of
interventions that prioritize prevention, risk school entry policies; however, facilitators of
reduction and early detection and treatment vaccination included transportation services,
(266–268). This was also emphasized by results late clinic opening hours, familial support and
from the WHO European Region: a study a doctor's recommendation (281–283). With
in Italy demonstrated that migrant women regards to vaccine uptake, a study concluded
have a 40% lower uptake of cervical smear that only 30.8% of refugee girls and women
tests than Italians and a 55% lower uptake of (aged 11–26 years) of Myanmar in the United
mammography (269). Similar findings elsewhere States completed the course of HPV vaccines
confirmed this trend, with migrant women (284). In Denmark, refugee girls displayed
reporting lower utilization of mammography significantly lower HPV vaccine uptake than
and cervical cancer screening compared with their Danish counterparts, with region of origin,
non-migrant women, as observed in many duration of residence and income all being
studies across several countries in the WHO associated with uptake (285).
European Region (270,271) and among Syrian
refugee women in Türkiye (272). The prevalence of digestive cancers among
migrants has also been studied in certain
Various studies found that levels of knowledge regions. In the WHO Region of the Americas,
and awareness about HPV and HPV vaccination gastric cancer diagnosed at a late stage was
as a protective measure against cervical cancer recorded among migrants from Mexico as
were low among refugee and migrant women, well as from African, Caribbean and Central
with many not having heard of HPV, unaware American countries (286). Lower rates of
it could lead to cervical cancer, incorrectly decline (among men aged ≥ 50 years) and
believing the vaccine was a cure and perceiving higher rates of increase of colorectal cancer
that their risk of HPV infection was low in Hispanic migrants compared with non-
(133,273–278). Many expressed a willingness Hispanic whites were reported in the United
to accept the HPV vaccine if a physician States (287). Finally, hepatocellular carcinoma
recommended it and could provide more caused by HBV has been detected mostly
information about cervical cancer. among male migrants in the United States
from China, the Lao People's Democratic
Among Syrian refugee women in Greece, a Republic, Mexico, the Republic of Korea,
study found that only 27.3% were aware of the Thailand and Viet Nam, as well as from
HPV vaccine; of those who were aware of the countries in eastern Africa (288).
119
3.5.3 Hypertension
The prevalence of hypertension, an important
risk factor for CVDs and a major cause of
NCDs constitute the major part
premature death worldwide, varies across of the burden of disease for all
regions and country income groups. The
WHO African Region demonstrated the
populations, including refugees
highest prevalence of hypertension (27%), and migrants. The increased
mainly because of a rise in risk factors for
hypertension (e.g. excessive salt consumption
prevalence is associated with
and being overweight) (289). Hypertension factors such as the social and
represents a burden of disease also among environmental determinants of
migrants from the African Region, as
documented in the WHO European Region, health, changing lifestyles and the
where hypertension has been reported to be impact of behavioural determinants
related to ethnicity overall (246).
such as use of tobacco and
Migrants often experience obstacles in alcohol, unhealthy diet and lack of
accessing medical care, which can result in
poor hypertension management. For example, exercise, ageing, social exclusion,
in the Netherlands migrants from Ghana low levels of health literacy and
have a higher prevalence of hypertension
and lower levels of awareness and control of
limited access to health care.
hypertension than the local population (290).
In the WHO Eastern Mediterranean Region, the
prevalence of hypertension among refugees
and migrants varied by ethnic group, and host
country; studies have reported a prevalence in In the WHO Region of the Americas, a study
Qatar ranging from < 30% (272,291–293) to 65% in the United States found that being born
for south-east Asians (including people from elsewhere and having been resident for only a
Bangladesh, India, Myanmar, Nepal, Pakistan short period in the host country was associated
and Sri Lanka) (294) and even 72% among a with better cardiovascular health and a lower
sample of Syrian refugees in Lebanon (295). incidence of CVD compared with those born
in the United States. However, cardiovascular
A study in the United Arab Emirates found that health among recently arrived migrants
the prevalence of hypertension among migrant declined as their duration of stay increased
workers from Bangladesh, India and Pakistan (237,299).
(30.5%) was much higher than that for the local
population (14.0%); further, 76% of migrants Another study conducted in the United States
classified as hypertensive were not aware among a diverse sample of migrants found that
of their condition (296). In the WHO Western those from south-east Asia and the Russian
Pacific Region, a higher risk of hypertension Federation had the highest prevalence of
was reported among refugees and migrants hypertension; migrants from India and from
because of factors such as poverty and a lack of Caribbean and Central American countries
knowledge about preventing or managing had the highest prevalence of overweight/
NCDs (280,297,298). obesity; migrants from Africa and the
120
Middle East had the highest prevalence of Diabetes prevalence, especially with regards to
diabetes; and migrants from Europe had the gestational diabetes, was noted to be higher
lowest prevalence of all three conditions, among Asian migrant women in Australia
demonstrating the importance of tailoring compared with both the host population and
interventions for migrants with different the population in the country of origin (305).
countries of origin and ethnic diversities (299). This indicates a need for more awareness of
gestational diabetes in these migrant women
3.5.4 Diabetes mellitus during ANC (306,307).
The literature on diabetes presents a complex
picture across the WHO regions. In a study of The influence of negative acculturation, related
the prevalence of type 2 diabetes in the WHO to the adoption of negative health behaviour
Eastern Mediterranean Region, prevalence that could impact the prevalence of diabetes,
estimates varied between 9.2% and 19.3% was examined in the WHO Region of the
among Syrian refugees in Jordan (291,300) Americas and the WHO Western Pacific Region
and between 8.3% and 15.8% among labour (233,235,308,309). Sociocultural factors, such as
migrants in the United Arab Emirates (301,302), cultural beliefs and traditions, affect the self-
suggesting perhaps potentially comparable management of diabetes, particularly dietary
levels of prevalence between refugees and habits and medication adherence. In particular,
migrants in the region. scepticism about the benefits of medication for
diabetes has been observed among migrants in
Conversely, however, a quality-of-life survey both the WHO Region of the Americas and the
conducted in the Gauteng province of South WHO Western Pacific Region (310–313).
Africa demonstrated that migratory status is
associated with a lower prevalence of type 2 The prevalence of diabetes among adult
diabetes and hypertension compared with Syrian refugees in Jordan, an urban middle-
non-migrant populations (303). income host setting, was estimated at 6.1%;
inadequate treatment was reported to lead
A number of studies have compared diabetes to other health complications (314). Similarly,
prevalence among refugee and migrant Syrian refugees in Türkiye faced challenges
populations with that of their host populations. in identifying and controlling diabetes, with
However, migration may be only one of the only 72% of those diagnosed with diabetes
many relevant determinant factors, making taking medication (272). A group of Syrian
such comparisons difficult. refugees in Lebanon scored 6 out of 10 on an
assessment scale for diabetes core knowledge
In the WHO European Region, all migrant (self-management) with higher scores linked
groups were found to have a higher prevalence to education level and previous diabetes
and likelihood of diabetes compared with their education and support (315).
host populations. Among all migrant groups
within the Region, those from the WHO South- 3.5.5 Substance use
East Asian Region were reported to present Substance use among refugees and migrants
the highest risk (304). This trend in migrant has been studied across several WHO regions
populations demonstrating a disproportionate and includes the use of alcohol, tobacco,
burden of disease, particularly diabetes, sedatives, cannabis, opioids, inhalants,
compared with host country populations is stimulants and hallucinogens. Many of these
also evident in the WHO Western Pacific Region. substances are commercially marketed and,
121
therefore, are associated with the commercial variations that may be explained by contextual
determinants of health, that is, the private sector factors, including acculturation. In many
activities that affect people's health positively high-income countries across the WHO Region
or negatively, including "production, price- of the Americas, the WHO European Region
setting and aggressive marketing of products and the WHO Western Pacific Region, dietary
such as ultra-processed foods, tobacco, sugar- acculturation, duration of stay and changes
sweetened beverages and alcohol" (316). in lifestyle as migrants integrate within host
communities may contribute to an increased
In Sweden, refugees and migrants have risk of poorer nutritional status and higher levels
significantly lower levels of all substance of obesity (324,330–332).
use disorders compared with the Swedish-
born population overall, although the A study of migrant workers in Thailand found
longitudinal data show that these levels that obesity is often associated with factors
converge with those of the Swedish- such as being older than 40 years, being female,
born population over time (317). having engaged in assimilation strategies to
become more adapted to the host society
In the WHO Eastern Mediterranean Region, a and having a lower level of education (328).
study among refugee school students residing The study also highlighted the need for
in the occupied Palestinian territory, including comprehensive preventive health interventions
east Jerusalem, found that these students targeting the health literacy of these groups.
were more likely than native-born students to In Australia, evidence from Arabic-speaking
use psychoactive substances such as energy refugee and migrant populations indicated that
drinks (318). In the United Arab Emirates, current they engaged in lower levels of physical activity
levels of smoking (28%) and using smokeless compared with host populations, with barriers
tobacco (11%) represent a significant public to participation including factors such as
health burden among migrant workers (319). mainstream language illiteracy, limited exercise
skills and a lack of female- or male-only settings
Among some refugee groups in the WHO for physical activities (310).
African Region, alcohol and substance use
were linked to a higher prevalence of mental Studies from the WHO African Region have
health conditions, including psychopathologies documented dietary and lifestyle changes
(320–322), as well as to the occurrence of SGBV related to displacement, which can often be
or IPV (321,323). Evidence suggests that factors associated with lower SES and loss of assets
such as mental health problems, the stress of (327,333). One such study reported that 5% of
adapting to a new environment, unemployment male and 32% of female Saharawi refugees
and previous experience of war can contribute living in the Western Sahara of Algeria faced
to an increase in substance use (323). obesity, and only 10% of households cultivated
vegetables, instead relying on starchy staple
3.5.6 Obesity foods (334). Differences between the sexes
Studies across regions demonstrate an for this health issue and others were also
increased risk of high BMI among refugee and discussed in Chapter 2.
migrant populations once they reside in host
countries, which also increases their risk for In the United States, it was observed that
NCDs (245,324–329). The literature presents length of stay in the destination country has
a nuanced picture, highlighting regional an impact on the prevalence of obesity.
122
The prevalence of obesity in Hispanic migrants of Korea in the Republic of Korea found that
who had been there for 15 years reached refugees who lost weight between two separate
24.2%, while those who had been there for examinations were more likely to exhibit
5 years had a lower prevalence of 14.5% (324). irregular meal consumption patterns and
Similar observations have been made in the consume insufficient levels of vitamin B2 and
WHO European Region, with the duration calcium (343).
of stay associated with the development of
overweight/obesity (335–337), even when Overweight among children. Overweight/
adjusted for age; this association is stronger obesity among children is a growing global
for women and African migrants (325). Several concern. It is, however, difficult to generalize
studies in the WHO European Region also about the prevalence of overweight/obesity in
noted the importance of using the central refugee and migrant children and adolescents
or abdominal obesity indicator, in addition because of the characteristic differences
to general obesity, for refugee and migrant in populations and destination countries.
groups, as it is a well-established indicator for Economic, social and other factors give rise to
CVD risk (338,339). the differentials found between refugee/migrant
children and those from the host populations,
Differences may exist between ethnic refugee as found in various studies mentioned below.
and migrant groups, with a study showing
a higher abdominal obesity risk compared In the WHO European Region, data indicate
with the general population for Bangladeshi that one in three children is overweight or
women, Pakistani men and women, Black obese, and that children and adolescents (aged
African women and Black Caribbean women 5–19 years) show rising obesity rates in most
(340). Therefore, WHO recommends that European countries (344). It is also observed
measures of abdominal obesity through waist that, overall, non-European refugee and migrant
circumference are particularly important for children are at a higher risk for overweight/
members of specific ethnic groups, including obesity than their host country counterparts
those of a south Asian origin (341). (205) and have a higher consumption of
low-priced, high-sugar and high-fat foods,
Although undernutrition has not been directly and poorer adherence to national dietary
linked with NCDs, protein-caloric deficiencies recommendations (345,346). Overweight
and/or micronutrient depletion can have and obese refugee and migrant children and
multiple ill effects. Adult refugees and migrants adolescents are also of concern in other
may arrive in the host country underweight high-income settings.
and with protein-caloric deficiencies and/
or micronutrient depletion but find it hard Studies from Canada, Germany and the United
to establish a healthy diet even after arrival. States have indicated that children with a
Evidence from Switzerland found that the migrant background are at a higher risk for
prevalence of underweight among adult overweight/obesity than their host country
refugees (5.7%) was higher than that in Swiss counterparts. Studies in the United States
adults (4.7%), with the study citing financial found that the prevalence of obesity levelled
hardship, language barriers and lack of cooking off for children from the host population but
skills, as obstacles to maintaining a healthy diet continued to increase for migrant children
(342). A study on changes in body weight among and adolescents (347–349). A study in Australia
refugees from the Democratic People's Republic found that migrant children from low- and
123
middle-income countries had higher rates of to report CVD risk factors, such as obesity
overweight/obesity compared with migrant and diabetes, than migrants who arrived
children from high-income countries or during adulthood, as younger migrants may
Australian children (350). Similarly, a mixed- be quicker to adopt the unhealthy diets and
methods cross-sectional study in Canada found lifestyles associated with their host countries
that older refugee children from privileged (235). Evidence from Canada and the United
backgrounds in low-income countries were at a States has indicated that older refugee and
higher risk of overweight/obesity (351). migrant children are particularly at risk for
overweight/obesity, with significant variation
Data from five countries in the Programme across children from different countries of
for International Student Assessment (PISA) origin and of different SES (353,354).
survey (352) on BMI showed that students who
are children of migrants (often referred to as These results are in contrast to those found
second-generation migrants) had lower levels for child and adolescent migrants in the WHO
of obesity compared with their host country Eastern Mediterranean Region, who displayed
counterparts, with migrants in China, Hong lower levels of overweight/obesity than host
Kong Special Administrative Region, and Spain country populations. Lower obesity levels were
having only marginally greater levels of obesity reported for migrant students in the United
(Table 3.1). Spain was also the only country Arab Emirates (5.7%) than for host country
to report a higher prevalence of overweight students (11%). In Qatar, Qatari students had
among children of migrants (11.9%) compared a higher likelihood of obesity than non-Qatari
with host country children (7.6%). Further, students (355). Even among young preschool
children of migrants in three countries (Ireland, children in the United Arab Emirates, host
Panama and the United Arab Emirates) were country children exhibited a higher prevalence
more likely to have BMI levels considered of overweight and consumed discretionary
healthier than host country students (352). calorie-high foods more frequently than
In Australia, Chinese migrants who arrived migrant children (356).
as children or adolescents were more likely
Table 3.1. Students with different nutritional status in selected countries, by BMI and migratory status in the PISA
survey, 2018
Country Nutritional status (no. (%))
Children from host population Children of migrants
Obesea Overweighta Healthya Obesea Overweighta Healthya
China, Hong Kong Special

38 (1.5) 185 (7.2) 2350 (91.3) 11 (2.5) 31 (7.2) 391 (90.3)
Administrative Region
Ireland 279 (13.0) 270 (12.6) 1597 (74.4) 26 (7.0) 44 (11.8) 302 (81.2)
Panama 248 (8.7) 337 (11.8) 2271 (79.5) 4 (3.6) 8 (7.2) 99 (89.2)
Spain 378 (1.7) 1740 (7.6) 20 660 (90.7) 39 (2.4) 190 (11.9) 1363 (85.6)
United Arab Emirates 801 (11.0) 1146 (15.8) 5323 (73.2) 290 (5.7) 641 (12.6) 4138 (81.6)
a
Obese, overweight and healthy are defined as having a BMI of > 30.0, > 25.0, or 18.5–24.9, respectively (353).
Source: Organisation for Economic Co-operation and Development (352).
124
3.6 Mental health Many migrants and refugees lack access to

mental health services or experience barriers in
accessing these. They also face disruptions in
• T
he prevalence of depression and continuity of care. The mental health needs of
anxiety can be higher among refugees migrants and refugees should be addressed by
and migrants at different stages of the organizing inclusive and accessible promotion
displacement and migration experience,
and prevention programmes; strengthening
based on various individual, social and
mental health as part of general health services;
environmental factors.
and ensuring timely diagnosis, treatment and
• Conflict- and war-affected refugees rehabilitation.
and migrants display higher levels of
PTSD and other mental health issues,
A recent WHO estimate of prevalence found
particularly younger migrants
and adolescents. that the burden of mental disorders is high
in conflict-affected populations, including
• There is limited evidence and a great
refugees, in whom the prevalence of many
need for research on how psychotic
of the major mental disorders is as high as
disorders and schizophrenia affect
refugees and migrants. 22.1% at any given time (357). Some studies
conducted in refugee populations resettled
• Evidence shows that the incidence of
in high-income countries have shown an
psychoses is higher among migrant
increased risk of suicidal behaviour, likely the
populations in a number of countries,
linked to the cumulative effect of social result of the combination of socioeconomic
disadvantages before, during and disadvantage, exposure to potentially traumatic
after migration. events, burden of mental disorders and lack of
• Refugee, asylum seeker and irregular appropriate and accessible care (358,359).
migrant children, in particular, display a
higher prevalence of 3.6.1 Depression and anxiety
mental health issues compared with A high prevalence of depression among
host populations. refugees and migrants across the WHO regions
is widely documented and can develop at
various points along the displacement and
migration pathways. For example, depression
Migrants and refugees can be exposed to can begin in home countries as a result of
various stress factors that affect their mental exposure to traumatic events, after experiencing
health and psychosocial well-being before violence along the displacement and migration
and during their migration journey and during journey, or when living in host countries as a
their settlement and integration. A wide range result of discrimination, marginalization and a
of mental health conditions may present, loss of resources (360–373).
including depression, anxiety, PTSD, suicide,
self-harm and psychotic disorders. The A global meta-analysis found that refugees
prevalence of these conditions is highly variable and asylum seekers had high and persistent
as it depends on social and environmental levels of PTSD and depression (374). However,
factors, in addition to access to mental health the prevalence of depression and anxiety in
services and diagnosis. The following results refugees and migrants varies widely across the
indicate, however, that the prevalence of WHO regions, driven by a number of regional
mental health problems may be high. and contextual factors. In the WHO European
125
Region, refugees have a somewhat similar for depression and 24.9% for PTSD. Several
prevalence of anxiety (13%) as the general factors increased the risk of these mental
population (9%), but a markedly higher health challenges, including a history of family
prevalence of depressive disorders (32% separation, discriminatory experiences, sexual
versus 4%) (375). violence and abuse, recent arrival in the country,
and being divorced or widowed (381,382).
In the WHO Eastern Mediterranean Region,
Syrian female refugees present higher scores of Mental health outcomes have been studied
maternal depression than low-income Lebanese among different refugee and migrant
mothers (370). Notably, data vary on the impact populations in the WHO South-East Asia Region,
of duration in the host country on the prevalence notably Rohingya refugees in Bangladesh.
of depression and anxiety. Among Syrian Studies among Rohingya refugees found high
workers in Egypt, an increased duration of living levels of PTSD, depression, sleep disorders and
in the host country is a significant risk factor for functional impairment (disability), along with
depression (373). very high levels of daily stressors associated
with camp life, such as food insecurity, lack of
A longitudinal study among young refugees freedom of movement and concerns about
(aged 19–25 years) in Sweden concluded that personal safety (383–385).
the prevalence of common mental disorders
decreased with increased education and that a The prevalence of mental health issues varies
decreasing prevalence of PTSD was associated among migrant workers. In Thailand, migrant
with a longer duration of stay in Sweden. Being workers from Myanmar exhibited a prevalence
a UASC was associated with a significantly of 11.9% for symptoms of depression or
higher risk of PTSD compared with the young anxiety; this reduction in prevalence compared
Swedish population or with accompanied with previous studies was possibly indicative
young migrants in Sweden (376). of a supportive community and workplace
environment, as well as effective delivery of
The literature indicates that mental health
issues among refugees and migrants in the
WHO Region of the Americas have increased in
recent years. For example, a study conducted
between 2018 and 2019 in Colombia shows that The prevalence of mental health
the number of Venezuelans in Colombia treated conditions among refugees
for depression increased by 108.3% and the
number treated for anxiety increased by 224.6%
and migrants is highly variable
(253). In the United States, Brazilian women as it depends on social and
have reported increased levels of depression
and anxiety as a result of separation from their
environmental factors, in addition to
families and social isolation (377). access to mental health services and
Among refugees in the WHO African Region,
diagnosis. However, results indicate
the prevalence of symptoms of common mental that the prevalence of mental health
health conditions is high (378–380).
A study among refugees in South Africa revealed
problems may be high.
a prevalence of 49.4% for anxiety, 54.6%
126
health promotion strategies that include and migrants: a prevalence of 24.3% was found
mental health (386,387). Nepalese migrant among refugees in Berlin (396) and of 35.7%
workers exhibit a prevalence of 28.2% for among Arabic-speaking asylum seekers living
psychological distress, 35.9% for depression in three collective accommodation centres in
and 41% for anxiety (388). Factors that migrants Erlangen, Germany (397). In Sweden, a survey
from Nepal attributed to poor mental health of 455 asylum seekers from Afghanistan, Eritrea,
included the high expectations of families in Iraq, Somalia and the Syrian Arab Republic
their home countries, unfair treatment at work, living in three large housing facilities found a
poor-quality accommodation and a poor social prevalence of 67.9% for depression, 60.7% for
life, in addition to limited access to mental PTSD and 59.3% for anxiety (398). These levels
health services (389). are considerably higher than those of other
groups, including refugees in the United States
Isolation and discrimination are significantly from countries where traumatic stress was
associated with depression and anxiety endemic (399).
among migrants in the WHO Western Pacific
Region. However, the formation of deep social Similarly, exposure to war and violence within
connections with the host community as well as families and communities was identified as a
the provision of social integration services are risk factor for PTSD and internalizing mental
reported to be valuable in promoting migrant health issues in the WHO African Region and
mental well-being (64,390–392). WHO Region of the Americas (400–404). Family
accumulation of PTSD symptoms was identified
3.6.2 Post-traumatic stress disorder in Burundian refugee families in Tanzanian
Exposure to traumatic events occurs throughout camps, where PTSD prevalence in mothers was
the world. However, exposure is unequally 33% and 29% in fathers. The same study found
distributed within the global population, that children living with two parents who had
and the risk of PTSD varies substantially with experienced traumatic events were also more
the type of traumatic event. Events involving likely to present high levels of PTSD symptoms
interpersonal violence (especially IPV) are and impairment (see also section 3.6.5 on child
associated with the highest risk of PTSD mental health) (405). In a study among asylum
(393). The long-term effects of abuse or other seekers from El Salvador, Guatemala and
traumatic events can include severe anxiety, Honduras in the United States, almost one third
stress or fear; the use of alcohol or drugs; met the diagnostic criteria for PTSD and about
depression; eating disorders; and self-injury 17% did so for both PTSD and depression (406).
or suicide (394).
However, it should be noted that signs of
Syrian refugees within the WHO Eastern normal distress and mental disorder are often
Mediterranean Region present numerous not easily distinguished in studies conducted
mental health complications, which have been in humanitarian settings, including in refugee
further exacerbated by the COVID-19 pandemic. settings, leading to inflated estimates of mental
For example, a study of mental health among health conditions such as PTSD (407).
Syrian refugees suggested that they had a
higher prevalence of PTSD resulting from 3.6.3 Suicide and self-harm
quarantine (82.5%) compared with the host The evidence identified in regional research
population (66.5%) (395). Studies have indicated on suicide and self-harm is limited, making it
relatively high levels of PTSD among refugees difficult to draw conclusions in this report on
127
their prevalence and the factors influencing exposure to conflict and persecution, lack of
them. However, a few studies described in this privacy and safe spaces, high levels of SGBV,
section have examined suicide attempts and and limited access to integrated mental
ideation in refugee settings, especially among health and psychosocial support (411,412).
adolescents. Some of the studies that focused A further problem in the camps was a scarcity
on refugee populations resettled in high-income of humanitarian staff with the capacity to deal
countries have shown increased risk of suicidal with suicide risk among refugees. In a study
behaviours, likely the result of a combination conducted among humanitarian staff working
of socioeconomic disadvantage, exposure to in Cox's Bazar in Bangladesh, 26% reported
potentially traumatic events, the burden of having worked with a person at risk of suicide
mental disorders and a lack of appropriate and a similar proportion disagreed with the
and accessible care. statement that suicide was a problem in the
community. Only 63% of those surveyed said
A study examining the psychosocial and clinical they felt confident in carrying out a suicide risk
profiles of people visiting the emergency assessment (413).
department in Qatar as a result of accidental
self-harm and suicide attempts found higher Although refugee and migrant populations
suicidal mortality among expatriates (35.5%) face unique challenges that may increase
than among Qataris (21.4%) (408). Adolescents their vulnerability to suicide and self-harm,
(the majority aged 13–15 years) living in the the evidence varies when comparing these
occupied Palestinian territory, including east populations with those of their host countries.
Jerusalem, and in five UNRWA camps in the Among people with a mental disorder in
occupied Palestinian territory, including east Sweden, the rates of suicide attempts are
Jerusalem, Jordan, Lebanon and the Syrian lower in refugees compared with Swedish-
Arab Republic expressed high rates of suicidal born individuals (414). A study assessing data
ideation (25.6%). Factors associated with from a psychiatric hospital in Qatar found no
suicidal thinking included using cannabis and difference in the levels of near-fatal deliberate
tobacco, having no close friends, experiencing self-harm between Qatari and non-Qatari
food insecurity, having worry-induced insomnia patients, possibly because of the small sample
and perceptions of limited parental support, sizes (415). The prevalence of suicide attempts
among others (409). among adolescent migrants in various
European countries has been reported to be
A study among adolescent refugees in higher than that for host populations (416).
Uganda concluded that female adolescents
had a higher prevalence of suicidal ideation 3.6.4 Schizophrenia and other
and psychological distress than their male psychotic disorders
counterparts, with major risk factors including There is good evidence that the prevalence of
loneliness, isolation and having no hope for psychosis is higher in many migrant populations
the future (410). than in host country populations in a number
of countries (417). Prevalence varies with
Rohingya refugee women face numerous region of origin, region of destination and their
challenges that increase their vulnerability combination, which suggests that prevalence
to suicidal ideation and other mental health is strongly influenced by the social context.
problems within the emergency operations in Research has identified a diverse range of social
Bangladesh. These factors include prolonged factors – including childhood separation from
128
parents, discrimination and, at an area level, statistically significantly higher both in female
ethnic density – as being of potential importance adolescents compared with adolescent males
(418). Studies also suggest that the cumulative and in children who had experienced the death
effect of social disadvantages (e.g. lower SES, of one or both parents compared with those
experiences of social disempowerment) before, whose parents were living (423). In Lebanon,
during and after migration is associated with Syrian refugee children commonly reported
the increased risk of psychosis in migrants, flashbacks (30%) and nightmares (22%) (424). In
independently of ethnicity or length of stay in the United Arab Emirates, adolescents
the country of arrival (417). (aged 12–18 years) from southern Asian
countries reported the highest prevalence of
Refugees and migrants in Sweden have symptoms of depression (33.3%) compared
been identified as having an above-average with their counterparts from Australia, Canada
risk of these conditions compared with host and the United States (12.8%), Arabic-speaking
populations (419). In a large, prospective countries (10.5%) and the United Arab Emirates
cohort study in Sweden, the prevalence of (22.0%) (425).
schizophrenia was elevated among migrants
(adjusted hazard ratio, 2.20) and their child- In the United States, children of irregular
ren (adjusted hazard ratio, 2.00) compared migrants (aged 4–8 years) experienced
with Swedish-born individuals. This is similar greater behavioural conduct problems
for compulsory hospitalization, for which and hyperactivity than did older children
the risk is highest for individuals from sub- (426). Children who had experienced family
Saharan African, Middle Eastern and north separation presented significantly more
African countries compared with Swedish-born emotional problems than children who had
individuals (420). not been separated (426). A meta-analysis of
eight studies of child and adolescent refugees
However, a meta-analysis comparing refugees and asylum seekers revealed that 22.7% were
with non-refugee migrants in Canada found diagnosed with PTSD (35% for those displaced
no association between the type of migration for over 2 years), 13.8% were diagnosed with
and risk of non-affective psychosis among depression and 15.8% with an anxiety disorder
refugees (421). Similarly, a study in Australia (427). In contrast, in general populations of
found no difference in overall rates of hospital children and adolescents globally, there is a
admission after presentation of a first episode of prevalence of 2.6% for any depressive disorder
psychosis among migrants compared with and 6.5% for any anxiety disorder (428).
host populations; however, there was a higher
rate of involuntary admission for migrants, Evidence from countries in the WHO African
especially those from Africa (422). Further Region, the WHO European Region and the
research is needed to better understand the WHO Western Pacific Region further suggests
link between migration and the prevalence of that UASC and unaccompanied adolescents are
psychotic disorders. at risk of developing mental health problems,
such as traumatic acute stress or anxiety, and a
3.6.5 Child mental health range of behavioural and emotional problems
In the WHO Eastern Mediterranean Region, resulting from higher levels of exposure to
a study found the prevalence of moderate- violence, family separation, deceased or missing
to-severe PTSD among refugee Syrian family members and living in closed detention
schoolchildren in Jordan to be 31%; it was (429–436). UASC are particularly vulnerable
129
because they may face not only exposure

to multiple traumatic events, such as armed
conflict, loss of close relationships and
Refugee and migrant workers
personal violence, but are also without have limited access to health care
the protective buffer of primary facilities and usually receive late
caregivers, as reported in research from
the WHO European Region (437,438). and/or substandard treatment
for malaria. Government policies
3.7 Communicable diseases may not always include malaria as
an occupational health concern,
• E
vidence shows that refugees and meaning that migrant workers
migrants do not spread diseases in
host countries; their susceptibility
can be excluded from malaria
to infection is increased by the prevention and treatment services
environmental risk factors related to
their living and working conditions. available under the labour laws of a
• D
elayed HIV testing and diagnosis host country.
are major challenges for refugee and
migrant populations due to barriers
such as limited access to health care,
social stigma and discrimination,
among others. Evidence indicates that
post-migration acquisition of HIV/AIDS re-emerging forms of infection will continue
plays a key role. to occur. These diseases disproportionally
• D
ata on prevalence of TB show a recent impact resource-constrained communities and
increase among refugee and migrant are linked to a complex range of overlapping
populations in countries hosting the determinants of health, including the
largest numbers. However, overall availability of safe drinking-water and basic
prevalence in many host countries sanitation (WASH), housing conditions, climate
remains low. Multidrug-resistant TB change risks, gender inequity, sociocultural
and LTBI affect refugees and migrants factors and poverty, among others.
at higher levels than host populations;
evidence varies regarding the
It is clear that displacement and migration
prevalence of extrapulmonary TB.
pathways may expose refugee and migrant
• T
ropical and parasitic diseases risk populations to communicable diseases during
spreading to non-endemic regions if
their journey to destination countries (439,440).
timely diagnosis and treatment are
Which specific diseases will vary immensely
not provided to mobile populations,
particularly in destination countries. by region because of endemicity and local
epidemiology. However, the highly prevalent
infectious diseases affecting refugees and
migrants globally, identified in the literature and
The control of communicable disease is a global discussed in this section, include HIV, TB and
priority, highlighted by the experience of the malaria. (SARS-CoV-2 is discussed separately
recent COVID-19 pandemic. New emerging and in section 3.8.)
130
The risk of transmission between and within marginalization (441–450). Discrimination,

regions is increased by a lack of preventive among other barriers to accessing health
and curative services that are mobility services, is discussed further in Chapter 4.
aware and by barriers to health care services
(Chapter 4) preventing refugees and migrants Research across the regions documents
from receiving timely diagnosis, treatment and numerous additional challenges for these
care for communicable diseases. populations, including language barriers, low
SES, lack of knowledge and low levels of health
3.7.1 HIV/AIDS literacy, all of which affect vulnerability to HIV
Refugee and migrant populations face transmission (72,451–455). Such challenges
numerous social, economic, political and also threaten the success of antiretroviral
legal barriers that have resulted in delayed therapy (ART), which is critical to maintaining
testing and higher risk for HIV transmission. viral suppression both in terms of the person's
Refugees and migrants living with HIV own health and in reducing the possibility
report stigma and discrimination from of transmission (456).
health care workers, host societies and
their own families and communities, with Increased rates of HIV transmission in
many choosing not to openly disclose their refugee and migrant populations have been
status because of fears of isolation and observed, particularly along border areas
Girls from the Baqa'a Palestinian refugee camp in Jordan visit the National Centre for Diabetes, Endocrinology & Genetics in Amman. Such
visits have become routine among school students and typically involve a general health check-up, weight measurement, and health
education. © WHO / Tania Habjouqa
131
and transportation routes around the world. migrants from sub-Saharan African countries
Several WHO regions have also identified a and 54% of migrants from south-east Asian
geographical link between HIV serostatus and countries present at a late stage of HIV
movement across international borders. One infection (460). Research indicates that almost
study from the WHO African Region found that 30% of HIV-positive migrants in the United
high levels of HIV prevalence were significantly States were diagnosed at a late stage, a
linked to high mobility at the national borders proportion higher than that of the equivalent
of Zimbabwe and discussed the potential for United States population; this is a common
conditions related to mobility leading to risky issue among Caribbean, particularly male,
behaviours, increasing vulnerability to migrants (461–463).
HIV (454).
However, there is increasing evidence of post-
In the WHO Western Pacific Region, the border migration acquisition of HIV, particularly in
between China and Viet Nam is a high-risk Europe (464,465): research has suggested that
area for HIV transmission, particularly for 63% of HIV-positive migrants in nine European
migrant sex workers seeking short-term work, countries acquired HIV after migration (466).
because of inconsistent condom use (457). In France, HIV acquisition after settlement was
Moreover, the Thailand–Myanmar border found to be linked to short or transactional
area, where TB–HIV coinfection is prevalent partnerships, unstable housing and lack of a
among refugees and migrants, is a difficult resident permit (449).
environment for detection and treatment
because many migrants are highly mobile Mobile migrant populations – such as
and difficult to reach for follow-up (458). This Shan migrant workers in Thailand and
example also raises the importance of cross- circular migrant female workers (i.e. those
border continuity of care. moving repeatedly between host and home
communities) across Lake Victoria (from
Refugees and migrants may often face Kenya, Uganda and the United Republic of
discrimination from their home communities Tanzania) – cite high mobility as a barrier to
and host society (459). For example, African- accessing HIV treatment once diagnosed, in
born women living in the United States addition to stigmatization, discrimination and
report pre- and post-migration HIV-related a perception of being at low risk (467,468).
stigma, including within their families and
with intimate partners, African migrant Other groups at higher risk of infection
communities and the host population (447). discussed in the literature are refugee and
At the border between Mexico and Guatemala, migrant MSM and male migrant sex workers.
research suggests that sex and gender, social In Lebanon, refugee MSM are more likely to
class and race/ethnicity are key determinants engage in unprotected sex with high-risk
of HIV/AIDS-related stigma, and also provide a partners compared with Lebanese MSM;
foundation on which migration-related stigma however, the refugees are significantly less
can be constructed (459). SGBV increases likely to have ever been tested for HIV (46%)
the risk of HIV infection (154). compared with Lebanese MSM (62%) (448).
In another study in Lebanon, refugee MSM
Late-stage diagnosis of HIV/AIDS is a reported feeling uncomfortable with doctors,
substantial health concern among refugee lacking information about where to obtain
and migrant populations. In Europe, 56% of free HIV testing and having experienced
132
discrimination from health care providers based risk factors for non-adherence to combination
on their refugee status (455). ART included low levels of social support and
education (477).
Male migrant sex workers in Europe have a
disproportionately high burden of STIs and Of concern are the poor health outcomes of
HIV infection, along with heightened exposure migrants living with HIV across various contexts.
to discrimination and social exclusion, as well In Botswana, a retrospective cohort study
as limited access to health services (76,469). In indicated that migrants initiated ART more
the WHO Western Pacific Region, migrant MSM rapidly than the host population; however,
display a higher prevalence of HIV and STIs analysis of 5-year survival rates indicated that
compared with resident MSM, with evidence migrants had a higher mortality than citizens
suggesting that newly arrived Asian-born MSM after entry into care and ART initiation (478).
are diagnosed at a more advanced stage of Compared with HIV-positive individuals
HIV infection than non-migrant MSM (470–472). from the host population in the Netherlands,
Similarly, a study conducted on male migrants HIV-positive migrants had poorer treatment
from African and Caribbean countries and on outcomes and lower treatment adherence
male Black migrants, including MSM, found (479). Among asylum seekers in Canada, a
that there was an association between HIV retrospective cohort study found that 62% of
infection and STIs, including an increased risk newly diagnosed HIV infections were in late
of HPV infection and syphilis (473). presenters, and only 45% received care within
30 days of diagnosis (480).
Access to treatment can be limited for refugees
and migrants living with HIV, with many Numerous interventions and policies can be
relying on various sources for support and integrated into national health systems to
services (474). Among migrant MSM with increase testing, reduce late-stage diagnosis
HIV in Australia, high costs led migrants to and improve treatment access for migrants (see
acquire ART through compassionate access also Chapter 4 on health systems). Evidence
schemes (471). from the WHO African Region, WHO South-
East Asia Region and WHO Western Pacific
Malawian migrants in South Africa expressed Region has shown that introducing diverse
appreciation for health care workers who opportunities for HIV testing (e.g. rapid or
dispensed a six-month supply of ART refills on self-testing) can provide useful alternatives for
their behalf to friends and family members, refugees and migrants who have limited access
who then organized delivery via bus and to or low levels of knowledge about local testing
truck drivers (475). A cross-sectional survey sites, or those concerned with stigmatization
found that migrants from Lesotho in South over seeking HIV services (481–483).
Africa experienced barriers to accessing ART,
including transport costs, a lack of knowledge Intervention mapping, or a method for
about where to obtain ART and fears over developing health promotion programmes,
their legal status (476). Service providers proved useful in a Ugandan refugee camp; HIV
also identified a lack of transfer letters (i.e. care was integrated with hypertension and
form referrals from another clinic or other diabetes services after involving community
health institution) as a primary challenge in members in the implementation and planning
facilitating care and treatment for migrants. process, thus reducing the stigma of treatment
Among migrants with HIV in the Netherlands, for HIV (484). Additional evidence from
133
Australia suggests that expanding access to description of housing and living settings
ART for all HIV-positive temporary residents as a health determinant) (487,488).
can reduce HIV transmission without placing
a significant financial burden on the national However, studies demonstrate that, while
government (485). risk of TB transmission is increased within
migrant communities and households, there
3.7.2 Tuberculosis is no increased risk of TB transmission to host
Globally, the proportion of TB cases of foreign populations. Where there is a functioning
origin varies considerably, with refugee- surveillance system and a universal public
and migrant-hosting locations – including health system that includes migrants, there
Australia and the United States, as well as is low risk of transmission from migrant
western European countries – reporting higher populations to host populations (489).
proportions of foreign-origin cases, as
illustrated in Fig. 3.7 (486). Foreign-born patients with TB represent 8.7%
of all TB cases in the WHO European Region in
Refugee and migrant populations experience a 2019, although this varies widely between EU
range of living conditions that often make them and European Economic Area (EEA) countries
more vulnerable to TB transmission, including (34.5%) and non-EU/EEA countries and areas
overcrowding, poorly ventilated living quarters, (2.2%) (490). There is also high variability
suboptimal shelters made with air-impermeable between countries: the proportion of TB cases
plastic sheets, informal settlements and of foreign origin is high in Malta (95.9%) and
unstable housing (see also Chapter 2 for a Luxembourg (90.0%), but low in Bulgaria (0%)
Fig. 3.7. Proportion of TB cases among foreign-born individuals, 2020
First quartile: 1–4%

Second quartile: 4.1–17.0%
Third quartile: 17.1–57.0%
Fourth quartile: 57.1–98.0%
No data
Not applicable
Source: WHO (483).

134
and Romania (0.4%) (note that Romania has Fig. 3.9 depicts the changing proportions
the highest incidence of TB cases in EU/EEA of new TB and retreatment of relapsed TB
countries at 66 per 100 000) (490). In Jordan, occurring in people of foreign origin in the
29.3% of TB cases among Syrian refugees countries hosting the largest (Germany; 2008–
are in refugees residing in camps, despite the 2020), second largest (Türkiye; 2008–2020) and
fact that only a small proportion of all Syrian fifth largest (Colombia; 2018–2020) number of
refugees (17.1%) reside in camps (491). refugees. The data indicate a steep increase in
the proportion of TB cases occurring in people
Fig. 3.8 illustrates the changing proportion of of foreign origin in Germany and Türkiye during
TB cases that were of foreign origin in the five 2008–2020. Data from the third- and fourth-
most popular destination and host countries largest refugee-hosting countries, Pakistan
for migrants during 2008–2020 (486). Although and Uganda, were not available: Pakistan
four of these countries (Germany, Saudi Arabia, does not currently collect or report TB data
the United Kingdom and the United States) disaggregated by foreign-born individuals,
showed a trend of a slow increase in the and data from Uganda were available only
proportion of TB cases of foreign origin, the for 2020 (3%). Germany is the only country
proportion remained almost unchanged in the to be included within the five most popular
Russian Federation during 2008–2020 (492). destinations for both refugees and migrants;
Fig. 3.8. Proportion of TB cases attributable to foreign-born individuals in the five top destination countries for
international migrants, 2008–2020
80 75 75
74 74 75 74 75 74 74 75 74
70 72
70 69 74 73 73
68 71 70
63 61
59 60 62
60 57 57
54 53 53
58 52 53
52
49 55 49
Percentage of cases
50 46 47
49 50 44
46
40
31
30
20
10
3 3 3 3 3 3 3
2 2 2 2
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Year
Germany Russian Federation Saudi Arabia United Kingdom United States
Source: WHO (483).

135
Fig. 3.9. Proportion of TB cases attributable to foreign-born individuals in three of the five top destination
countries for refugees, 2008–2020
80
74 73
70 72 71 70
70
61
60
55
49 49 50
Percentage of cases
50 46
40
31
30
20 16
13
11
10 9
6 7 7 6
4 3
1 1 1 1 2 2
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Year
Colombia Germany Türkiye
Source: WHO (483).
the proportion of TB cases in Germany condition is affected by the expensive and

occurring in refugees and migrants was arduous cross-border migration between
70% in 2020. countries with different burdens of TB; the
unavailability of appropriate treatment
The numerous challenges to be faced along regimens at various stages of migration; and
the displacement and migration pathways interrupted, unsuccessful or unaffordable
can simultaneously increase the vulnerability treatment (498). The nature of the disease,
of refugees and migrants to TB and limit coupled with an increased risk of exposure
their access to care. As for HIV, treatment to other communicable diseases, also
interruption poses a major risk and can increases the coinfection risk for migrants
contribute to drug resistance. Factors such (Box 3.4) (499–501).
as deportation, low levels of screening and
exposure to medical and social risk factors
can complicate the detection and successful
treatment of TB for refugee and migrant
populations (493–497).
As observed in migrants along the Thailand–

Myanmar border, the ability to manage the
136
Box 3.4.
Coinfection with tuberculosis and HIV
Sub-Saharan Africa experiences the largest burden of TB and HIV, accounting for two thirds (67%) of the
population living with HIV globally in 2020 and 95% of global TB deaths. Infection with HIV is a known
risk factor for new infection with Mycobacterium tuberculosis and for progression of latent tuberculosis
(TB) to active disease (492,499,502). TB–HIV coinfection accelerates the decline of immunological
functions if untreated and makes both harder to treat. TB–HIV coinfection is of particular concern among
refugee and migrant populations. Data from refugee camps in Ethiopia indicate that HIV infection is
associated with unsuccessful TB treatment outcomes (500). Evidence from the Gambella region in
Ethiopia further supports these findings; a retrospective study comparing treatment outcomes for TB
found lower treatment success rates (74.2%) in refugees than in surrounding communities (88.1%), while
rural, female and HIV-negative patients with TB were more likely to be successfully treated than their
respective counterparts (i.e. urban, male and TB–HIV-coinfected patients) (501). A high prevalence of HIV
(24.2%) has been reported in communities in southern Mozambique, the origin of migrant miners.
A further 7.5% of miners within these communities have reported previous TB infection, a major concern
because many display limited knowledge of TB prevention methods as well as low levels of condom
use (57).
Multidrug-resistant TB, LTBI and resistance to ethambutol (509). Similarly,

extrapulmonary TB. Various forms of TB newly arrived migrants in Qatar are more
affect refugees and migrants on a regional likely to have drug-resistant TB than the
level, with notable trends varying across the local population (510).
WHO regions. Drug-resistant TB is a prominent
emerging concern for migrant and displaced There is limited evidence about how refugee
populations in many regions (458,503–507). and migrant populations are affected by
extrapulmonary TB, although its lower
In EU and EEA countries, the highest prevalence in migrants (16.7%) in Saudi
prevalence of multidrug-resistant TB and Arabia compared with the host population
extensively drug-resistant TB was observed (83.3%) has been reported (511,512). However,
among migrants of non-EU/EEA origin (508). evidence from Ethiopian refugee camps
In the United States, migrants present with has indicated a slightly higher prevalence
greater resistance to anti-TB medicines of extrapulmonary TB in refugees (22.8%)
compared with the local population, compared with populations in surrounding
although this varies by regional origin and communities (18.2%), as well as higher risk
type of medicine. Compared with the local of unsuccessful treatment outcomes (501).
population, migrants from Latin America have According to a cross-sectional analysis of 23
TB with more resistance to pyrazinamide, and years of data (1995–2017) from 32 countries in
migrants from other subregions, including the WHO European Region, the proportion of
southern Asia, Asian–Pacific and eastern extrapulmonary TB among all cases of TB is
European countries, have TB with higher greater among migrants (45.2%) than among
137
non-migrants (21.7%) (513). Extrapulmonary Therefore, a comprehensive package

TB is linked to risk factors such as extremes of interventions is necessary, including
of age (children and older adults), female testing relevant individuals, ensuring
sex, HIV-positive status, comorbidities consistent monitoring and evaluation of
(e.g. chronic renal disease and diabetes) TB interventions, and delivering safe and
and coming from countries with a high TB effective treatment regimens with no (or
incidence rate. minimal) risk of adverse events (519–521).
Interventions should also include public
Throughout the WHO Western Pacific Region, health services that specifically include
TB cases attributed to the reactivation of LTBI refugees and migrants as well as testing and
in migrants from high-incidence countries is a treatment focused on mobile populations.
growing concern for low-incidence countries.
In Australia, 34.4% of LTBI cases in 2016 were Various studies and analyses have been
estimated to have occurred in migrants who conducted to determine the feasibility and
had migrated since 2007, mostly from China, effectiveness of different TB programmes.
India and the Philippines, with new migrants A study in Canada highlighted the cost–
who were younger than 35 years making up effectiveness of pre-immigration LTBI screening
16.3% of those with LTBI (514). Similarly, in for migrants moving to low-incidence countries
Singapore the prevalence of LTBI was higher in (522). Evidence from the United Kingdom
migrants from India (30.8%) and China (17.1%) supports multidisease screening – combining
than for Singapore-born study participants testing for LTBI, HIV, HBV and hepatitis C virus
(10.7%) (515). Further evidence from Japan (HCV) – indicating it is not only feasible but
suggests that migrant populations faced a also needed, considering the high proportion
greater risk of interrupting their LTBI treatment of previously unscreened migrants (523).
and being lost to follow-up (516). In response to the lack of evidence for the
cost–effectiveness of screening migrants for
As a result of the high prevalence of LTBI TB, a European database of multicountry
among migrants, it has been suggested evidence has been established (524). A study
that low-incidence countries should make of TB prevalence among visa applicants
screening for LTBI a top priority. This has been to Australia – predominantly young adults
implemented in the WHO European Region, from various Asian countries – reported
where 22 of the 36 countries assessed were that prevalence among this group was
found to include LTBI screenings in refugee declining and likely to remain low. The study
centres (517). However, this approach is concluded that Australian support for TB
complex since evidence indicates that mass control programmes overseas and preventive
population-wide LTBI testing and treatment interventions were likely to have the greatest
are not feasible because of imperfect tests, impact on the domestic TB burden (525).
stigma around screening, the risk of serious
or fatal side-effects from treatment, and high Consistently, studies have shown that the
costs for an unproven public health impact. various types of TB disproportionately
Current guidance, including that of the affect refugees and migrants. In Spain, a
European Centre for Disease Prevention and retrospective observational study of people
Control, indicate targeting LTBI screening at with spinal TB found that the percentage of
individuals from countries with higher these who were foreign born increased from
TB incidence (518). 14% to 45.2% over 10 years (526). According
138
to one study, 90% of all cases of bone and of malaria among migrants, underscoring
joint TB in the United Kingdom occurred in the importance of having national malaria
migrants, with many experiencing treatment surveillance systems in place to detect
delays between the onset of symptoms and areas of concern (539–541). Evidence from
referral to a tertiary orthopaedic centre (527). Henan Province in China, which has been
in the malaria elimination stage since 2010,
Also in the United Kingdom, a retrospective illustrates these risks: more than 90% of
study concluded that 93% of patients with imported malaria cases have occurred in
intestinal TB were born abroad, primarily in labour migrants from Africa, primarily Angola,
Africa and the Indian subcontinent; however, Equatorial Guinea and Nigeria (542). Similarly,
diagnosis is challenging and often delayed evidence from Nepal shows that more than
(528). Among Syrian refugees with pulmonary half (54.1%) of cases of malaria occurring
TB in Türkiye, higher numbers of patients in border districts are imported (543).
stopping or transferring treatment were
reported and fewer Syrian patients Research from the WHO South-East Asia
were successfully treated (63.6%) compared Region indicates that refugee and migrant
with Turkish patients (88.8%) (529). populations face multiple barriers to accessing
health care for malaria, such as reduced
3.7.3 Malaria access to health facilities, including issues with
Displacement and migration are critical when distance and lack of transportation; a lack of
considering the control of malaria, particularly awareness of health services, particularly the
in low-transmission or non-endemic countries availability of free testing and treatment for
where imported cases can present additional malaria, as well as low levels of health literacy;
challenges to diagnosis and treatment, and the perception that screening is necessary
such as in refugee transit or reception only for the unwell (543–545).
centres or in labour migrant contexts.
Conversely, refugees and migrants moving There is ongoing intraregional transmission
to areas of high transmission of malaria of malaria in the WHO African Region and
from non-endemic areas are at a higher risk WHO Region of the Americas where, for
of developing severe forms of malaria. example, Venezuelan refugees and migrants in
Colombia are seeking health care services for
Notably, the WHO European Region and WHO malaria in increasing numbers (546), and the
Eastern Mediterranean Region demonstrate transmission of malaria in refugee camps in
interregional transmission of malaria, with Ethiopia and Uganda continues to particularly
countries reporting an increase in imported affect young children, especially those under
malaria cases (530–534). In the WHO European 5 years of age (547–549).
Region, the re-emergence of cases of malaria
has been attributed to people in transit Fig. 3.10 shows the incidence of malaria
from sub-Saharan African countries and to among refugees in Ethiopia, Kenya, Sudan and
malaria occurring in refugees and migrants Uganda from 2015 to 2020, as recorded by the
from countries where the disease is prevalent Integrated Refugee Health Information System
(535–538). In the WHO Eastern Mediterranean (also known as the iRHIS) (550). The incidence
Region, low- and zero-incidence countries, of malaria among refugees remained relatively
such as Kuwait, Qatar and Saudi Arabia, have constant in Ethiopia and Sudan, declining
experienced increased numbers of cases only slightly from 2015 to 2020. However, an
139
increase in incidence was observed in Kenya proven to combat malaria. These data
from 2019 to 2020, following a steady decline indicate the need for further interventions to
during previous years. A gradual increase in convert available knowledge into practice.
malaria incidence was reported in Uganda
from 2015 to 2019, with a slight decrease Geography and type of employment often
in 2020. influence, and can increase, the risk of malaria
for refugee and migrant populations. In the
According to data from the Standardized Greater Mekong subregion of south-east
Expanded Nutrition Survey (551), there was a Asia, migrants employed as rubber tappers,
sharp decline in the proportion of households forest workers, miners, military personnel and
with at least one long-lasting insecticide- farmers often work near border regions and
treated net in refugee camps in Kenya from forest fringe areas that are highly receptive
2018 to 2019 (Fig. 3.11). Although the data sets to malaria, such as the Thailand–Myanmar
in Fig. 3.10 and Fig. 3.11 are of different types, border (552–554). Refugee and migrant workers
and a decrease in the incidence of malaria have limited access to health care facilities
cannot be directly associated with increased and usually receive late and/or substandard
use of the long-lasting insecticide-treated treatment for malaria. Government policies
net, the nets are one of the interventions may not always include malaria as an
Fig. 3.10. Incidence of malaria among refugee populations in Ethiopia, Kenya, Sudan and Uganda, 2015–2020
800
767.03
706.15
700
606.24
600
565.67 558.12
Incidence /1000 population
508.69
500
400
300 250.87 244.6 230.88

211.67 198.36 208.74
200 182.8 173.73
163.81
208.33 124.44
96.9
100 113.51 119.69 113.85
96.79 79.23
0 28.25
2015 2016 2017 2018 2019 2020
Year
Ethiopia Kenya Sudan Uganda
Source: UNHCR, unpublished data.

140
Fig. 3.11. Proportion of households owning at least one long-lasting insecticide-treated net in selected refugee
camps in Ethiopia, Kenya, Sudan and Uganda, 2015–2019
100
92
90
80
74 73
70 64 64
60
% of households
60 56 55 62
50 49
50 52 43
40 36 46
36
30
21
20
10
0
2015 2016 2017 2018 2019
Year
Ethiopia Kenya Sudan Uganda
Source: UNHCR (545).
occupational health concern, meaning that and there are gaps in the data that reveal
migrant workers can be excluded from the need for increased diagnosis, testing
malaria prevention and treatment services and surveillance to contain transmission
available under the labour laws of a host and provide treatment. Several diseases
country (555,556). affect refugee and migrant populations
across the WHO regions, including leprosy in
In the WHO African Region, increased elevation islands off the coast of eastern Africa (e.g. the
also appears to be associated with a higher Comoros archipelago, Madagascar, Mayotte
burden of malaria, as observed in the elevated and Réunion), strongyloidiasis in migrants
Kiziba refugee camps in Rwanda and in from Latin America in the United States
migrant labourers in north-western Ethiopia; and Europe, and dengue and chikungunya
evidence has suggested that labourers in in migrants in Qatar (559–561). Hepatitis,
highland areas are 2.34 times more likely to leishmaniasis and Chagas disease are briefly
develop malaria than those in lowland discussed in this section, as they continue
areas (557,558). to affect refugee and migrant populations
across several WHO regions. Additional
3.7.4 Other communicable diseases waterborne, tropical and parasitic infections
Other communicable diseases affect refugees known to affect refugees and migrants are
and migrants on a regional or more local level, also briefly discussed.
141
Hepatitis. Throughout the regions, In the WHO Eastern Mediterranean Region,

refugees and migrants consistently have hepatitis E virus antibody-positive cases are
a higher prevalence of hepatitis than nearly double (22.9%) in non-Qataris than in
their host country counterparts. the host population (11.5%) (567). In Lebanon,
outbreaks of hepatitis A virus infection have
In data collected from a sample of the pre- been associated with the Syrian refugee crisis,
entry health assessments conducted on all particularly in the settlement areas in the Beqaa
refugee applicants to the United Kingdom and North governorates (568). This highlights
as part of their resettlement, the positivity the need for greater surveillance efforts in the
rate for HBV infection was found to be the Region in addition to vaccination and sanitation
highest among the communicable diseases efforts to prevent further outbreaks. A small
assessed (2.04% of the cohort), with risk pilot study among Rohingya refugees
factors including sub-Saharan African origin in Bangladesh found a prevalence of HCV
and a history of blood transfusions (562). infection that was 10 times greater than that
In Canada, a higher prevalence of HCV of the host population, highlighting the risk
infection was detected in migrants than of severe liver disease in the long term in this
in non-migrants, with migrants having a migrant group (569).
seroprevalence 1.5–1.7 times higher than the
host population (563). Among undocumented A lack of awareness or knowledge of hepatitis
migrants and uninsured legal residents in was reported as a key risk factor among
the Netherlands, one study found a higher refugees and migrants in several studies. In
prevalence of chronic HBV and HCV infections Ethiopia, 86.5% of refugees in the Gambella
than in the host population, with many cases Region did not know how HBV and HCV
being newly diagnosed (564). In Thailand, infections are transmitted, and 86.8% were
migrant sex workers have a higher prevalence unaware of the availability of the HBV vaccine
of HBV infection (11.4%) than that observed (570); this lack of knowledge was of major
in the general population (4%) (74); in the concern as, in this study, the overall prevalence
EU/EEA, the HBV prevalence for migrants of the HBV surface antigen (HBsAg, indicating
from endemic regions is 5% compared with infectious disease) and HCV antibodies among
1% in the general population (74,565). refugees was 7.3% and 2.0%, respectively.
Similarly, in Australia limited knowledge of the
A review of national policies and guidelines types of hepatitis, as well as transmission and
for delivering TB, HIV, HBV and HCV treatment for the disease, was reported among
services for refugees and migrants in the Arabic- and Assyrian-speaking migrants; most
WHO European Region found that policies strikingly, community health workers (CHWs)
are often not in alignment with WHO's were found to have little knowledge of HBV
recommendations, and services may not infection (571).
always be accessible to migrant populations.
For example, France, Italy and the United Leishmaniasis. Leishmaniasis, a neglected
Kingdom have similar HBV screening policies; tropical disease, has been identified in
however, screening and testing may not refugee and migrant populations in the WHO
always be routine, and can depend on the African Region, WHO Region of the Americas,
judgement of a physician (566). In Italy, WHO European Region and WHO Eastern
thresholds are reported for both HBV and Mediterranean Region. It has also been
HCV (566). diagnosed among refugees in Türkiye, Syrian
142
refugees in Jordan, Venezuelan migrants in disease are undiagnosed (581,582). Challenges

Brazil and agricultural migrant labourers in to early detection include the high proportion
north-west Ethiopia: coinfection with malaria of asymptomatic cases, but there are also
and visceral leishmaniasis was also diagnosed policy barriers to health services for this
in Ethiopia (572–575). disease (583).
Various changes in disease patterns have For example, research suggests that Bolivian
been noted, including visceral leishmaniasis migrants in Brazil have faced obstacles to
changing from endemic to a sporadic accessing Chagas-related services, such
form among migrants in rural parts of as language barriers and requirements
the Islamic Republic of Iran, as well as for identity documents, but also current
high rates of cutaneous leishmaniasis in approaches to the disease do not consider the
migrants in Saudi Arabia (576–578). Timely distinct epidemiological profiles of different
diagnosis can be complicated by the groups (584). Access to screening and care is
introduction of locally uncommon species particularly important for Bolivian migrants in
of leishmaniasis following intraregional Brazil, since research suggests that a history of
migration, and various socioeconomic and rural jobs in the Plurinational State of Bolivia is
environmental factors can lead to complex significantly associated with the disease (585).
clinical presentations, requiring frequent
and repeated systemic treatment (579,580). Migration from Latin America to Europe has
raised concerns over diagnosis and treatment
Chagas disease. Chagas disease, a parasitic of Chagas disease. Of concern is the high
disease endemic in Latin America, has had prevalence among Latin American migrants in
regional implications for migrant populations Europe compared with Latin Americans in their
in the WHO Region of the Americas and the country of origin. For example, prevalences
WHO European Region as it is estimated that of 18.1% and 5.5% were recorded among
many infected with this neglected tropical migrants from the Plurinational State of Bolivia
and Paraguay, respectively, higher than their
national prevalence estimates (586). Further,
43% of identified cases in Europe are among
people living in Spain (587).
Recent research from across However, comprehensive public health

approaches can have a positive impact. For
WHO regions indicates that example, improved rates of screening among
various refugee and migrant Bolivians in Madrid were associated with
groups, including children, have people having received information about

Chagas in Spain and being advised to test,
experienced a disproportionate especially if the advice was provided by a
burden of COVID-19, often medical professional (588).
exacerbated by socioeconomic
and health system factors.
143
Waterborne, tropical and parasitic 3.8 COVID-19

infections. Several waterborne, tropical
and parasitic infections affect refugees and
migrants, with specific subpopulations at • T
here are increased risks for SARS-
higher risk. In the WHO African Region CoV-2 infection and severe COVID-19
and WHO Region of the Americas, among some refugees and migrants,
especially for those who live in crowded
cholera and diarrhoeal diseases affect
conditions, have occupations in which
refugee and migrant groups, with a
working from home is not possible, and
particularly high prevalence reported in live in countries where national and
children under 5 years of age (126,589,590): local policies exclude refugees
for example, children in refugee camps in and migrants from pandemic-related
Kenya who are younger than 5 years were health services.
reported as having a risk of cholera that was • P
ositive examples exist from countries
51% higher than for children aged 5 years that include and encourage refugees
and older (591). and migrants, regardless of status, to
get tested and vaccinated and seek
Factors contributing to an increased risk health care.
of childhood diarrhoea include a lack of • T
he indirect impacts of the COVID-19
proper handwashing facilities, consumption pandemic are significant, including loss
of surface water and the lack of a latrine, as of income, being stranded by travel
indicated in the context of a refugee camp restrictions, having limited access to
in Ethiopia (592). information due to language and other
barriers and facing discrimination.
Regarding parasitic infections, refugees and • F inancial barriers, language barriers,
migrants are at risk of a variety of infections, fear of deportation and lack of trust
including helminth infections among TB- in health care services prove to be
positive refugees in the United States, significant barriers for refugees and
migrants in seeking health care,
Cryptosporidium spp. infections among
including for suspected COVID-19.
migrant workers in Qatar and schistosomiasis
among asymptomatic Eritrean refugees in • W
here essential health care workers
Europe (593–595). Refugees and migrants in include significant numbers of migrants,
such workers were at a much greater
sub-Saharan African countries continue to
risk of severe COVID-19 than non-
be at risk for infection from tropical and essential workers.
other communicable diseases, including
leprosy, Rift Valley fever and trachoma
(559,596–598).
The COVID-19 pandemic has exposed
vulnerabilities and exacerbated inequalities
within and between all countries. The pandemic
has been very hard on the poor, who have
experienced higher rates of infection,
hospitalization and death than the wealthier.
They have also been hit particularly hard by
the economic slowdowns associated with
restrictive measures.
144
Among the most adversely affected people Conversely, a study investigating the impact
have been refugees and migrants, who have of COVID-19 in the Italian reception system for
been disproportionately and systematically migrants and refugees in the first pandemic
disadvantaged with respect to social wave reported an incidence of cases in line
standing and economic and political power, with that of the general resident population
often experiencing crowded work or living in Italy (612).
conditions over which they have no effective
control, and who have had less access to Refugees and migrants also face additional
vaccinations and health care. risks as a result of their living and working
conditions. For refugees from Bhutan and
3.8.1 Burden of disease Myanmar in the United States who were part
Recent research from across WHO regions of the essential workforce, having an infected
indicates that various refugee and migrant family member increased their likelihood of
groups, including children, have experienced infection by 26.9%, which was of particular
a disproportionate burden of COVID-19, often concern given that refugee families often reside
exacerbated by socioeconomic and health in multigenerational households (615). Early
system factors (599–605). Older refugees and evidence suggests that COVID-19 transmission
migrants are at particular risk because of the was significantly lower than might have
nature of the disease and their migratory been expected among refugees in camps in
status, particularly those in transit or irregular Bangladesh (616).
situations (606,607).
However, there are insufficient disaggregated
In June 2021, the European Centre for Disease data from which to make generalizations.
Prevention and Control identified Moreover, as with most refugee and migrant
occupational risk, overcrowded health concerns, disease transmission is context
accommodation in camps and closed settings specific and subject to many determinants
(including detention and reception centres), (Fig. 3.12) (617).
and lower levels of accessibility of public
health services as the main risk factors for 3.8.2 Health and other impacts
refugee and migrant exposure to SARS-CoV-2, The COVID-19 pandemic has had a variety of
and low COVID-19 vaccine uptake in migrants indirect effects on the health of refugee and
compounding the issue (608). This is migrant populations across a wide range of
consistent with reported outbreaks in WHO sectors. In several high-income countries in
European Region detention centres (see the WHO European Region, for example, social
section 2.11.2 on immigration detention) and distancing and lockdown measures affected the
camp-like settings, and in non-closed ability of migrants to access social protections,
containment settings, in which transmission such as furlough-type payments, particularly
is linked to neighbourhood deprivation levels, for self-employed and day labourers (618,619).
poor hygiene facilities and limited ability to Other indirect impacts include proliferating
physically distance or self-isolate (609–612). restrictive migration measures, such as border
For example, countries that host large closings, the suspension of resettlement
numbers of low-wage migrant workers had a programmes and processing of asylum
significantly higher proportion of migrants applications (620) and job losses (621–624),
testing positive compared with the host which have often exacerbated pre-existing
population (613,614). structural inequalities.
145
Fig. 3.12. Compounding risks for migrants in the context of COVID-19
UNDOCUMENTED OR STIGMA AND POOR LIVING AND WORKING

IRREGULAR STATUS DISCRIMINATION CONDITIONS
Lack of legal status may Increasing discrimination Conditions may include
create formal barriers or lead and stigma, as well as blame overcrowding, such as in
to a reluctance to access for spreading COVID-19, can camp or detention settings,
assistance because of fear prevent people from seeking inadequate sanitation and
of arrest. assistance and support. hygiene, and inability to
isolate or physically distance.
EXCLUSION LOSS OF SOCIAL SUPPORTS LABOUR EXPLOITATION AND

Migrants may be deprioritized Loss of contact with family HUMAN TRAFFICKING
or excluded from health and community networks Epidemics and pandemics
care and prevention and because of quarantine and/or can exacerbate existing
response efforts. border closures, can prevent vulnerabilities and put people
return home and lead to at a greater risk of exploitation
anxiety because of isolation. and trafficking.
LIMITED OR NO ACCESS TO SEX AND GENDER SOCIAL, RELIGIOUS AND

ESSENTIAL SERVICES Female domestic workers CULTURAL OBSTACLES
There may be informal and are often employed in Lack of familiarity with
formal barriers to accessing isolated workplaces and at and awareness of health
essential services, such as an increased risk of sexual procedures and available
food, shelter, health care, and gender-based violence support, and a lack of
psychosocial support, legal because of lockdown and culturally appropriate
assistance, and water, sanitation movement restrictions. services may prevent health
and hygiene services. care access.
COMMUNICATION BARRIERS FINANCIAL BARRIERS PROTECTION AND SAFETY

There may be barriers in Financial barriers may prevent Refugees and migrants may be
understanding or accessing access to health systems and unable to seek safety because
key information on health care support, including a lack of of border closures and travel
and challenges in reporting insurance and high costs of or movement restrictions.
health conditions. care or the cost of transport to
health care centres.
Source: International Federation of Red Cross and Red Crescent Societies (610).
In the WHO ApartTogether survey of 30 000 schooling, were also less likely to seek health
refugees and migrants globally (625), refugees care for suspected COVID-19 symptoms. As
and migrants reported that the COVID-19 shown in Fig. 3.13, the main reasons for not
pandemic significantly affected their access seeking health care were financial constraints
to work, their personal safety and financial (35%) and fear of deportation (22%).
means, as well as their social and mental
well-being. Homeless refugees and migrants, Impact on women and girls. There is
refugees and migrants living in insecure considerable evidence that refugee and migrant
accommodation or asylum centres, and women and girls have been severely affected
irregular migrants reported the worst impacts in many ways, from their mental health to their
of the pandemic on their daily lives. The same ability to earn their livelihoods to an increased
groups, as well as respondents without any risk of child marriage (626–631).
146
Fig. 3.13. Reasons for not seeking medical care in case of suspected COVID-19 symptoms
1.4% 0.8%
1.8% 0.6%
2.8%
Lack of availability of health care

4.0% No entitlement to health care
Lack of ﬁnancial means
4.2%
Fear of deportation
5.4% Lack of transport
34.6% Do not know where to ﬁnd a doctor/health worker
Do not speak the language
10.0% I would self-isolate
Do not trust doctors/health workers
Only if symptoms get worse
Afraid of becoming infected at hospital/
12.5%
consultation room/health facility
21.9% Do not think the coronavirus is as bad
Source: WHO (618).
A qualitative study on refugee women in The pandemic has also had significant
Nairobi, Kenya, reported an increase in home impacts on the trafficking and exploitation
deliveries during the pandemic and reduced of Sri Lankan female migrant workers, as
uptake of ANC services, as well as the uptake illegal recruiters and traffickers have taken
of facility-based services becoming more advantage of their increased livelihood
challenging (632). insecurity, school closures, and job and
income losses (634). A study on SGBV against
The United Nations Population Fund women in Syrian refugee camps in Jordan
reported that the increased poverty and provided evidence of a trend of increased
school closures associated with the COVID-19 violence during the pandemic (635).
pandemic led to an even higher prevalence
of marriage at a young age in the Middle Impact on mental health. Refugees
East and in northern African countries (633). and migrants participating in the WHO
In 2020 it was estimated that half a million ApartTogether survey reported a significant
more girls were at risk of child marriage impact of the COVID-19 pandemic and
because of the pandemic. As many as half associated lockdowns on their mental
of all refugee girls in secondary school will health conditions (Fig. 3.14). About 50%
not return when schools reopen; in countries of respondents reported higher levels of
where the enrolment at school of refugee symptoms of depression, worry, anxiety and
girls is less than 10%, such as Ethiopia loneliness, while 20% reported an increased
and Pakistan, all school-aged girls are at use of drugs and alcohol. Other preliminary
risk of dropping out permanently (630). evidence supported the finding that the mental
147
health of refugees and migrants worsened continue their education at home and
during the pandemic (623,636–640). experienced behavioural changes because
of increased stress and anxiety (621).
Impact on livelihoods and nutrition.
The indirect or secondary consequences of Regarding food security, refugee camps in
the COVID-19 pandemic have extended well Rwanda experienced a reduction in food
beyond physical health to have economic, rations as a result of declining donations to
nutritional, educational and security the World Food Programme (641). In Asia,
implications. Syrian refugee families in Lebanon nearly 660 000 migrant workers were returned
have been economically affected, with 80% to Bangladesh following the outbreak of the
of breadwinners losing their jobs and 60% pandemic, a further 2 million face possible
experiencing a reduction in wages, leaving deportation and at least 71 000 migrants were
many unable to afford basic needs. A total of estimated to have returned to Myanmar by
70% of Syrian refugee children did not May 2020, primarily from Thailand (642–645).
Fig. 3.14. Migrant and refugee respondents identifying deterioration in their mental health since the beginning of
the COVID-19 pandemic, by their housing situation
80
71.5
69.6
68.3
70
65.3
65.9
64.3
64.2
64.3
60.1
60.8
60.9
59.1
59.3
58.6
60
58.5
58.1
57.7
56.4
55.3
54.1
54.2
52.5
52.0
51.9
50
46.2
46.8
% of respondents
45.4
45.2
43.7
43.4
43.5
42.0
42.5
42.9
41.0
41.9
40.8
40.6
39.5
40
33.6
33.9
33.2
30
24.2
22.8
20
10
0
Depression Worry Anxiety Loneliness Anger Reminders Physical Irritability Hopelessness Sleep Drugs and
stress problems alcohol
reactions
Type of mental health problem
House/apartment Asylum centre Refugee camp On the streets or insecure
Note: number of respondents for each issue: 15 278 depression, 15 483 worry, 15 291 anxiety, 14 730 loneliness, 13 340 anger, 13 454 reminders, 12 344 physical stress
reactions, 13 343 irritability, 13 314 hopelessness, 13 232 sleep problems, 8 915 drugs and alcohol (survey question used this term); number of participants differed by
housing situation, e.g. for depression the number responding were 13 562 for house/apartment, 359 for asylum center, 1190 for refugee camp, 167 for on the streets or in
insecure accommodation.
Source: WHO (618).

148
Discrimination and stigma. Refugees Restrictions on movement. The COVID-19

and migrants participating in the WHO pandemic and resulting restrictive migration
ApartTogether survey also reported that policies strongly affected global mobility and
discrimination increased in the context of international migration. Shortly after WHO
the pandemic (Fig. 3.15); this was particularly declared the SARS-CoV-2 outbreak a pandemic
felt by homeless respondents and those in March 2020 (648), many States introduced
living in insecure accommodation or asylum travel restrictions and border closures.
centres. Other reports also suggest that
racism and discrimination increased during Mobility restrictions in 2020 during the
the pandemic. For example, discrimination pandemic can be categorized into three
and xenophobia against Asian individuals was phases. In the first phase (January–March
reported to have increased in some countries 2020), countries introduced many mobility
following the virus outbreak in Wuhan, restrictions in the form of travel bans and
China (646,647). health requirements. Borders were closed
at an unprecedented level, even within
the border-free Schengen area (622).
Fig. 3.15. Migrant and refugee respondents identifying worsening of perceived discrimination because of the
COVID-19 pandemic
80
76.5
75.0
75.2
72.3
70
65.8
64.3
60
50
% of respondents
40
27.0
30
23.2
22.1
20
17.4
16.4
13.8
12.5
11.0
10
8.7
7.2
6.1
5.5
0
Treated Treated with Called names Being avoided Being anxious Unfair
differently kindness because of about me treatment by
because of origin origin/religion police
Type of discrimination
Worse than before Same as before Better than before
Note: data from a total of 19 009 respondents. 16 143 treated differently because of origin; 18 131 treated with kindness; 13 185 called names because of origin/religion,
13 499 being avoided, 13 932 being anxious about me, 11 062 unfair treatment by police.
Source: WHO (618).

149
In April 2020, about 91% of the world's the pandemic, a serious burden for those
population lived in countries with travel who had lost their jobs. The IOM estimated
restrictions for non-citizens and non-residents; that at least 2.75 million migrants were
39% lived in countries with complete border stranded as of July 2020 (653), some without
closure for non-citizens and non-residents (649). sufficient resources or access to consular
assistance and at risk of losing their legal
In the second phase (June–September 2020), status (622). Many migrant workers decided
most countries introduced a staggered to return to their home countries out of fear
reopening. Travel bans were increasingly of a worsening COVID-19 situation, job loss,
replaced by health measures, such as expected job loss or expiration of their work
COVID-19 tests. However, some island permit. However, particularly during the
countries, such as Australia and New Zealand, first months of the pandemic in 2020, many
kept their borders closed to pursue an migrant workers were not able to return
elimination strategy against the virus. In because international flights were reduced or
the third phase (October–December 2020), cancelled, and home governments were not
countries responded to new outbreaks accepting large numbers of returnees (654).
and virus mutations. Health certificates
were increasingly introduced as new travel Irregular migration continued throughout
measures, while screening and quarantine the pandemic, but at lower levels than would
requirements were increasingly phased out. normally have been observed (655). Many
Because of new virus mutations, restrictions risks of the journey were exacerbated; for
were imposed on travel from South Africa example, fewer search and rescue operations
and the United Kingdom. These measures were running and border closures often
continued into the first months of 2021 (622). resulted in individuals travelling by more
dangerous routes.
UNDESA estimated that by mid-2020 the
number of migrants globally decreased by Impact on working and living conditions.
2 million. This corresponds to a decrease of Refugees and migrants living and working in
27% in the expected growth between July crowded settings were particularly exposed
2019 and June 2020 (650). Member States of to SARS-CoV-2 infection. Outbreaks were
the Organisation for Economic Co-operation reported globally in different refugee camps,
and Development (OECD) reported that the shelters, accommodation facilities for migrant
number of new residence permits granted workers, and reception and detention centres
to migrants dropped by an average of 46% (614,656–658). Because of the crowded
in the first half of 2020 (651). Similarly, settings, refugees and migrants may not have
refugee flows were affected. In the first half been able to follow prevention measures,
of 2020, 586 100 new claims for asylum were such as hand hygiene, social distancing or
submitted globally, corresponding to 32% self-isolation for symptoms and infection
less than during the same period in 2019. (609,656,658,659). Data on the spread of SARS-
Resettlement numbers dropped even more CoV-2 in refugee camps are scarce, although
significantly in the first half of 2020 (by 46%) some reports indicated that the number
compared with the same period in 2019 (652). of cases in refugee camps remained lower
than projected. Reasons for this could be the
Many labour migrants were not able to isolation of camps from local communities
return to their countries of origin during and undertesting (660,661).
150
However, migrant workers, and particularly deemed critical to the COVID-19 response)
low-skilled migrant workers, faced an were at heightened risk of infection and severe
increased risk of exposure to the virus at COVID-19. At the top of this category, health
their workplaces and dormitories. During care workers were found to have a sevenfold
the early months of the COVID-19 pandemic higher risk of infection, while social care
in Kuwait, significant spread and clustering and transport workers had a twofold higher
events occurred among migrant workers risk. Further analysis of the data revealed
as a result of their poor and densely that non-white essential workers had the
populated living conditions (662). Data from highest risk of severe COVID-19 (670).
Singapore show that migrant workers were
disproportionally affected by the pandemic, 3.8.3 Policy responses
with migrant workers living in dormitories National responses to COVID-19 varied
accounting for 93% of the total confirmed considerably; policies ranged from
COVID-19 cases in that country (614,663). discriminatory practices, excluding refugees
and migrants from access to health care, to
Refugees and migrants often work in critical inclusive policies, integrating migrants and
sectors, which were strongly affected by the refugees within COVID-19 responses and
pandemic (664–666). In the United States, protecting them according to international
69% of all migrants in the labour force, conventions. Although national responses
74% of all migrant workers with irregular varied, many countries ensured access to
status and 70% of refugees were classified health care for all migrants and refugees
as essential workers, that is, they were regardless of nationality and legal status.
employed in sectors such as meat packaging, With regards to legal status and access
agriculture, health care, construction, to the labour market, numerous States
child care or critical retail (667). followed a flexible approach in terms of
administrative migration procedures.
Health care workers were disproportionately Several States suspended forced returns and
affected, and contributed substantially to implemented alternatives to immigration
the front line of the COVID-19 response detention, taking into consideration the
in many countries (658,668). A study of health concerns of the public (620).
the contributions of migrants in OECD
countries cited the examples of Australia Research from the WHO African Region
and Luxembourg, where 50% of doctors are suggests that previous experience of Ebola
foreign born, and of Israel and Switzerland, outbreaks was beneficial to the response
where 30% of nurses are foreign born (669). Of to COVID-19; for example, populations
the 20 countries with the highest numbers of were already familiar with the importance
COVID-19 cases globally (as of 1 March 2021), of handwashing; previously established
seven depend heavily on migrant workers laboratory systems assisted in providing earlier
in the health care sector: Czechia, France, COVID-19 diagnoses; control over irregular
Germany, Italy, Spain, the United Kingdom border crossings was improved; and health
and the United States (669). care workers had already received training
in both containing transmission of the virus
A study among different occupational groups and in understanding how xenophobia and
in the United Kingdom showed that many discrimination could affect refugees and
essential workers (i.e. those occupations migrants during disease outbreaks (671–673).
151
Countries in the WHO Eastern Mediterranean health care services only for emergencies; a
Region, such as Saudi Arabia and the United further 16% reported a total lack of access to
Arab Emirates, announced that those with health services (680). In the town of Tijuana,
COVID-19 could receive free medical treatment Mexico, near the border with the United
in public health hospitals regardless of States, migrants reported increased financial
their migratory status (674). However, a lack and administrative barriers to accessing
of institutional trust may have deterred health care during the pandemic (681).
undocumented migrants from accessing care in
medical facilities because of fears of deportation It is also important to consider the invisibility
or arrest (675). The Government of Qatar also of migrants in the definition of public and
declared that migrants who tested positive health policies. It has been reported that
for SARS-CoV-2 could access free treatment tightened migration policies in the United
and that migrant workers under quarantine States, such as a restrictive interpretation
could continue to receive wages, although of the Title 42 public health statute (682)
this may not have occurred in practice (676). and strong migration control measures in
Mexico, may have negatively affected not only
International organizations, including the access to health care but also the migration
IOM and WHO, played key roles in Libya in patterns within the whole region (683).
assisting with the preparation of a nine-pillar
COVID-19 preparedness and response plan, 3.8.4 Testing, treatment and
and in strengthening COVID-19 surveillance vaccination
by consolidating data from health facilities Even before the pandemic, vaccine uptake
and migrant sites covered by the IOM was lower among migrants than in the general
Displacement Tracking Matrix (677). population. Accordingly, vaccine hesitancy
and structural barriers, such as language and
In Latin America, the pandemic revealed cultural barriers, played a vital part in the
and exacerbated the social vulnerability of COVID-19 vaccine roll out and uptake for migrant
migrants in various contexts, as well as the communities (684,685). In the United States,
impact of non-inclusive public health policies a study conducted among Brazilian migrants
(678). For example, the closing of the border found that contact testing and tracing for
between Colombia and Venezuela might have COVID-19 was hindered by fears of deportation,
contributed to negative perceptions of refugees limiting responses to the pandemic and leading
and migrants by portraying them as a source to increased infection risks (686). A study from
of COVID-19. This, in turn, may have increased South Africa indicated that non-citizens were
their health risks, despite Colombian efforts largely excluded from the national response to
to promote the health of Venezuelan refugees the pandemic, including the responses related
and migrants (679). to issues of poverty, hunger, the economy and
mental health (624).
Studies indicate that some Venezuelan
refugees and migrants in the region However, there are positive examples. For
experienced a decrease in access to health example, Australia and Egypt offered free access
care services because of the pandemic. For to COVID-19 testing for migrants, similar to that
example, almost half of the 959 individuals provided for the host population (617,687). In
included in a study across Colombia, Ecuador Australia, this was carried out in collaboration
and Peru reported that they could access with the Australian Red Cross, and subsequent
152
treatment was also offered by all states and Unlike the beginning of the HIV epidemic,
territories. After large COVID-19 outbreaks in when refugees were not included in national
dormitories of migrant workers in Singapore, AIDS control programmes or able to access
a national task force to address the outbreak ART (690), refugees have been included in
response in the country was launched, the COVID-19 planning and vaccination
deploying on-site medical posts to dormitories programmes of various countries (691,692).
to provide testing and screening services As of November 2021, 128 countries were
(614,663). Countries such as Colombia, Nepal, confirmed to be providing vaccinations for
Peru, Portugal and Türkiye guaranteed refugees forced migrants, with Jordan being among the
and migrants, including irregular migrants and first to do so (693).
migrants with a pending application, access
to health care services including testing and However, when it comes to routine
vaccination (620). immunization, gaps in coverage for refugees
and migrants persisted even before the
There are also examples of national leadership pandemic. A study published in 2018 reported
that used the pandemic to expand or improve that out of 21 randomly selected low- and
access to health services for refugees and middle-income countries from the Asia–Pacific
migrants. During the COVID-19 pandemic, Region, only the Maldives, Papua New Guinea
the Ministry of Health of Peru launched a and Thailand included migrants in their
community-based initiative to improve both pandemic influenza preparedness plans (694).
access to TB screening and active detection
of COVID-19 cases within the Venezuelan A recent survey conducted by UNICEF found
refugee and migrant population, expanding that refugees and migrants were not covered
active case detection efforts for COVID-19 under new or expanded social protection
(688). Free UHC for all non-citizens was measures related to COVID-19 in half of the
offered by Saudi Arabia and the United Arab 159 countries included in the survey (231).
Emirates during the COVID-19 pandemic (674). As a response to this issue, the Inter-Agency
However, there is evidence that some migrants Standing Committee and partners launched
were hesitant to use such opportunities in the Humanitarian Buffer mechanism within the
these contexts because of fear of identity COVAX Facility to provide access to COVID-19
exposure, arrest or even deportation (675). vaccines to refugees, asylum seekers, IDPs
The United Kingdom has a specific initiative and other vulnerable and humanitarian
encouraging undocumented migrants and populations (695). Through this mechanism,
other unregistered migrant groups to register for example, the Islamic Republic of Iran
with PHC providers to access the national received 1.6 million doses to cover the needs
vaccination programme (689). One of the few of Afghan refugees in the country (696).
nationally representative studies within the
WHO Eastern Mediterranean Region explored The 2021 WHO publication Refugees and
COVID-19 vaccine hesitancy in Qatar and found migrants in times of COVID-19: mapping trends
that migrants, who account for the majority of of public health and migration policies and
the country's population, had a substantially practices (620) identifies three components
higher intention of avoiding vaccination necessary for an integrated approach to
than the host population, highlighting the migration and public health policies in the
importance of specialized outreach to address COVID-19 context: (i) ensuring protection-
hesitancy (684). sensitive access to territory (e.g. enabling
153
access to territory and asylum procedures for Refugees and migrants are at particular risk of
people in need of international protection), NCDs; some of these are significant causes of
(ii) ensuring immigration status flexibility (e.g. premature mortality, especially where there are
facilitating regularization of undocumented barriers to accessing health care. Such NCDs
migrants to ensure safe and lawful access include CVDs, hypertension, diabetes, chronic
to health services), and (iii) ensuring non- respiratory disease and cancer, which is often
discriminatory access to health care (e.g. diagnosed late; unhealthy diet, lack of physical
providing equal access to health care for all, exercise, overweight/obesity and use of alcohol
regardless of status, nationality, sex or gender, and tobacco are risk factors for NCDs.
or ethnicity).
Although refugees and migrants may experience
a wide range of mental health conditions, these
3.9 Summary vary depending on social and environmental
factors, such as the absence of family or social
It is clear that refugees and migrants face poorer support, discrimination, age, ethnicity and
health outcomes than people in host countries time spent in the host country. Some specific
around the world if the conditions they live populations are more affected than others, for
and work in are not conducive to good health. example, younger people from conflict-affected
However, the threats, risks and vulnerabilities countries, undocumented children, UASC and
often differ between regions and among groups. older people.
It is also clear that poorer health outcomes
for refugees and migrants are not universal; Similar to the rest of the population, refugees
research has revealed deviations from this rule and migrants may encounter infectious diseases
in some regions and for some diseases. along their journey. However, they also face
additional barriers to receiving timely diagnosis,
Refugees and migrants tend to be employed treatment and care. For example, stigma and
in low-paid sectors in which their safety and discrimination often hamper access to health
well-being are at risk, the so-called 3D jobs, services related to HIV/AIDS, and the process of
and in low-paid high-risk sectors in which migration can make access and adherence to
conditions are poor and they may face risks to TB treatment more difficult.
physical and mental health, including abuse.
All these factors are exacerbated by their lack Finally, refugees and migrants have been
of social protection. disproportionately affected by the COVID-19
pandemic, which has increased their burden
Across regions, the SRH needs of refugees and of disease, reduced their income, affected their
migrants are not as well met as they are for host social and mental well-being and reduced
populations, with low awareness and use of their mobility through travel restrictions.
contraception, unmet family planning needs,
and structural and legal barriers to accessing SRH
health care. Refugees and migrants also tend
to experience poorer access to MCH services
than women in the host country, including low
attendance at ANC, hampered by barriers such as
out-of-pocket costs, low awareness, low level of
education and cultural beliefs.
154
References 11. Migrant access to social protection under Bilateral

Labour Agreements: a review of 120 countries and
nine bilateral arrangements. Report No. 57. Geneva:
International Labour Organization; 2017 (ESS Working
Paper, no. 57; https://labordoc.ilo.org/discovery/fulldisplay/
1. Ottawa charter for health promotion. Geneva: World alma994955792602676/41ILO_INST:41ILO_V2, accessed
Health Organization; 1987 (https://apps.who.int/iris/rest/ 29 March 2022).
bitstreams/1152389/retrieve, accessed 29 March 2022).
12. Andrade M, Sato L, Hammad M. Improving social protection
2. Missing migrants project [website]. Geneva: International for migrants, refugees and asylum seekers in Egypt: an
Organization for Migration; 2022 (https://missingmigrants. overview of international practices. Brasília: International
iom.int/, accessed 6 February 2022). Policy Centre for Inclusive Growth (IPC-IG); 2021 (https://www.
3. ILO global estimates on international migrant workers – unicef.org/egypt/media/6881/file/Improving%20social%20
results and methodology, third edition. Geneva: International protection%20for%20migrants,%20refugees%20and%20
Labour Organization; 2021 (https://www.ilo.org/wcmsp5/ asylum%20seekers%20in%20Egypt%20%7C%20Full%20
groups/public/@dgreports/@dcomm/@publ/documents/ report.pdf, accessed 29 March 2022).
publication/wcms_808935.pdf, accessed 29 March 2022). 13. Hargreaves S, Rustage K, Nellums LB, McAlpine A, Pocock N,
4. Simon J, Kiss N, Łaszewska A, Mayer S. Public health aspects Devakumar D et al. Occupational health outcomes among
of migrant health: a review of the evidence on health status international migrant workers: a systematic review and meta-
for labour migrants in the European Region. Copenhagen: analysis. Lancet Glob Health. 2019;7(7):e872–82. doi:10.1016/
WHO Regional Office for Europe; 2015 (Health Evidence S2214-109X(19)30204-9.
Network Synthesis report no. 43; https://apps.who.int/iris/ 14. Moyce SC, Schenker M. Migrant workers and their
handle/10665/326345, accessed 29 March 2022). occupational health and safety. Annu Rev Public
5. Abbas M, Kashif M, Balkhyour M, Ahmad I, Asam Z-U-Z, Saeed Health. 2018;39:351–65. doi:10.1146/annurev-
R. Trends in occupational injuries and diseases among Saudi publhealth-040617-013714.
and non-Saudi insured workers. East Mediterr Health J. 15. Employment, unemployment, and participation rates by
2018;24(10):1010–17. doi:10.26719/2018.24.10.1010. place of birth and sex. International Migration Database. Paris:
6. Moyce SC, Schenker M. Occupational exposures and health Organisation for Economic Co-operation and Development;
outcomes among immigrants in the USA. Curr Environ Health 2021 (https://stats.oecd.org/Index.aspx?DataSetCode=MIG_
Rep. 2017;4(3):349–54. doi:10.1007/s40572-017-0152-1. NUP_RATES_GENDER, accessed 29 March 2022).
7. Adhikary P, Keen S, van Teijlingen E. Workplace accidents 16. WHO global plan of action on workers' health (2008–2017):
among Nepali male workers in the Middle East and Malaysia: baseline for implementation. Geneva: World Health
a qualitative study. J Immigr Minor Health. 2019;21(5):1115– Organization; 2013 (https://apps.who.int/iris/rest/
22. doi:10.1007/s10903-018-0801-y. bitstreams/1344161/retrieve, accessed 4 May 2022).
8. Tilahun M, Workicho A, Angaw DA. Common mental disorders 17. Lyu S, Hon C, Chan A, Wong F, Javed A. Relationships among
and its associated factors and mental health care services safety climate, safety behavior, and safety outcomes for
for Ethiopian labour migrants returned from Middle East ethnic minority construction workers. Int J Environ Res Public
countries in Addis Ababa, Ethiopia. BMC Health Serv Res. Health. 2018;15(3):484. doi:10.3390/ijerph15030484.
2020;20(1):681. doi:10.1186/s12913-020-05502-0. 18. Öztaş D, Kurt B, Koç A, Akbaba M. Living conditions, access
9. Pega F, Govindaraj S, Tran NT. Health service use and health to healthcare services, and occupational health and safety
outcomes among international migrant workers compared conditions of migrant seasonal agricultural workers in the
with non-migrant workers: a systematic review and meta- Çukurova Region. J Agromedicine. 2018;23(3):262–9. doi:10.
analysis. PLOS One. 2021;16(6):e0252651. doi:10.1371/journal. 1080/1059924X.2018.1470048.
pone.0252651. 19. Biering K, Lander F, Rasmussen K. Work injuries among
10. Aryal N, Regmi PR, van Teijlingen E, Simkhada P, migrant workers in Denmark. Occup Environ Med.
Adhikary P, Bhatta YKD et al. Injury and mortality in 2017;74(4):235–42. doi:10.1136/oemed-2016-103681.
young Nepalese migrant workers: a call for public health 20. Giraudo M, Bena A, Mosca M, Farina E, Leombruni R, Costa
action. Asia Pac J Public Health. 2016;28(8):703–5. G. Differences in work injury risk between immigrants and
doi:10.1177/1010539516668628. natives: changes since the economic recession in Italy. BMC
Public Health. 2019;19(1):836. doi:10.1186/s12889-019-7178-2.
155
21. Saquib N, Zaghloul MS, Saquib J, Alhomaidan HT, Al- 32. Al-Surimi K, Al Omar M, Alahmary K, Salam M. Prevalence
Mohaimeed A, Al-Mazrou A. Association of cumulative of workplace bullying and its associated factors at a multi-
job dissatisfaction with depression, anxiety and stress regional Saudi Arabian hospital: a cross-sectional study. Risk
among expatriate nurses in Saudi Arabia. J Nurs Manage. Manag Healthc Policy. 2020;13:1905–14. doi:10.2147/
2019;27(4):740–8. doi:10.1111/jonm.12762. RMHP.S265127.
22. Dhungana RR, Aryal N, Adhikary P, Kc RK, Regmi PR, Devkota 33. Basok T, Bélanger D, Rivas E. Reproducing deportability:
B et al. Psychological morbidity in Nepali cross-border migrant agricultural workers in south-western Ontario.
migrants in India: a community based cross-sectional study. J Ethn Migr Stud. 2014;40(9):1394–413. doi:10.1080/
BMC Public Health. 2019;19(1):1534. doi:10.1186/s12889-019- 1369183X.2013.849566.
7881-z.
34. Holmes SM. An ethnographic study of the social context
23. Ziersch A, Walsh M, Due C, Reilly A. Temporary refugee of migrant health in the United States. PLOS Med.
and migration visas in Australia: an occupational health 2006;3(10):e448. doi:10.1371/journal.pmed.0030448.
and safety hazard. Int J Health Serv. 2021;51(4):531–44.
35. Kammogne CL, Marchand A. Ethnicité et statut d'immigrant:
doi:10.1177/0020731420980688.
quelle association avec le travail et les symptômes
24. Reform of the Kafala (sponsorship) system. Quezon City: dépressifs? Rev Epidemiol Sante Publique. 2021;69(3):145–53.
Migrant Forum in Asia; Policy Brief No. 2; 2012 (https://www. doi:10.1016/j.respe.2021.01.009.
ilo.org/dyn/migpractice/docs/132/PB2.pdf, accessed
36. Rauf M. Socio-economic and legal issues and challenges
20 June 2022)
of foreign migrant worker in Maldives: a case study
25. Strauss K, McGrath S. Temporary migration, precarious of construction industry in male. J Leg Stud Res.
employment and unfree labour relations: exploring the 2019;5(5):188–209 (https://thelawbrigade.com/wp-content/
"continuum of exploitation" in Canada's Temporary Foreign uploads/2019/10/Mohammad-Rauf.pdf, accessed
Worker Program. Geoforum. 2017;78:199–208. doi:10.1016/j. 29 March 2020).
geoforum.2016.01.008.
37. Asia‐Pacific migration report 2020: assessing implementation
26. Binford AL. Assessing temporary foreign worker programs of the global compact for migration. Bangkok: United Nations
through the prism of Canada's Seasonal Agricultural Worker Economic and Social Commission for Asia and the Pacific;
Program: can they be reformed or should they be eliminated? 2020 (https://www.unescap.org/resources/asia-pacific-
Dialect Anthropol. 2019;43(4):347–66. doi:10.1007/s10624- migration-report-2020, accessed 5 April 2022).
019-09553-6.
38. Women migrant workers in the Asean economic community.
27. Cranford C, Vosko L, Zukewich N. The gender of New York: United Nations Entity for Gender Equality
precarious employment in Canada. Relat Ind. 2003;58. and the Empowerment of Women (UN Women); 2017
doi:10.7202/007495ar. (https://asiapacific.unwomen.org/en/digital-library/
publications/2017/06/women-migration-workers-in-asean,
28. Sidorchuk A, Engström K, Johnson CM, Kayser Leeoza N,
accessed 29 March 2022).
Möller J. Employment status and psychological distress
in a population-based cross-sectional study in Sweden: 39. Gosselin A, Daly A, El Zaemey S, Fritschi L, Glass D, Perez
the impact of migration. BMJ Open. 2017;7(4):e014698. ER et al. Does exposure to workplace hazards cluster by
doi:10.1136/bmjopen-2016-014698. occupational or sociodemographic characteristics? An
analysis of foreign‐born workers in Australia. Am J Ind Med.
29. Di Napoli A, Rossi A, Baralla F, Ventura M, Gatta R, Perez M et
2020;63(9):803–16. doi:10.1002/ajim.23146.
al. Self-perceived workplace discrimination and mental health
among immigrant workers in Italy: a cross-sectional study. 40. Leiva Gomez S, Agüero MM, Fornes AC. Condiciones laborales
BMC Psychiatry. 2021;21(1):85. doi:10.1186/s12888-021- de migrantes bolivianas que realizan trabajo de cuidado en
03077-6. Iquique [Labor conditions of Bolivian migrants who provide
care work in Iquique]. Si Somos Am. 2017;17(1):11–37
30. Di Napoli A, Gatta R, Rossi A, Perez M, Costanzo G, Mirisola C et
(in Spanish). doi:10.4067/S0719-09482017000100011.
al. [Perceived discrimination at work for being an immigrant:
a study on self-perceived mental health status among 41. Joshi M. Occupational hazards among migrant workers:
immigrants in Italy]. Epidemiol Prev. 2017;41(3–4 suppl 1):33– impact on their fertility and mental health. Occup Env Med.
40 (in Italian). doi:10.19191/EP17.3-4S1.P033.063. 2019;76(1):A99. doi:10.1136/OEM-2019-EPI.273.
31. Carey RN, El-Zaemey S, Daly A, Fritschi L, Glass DC, Reid A. 42. Obali Odolla J. The other side of "economic migration":
Are there ethnic disparities in exposure to workplace hazards psychosocial issues affecting young people returning to
among New Zealand migrants to Australia? Asia Pac J Public Ethiopia. Intervention. 2016;14(3):330–4 (https://www.
Health. 2021;33(8):870–9. doi:10.1177/10105395211007648. interventionjournal.com/sites/default/files/The_other_side_
of__economic_migration___.15.pdf, accessed 29 March 2022).
156
43. Valenti A, Persechino B, Rondinone BM, Fortuna G, Boccuni 53. Chan JS, Chia DW, Hao Y, Lian SW, Chua MT, Ong ME. Health-
V, Iavicolo S. Risk perception among migrant agricultural seeking behaviour of foreign workers in Singapore: insights
workers. Occup Environ Med. 2018;75(suppl 2):A477. from emergency department visits. Ann Acad Med Singapore.
doi:10.1136/oemed-2018-ICOHabstracts.1358. 2021;50(4):315–24. doi:10.47102/annals-acadmedsg.2020484.
44. Bailey R. Health care management in Australia's and New 54. Roche J, Vos AG, Lalla-Edward ST, Venter WDF, Scheuermaier
Zealand's seasonal worker schemes. Canberra: Department of K. Relationship between sleep disorders, HIV status and
Pacific Affairs (ANU); 2020 (DPA Working Paper 2020/2; https:// cardiovascular risk: cross-sectional study of long-haul
apo.org.au/node/302960, accessed 29 March 2022). truck drivers from southern Africa. Occup Environ Med.
2021;oemed-2020-107208. doi:10.1136/oemed-2020-107208.
45. Linardelli MF. [Among the farm, the factory, and home:
productive and reproductive work of female migrant 55. Michalopoulos LM, Ncube N, Simona SJ, Kansankala
farmworkers in Mendoza (Argentina) and its impact in the B, Sinkala E, Raidoo J. A qualitative study of migrant-
health-disease process.] Salud Colect. 2018;14(4):757–77 (in related stressors, psychosocial outcomes and HIV risk
Spanish). doi:10.18294/sc.2018.1395. behaviour among truck drivers in Zambia. Afr J AIDS Res.
2016;15(3):219–26. doi:10.2989/16085906.2016.1179653.
46. McClure HH, Josh Snodgrass J, Martinez CR, Squires EC,
Jiménez RA, Isiordia LE et al. Stress, place, and allostatic load 56. Ehrlich R, Montgomery A, Akugizibwe P, Gonsalves G. Public
among Mexican immigrant farmworkers in Oregon. J Immigr health implications of changing patterns of recruitment into
Minor Health. 2015;17(5):1518–25. doi:10.1007/s10903-014- the South African mining industry, 1973–2012: a database
0066-z. analysis. BMC Public Health. 2017;18(1):93. doi:10.1186/
s12889-017-4640-x.
47. Desarrollo y salud en Costa Rica: elementos para su análisis
[Development and health in Costa Rica: elements for 57. Baltazar CS, DeLima YV, Ricardo H, Botão C, Langa DC, da
analysis]. Organización Panamericana de la Salud Ministerio Costa P et al. HIV prevalence and TB in migrant miners
de Salud Organización Panamericana de la Salud, Facultad communities of origin in Gaza Province, Mozambique: the
Latinoamericana de Ciencias Sociales. – Organización need for increasing awareness and knowledge. PLOS One.
Panamericana de la Salud (https://www.acnur.org/fileadmin/ 2020;15(4):e0231303. doi:10.1371/journal.pone.0231303.
Documentos/Publicaciones/2008/6307.pdf, accessed
58. Falcao J, Zerbe A, Lahuerta M, Baggaley R, Ahoua L, DiMattei P
24 June 2022).
et al. Factors associated with use of short-term pre-exposure
48. Gálvez M del CA, Gordillo G del CA, Solana EE, Gálvez M del prophylaxis for HIV among female partners of migrant miners
CA, Gordillo G del CA, Solana EE. Prácticas de alimentación in Mozambique. AIDS Patient Care STDS. 2017;31(12):528–34.
y salud entre trabajadores agrícolas migrantes en Miguel doi:10.1089/apc.2017.0179.
Alemán, Sonora, México [Nutrition and health practices
59. Smith J, Blom P. Those who don't return: improving
among migrant farm workers in Miguel Aleman, Sonora,
efforts to address tuberculosis among former miners
Mexico]. Poblac Salud Mesoamérica. 2019;17(1):201–24
in southern Africa. New Solut. 2019;29(1):76–104.
(in Spanish). doi:10.15517/psm.v17i1.37822.
doi:10.1177/1048291119832082.
49. Lee J-Y, Cho S. Prohibition on changing workplaces
60. Kistnasamy B, Yassi A, Yu J, Spiegel SJ, Fourie A, Barker S et
and fatal occupational injuries among Chinese migrant
al. Tackling injustices of occupational lung disease acquired
workers in South Korea. Int J Environ Res Public Health.
in South African mines: recent developments and ongoing
2019;16(18):3333. doi:10.3390/ijerph16183333.
challenges. Global Health. 2018;14(1):60. doi:10.1186/s12992-
50. de Gruchy T. Responding to the health needs of migrant farm 018-0376-3.
workers in South Africa: opportunities and challenges for
61. Green O, Ayalon L. Violations of workers' rights and exposure
sustainable community‐based responses. Health Soc Care
to work-related abuse of live-in migrant and live-out local
Community. 2020;28(1):60–8. doi:10.1111/hsc.12840.
home care workers - a preliminary study: implications
51. de Gruchy T, Vearey J. "Left behind": why implementing for health policy and practice. Isr J Health Policy Res.
migration-aware responses to HIV for migrant farm workers is 2018;7(1):32. doi:10.1186/s13584-018-0224-1.
a priority for South Africa. Afr J AIDS Res. 2020;19(1):57–68.
62. Labao HC, Faller EM, Bacayo MFD. "Aches and pains" of
doi:10.2989/16085906.2019.1698624.
Filipino migrant workers in Malaysia: a profile of work-related
52. Work permits and employment of Syrian refugees in Jordan: musculoskeletal disorders. Ann Glob Health. 2018;84(3):474–
towards formalising the work of Syrian refugees. Geneva: 80. doi:10.29024/aogh.2331.
International Labour Organization; 2017 (http://www.ilo.
63. Mendoza NB, Mordeno IG, Latkin CA, Hall BJ. Evidence of
org/beirut/publications/WCMS_559151/lang--en/index.htm,
the paradoxical effect of social network support: a study
among Filipino domestic workers in China. Psychiatry Res.
2017;255:263–71. doi:10.1016/j.psychres.2017.05.037.
157
64. Hall BJ, Pangan CAC, Chan EWW, Huang RL. The effect of 75. Selvey LA, Lobo RC, McCausland KL, Donovan B, Bates J,
discrimination on depression and anxiety symptoms and Hallett J. Challenges facing Asian sex workers in Western
the buffering role of social capital among female domestic Australia: implications for health promotion and support
workers in Macao, China. Psychiatry Res. 2019;271:200–7. services. Front Public Health. 2018;6:171. doi:10.3389/
doi:10.1016/j.psychres.2018.11.050. fpubh.2018.00171.
65. Women on the move: migration, care work and health. 76. Ruiz-Burga E. Implications of migration patterns and sex
Geneva: World Health Organization; 2017 (https://apps.who. work on access to health services and key health outcomes: a
int/iris/handle/10665/259463, accessed 21 April 2022). qualitative study on male migrant sex workers in London. Int J
Sex Health. 2021;33(3):237–47. doi:10.1080/19317611.2021.
66. Rhead RD, Chui Z, Bakolis I, Gazard B, Harwood H,
1902893.
MacCrimmon S. Impact of workplace discrimination and
harassment among National Health Service staff working in 77. Febres-Cordero B, Brouwer KC, Rocha-Jimenez T, Fernandez-
London trusts: results from the TIDES study. BJPsych Open. Casanueva C, Morales-Miranda S, Goldenberg SM. Influence
2020;7(1):e(10). doi:10.1192/bjo.2020.137. of peer support on HIV/STI prevention and safety amongst
international migrant sex workers: a qualitative study at the
Mexico–Guatemala border. PLOS One. 2018;13(1):e0190787.
health in the WHO European Region (2020). Copenhagen:
WHO Regional Office for Europe; 2020 (https://apps.who.int/
iris/handle/10665/337694, accessed 29 March 2022). 78. Challenges for the collection of reliable OSH data - fact sheet.
Geneva: International Labour Organization; 2017 (https://
68. Ennis CA, Walton-Roberts M. Labour market regulation
www.ilo.org/global/topics/safety-and-health-at-work/
as global social policy: the case of nursing labour
events-training/events-meetings/world-day-for-safety/
markets in Oman. Glob Soc Policy. 2018;18(2):169–88.
WCMS_546702/lang--en/index.htm, accessed 29 March 2022).
doi:10.1177/1468018117737990.
79. ILOSTAT Data. Geneva: International Labour Organization;
69. Walker R. Selling sex, mothering and "keeping well" in the
2022 (https://ilostat.ilo.org/data/, accessed 4 May 2022).
city: reflecting on the everyday experiences of cross-border
migrant women who sell sex in Johannesburg. Urban Forum. 80. Orrenius PM, Zavodny M. Do immigrants work in riskier jobs?
2016;28:59–73. doi:10.1007/s12132-016-9284-x. Demography. 2009;46(3):535–51. doi:10.1353/dem.0.0064.
70. Mutola S, Pemunta NV, Ngo NV, Otang OI, Tabenyang T-CJ. 81. Orellana C, Kreshpaj B, Burstrom B, Davis L, Frumento P,
The plight of female Cameroonian migrant sex workers in Hemmingsson T et al. Organisational factors and under-
N'Djamena, Chad: a case of intersectionality. J Immigr Minor reporting of occupational injuries in Sweden: a population-
Health. 2022;24(2):430–6. doi:10.1007/s10903-021-01216-5. based study using capture–recapture methodology.
Occup Environ Med. 2021;78(10):745–52. doi:10.1136/
71. Rosenberg JS, Bakomeza D. Let's talk about sex work in
oemed-2020-107257.
humanitarian settings: piloting a rights-based approach to
working with refugee women selling sex in Kampala. Reprod 82. World social protection report 2020–22. Geneva:
Health Matters. 2017;25(51):95–102. doi:10.1080/09688080. International Labour Organization; 2021 (https://www.ilo.
2017.1405674. org/global/research/global-reports/world-social-security-
report/2020-22/lang--en/index.htm, accessed 29 March 2022).
72. Sex workers: monitoring implementation of the Dublin
Declaration on Partnership to Fight HIV/AIDS in Europe and 83. Salminen S. Are immigrants at increased risk of occupational
Central Asia: 2014 progress report. Stockholm: European injury? A literature review. Ergon Open J. 2011;4:125–30.
Centre for Disease Prevention and Control; 2015 (https:// doi:10.2174/1875934301104010125.
op.europa.eu/en/publication-detail/-/publication/f2695f12-
84. Coderre-Proulx M, Campbell C, Mandé I. International migrant
8450-11e5-b8b7-01aa75ed71a1/language-en, accessed
workers in the mining sector. Geneva: International Labour
29 March 2022).
Organization; 2016 (http://www.ilo.int/wcmsp5/groups/
73. Goldenberg SM, Krüsi A, Zhang E, Chettiar J, Shannon K. public/---ed_protect/---protrav/---migrant/documents/
Structural determinants of health among im/migrants publication/wcms_537175.pdf, accessed 29 March 2022).
in the indoor sex industry: experiences of workers and
85. Bulat P, Protić J, Hirose K. Occupational safety and health
managers/owners in Metropolitan Vancouver. PLOS One.
in the construction sector in Serbia. Geneva: International
Labour Organization; 2019 (http://www.ilo.org/budapest/
74. Hongjaisee S, Khamduang W, Sripan P, Choyrum S, what-we-do/publications/WCMS_671139/lang--en/index.htm,
Thepbundit V, Ngo-Giang-Huong N. Prevalence and factors accessed 29 March 2022).
associated with hepatitis B and D virus infections among
migrant sex workers in Chiangmai, Thailand: a cross-sectional
study in 2019. Int J Infect Dis. 2020;100:247–54. doi:10.1016/j.
ijid.2020.09.004.
158
86. Buckley M, Zendel A, Biggar J, Frederiksen L, Wells J. Migrant 96. Logie CH, Okumu M, Mwima SP, Kyambadde P, Hakiza R,
work and employment in the construction sector. Geneva: Kibathi IP et al. Exploring associations between adolescent
International Labour Organization; 2016 (https://www.ilo.org/ sexual and reproductive health stigma and HIV testing
wcmsp5/groups/public/---ed_protect/---protrav/---migrant/ awareness and uptake among urban refugee and displaced
documents/publication/wcms_538487.pdf, accessed youth in Kampala, Uganda. Sex Reprod Health Matters.
29 March 2022). 2019;27(3):86–106. doi:10.1080/26410397.2019.1695380.
87. Vallejos QM, Quandt SA, Grzywacz JG, Isom S, Chen H, Galván 97. Dune T, Mapedzahama V. Culture clash: Shona (Zimbabwean)
L et al. Migrant farmworkers' housing conditions across migrant women's experiences with communicating about
an agricultural season in North Carolina. Am J Ind Med. sexual health and wellbeing across cultures and generations.
2011;54(7):533–44. doi:10.1002/ajim.20945. Afr J Reprod Health. 2017;21(1):18–29. doi:10.29063/ajrh2017/
v21i1.1.
88. Family planning - a global handbook for providers. Geneva:
World Health Organization; 2018 (https://apps.who.int/iris/ 98. Kågesten AE, Zimmerman L, Robinson C, Lee C, Bawoke T,
handle/10665/260156/, accessed 29 March 2022). Osman S et al. Transitions into puberty and access to sexual
and reproductive health information in two humanitarian
89. Ivanova O, Rai M, Mlahagwa W, Tumuhairwe J, Bakuli A,
settings: a cross-sectional survey of very young adolescents
Nyakato VN et al. A cross-sectional mixed-methods study
from Somalia and Myanmar. Confl Health. 2017;11
of sexual and reproductive health knowledge, experiences
(suppl 1):24. doi:10.1186/s13031-017-0127-8.
and access to services among refugee adolescent girls in
the Nakivale refugee settlement, Uganda. Reprod Health. 99. Kannappan S, Shanmugam K. Peer educators as change
2019;16(1):35. doi:10.1186/s12978-019-0698-5. leaders - effectiveness of peer education process in creating
awareness on reproductive health among women workers in
90. Ahmed R, Farnaz N, Aktar B, Hassan R, Shafique SB, Ray P et
textile industry. Indian J Community Med. 2019;44(3):252–5.
al. Situation analysis for delivering integrated comprehensive
doi:10.4103/ijcm.IJCM_6_19.
sexual and reproductive health services in humanitarian
crisis condition for Rohingya refugees in Cox's Bazar, 100. Botfield J, Newman C, Zwi A. P4.51 Engaging young
Bangladesh: protocol for a mixed-method study. BMJ Open. people from migrant and refugee backgrounds with
2019;9(7):e028340. doi:10.1136/bmjopen-2018-028340. sexual and reproductive health promotion and care in
Sydney, Australia. Sex Trans Inf. 2017;93(2). doi:10.1136/
91. Botfield JR, Zwi AB, Rutherford A, Newman CE. Learning
sextrans-2017-053264.548.
about sex and relationships among migrant and refugee
young people in Sydney, Australia: "I never got the talk about 101. Botfield JR, Newman CE, Zwi AB. Engaging refugee and
the birds and the bees". Sex Educ. 2018;18(6):705–20. doi:10.1 migrant young people with sexual health care: does
080/14681811.2018.1464905. generation matter more than culture? Sex Res Soc Policy.
2018;15(4):398–408. doi:10.1007/s13178-018-0320-6.
92. Matsumoto M, Wimer G, Sethi A. Health needs of refugees:
port of arrival versus permanent camp settings. East Mediterr 102. Lee C, Aules Y, Sami S, Lar PK, Schlect J, Robinson C. Sexual
Health J. 2019;25(5):306–14. doi:10.26719/emhj.18.041. and reproductive health needs and risks of very young
adolescent refugees and migrants from Myanmar living in
93. Tapales A, Douglas-Hall A, Whitehead H. The sexual and
Thailand. Confl Health. 2017;11(suppl 1):30. doi:10.1186/
reproductive health of foreign-born women in the United
s13031-017-0130-0.
States. Contraception. 2018;98(1):47–51. doi:10.1016/j.
contraception.2018.02.003. 103. Rogers C, Earnest J. Sexual and reproductive health
communication among Sudanese and Eritrean women: an
94. Schmidt N, Quack K, Fargnoli V, Epiney M, Irion O.
exploratory study from Brisbane, Australia. Cult Health Sex.
Exploring barriers to reproductive health services for
2015;17(2):223–36. doi:10.1080/13691058.2014.967302.
migrant women in Geneva using a community-based
approach. Geburtshilfe Frauenheilkd. 2017;77(02):182–91. 104. Ganle JK, Amoako D, Baatiema L, Ibrahim M. Risky sexual
doi:10.1055/s-0037-1598145. behaviour and contraceptive use in contexts of displacement:
insights from a cross-sectional survey of female adolescent
95. Logie CH, Okumu M, Mwima S, Kyambadde P, Hakiza R,
refugees in Ghana. Int J Equity Health. 2019;18(1):127.
Kibathi IP et al. Sexually transmitted infection testing
doi:10.1186/s12939-019-1031-1.
awareness, uptake and diagnosis among urban refugee and
displaced youth living in informal settlements in Kampala, 105. Gebrecherkos K, Gebremariam B, Gebeyehu A, Siyum H,
Uganda: a cross-sectional study. BMJ Sex Reprod Health. Kahsay G, Abay M. Unmet need for modern contraception and
2020;46(3):192–9. doi:10.1136/bmjsrh-2019-200392. associated factors among reproductive age group women
in Eritrean refugee camps, Tigray, north Ethiopia: a cross-
sectional study. BMC Res Notes. 2018;11(1):851. doi:10.1186/
s13104-018-3956-7.
159
106. Inci MG, Kutschke N, Nasser S, Alavi S, Abels I, Kurmeyer C et 115. Health access and utilization survey among Syrian refugees
al. Unmet family planning needs among female refugees and in Lebanon - November 2017. Geneva: Office of the United
asylum seekers in Germany – is free access to family planning Nations High Commissioner for Refugees, Public Health;
services enough? Results of a cross-sectional study. Reprod 2017 (https://reliefweb.int/report/lebanon/health-access-
Health. 2020;17(1):115. doi:10.1186/s12978-020-00962-3 . and-utilization-survey-among-syrian-refugees-lebanon-
november-2017, accessed 29 April 2022).
107. Raben LAD, van den Muijsenbergh METC. Inequity in
contraceptive care between refugees and other migrant 116. Health access and utilization survey among Syrian refugees
women? A retrospective study in Dutch general practice. Fam in Lebanon - December 2018. Geneva: Office of the United
Pract. 2018;35(4):468–74. doi:10.1093/fampra/cmx133. Nations High Commissioner for Refugees, Public Health;
2018 (https://reliefweb.int/report/lebanon/health-access-
108. Åkerman E, Larsson EC, Essén B, Westerling R. A missed
and-utilization-survey-among-syrian-refugees-lebanon-
opportunity? Lack of knowledge about sexual and
december-2018, accessed 29 April 2022).
reproductive health services among immigrant women in
Sweden. Sex Reprod Healthc. 2019;19:64–70. doi:10.1016/j. 117. Health access and utilization survey among Syrian refugees
srhc.2018.12.005. in Lebanon - November 2019. Geneva: Office of the United
Nations High Commissioner for Refugees, Public Health;
109. Mamuk R, Şahin NH. Reproductive health issues of
undocumented migrant women living in Istanbul. Eur J
Contracept Reprod Health Care. 2021;26(3):202–8. doi:10.
1080/13625187.2020.1843618.
118. Health access and utilization survey among Syrian refugees
110. Action plan for sexual and reproductive health: towards
in Lebanon - October 2020. Geneva: Office of the United
achieving the 2030 Agenda for Sustainable Development
Nations High Commissioner for Refugees, Public Health; 2020
in Europe - leaving no one behind. Copenhagen: WHO
(https://reliefweb.int/report/lebanon/unhcr-health-access-
Regional Office for Europe; 2016 (https://www.euro.who.
int/__data/assets/pdf_file/0003/322275/Action-plan-sexual-
october-2020, accessed 29 April 2022).
reproductive-health.pdf, accessed 29 March 2022).
119. Kanwal N, Muttappallymyalil J, Al-Sharbatti S, Ismail I.
111. Jones NA, Baird S, Kilburn A, Hamad BA, Banioweda J,
Contraceptive utilisation among mothers of reproductive age
Alabbadi K et al. Adolescent well-being in Jordan: exploring
in Ajman, United Arab Emirates. Sultan Qaboos Univ Med J.
gendered capabilities, contexts and change strategies - a
2017;17(1):e50–8. doi:10.18295/squmj.2016.17.01.010.
synthesis report on GAGE Jordan baseline findings. In:
Gender and Adolescence: Global Evidence. London: Overseas 120. Tran TDH, Tuan DK, Anh ND, Le TKA, Bui TTH. Premarital sex,
Development Institute; 2019 (https://reliefweb.int/report/ contraceptive use among unmarried women migrant workers
jordan/adolescent-well-being-jordan-exploring-gendered- in industrial parks in Vietnam, 2015. Health Care Women Int.
capabilities-contexts-and-change, accessed 29 March 2019). 2018;39(4):377–88. doi:10.1080/07399332.2017.1412439.
112. Jordan population and family health survey 2017–18. 121. Shah R, Kiriya J, Shibanuma A, Jimba M. Use of modern
Amman: Department of Statistics, Government of Jordan; contraceptive methods and its association with QOL among
2019 (http://dosweb.dos.gov.jo/products/dhs2017-2018/, Nepalese female migrants living in Japan. PLOS One.
accessed 29 March 2022). 2018;13(5):e0197243. doi:10.1371/journal.pone.0197243.
113. At a glance: health access and utilization survey among non- 122. Ellawela Y, Nilaweera I, Holton S, Rowe H, Kirkman M, Jordan
camp refugees in Lebanon - November 2015. Geneva: Office L et al. Contraceptive use and contraceptive health care needs
of the United Nations High Commissioner for Refugees, Public among Sri Lankan migrants living in Australia: findings from
Health; 2015 (https://reliefweb.int/report/lebanon/glance- the understanding fertility management in contemporary
health-access-and-utilization-survey-among-non-camp- Australia survey. Sex Reprod Healthc. 2017;12:70–5.
refugees-lebanon-november, accessed 29 April 2022). doi:10.1016/j.srhc.2017.03.003.
114. At a glance: health access and utilization survey among Syrian 123. Dolan H, Li M, Bateson D, Thompson R, Tam CWM, Bonner C
refugees in Lebanon - September 2016. Geneva: Office of et al. "Every medicine is part poison": a qualitative inquiry into
the United Nations High Commissioner for Refugees, Public the perceptions and experiences of choosing contraceptive
Health; 2016 (https://reliefweb.int/report/lebanon/glance- methods of migrant Chinese women living in Australia. BMC
health-access-and-utilization-survey-among-syrian-refugees- Womens Health. 2021;21(1):100. doi:10.1186/s12905-021-
lebanon-september, accessed 29 April 2022). 01226-3.
160
124. Inoue K, Kelly M, Bateson D, Rutherford A, Stewart M, Richters 134. Tanabe M, Greer A, Leigh J, Modi P, Davis WW, Mhote PP et al.
J. Contraceptive choices and sexual health of Japanese An exploration of gender-based violence in eastern Myanmar
women living in Australia: a brief report from a qualitative in the context of political transition: findings from a qualitative
study. Aust Fam Physician. 2016;45(7):523–7. PMID:27610438. sexual and reproductive health assessment. Sex Reprod
Health Matters. 2019;27(2):1665161. doi:10.1080/26410397.
125. Metusela C, Ussher J, Perz J, Hawkey A, Morrow M, Narchal
2019.1665161.
R et al. "In my culture, we don't know anything about that":
sexual and reproductive health of migrant and refugee 135. Obregón M. Extending the Latina Paradox: comparative
women. Int J Behav Med. 2017;24(6):836–45. doi:10.1007/ findings of sexually transmitted infections among Mexican
s12529-017-9662-3. origin, black, and white birth-giving women. Popul Rev.
2019;58(1). doi:10.1353/prv.2019.0003.
126. Migración y salud en Costa Rica: elementos para su análisis
[Migration and health in Costa Rica: elements for analysis]. 136. Tangmunkongvorakul A, Musumari PM, Srithanaviboonchai K,
San José: Ministerio de Salud, Costa Rica; 2003 Manoyos V, Techasrivichien T, Suguimoto SP et al. "When I first
(in Spanish; https://www.acnur.org/fileadmin/Documentos/ saw a condom, I was frightened": a qualitative study of sexual
Publicaciones/2008/6307.pdf, accessed 29 March 2022). behavior, love and life of young cross-border migrants in
urban Chiang Mai, Thailand. PLOS One. 2017;12(8):e0183255.
127. Cardozo Delgado S. Mujeres que migran: atención en salud
sexual y reproductiva a migrantes afrocaribeñas en Uruguay
[Women on the move: sexual and reproductive health 137. Bhatta MP, Johnson DC, Lama M, Maharjan B, Lhaki P,
care for Afro-Caribbean migrants in Uruguay]. Encuentros Shrestha S. Cervical cancer and human papillomavirus
Latinoamericanos (segunda época). 2018;2(2):49–85 vaccine awareness among married Bhutanese refugee
(in Spanish; https://ojs.fhce.edu.uy/index.php/enclat/article/ and Nepali women in eastern Nepal. J Community Health.
view/124, accessed 29 March 2022). 2020;45(3):516–25. doi:10.1007/s10900-019-00770-2.
128. Sieverding M, Krafft C, Berri N, Keo C. Persistence and change 138. Jirattikorn A, Tangmunkongvorakul A, Musumari PM,
in marriage practices among Syrian refugees in Jordan. Stud Ayuttacorn A, Srithanaviboonchai K, Banwell C et al. Sexual
Fam Plann. 2020;51(3):225–49. doi:10.1111/sifp.12134. risk behaviours and HIV knowledge and beliefs of Shan
migrants from Myanmar living with HIV in Chiang Mai,
129. Wanigaratne S, Wiedmeyer M-L, Brown HK, Guttmann A,
Thailand. Int J Migr Health Soc Care. 2020;16(4). doi:10.1108/
Urquia ML. Induced abortion according to immigrants'
IJMHSC-09-2019-0080.
birthplace: a population-based cohort study. Reprod Health.
2020;17(1):143. doi:10.1186/s12978-020-00982-z. 139. Morales A, Li Wing-Ching K, Acuña G. Migración y salud en
zonas fronterizas: Nicaragua y Costa Rica [Migration and
130. Fetters T, Rubayet S, Sultana S, Nahar S, Tofigh S, Jones L et
health in border areas: Nicaragua and Costa Rica]. United
al. Navigating the crisis landscape: engaging the ministry of
Nations Economic Commission for Latin America and the
health and United Nations agencies to make abortion care
Caribbean; 2010 (in Spanish; https://repositorio.cepal.org/
available to Rohingya refugees. Confl Health. 2020;14(1):50.
doi:10.1186/s13031-020-00298-6.
140. Montiel Armas I, Canales Cerón AI, Vargas Becerra PN.
131. Fontanelli Sulekova L, Spaziante M, Vita S, Zuccalà P,
Migración y salud en zonas fronterizas: Guatemala y México
Mazzocato V, Spagnolello O et al. The pregnancy outcomes
[Migration and health in border areas: Guatemala and
among newly arrived asylum-seekers in Italy: implications
Mexico]. United Nations Economic Commission for Latin
of public health. J Immigr Minor Health. 2021;23(2):232–9.
America and the Caribbean; 2010 (in Spanish; https://
doi:10.1007/s10903-020-01126-y.
repositorio.cepal.org/handle/11362/7233, accessed
132. Jokela S, Lilja E, Kinnunen TI, Gissler M, Castaneda AE, 29 March 2022).
Koponen P. Births and induced abortions among women
141. Reques L, Aranda-Fernandez E, Rolland C, Grippon A, Fallet
of Russian, Somali and Kurdish origin, and the general
N, Reboul C et al. Episodes of violence suffered by migrants
population in Finland - comparison of self-reported and
transiting through Libya: a cross-sectional study in "Médecins
register data. BMC Pregnancy Childbirth. 2018;18(1):296.
du Monde's" reception and healthcare centre in Seine-Saint-
doi:10.1186/s12884-018-1931-x.
Denis, France. Confl Health. 2020;14(1):12. doi:10.1186/
133. Loganathan T, Chan ZX, de Smalen AW, Pocock NS. Migrant s13031-020-0256-3.
women's access to sexual and reproductive health services in
142. Parrado EA, Flippen CA, McQuiston C. Migration and
Malaysia: a qualitative study. Int J Environ Res Public Health.
relationship power among Mexican women. Demography.
2020;17(15):5376. doi:10.3390/ijerph17155376.
2005;42(2):347–72. doi:10.1353/dem.2005.0016.
161
143. Vu A, Wirtz A, Pham K, Singh S, Rubenstein L, Glass N et al. 153. Leyva-Flores R, Infante C, Gutierrez JP, Quintino-Perez F,
Psychometric properties and reliability of the Assessment Gómez-Saldivar M, Torres-Robles C. Migrants in transit
Screen to Identify Survivors Toolkit for Gender Based Violence through Mexico to the US: experiences with violence and
(ASIST-GBV): results from humanitarian settings in Ethiopia related factors, 2009-2015. PLOS One. 2019;14(8):e0220775.
and Colombia. Confl Health. 2016;10:1. doi:10.1186/s13031- doi:10.1371/journal.pone.0220775.
016-0068-7.
154. Baranowski KA, Wang E, D'Andrea MR, Singer EK. Experiences
144. Al-Modallal H. Effect of intimate partner violence on health of of gender-based violence in women asylum seekers from
women of Palestinian origin. Int Nurs Rev. 2016;63(2):259–66. Honduras, El Salvador and Guatemala. Torture. 2019;29(3):46–
doi:10.1111/inr.12239. 58. doi:10.7146/torture.v29i3.111970.
145. Delkhosh M, Merghati Khoei E, Ardalan A, Rahimi Foroushani 155. Soria-Escalante H, Alday-Santiago A, Alday-Santiago E, Limón-
A, Gharavi MB. Prevalence of intimate partner violence and Rodríguez N, Manzanares-Melendres P, Tena-Castro A. "We all
reproductive health outcomes among Afghan refugee women get raped": sexual violence against Latin American women
in Iran. Health Care Women Int. 2019;40(2):213–37. doi:10. in migratory transit in Mexico. Violence Against Women.
1080/07399332.2018.1529766. 2022;28(5):1259–81. doi:10.1177/10778012211013909.
146. Bartels SA, Michael S, Bunting A. Child marriage among Syrian 156. Infante C, Leyva-Flores R, Gutierrez JP, Quintino-Perez F,
refugees in Lebanon: at the gendered intersection of poverty, Torres-Robles CA, Gomez-Zaldívar M. Rape, transactional sex
immigration, and safety. J Immigr Refug Stud. 2021;19(4):472– and related factors among migrants in transit through Mexico
87. doi:10.1080/15562948.2020.1839619. to the USA. Cult Health Sex. 2020;22(10):1145–60. doi:10.1080/
13691058.2019.1662088.
147. Al-Natour A, Al-Ostaz SM, Morris EJ. Marital violence
during war conflict: the lived experience of Syrian 157. Lemus-Way MC, Johansson H. Strengths and resilience
refugee women. J Transcult Nurs. 2019;30(1):32–8. of migrant women in transit: an analysis of the narratives
doi:10.1177/1043659618783842. of Central American Women in irregular transit through
Mexico towards the USA. J Int Migr Integr. 2020;21(3):745–63.
148. Hirsch JS, Muñoz-Laboy M, Nyhus CM, Yount KM,
doi:10.1007/s12134-019-00690-z.
Bauermeister JA. They "miss more than anything their normal
life back home": masculinity and extramarital sex among 158. Female refugees face physical assault, exploitation and
Mexican migrants in Atlanta. Perspect Sex Reprod Health. sexual harassment on their journey through Europe. London:
2009;41(1):23–32. doi:10.1111/j.1931-2393.2009.4112309.x. Amnesty International; 2016 (https://www.amnesty.org/en/
latest/news/2016/01/female-refugees-face-physical-assault-
149. Granada I, Ortiz P, Muñoz F, Jiménez AS, Pombo C, Tamayo
exploitation-and-sexual-harassment-on-their-journey-
L. La migración desde una perspectiva de género: ideas
through-europe/, accessed 29 March 2022).
operativas para su integración en proyectos de desarrollo
[Migration from a gender perspective: operational ideas for 159. Harrowing journeys: children and youth on the move across
mainstreaming in development projects]. Washington (DC): the Mediterranean Sea, at risk of trafficking and exploitation.
Inter-American Development Bank; 2021 (in Spanish; https:// New York: United Nations Children's Fund (UNICEF); 2017
publications.iadb.org/publications/spanish/document/ (https://publications.iom.int/books/harrowing-journeys-
La-migracion-desde-una-perspectiva-de-genero-Ideas- children-and-youth-move-across-mediterranean-sea-risk-
operativas-para-su-integracion-en-proyectos-de-desarrollo. trafficking-and, accessed 29 March 2022).
pdf, accessed 29 March 2022).
160. Chynoweth SK, Buscher D, Martin S, Zwi AB. Characteristics
150. Oliveira C, Keygnaert I, Oliveira Martins M do R, Dias S. and impacts of sexual violence against men and boys in
Assessing reported cases of sexual and gender-based conflict and displacement: a multicountry exploratory
violence, causes and preventive strategies, in European study. J Interpers Violence. 2020;088626052096713.
asylum reception facilities. Glob Health. 2018;14(1):48. doi:10.1177/0886260520967132.
doi:10.1186/s12992-018-0365-6.
161. Female genital mutilation (FGM) statistics. New York: United
151. Keygnaert I, Guieu A. What the eye does not see: a critical Nations Children's Fund (UNICEF); 2021 (https://data.unicef.
interpretive synthesis of European Union policies addressing org/topic/child-protection/female-genital-mutilation/,
sexual violence in vulnerable migrants. Reprod Health accessed 29 March 2022).
Matters. 2015;23(46):45–55. doi:10.1016/j.rhm.2015.11.002.
162. WHO guidelines on the management of health
152. Nisrane BL, Ossewaarde R, Need A. The exploitation narratives complications from female genital mutilation. Geneva:
and coping strategies of Ethiopian women return migrants World Health Organization; 2016 (https://apps.who.int/iris/
from the Arabian Gulf. Gend Place Cult. 2020;27(4):568–86. handle/10665/206437, accessed 29 March 2022).
doi:10.1080/0966369X.2019.1611545.
162
163. Turkmani S, Homer CSE, Dawson A. Maternity care 173. Fakoya I, Álvarez-del Arco D, Copas AJ, Teixeira B, Block
experiences and health needs of migrant women from K, Gennotte A-F et al. Factors associated with access to
female genital mutilation-practicing countries in high-income HIV testing and primary care among migrants living in
contexts: a systematic review and meta-synthesis. Birth. Europe: cross-sectional survey. JMIR Public Health Surveill.
2019;46(1):3–14. doi:10.1111/birt.12367. 2017;3(4):e84. doi:10.2196/publichealth.7741.
164. Rouzi AA, Berg RC, Alamoudi R, Alzaban F, Sehlo M. 174. Kentoffio K, Berkowitz SA, Atlas SJ, Oo SA, Percac-Lima
Survey on female genital mutilation/cutting in Jeddah, S. Use of maternal health services: comparing refugee,
Saudi Arabia. BMJ Open. 2019;9(5):e024684. doi:10.1136/ immigrant and US-born populations. Matern Child Health J.
bmjopen-2018-024684. 2016;20(12):2494–501. doi:10.1007/s10995-016-2072-3.
165. Johansen REB. Virility, pleasure and female genital 175. Mahon A, Merry L, Lu O, Gagnon AJ. Postpartum pain in
mutilation/cutting. A qualitative study of perceptions and the community among migrant and non-migrant women
experiences of medicalized defibulation among Somali and in Canada. J Immigr Minor Health. 2017;19(2):407–14.
Sudanese migrants in Norway. Reprod Health. 2017;14(1):25. doi:10.1007/s10903-016-0364-8.
doi:10.1186/s12978-017-0287-4.
176. Wanigaratne S, Shakya Y, Gagnon AJ, Cole DC, Rashid M, Blake
166. Wahlberg A, Johnsdotter S, Selling KE, Källestål C, Essén B. J et al. Refugee maternal and perinatal health in Ontario,
Baseline data from a planned RCT on attitudes to female Canada: a retrospective population-based study. BMJ Open.
genital cutting after migration: when are interventions 2018;8(4):e018979. doi:10.1136/bmjopen-2017-018979.
justified? BMJ Open. 2017;7(8): e017506. doi:10.1136/
177. Sharifi M, Amiri-Farahani L, Haghani S, Hasanpoor-Azghady
bmjopen-2017-017506.
SB. Predicting factors of postnatal information needs of
167. Tittle V, Bennett DL, Hajat S, Shishtawi A, Zeidan W, Afghan migrants women in Iran. Nurs Pract Today; 2019:6(4).
Abuzabaida F et al. Antenatal care among Palestine refugees doi:10.18502/npt.v6i4.1945.
in Jordan: factors associated with UNRWA attendance.
178. Alnuaimi K, Kassab M, Ali R, Mohammad K, Shattnawi K.
East Mediterr Health J. 2019;25(2):98–103. doi:10.26719/
Pregnancy outcomes among Syrian refugee and Jordanian
emhj.18.017.
women: a comparative study. Int Nurs Rev. 2017;64(4):584–92.
168. Children in the State of Palestine: child development doi:10.1111/inr.12382.
data from the 2019/2020 multiple indicator cluster survey
179. Abdulrahim S, Rafei RE, Beydoun Z, Hayek GYE, Nakad P,
(MICS) New York: United Nations Children's Fund (UNICEF);
Yunis K. A test of the epidemiological paradox in a context of
2021 (https://www.unicef.org/sop/reports/children-state-
forced migration: low birthweight among Syrian newborns in
palestine-0, accessed 29 March 2022).
Lebanon. Int J Epidemiol. 2019;48(1):275–86. doi:10.1093/
169. Gumede S, Black V, Naidoo N, Chersich MF. Attendance at ije/dyy200.
antenatal clinics in inner-city Johannesburg, South Africa
180. Pedersen GS, Grøntved A, Mortensen LH, Andersen A-MN,
and its associations with birth outcomes: analysis of data
Rich-Edwards J. Maternal mortality among migrants in
from birth registers at three facilities. BMC Public Health.
western Europe: a meta-analysis. Matern Child Health J.
2017;17(suppl 3):443. doi:10.1186/s12889-017-4347-z.
2014;18(7):1628–38. doi:10.1007/s10995-013-1403-x.
170. Rustad SA, Binningsbø HM, Gjerløw H, Mwesigye F,
181. Merry L, Semenic S, Gyorkos TW, Fraser W, Gagnon AJ.
Odokonyero T, Østby G. Maternal health care among
Predictors of unplanned cesareans among low‐risk migrant
refugees and host communities in northern Uganda: access,
women from low‐and middle‐income countries living in
quality, and discrimination. Front Glob Womens Health.
Montreal, Canada. Birth. 2016;43(3):209–19. doi:10.1111/
2021;2:626002. doi:10.3389/fgwh.2021.626002.
birt.12234.
171. Di Napoli A, Rossi A, Battisti L, Cacciani L, Caranci N,
182. Tsai H-J, Surkan PJ, Stella MY, Caruso D, Hong X, Bartell
Cernigliaro A et al. [Evaluating health care of the immigrant
TR et al. Differential effects of stress and African ancestry
population in Italy through indicators of a national monitoring
on preterm birth and related traits among US born
system]. Epidemiol Prev. 2020;44(5-6 suppl 1):85–93 (in
and immigrant Black mothers. Medicine (Baltimore).
Italian). doi:10.19191/EP20.5-6.S1.P085.077.
2017;96(5):e5899. doi:10.1097/MD.0000000000005899.
172. Ludwig A, Miani C, Breckenkamp J, Sauzet O, Borde T,
183. Bahamondes L, Laporte M, Margatho D, de Amorim HSF,
Doyle I-M et al. Are social status and migration background
Brasil C, Charles CM et al. Maternal health among Venezuelan
associated with utilization of non-medical antenatal care?
women migrants at the border of Brazil. BMC Public Health.
Analyses from two German studies. Matern Child Health J.
2020;20(1):1771. doi:10.1186/s12889-020-09912-x.
2020;24(7):943–52. doi:10.1007/s10995-020-02937-z.
163
184. Verschuuren AEH, Postma IR, Riksen ZM, Nott RL, Feijen-de 195. Jablonka A, Wetzke M, Sogkas G, Dopfer C, Schmidt RE,
Jong EI, Stekelenburg J. Pregnancy outcomes in asylum Behrens GMN et al. Prevalence and types of anemia in a large
seekers in the north of the Netherlands: a retrospective refugee cohort in western Europe in 2015. J Immigr Minor
documentary analysis. BMC Pregnancy Childbirth. Health. 2018;20(6):1332–8. doi:10.1007/s10903-018-0725-6.
2020;20(1):320. doi:10.1186/s12884-020-02985-x.
196. Joseph J, Brodribb W, Liamputtong P. "Fitting-in Australia"
185. Yelland J, Mensah F, Riggs E, McDonald E, Szwarc J, Dawson as nurturers: meta-synthesis on infant feeding experiences
W et al. Evaluation of systems reform in public hospitals, among immigrant women. Women Birth. 2019;32(6):533–42.
Victoria, Australia, to improve access to antenatal care for doi:10.1016/j.wombi.2018.12.002.
women of refugee background: an interrupted time series
197. Primary health care in the Western Pacific Region: looking
design. Spiegel P, editor. PLOS Med. 2020;17(7):e1003089.
back and future directions. Manila: WHO Regional Office
doi:10.1371/journal.pmed.1003089.
for the Western Pacific; 2018 (https://apps.who.int/iris/
186. Mozooni M, Pennell CE, Preen DB. Healthcare factors handle/10665/276248, accessed 29 March 2022).
associated with the risk of antepartum and intrapartum
198. Azad F, Rifat MA, Manir MZ, Biva NA. Breastfeeding support
stillbirth in migrants in Western Australia (2005–2013): a
through wet nursing during nutritional emergency: a cross
retrospective cohort study. PLOS Med. 2020;17(3):e1003061.
sectional study from Rohingya refugee camps in Bangladesh.
doi:10.1371/journal.pmed.1003061.
PLOS One. 2019;14(10):e0222980. doi:10.1371/journal.
187. Grundy S, Lee P, Small K, Ahmed F. Maternal region of origin pone.0222980.
and small for gestational age: a cross-sectional analysis
199. Lenters L, Wazny K, Bhutta ZA. Management of severe
of Victorian perinatal data. BMC Pregnancy Childbirth.
and moderate acute malnutrition in children. In: Black
2021;21(1):409. doi:10.1186/s12884-021-03864-9.
RE, Laxminarayan R, Temmerman M, Walker N, editors.
188. Lee SJ, Hashmi AH, Min AM, Gilder ME, Tun NW, Wah LL Reproductive, maternal, newborn, and child health: disease
et al. Short maternal stature and gestational weight gain control priorities, third edition (volume 2). Washington (DC):
among refugee and migrant women birthing appropriate for The International Bank for Reconstruction and Development,
gestational age term newborns: a retrospective cohort on The World Bank; 2016 (https://www.ncbi.nlm.nih.gov/books/
the Myanmar-Thailand border, 2004–2016. BMJ Glob Health. NBK361900/, accessed 29 March 2022).
2021;6(2):e004325. doi:10.1136/bmjgh-2020-004325.
200. Hoddinott J, Dorosh P, Filipski M, Rosenbach G, Tiburcio E.
189. A "SMART" core [website]. Geneva: Office of the United Food transfers, electronic food vouchers and child nutritional
Nations High Commissioner for Refugees; 2021 (https://sens. status among Rohingya children living in Bangladesh. PLOS
unhcr.org/about-us/a-smart-core/, accessed 29 March 2022). One. 2020;15(4):e0230457. doi:10.1371/journal.pone.0230457.
190. AbuKishk N, Turki Y, Saleh S, Albaik S, Hababeh M, El-Khatib 201. Rahman MT. Rohingya crisis in Bangladesh and health sector
Z et al. Anaemia prevalence in children newly registered challenges. Anwer Khan Mod Med Coll J. 2018;9(1):3–4.
at UNRWA schools: a cross-sectional study. BMJ Open. doi:10.3329/akmmcj.v9i1.35814.
2020;10(9):e034705. doi:10.1136/bmjopen-2019-034705.
202. Islam K, Kundu C, Rahman MF, Alam N, Mohsin SS, Mohsin
191. Asmar MK, Zablit CG, Daou R, Yéretzian JS, Daoud H, Rady FM et al. Nutritional status of under-5 children of forcibly
A. Prevalence of anemia and associated factors in women migrated people living in Ukhia, Cox Bazar, Bangladesh. J Nutr
of childbearing age in rural Lebanon. J Public Health. Health Sci. 2018;5(4):409–13 (http://www.annexpublishers.
2018;26(3):39–49. doi:10.1007/s10389-017-0853-9. com/articles/JNH/5409-Nutritional-Status-of-Under-5-
Children-of-Forcibly-Migrated-People-Living-in-Ukhia-Cox-
192. Elmardi KA, Adam I, Malik EM, Abdelrahim TA, Elhag MS,
Bazar-Bangladesh.pdf, accessed 29 March 2022).
Ibrahim AA et al. Prevalence and determinants of anaemia
in women of reproductive age in Sudan: analysis of a 203. Vakos A, Khalil N, Kumar A, Menezes L, Ahson M.
cross-sectional household survey. BMC Public Health. Assessment of growth in pediatric Syrian refugee
2020;20(1):1125. doi:10.1186/s12889-020-09252-w. populations in Jordan. Avicenna J Med. 2021;11(4):167–71.
doi:10.1055/s-0041-1736544.
193. Jemal Y, Haidar J, Makau WK. The magnitude and
determinants of anaemia among refugee preschool children 204. Lwin SWW, Geater AF. Ethnic groups and father's job
from the Kebribeyah refugee camp, Somali region, Ethiopia. influencing nutritional status of children (0–30 months) from
South Afr J Clin Nutr. 2017;30(1):1–6. doi:10.1080/16070658.20 Myanmar migrant community in southern Thailand. J Racial
17.1237446. Ethn Health Disparities. 2019;6(5):944–52. doi:10.1007/s40615-
019-00595-8.
194. Orbatu D, Alaygut D, Siviş ZO, Pakdemirli A, Malbora B.
Evaluation of nutritional anemia in Middle Eastern migrant
and refugee children. Turk J Pediatr Dis. 2020;14(3):244–8.
doi:10.12956/tchd.718636.
164
205. Baauw A, Holthe JK van, Slattery B, Heymans M, Chinapaw M, 215. Marrone R, Baglio G, Bruscino G, Costanzo G, Cavani A,
van Goudoever H. Health needs of refugee children identified Mirisola C. Prevalence of latent tuberculosis infection,
on arrival in reception countries: a systematic review and hepatitis B, hepatitis C, and syphilis among newly arrived
meta-analysis. BMJ Paediatr Open. 2019;3(1):e000516. unaccompanied minors living in reception centers in
doi:10.1136/bmjpo-2019-000516. Rome. Int J Infect Dis. 2020;101:126–30. doi:10.1016/j.
ijid.2020.09.020.
206. Aakre I, Lilleengen AM, Lerseth Aarsand M, Strand TA, Barikmo
I, Henjum S. Infant feeding practices in the Saharawi refugee 216. Oliván-Gonzalvo G. Health status and infectious diseases in
camps Algeria, a cross-sectional study among children male unaccompanied immigrant minors from Africa in Spain.
from birth to six months of age. Int Breastfeed J. 2017;12:8. Enferm Infecc Microbiol Clin (Engl Ed). 2021;39(7):340–4.
doi:10.1186/s13006-016-0098-1. doi:10.1016/j.eimce.2020.05.018.
207. Altare C, Delbiso TD, Guha-Sapir D. Child wasting in 217. Muñoz-Pino N, Vives-Cases C, Agudelo-Suárez AA, Ronda-
emergency pockets: a meta-analysis of small-scale surveys Pérez E. Comparing oral health services use in the Spanish
from Ethiopia. Int J Environ Res Public Health. 2016;13(2):178. and immigrant working population. J Immigr Minor Health.
doi:10.3390/ijerph13020178. 2018;20(4):809–15. doi:10.1007/s10903-017-0630-4.
208. Grammatikopoulou MG, Theodoridis X, Poulimeneas 218. Makan R, Gara M, Awwad MA, Hassona Y. The oral health
D, Maraki MI, Gkiouras K, Tirodimos I et al. Malnutrition status of Syrian refugee children in Jordan: an exploratory
surveillance among refugee children living in reception study. Spec Care Dentist. 2019;39(3):306–9. doi:10.1111/
centres in Greece: a pilot study. Int Health. 2019;11(1):30–5. scd.12377.
doi:10.1093/inthealth/ihy053.
219. Smadi L, Azab R, Khlaifat F, Rodan R, Abdalmohdi A, Maata
209. Hashmi AH, Nyein PB, Pilaseng K, Paw MK, Darakamon MC, R et al. Prevalence and severity of dental caries in school
Min AM et al. Feeding practices and risk factors for chronic students aged 6-12 years in Mafraq governorate: northeast of
infant undernutrition among refugees and migrants along Jordan. J Oral Health Oral Epidemiol. 2017;6(1):40–7 (https://
the Thailand-Myanmar border: a mixed-methods study. BMC johoe.kmu.ac.ir/article_84868.html, accessed 29 March 2022).
Public Health. 2019;19(1):1586. doi:10.1186/s12889-019-
220. Khadri FA, Gopinath VK, Hector MP, Davenport ES. Evaluating
7825-7.
the risk factors that link obesity and dental caries in
210. Kim SY, Choi SW. Double burden of malnutrition and obesity 11-17-year-old school going children in the United Arab
in children and adolescents from North Korean refugee Emirates. Eur J Dent. 2018;12(2):217–24. doi:10.4103/ejd.
families. PLOS One. 2020;15(11):e0241963. doi:10.1371/ ejd_29_18.
221. Ferrazzano GF, Cantile T, Sangianantoni G, Ingenito A, Rengo
211. Massad S, Deckelbaum RJ, Gebre-Medhin M, Holleran S, S, Alcidi B et al. Oral health status and unmet restorative
Dary O, Obeidi M et al. Double burden of undernutrition treatment needs (UTN) in disadvantaged migrant and not
and obesity in Palestinian schoolchildren: a cross- migrant children in Italy. Eur J Paediatr Dent. 2019;20(1):
sectional study. Food Nutr Bull. 2016;37(2):144–52. 10–14. doi:10.23804/ejpd.2019.20.01.02.
doi:10.1177/0379572116637720.
222. Child migration [website]. New York: United Nations
212. Chelwa NM, Likwa RN, Banda J. Under-five mortality among Children's Fund (UNICEF); 2021 (https://data.unicef.org/topic/
displaced populations in Meheba refugee camp, Zambia, child-migration-and-displacement/migration/, accessed
2008–2014. Arch Public Health. 2016;74:49. doi:10.1186/ 29 March 2022).
s13690-016-0161-9.
223. Child displacement [website]. New York: United Nations
213. Health of refugee and migrant children: technical guidance. Children's Fund (UNICEF); 2021 (https://data.unicef.org/topic/
Copenhagen: WHO Regional Office for Europe; 2018 (https:// child-migration-and-displacement/displacement/, accessed
apps.who.int/iris/handle/10665/342285, accessed 29 March 2022).
29 March 2022).
224. Health and children on the move. New York: United Nations
214. Garcia-Tizon Larroca S, Arevalo-Serrano J, Duran Vila A, Children's Fund; 2022 (Thematic-brief; https://www.unicef.
Pintado Recarte MP, Cueto Hernandez I, Solis Pierna A et al. org/media/119926/file/Health-and-Children-on-the-Move-
Human development index (HDI) of the maternal country of Thematic-Brief-2022%20.pdf, accessed 20 June 2022).
origin as a predictor of perinatal outcomes - a longitudinal
225. van Hook J, Landale N, Hillemeier M. Is the United States
study conducted in Spain. BMC Pregnancy Childbirth.
bad for children's health? Risk and resilience among young
2017;17(1):314. doi:10.1186/s12884-017-1515-1.
children of immigrants. Washington (DC): Migration Policy
Institute; 2013 (https://www.migrationpolicy.org/research/
united-states-bad-children%E2%80%99s-health-risk-and-
resilience-among-young-children-immigrants, accessed
29 March 2022).
165
226. von Werthern M, Grigorakis G, Vizard E. The mental 236. Reuven Y, Dreiher J, Shvartzman P. The prevalence of diabetes,
health and wellbeing of unaccompanied refugee minors hypertension and obesity among immigrants from East Africa
(URMs). Child Abuse Negl. 2019;98:104146. doi:10.1016/j. and the former Soviet Union: a retrospective comparative
chiabu.2019.104146. 30-year cohort study. Cardiovasc Diabetol. 2016;15:74.
doi:10.1186/s12933-016-0392-7.
227. Mental health and psychosocial support (MHPSS) for families
at the US-Mexico border. New York: United Nations Children's 237. Lê-Scherban F, Albrecht SS, Bertoni A, Kandula N, Mehta N,
Fund (UNICEF); 2020 (https://www.unicef.org/media/89621/ Diez Roux AV. Immigrant status and cardiovascular risk over
file/MHPSS%20Field%20Guide%20(English).pdf, accessed time: results from the Multi-Ethnic Study of Atherosclerosis.
29 March 2022). Ann Epidemiol. 2016;26(6):429-435.e1. doi:10.1016/j.
annepidem.2016.04.008.
228. Ahmad A, Sofi MA, Sundelin-Wahlsten V, von Korring AL.
Posttraumatic stress disorder in children after the military 238. Ververs M, Muriithi JW, Burton A, Burton JW, Lawi AO. Scurvy
operation "Anfal" in Iraqi Kurdistan. Eur Child Adolesc outbreak among South Sudanese adolescents and young
Psychiatry. 2000;9(4):235–43. doi:10.1007/s007870070026. men — Kakuma Refugee Camp, Kenya, 2017–2018. MMWR
Morb Mortal Wkly Rep. 2019;68(3):72–5. doi:10.15585/
229. Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis
mmwr.mm6803a4.
E, Garcés-Ferrer J et al. Migrants' and refugees' health status
and healthcare in Europe: a scoping literature review. BMC 239. Style S, Tondeur M, Grijalva-Eternod C, Pringle J, Kassim
Public Health. 2020;20(1):1039. doi:10.1186/s12889-020- I, Wilkinson C et al. Assessment of the effectiveness of
08749-8. a small quantity lipid-based nutrient supplement on
reducing anaemia and stunting in refugee populations
230. Health of refugees and migrants: regional situation analysis,
in the Horn of Africa: secondary data analysis. PLOS One.
practices, experiences, lessons learned and ways forward.
New Delhi: WHO Regional Office for South-East Asia; 2018
(https://www.who.int/docs/default-source/documents/ 240. Shi HY, Levy AN, Trivedi HD, Chan FKL, Ng SC,
publications/health-of-refugees-and-migrants-searo-2018. Ananthakrishnan AN. Ethnicity influences phenotype and
pdf?sfvrsn=b7c1ad1f_1, accessed 29 March 2022). outcomes in inflammatory bowel disease: a systematic
review and meta-analysis of population-based studies. Clin
231. COVID-19 has led to dramatic reduction in essential
Gastroenterol Hepatol. 2018;16(2):190-197.e11. doi:10.1016/j.
services and protection for migrant and displaced children
cgh.2017.05.047.
in countries around the world. New York: United Nations
Children's Fund (UNICEF); 2020 (https://www.unicef.org/ 241. Benchimol EI, Manuel DG, Mojaverian N, Mack DR, Nguyen
press-releases/covid-19-has-led-dramatic-reduction- GC, To T et al. Health services utilization, specialist care,
essential-services-and-protection-migrant-and, accessed and time to diagnosis with inflammatory bowel disease in
29 March 2022). immigrants to Ontario, Canada: a population-based cohort
study. Inflamm Bowel Dis. 2016;22(10):2482–90. doi:10.1097/
232. Doocy S, Lyles E, Hanquart B, Woodman M; Lebanon Health
MIB.0000000000000905.
Access Survey (LHAS) Study Team. Prevalence, care-seeking,
and health service utilization for non-communicable diseases 242. Carroll MW, Hamilton Z, Gill H, Simkin J, Smyth M, Espinosa
among Syrian refugees and host communities in Lebanon. V et al. Pediatric inflammatory bowel disease among
Confl Health. 2016;10:21. doi:10.1186/s13031-016-0088-3. South Asians living in British Columbia, Canada: a distinct
clinical phenotype. Inflamm Bowel Dis. 2016;22(2):387–96.
233. Bilal PI, Chan CKY, Somerset SM. Depression mediates
doi:10.1097/MIB.0000000000000651.
association between perceived ethnic discrimination and
elevated blood glucose levels among sub-Saharan African 243. Van Biesen W, Vanholder R, Ernandez T, Drewniak D, Luyckx
migrants in Australia. J Immigr Minor Health. 2021;23(2):199– V. Caring for migrants and refugees with end-stage kidney
206. doi:10.1007/s10903-020-01131-1. disease in Europe. Am J Kidney Dis. 2018;71(5):701–9.
doi:10.1053/j.ajkd.2017.10.015.
234. Nagamatsu Y, Barroga E, Sakyo Y, Igarashi Y, Hirano O Y. Risks
and perception of non-communicable diseases and health 244. Wändell P, Carlsson AC, Li X, Gasevic D, Ärnlöv J, Sundquist
promotion behavior of middle-aged female immigrants in J et al. End-stage kidney diseases in immigrant groups:
Japan: a qualitative exploratory study. BMC Womens Health. a nationwide cohort study in Sweden. Am J Nephrol.
2020;20(1):88. doi:10.1186/s12905-020-00955-1. 2019;49(3):186–92. doi:10.1159/000497063.
235. Jin K, Gullick J, Neubeck L, Koo F, Ding D. Acculturation is 245. Cappuccio FP, Modesti PA, Parati G, editors. Ethnic diversities,
associated with higher prevalence of cardiovascular disease hypertension and global cardiovascular risk: updates in
risk-factors among Chinese immigrants in Australia: evidence hypertension and cardiovascular protection. Cham: Springer
from a large population-based cohort. Eur J Prev Cardiol. International Publishing; 2018.
2017;24(18):2000–8. doi:10.1177/2047487317736828.
166
246. Modesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi 255. Mansour Z, Said R, Dbaibo H, Mrad P, Torossian L, Rady A et
G, Rapi S et al. Panethnic differences in blood pressure in al. Non-communicable diseases in Lebanon: results from
Europe: a systematic review and meta-analysis. PLOS One. World Health Organization STEPS survey 2017. Public Health.
2016;11(1):e0147601. doi:10.1371/journal.pone.0147601. 2020;187:120–6. doi:10.1016/j.puhe.2020.08.014.
247. George J, Mathur R, Shah AD, Pujades-Rodriguez M, Denaxas 256. Cheung MC, Earle CC, Fischer HD, Camacho X, Liu N, Saskin
S, Smeeth L et al. Ethnicity and the first diagnosis of a wide R et al. Impact of immigration status on cancer outcomes
range of cardiovascular diseases: associations in a linked in Ontario, Canada. J Oncol Pract. 2017;13(7):e602–12.
electronic health record cohort of 1 million patients. PLOS doi:10.1200/JOP.2016.019497.
One. 2017;12(6):e0178945. doi:10.1371/journal.pone.0178945.
257. Oyarte M, Delgado I, Pedrero V, Agar L, Cabieses B.
248. Fedeli U, Avossa F, Ferroni E, Schievano E, Bilato C, Modesti Hospitalizaciones por cáncer en migrantes internacionales y
PA et al. Diverging patterns of cardiovascular diseases población local en Chile [Cancer admissions in international
across immigrant groups in northern Italy. Int J Cardiol. migrants and the local population in Chile]. Rev Saude
2018;254:362–7. doi:10.1016/j.ijcard.2017.12.014. Publica. 2018;52:36 (in Spanish). doi:10.11606/S1518-
8787.2018052000222.
249. Fedeli U, Cestari L, Ferroni E, Avossa F, Saugo M, Modesti
PA. Ethnic inequalities in acute myocardial infarction 258. Schlumbrecht M, Cerbon D, Castillo M, Jordan S, Butler R,
hospitalisation rates among young and middle-aged adults in Pinto A et al. Race and ethnicity influence survival outcomes
northern Italy: high risk for South Asians. Intern Emerg Med. in women of Caribbean nativity with epithelial ovarian cancer.
2018;13(2):177–82. doi:10.1007/s11739-017-1631-y. Front Oncol. 2020;10:880. doi:10.3389/fonc.2020.00880.
250. Fedeli U, Pigato M, Avossa F, Ferroni E, Nardetto L, Giometto 259. Aldridge RW, Nellums LB, Bartlett S, Barr AL, Patel P,
B et al. Large variations in stroke hospitalization rates across Burns R et al. Global patterns of mortality in international
immigrant groups in Italy. J Neurol. 2016;263(3):449–54. migrants: a systematic review and meta-analysis. Lancet.
doi:10.1007/s00415-015-7995-x. 2018;392(10164):2553–66. doi:10.1016/S0140-6736(18)
32781-8.
251. Fang J, Yuan K, Gindi RM, Ward BW, Ayala C, Loustalot
F. Association of birthplace and coronary heart disease 260. Nisar M, Kolbe-Alexander TL, Burton NW, Khan A. A
and stroke among US adults: National Health Interview longitudinal assessment of risk factors and chronic diseases
Survey, 2006 to 2014. J Am Heart Assoc. 2018;7(7):e008153. among immigrant and non-immigrant adults in Australia. Int
doi:10.1161/JAHA.117.008153. J Environ Res Public Health. 2021;18(16):8621. doi:10.3390/
ijerph18168621.
252. dos Santos Pereira P, Valeriano Alves S, Sales Moreira de
Souza T. Relatório informativo sobre a população migrante 261. Si S, Peters S, Reid A. Variations in mesothelioma mortality
internacional e a rede de saúde do Estado de Goiás [Report rates among migrants to Australia and Australian-born. Ethn
on the international migrant population and the health Health. 2018;23(5):480–7. doi:10.1080/13557858.
network of the State of Goiás]. Goiânia: Secretaria Estadual 2017.1280138.
de Saúde de Goiás; 2020 (in Portuguese; https://www.saude.
262. Thøgersen H, Møller B, Åsli LM, Bhargava S, Kvåle R,
go.gov.br/files/boletins/informativos/populacao-migrante/
Fjellbirkeland L et al. Waiting times and treatment following
RelatorioPopMigranteInternacionalGERPOP.pdf, accessed
cancer diagnosis: comparison between immigrants and the
30 March 2022).
Norwegian host population. Acta Oncol. 2020;59(4):376–83.
253. Health services inequalities affecting the Venezuelan migrant doi:10.1080/0284186X.2019.1711167.
and refugee population in Colombia. Bogatá: Profamilia;
263. Campari C, Fedato C, Iossa A, Petrelli A, Zorzi M, Anghinoni
Washington (DC): United States Agency for International
E et al. Cervical cancer screening in immigrant women
Development (USAID); 2020 (https://profamilia.org.co/
in Italy: a survey on participation, cytology and histology
wp-content/uploads/2020/06/Health-services-inequalities-
results. Eur J Cancer Prev. 2016;25(4):321–8. doi:10.1097/
affecting-the-Venezuelan-migrant-and-refugee-population-
CEJ.0000000000000173.
in-Colombia-how-to-improve-the-local-response-to-the-
humanitarian-emergency.pdf, accessed 30 March 2022). 264. Spiegel PB, Cheaib JG, Aziz SA, Abrahim O, Woodman
M, Khalifa A et al. Cancer in Syrian refugees in Jordan
254. Collins DRJ, Jobanputra K, Frost T, Muhammed S, Ward A,
and Lebanon between 2015 and 2017. Lancet Oncol.
Shafei AA et al. Cardiovascular disease risk and prevention
2020;21(5):e280–91. doi:10.1016/S1470-2045(20)30160-1.
amongst Syrian refugees: mixed methods study of Médecins
Sans Frontières programme in Jordan. Confl Health. 265. Spiegel P, Khalifa A, Mateen FJ. Cancer in refugees in Jordan
2017;11:14. doi:10.1186/s13031-017-0115-z. and Syria between 2009 and 2012: challenges and the
way forward in humanitarian emergencies. Lancet Oncol.
2014;15(7):e290–7. doi:10.1016/S1470-2045(14)70067-1.
167
266. Adoch W, Garimoi CO, Scott SE, Okeny GG, Moodley J, 276. Ghebrendrias S, Pfeil S, Crouthamel B, Chalmiers M, Kully
Komakech H et al. Knowledge of cervical cancer risk factors G, Mody S. An examination of misconceptions and their
and symptoms among women in a refugee settlement: a impact on cervical cancer prevention practices among sub-
cross-sectional study in northern Uganda. Confl Health. Saharan African and Middle Eastern refugees. Health Equity.
2020;14(1):85. doi:10.1186/s13031-020-00328-3. 2021;5(1):382–9. doi:10.1089/heq.2020.0125.
267. Lieber M, Afzal O, Shaia K, Mandelberger A, Preez CD, Beddoe 277. Riza E, Karakosta A, Tsiampalis T, Lazarou D, Karachaliou A,
AM. Cervical cancer screening in HIV-positive farmers in Ntelis S et al. Knowledge, attitudes and perceptions about
South Africa: mixed-method assessment. Ann Glob Health. cervical cancer risk, prevention and human papilloma virus
2019;85(1):58. doi:10.5334/aogh.37. (HPV) in vulnerable women in Greece. Int J Environ Res Public
Health. 2020;17(18):E6892. doi:10.3390/ijerph17186892.
268. Hailemariam G, Gebreyesus H, Wubayehu T, Gebregyorgis
T, Gebrecherkos K, Teweldemedhin M et al. Magnitude and 278. Gebre H, Ghamli S, Jackson F, Chavan B, Kingori C.
associated factors of VIA positive test results for cervical Knowledge, perception and utilization of cervical cancer
cancer screening among refugee women aged 25–49 years screening and human papillomavirus (HPV) vaccination
in North Ethiopia. BMC Cancer. 2020;20(1):858. doi:10.1186/ among immigrants and refugees in Central Ohio. Columbia
s12885-020-07344-9. Univ J Glob Health. 2021;11(1). doi:10.52214/cujgh.v11i1.7225.
269. Petrelli A, Rossi PG, Francovich L, Giordani B, Napoli AD, 279. Dalla V, Panagiotopoulou E-K, Deltsidou A, Kalogeropoulou
Zappa M et al. Geographical and socioeconomic differences M, Kostagiolas P, Niakas D et al. Level of awareness regarding
in uptake of Pap test and mammography in Italy: results cervical cancer among female Syrian refugees in Greece. J
from the National Health Interview Survey. BMJ Open. Cancer Educ. Epub 2020 Sep 22. doi:10.1007/s13187-020-
2018;8(9):e021653. doi:10.1136/bmjopen-2018-021653. 01873-4.
270. Bakkal Temi Y, Murat Sedef A, Gokcay S, Coskun H, Oskeroglu 280. Netfa F, King C, Davies C, Rashid H, Tashani M, Booy R et
Kaplan S, Ozkul O et al. A study on basic demographic al. Knowledge, attitudes, and perceptions of the Arabic-
and disease characteristics of cancer-diagnosed Syrian speaking community in Sydney, Australia, toward the
refugees treated in the border city of Turkey, Sanliurfa; a human papillomavirus (HPV) vaccination program: a
hospital-based retrospective case series study. J BUON. qualitative study. Vaccines (Basel). 2021;9(9):940. doi:10.3390/
2017;22(6):1591–4. PMID:29332358. vaccines9090940.
271. Gallo F, Caprioglio A, Castagno R, Ronco G, Segnan N, 281. Allen EM, Lee HY, Pratt R, Vang H, Desai JR, Dube A et al.
Giordano L. Inequalities in cervical cancer screening Facilitators and barriers of cervical cancer screening and
utilisation and results: a comparison between Italian natives human papilloma virus vaccination among Somali refugee
and immigrants from disadvantaged countries. Health Policy. women in the United States: a qualitative analysis. J Transcult
2017;121(10):1072–8. doi:10.1016/j.healthpol.2017.08.005. Nurs. 2019;30(1):55–63. doi:10.1177/1043659618796909.
272. Balcilar M. Health status survey of Syrian refugees in Turkey: 282. Vamos CA, Kline N, Vázquez-Otero C, Lockhart EA, Lake PW,
non-communicable disease risk factor surveillance among Wells KJ et al. Stakeholders' perspectives on system-level
Syrian refugees living in Turkey. Ankara: Disaster and barriers to and facilitators of HPV vaccination among Hispanic
Emergency Management (AFAD) and Ministry of Health; 2016 migrant farmworkers. Ethn Health. Epub 2021 Mar 18. doi:10.
(https://hsgm.saglik.gov.tr/depo/birimler/kronik-hastaliklar- 1080/13557858.2021.1887820.
engelli-db/hastaliklar/kronik_havayolu/raporlar/HEALT_
283. Vamos CA, Vázquez-Otero C, Kline N, Lockhart EA, Wells KJ,
STATUS_SURVEY_of_SYRIAN_REFUGEES_in_TURKEY.pdf,
Proctor S et al. Multi-level determinants to HPV vaccination
among Hispanic farmworker families in Florida. Ethn Health.
273. Napolitano F, Gualdieri L, Santagati G, Angelillo IF. Knowledge 2021;26(3):319–36. doi:10.1080/13557858.2018.1514454.
and attitudes toward HPV infection and vaccination among
284. Kenny DX, Hsueh K, Walters RW, Coté JJ. Human
immigrants and refugees in Italy. Vaccine. 2018;36(49):7536–
papillomavirus vaccination and Pap smear rates among
41. doi:10.1016/j.vaccine.2018.10.050.
Burmese refugee girls in a healthcare system in Omaha,
274. McComb E, Ramsden V, Olatunbosun O, Williams-Roberts H. Nebraska. J Community Health. 2021;46(6):1170–6.
Knowledge, attitudes and barriers to human papillomavirus doi:10.1007/s10900-021-01003-1.
(HPV) vaccine uptake among an immigrant and refugee catch-
285. Møller SP, Kristiansen M, Norredam M. Human papillomavirus
up group in a western Canadian province. J Immigr Minor
immunization uptake among girls with a refugee background
Health. 2018;20(6):1424–8. doi:10.1007/s10903-018-0709-6.
compared with Danish-born girls: a national register-based
275. Wilson LA, Quan AML, Bota AB, Mithani SS, Paradis M, Jardine cohort study. Eur J Cancer Prev. 2018;27(1):42–5. doi:10.1097/
C et al. Newcomer knowledge, attitudes, and beliefs about CEJ.0000000000000274.
human papillomavirus (HPV) vaccination. BMC Fam Pract.
2021;22(1):17. doi:10.1186/s12875-020-01360-1.
168
286. Morgan R, Cassidy M, DeGeus SWL, Tseng J, McAneny D, Sachs 297. Shahin W, Kennedy GA, Stupans I. A qualitative exploration of
T. Presentation and survival of gastric cancer patients at an the impact of knowledge and perceptions about hypertension
urban academic safety-net hospital. J Gastrointest Surg. in medication adherence in Middle Eastern refugees and
2019;23(2):239–46. doi:10.1007/s11605-018-3898-3. migrants. Explor Res Clin Social Pharm. 2021;3:100038.
287. Garcia S, Pruitt SL, Singal AG, Murphy CC. Colorectal cancer 298. Gallegos D, Do H, To QG, Vo B, Goris J, Alraman H. Differences
incidence among Hispanics and non-Hispanic Whites in the in cardiometabolic risk markers among ethnic groups
United States. Cancer Causes Control. 2018;29(11):1039–46. in Queensland, Australia. Health Soc Care Community.
doi:10.1007/s10552-018-1077-1. 2019;27(4):e449–58. doi:10.1111/hsc.12745.
288. Ashhab AA, Rodin H, Powell J, Debes JD. Impact of 299. Commodore-Mensah Y, Selvin E, Aboagye J, Turkson-Ocran
immigration in presentation and outcomes of hepatocellular R-A, Li X, Himmelfarb CD et al. Hypertension, overweight/
carcinoma in the USA. Eur J Gastroenterol Hepatol. obesity, and diabetes among immigrants in the United States:
2019;31(1):24–8. doi:10.1097/MEG.0000000000001212. an analysis of the 2010–2016 National Health Interview
Survey. BMC Public Health. 2018;18(1):773. doi:10.1186/
289. Hypertension. In: Fact sheets. Geneva: World Health
s12889-018-5683-3.
Organization; 2021 (https://www.who.int/news-room/fact-
sheets/detail/hypertension, accessed 30 March 2022). 300. Rehr M, Shoaib M, Ellithy S, Okour S, Ariti C, Ait-Bouziad I et al.
Prevalence of non-communicable diseases and access to care
290. Agyemang C, Nyaaba G, Beune E, Meeks K, Owusu-Dabo E,
among non-camp Syrian refugees in northern Jordan. Confl
Addo J et al. Variations in hypertension awareness, treatment,
Health. 2018;12:33. doi:10.1186/s13031-018-0168-7.
and control among Ghanaian migrants living in Amsterdam,
Berlin, London, and nonmigrant Ghanaians living in rural and 301. Shah SM, Jaacks LM, Al-Maskari F, Al-Kaabi J, Aziz F,
urban Ghana - the RODAM study. J Hypertens. 2018;36(1):169– Soteriades E et al. Association between duration of residence
77. doi:10.1097/HJH.0000000000001520. and prevalence of type 2 diabetes among male South Asian
expatriate workers in the United Arab Emirates: a cross-
291. Ratnayake R, Rawashdeh F, Abualrub R, Al-Ali N, Fawad M,
sectional study. BMJ Open. 2020;10(12):e040166. doi:10.1136/
Hani MB et al. Access to care and prevalence of hypertension
bmjopen-2020-040166.
and diabetes among Syrian refugees in northern Jordan.
JAMA Netw Open. 2020;3(10):e2021678. doi:10.1001/ 302. Sulaiman N, Albadawi S, Abusnana S, Mairghani M, Hussein A,
jamanetworkopen.2020.21678. Al-Awadi F et al. High prevalence of diabetes among migrants
in the United Arab Emirates using a cross-sectional survey. Sci
292. Sulaiman N, Elbadawi S, Hussein A, Abusnana S, Madani A,
Rep. 2018;8(1):6862. doi:10.1038/s41598-018-24312-3.
Mairghani M et al. Prevalence of overweight and obesity in
United Arab Emirates expatriates: the UAE National Diabetes 303. Motlhale M, Ncayiyana JR. Migration status and prevalence
and Lifestyle Study. Diabetol Metab Syndr. 2017;9:88. of diabetes and hypertension in Gauteng province,
doi:10.1186/s13098-017-0287-0. South Africa: effect modification by demographic and
socioeconomic characteristics—a cross-sectional population-
293. Al-Hashel JY, Ismail II, Ibrahim M, John JK, Husain F, Kamel WA
based study. BMJ Open. 2019;9(9):e027427. doi:10.1136/
et al. Demographics, clinical characteristics, and management
bmjopen-2018-027427.
of idiopathic intracranial hypertension in Kuwait: a single-
center experience. Front Neurol. 2020;11:672. doi:10.3389/ 304. Meeks KAC, Freitas-Da-Silva D, Adeyemo A, Beune EJAJ,
fneur.2020.00672. Modesti PA, Stronks K et al. Disparities in type 2 diabetes
prevalence among ethnic minority groups resident in Europe:
294. Akhtar N, Salam A, Kamran S, Bourke P, Joseph S, Santos M et
a systematic review and meta-analysis. Intern Emerg Med.
al. Ethnic variation in acute cerebrovascular disease: analysis
2016;11(3):327–40. doi:10.1007/s11739-015-1302-9.
from the Qatar stroke registry. Eur Stroke J. 2016;1(3):231–41.
doi:10.1177/2396987316663776. 305. Li LJ, Zhang J, Shub A, Aris I, Tan KH. Exploring abnormal
glucose metabolism in pregnancy among Australian Chinese
295. Boulle P, Sibourd-Baudry A, Ansbro É, Prieto Merino D, Saleh
migrants. BMJ Open Diabetes Res Care. 2020;8(1):e000903.
N, Zeidan RK et al. Cardiovascular disease among Syrian
doi:10.1136/bmjdrc-2019-000903.
refugees: a descriptive study of patients in two Médecins
Sans Frontières clinics in northern Lebanon. Confl Health. 306. Jirojwong S, Brownhill S, Dahlen HG, Johnson M, Schmied
2019;13(1):37. doi:10.1186/s13031-019-0217-x. V. Going up, going down: the experience, control and
management of gestational diabetes mellitus among
296. Shah SM, Loney T, Sheek-Hussein M, El Sadig M, Al Dhaheri S, El
Southeast Asian migrant women living in urban Australia.
Barazi I et al. Hypertension prevalence, awareness, treatment,
Health Promot J Austr. 2017;28(2):123–31. doi:10.
and control, in male South Asian immigrants in the United
1071/HE15130.
Arab Emirates: a cross-sectional study. BMC Cardiovasc Disord.
2015;15:30. doi:10.1186/s12872-015-0024-2.
169
307. Wan CS, Abell S, Aroni R, Nankervis A, Boyle J, Teede H. Ethnic 317. Harris S, Dykxhoorn J, Hollander A-C, Dalman C, Kirkbride
differences in prevalence, risk factors, and perinatal outcomes JB. Substance use disorders in refugee and migrant groups
of gestational diabetes mellitus: a comparison between in Sweden: a nationwide cohort study of 1.2 million people.
immigrant ethnic Chinese women and Australian‐born PLOS Med. 2019;16(11):e1002944. doi:10.1371/journal.
Caucasian women in Australia. J Diabetes. 2019;11(10):809– pmed.1002944.
17. doi:10.1111/1753-0407.12909.
318. Damiri BR. The use of psychoactive substances in a conflict
308. Pierola D, Rodriguez Chatruc M. Migrants in Latin America: area in the West Bank: drug use risk factors and practices
disparities in health status and in access to healthcare. in Palestinian refugee camps. Int J Ment Health Addict.
Rochester (NY): Social Science Research Network; 2021 2020;18(6):1507–20. doi:10.1007/s11469-019-00183-1.
(https://papers.ssrn.com/abstract=3682760, accessed
319. Ali R, Loney T, Al-Houqani M, Blair I, Aziz F, Al Dhaheri S et
30 March 2022).
al. Cigarette smoking and smokeless tobacco use among
309. Wilson A, Renzaho A. Intergenerational differences in male south Asian migrants in the United Arab Emirates: a
acculturation experiences, food beliefs and perceived health cross-sectional study. BMC Public Health. 2020;20(1):815.
risks among refugees from the Horn of Africa in Melbourne, doi:10.1186/s12889-020-08942-9.
Australia. Public Health Nutr. 2015;18(1):176–88. doi:10.1017/
320. Widmann M, Apondi B, Musau A, Warsame AH, Isse M,
S1368980013003467.
Mutiso V et al. Comorbid psychopathology and everyday
310. Alzubaidi H, McNarmara K, Kilmartin GM, Kilmartin functioning in a brief intervention study to reduce khat
JF, Marriott J. The relationships between illness and use among Somalis living in Kenya: description of baseline
treatment perceptions with adherence to diabetes self- multimorbidity, its effects of intervention and its moderation
care: a comparison between Arabic-speaking migrants and effects on substance use. Soc Psychiatry Psychiatr Epidemiol.
Caucasian English-speaking patients. Diabetes Res Clin Pract. 2017;52(11):1425–34. doi:10.1007/s00127-017-1368-y.
2015;110(2):208–17. doi:10.1016/j.diabres.2015.08.006.
321. Chiumento A, Rutayisire T, Sarabwe E, Hasan MT, Kasujja
311. Eh K, McGill M, Wong J, Krass I. Cultural issues and other R, Nabirinde R et al. Exploring the mental health and
factors that affect self-management of type 2 diabetes psychosocial problems of Congolese refugees living in
mellitus (T2D) by Chinese immigrants in Australia. refugee settings in Rwanda and Uganda: a rapid qualitative
Diabetes Res Clin Pract. 2016;119:97–105. doi:10.1016/j. study. Confl Health. 2020;14(1):77. doi:10.1186/s13031-020-
diabres.2016.07.006. 00323-8.
312. Fernández A, Quan J, Moffet H, Parker MM, Schillinger 322. Amosu SM, Onifade PO, Adamson TA. Psychoactive substance
D, Karter AJ. Adherence to newly prescribed diabetes use and general mental health among refugees in a Nigerian
medications among insured Latino and White patients with camp. J Subst Use. 2016;21(3):230–6. doi:10.3109/14659891.2
diabetes. JAMA Intern Med. 2017;177(3):371–9. doi:10.1001/ 013.820800.
jamainternmed.2016.8653.
323. Sharma V, Papaefstathiou S, Tewolde S, Amobi A, Deyessa
313. Baghikar S, Benitez A, Fernandez Piñeros P, Gao Y, Baig AA. N, Relyea B et al. Khat use and intimate partner violence in a
Factors impacting adherence to diabetes medication among refugee population: a qualitative study in Dollo Ado, Ethiopia.
urban, low income Mexican-Americans with diabetes. J BMC Public Health. 2020;20(1):670. doi:10.1186/s12889-020-
Immigr Minor Health. 2019;21(6):1334–41. doi:10.1007/s10903- 08837-9.
019-00867-9.
324. Shaw PM, Chandra V, Escobar GA, Robbins N, Rowe V, Macsata
314. Lyles BE, Chua S, Barham Y, Pfieffer-Mundt K, Spiegel P, R. Controversies and evidence for cardiovascular disease in
Burton A et al. Improving diabetes control for Syrian refugees the diverse Hispanic population. J Vasc Surg. 2018;67(3):
in Jordan: a longitudinal cohort study comparing the effects 960–9. doi:10.1016/j.jvs.2017.06.111.
of cash transfers and health education interventions. Confl
325. Qureshi SA, Straiton M, Gele AA. Associations of socio-
Health. 2021;15(1):41. doi:10.1186/s13031-021-00380-7.
demographic factors with adiposity among immigrants
315. Elliott JA, Das D, Cavailler P, Schneider F, Shah M, Ravaud in Norway: a secondary data analysis. BMC Public Health.
A et al. A cross-sectional assessment of diabetes self- 2020;20(1):772. doi:10.1186/s12889-020-08918-9.
management, education and support needs of Syrian refugee
326. Damiri B, Abualsoud MS, Samara AM, Salameh SK.
patients living with diabetes in Bekaa Valley Lebanon. Confl
Metabolic syndrome among overweight and obese adults in
Health. 2018;12(1):40. doi:10.1186/s13031-018-0174-9.
Palestinian refugee camps. Diabetol Metab Syndr. 2018;10:34.
316. Commercial determinants of health. In: Fact sheets. Geneva: doi:10.1186/s13098-018-0337-2.
World Health Organization; 2021 (https://www.who.int/news-
room/fact-sheets/detail/commercial-determinants-of-health,
170
327. Ross WL, Gallego‐Pérez DF, Lartey A, Sandow A, Pérez‐ 339. Carlsson AC, Wändell P, Riserus U, Ärnlöv J, Borné Y, Engström
Escamilla R, Hromi‐Fiedler A. Dietary patterns in Liberian G et al. Differences in anthropometric measures in immigrants
refugees in Buduburam, Ghana. Matern Child Nutr. and Swedish-born individuals: results from two community-
2017;13(4):e12401. doi:10.1111/mcn.12401. based cohort studies. Prev Med. 2014;69:151–6. doi:10.1016/j.
ypmed.2014.09.020.
328. Aung TNN, Shirayama Y, Moolphate S, Lorga T, Yuasa M, Aung
MN. Acculturation and its effects on health risk behaviors 340. Sproston K, Mindell J. Health survey for England 2004: the
among Myanmar migrant workers: a cross-sectional survey health of minority ethnic groups. London: National Centre
in Chiang Mai, northern Thailand. Int J Env Res Public Health. for Social Research; 2006 (https://digital.nhs.uk/data-and-
2020;17(14):5108. doi:10.3390/ijerph17145108. information/publications/statistical/health-survey-for-
england/health-survey-for-england-2004-health-of-ethnic-
329. El Masri A, Kolt GS, George ES. The perceptions, barriers
minorities-headline-results, accessed 23 June 2022).
and enablers to physical activity and minimising sedentary
behaviour among Arab-Australian adults aged 35–64 years. 341. Waist circumference and waist-hip ratio: report of a WHO
Health Promot J Aust. 2021;32(2):312–21. doi:10.1002/ expert consultation, Geneva, 8-11 December 2008. Geneva:
hpja.345. World Health Organization; 2011 (https://apps.who.int/iris/
330. Babatunde-Sowole OO, Power T, Davidson P, Ballard
C, Jackson D. Exploring the diet and lifestyle changes 342. Amstutz D, Gonçalves D, Hudelson P, Stringhini S, Durieux-
contributing to weight gain among Australian West African Paillard S, Rolet S. Nutritional status and obstacles to healthy
women following migration: a qualitative study. Contemp eating among refugees in Geneva. J Immigr Minor Health.
Nurse. 2018;54(2):150–9. doi:10.1080/10376178.2018.1459760. 2020;22(6):1126–34. doi:10.1007/s10903-020-01085-4.
331. Casali ME, Borsari L, Marchesi I, Borella P, Bargellini A. 343. Jeong H, Lee S-K, Kim S-G. Changes in body weight and
Lifestyle and food habits changes after migration: a focus on food security of adult North Korean refugees living in South
immigrant women in Modena (Italy). Ann Ig. 2015;27(5): Korea. Nutr Res Pract. 2017;11(4):307–18. doi:10.4162/
748–59. doi:10.7416/ai.2015.2067. nrp.2017.11.4.307.
332. Maqoud F, Vacca E, Tommaseo-Ponzetta M. From Morocco to 344. Childhood Obesity Surveillance Initiative (COSI): severe
Italy: how women's bodies reflect their change of residence. obesity among children aged 6–9 years. Copenhagen: WHO
Coll Antropol. 2016;40(1):9–15. PMID:27301231. Regional Office for Europe; 2019 (https://apps.who.int/iris/
handle/10665/346474, accessed 23 June 2022).
333. Lendorfer J, Etang-Ndip A, Hoogeveen J. Socio-economic
impact of the crisis in northern Mali on displaced people. J 345. Esteban-Gonzalo L, Veiga OL, Gómez-Martínez S, Regidor E,
Refug Stud. 2016;29:315–40. doi:10.1093/jrs/few011. Martínez D, Marcos A et al. Adherencia a las recomendaciones
nutricionales entre adolescentes españoles e inmigrantes
334. Morseth MS, Grewal NK, Kaasa IS, Hatloy A, Barikmo I, Henjum
residentes en España; estudio AFINOS [Adherence to
S. Dietary diversity is related to socioeconomic status among
dietary recommendations among Spanish and immigrant
adult Saharawi refugees living in Algeria. BMC Public Health.
adolescents living in Spain; the AFINOS study]. Nutr Hosp.
2017;17(1):621. doi:10.1186/s12889-017-4527-x.
2013;28(6):1926–36. doi:10.3305/nh.2013.28.6.6836.
335. Campostrini S, Carrozzi G, Severoni S, Masocco M, Salmaso
346. Moreira S, Gonçalves L. Overweight and obesity in children of
S. Migrant health in Italy: a better health status difficult to
immigrant versus native parents: exploring a local setting in
maintain - country of origin and assimilation effects studied
Portugal. Int J Environ Res Public Health. 2020;17(21):7897.
from the Italian risk factor surveillance data. Popul Health
doi:10.3390/ijerph17217897.
Metr. 2019;17(1):14. doi:10.1186/s12963-019-0194-8.
347. Kobel S, Lämmle C, Wartha O, Kesztyüs D, Wirt T, Steinacker
336. Stronks K, Kunst AE. The complex interrelationship between
JM. Effects of a randomised controlled school-based health
ethnic and socio-economic inequalities in health. J Public
promotion intervention on obesity related behavioural
Health (Oxf). 2009;31(3):324–5. doi:10.1093/pubmed/fdp070.
outcomes of children with migration background. J Immigr
337. Hamad R, Öztürk B, Foverskov E, Pedersen L, Sørensen HT, Minor Health. 2017;19(2):254–62. doi:10.1007/s10903-016-
Bøtker HE et al. Association of neighborhood disadvantage 0460-9.
with cardiovascular risk factors and events among refugees in
348. Iguacel I, Fernández-Alvira JM, Ahrens W, Bammann K,
Denmark. JAMA Netw Open. 2020;3(8):e2014196. doi:10.1001/
Gwozdz W, Lissner L et al. Prospective associations between
jamanetworkopen.2020.14196.
social vulnerabilities and children's weight status. Results
338. Commodore-Mensah Y, Agyemang C, Aboagye JA, from the IDEFICS study. Int J Obes (Lond). 2018;42(10):1691–
Echouffo-Tcheugui JB, Beune E, Smeeth L et al. Obesity 703. doi:10.1038/s41366-018-0199-6.
and cardiovascular disease risk among Africans residing in
Europe and Africa: the RODAM study. Obes Res Clin Pract.
2020;14(2):151–7. doi:10.1016/j.orcp.2020.01.007.
171
349. Tsujimoto T, Kajio H, Sugiyama T. Obesity, diabetes, and 361. Lindheimer N, Karnouk C, Hahn E, Churbaji D, Schilz L, Rayes
length of time in the United States: analysis of National D et al. Exploring the representation of depressive symptoms
Health and Nutrition Examination Survey 1999 to 2012. and the influence of stigma in Arabic-speaking refugee
Medicine (Baltimore). 2016;95(35):e4578. doi:10.1097/ outpatients. Front Psychiatry. 2020;11:579057. doi:10.3389/
MD.0000000000004578. fpsyt.2020.579057.
350. Zulfiqar T, Strazdins L, Dinh H, Banwell C, D'Este C. Drivers of 362. Markova V, Sandal GM, Pallesen S. Immigration, acculturation,
overweight/obesity in 4-11 year old children of Australians and preferred help-seeking sources for depression:
and immigrants; evidence from growing up in Australia. J comparison of five ethnic groups. BMC Health Serv Res.
Immigr Minor Health. 2019;21(4):737–50. doi:10.1007/s10903- 2020;20(1):648. doi:10.1186/s12913-020-05478-x.
018-0841-3.
363. Poole DN, Hedt-Gauthier B, Liao S, Raymond NA,
351. Lane G, Farag M, White J, Nisbet C, Vatanparast H. Chronic Bärnighausen T. Major depressive disorder prevalence and
health disparities among refugee and immigrant children risk factors among Syrian asylum seekers in Greece. BMC
in Canada. Appl Physiol Nutr Metab. 2018;43(10):1043–58. Public Health. 2018;18(1):908. doi:10.1186/s12889-018-5822-x.
doi:10.1139/apnm-2017-0407.
364. Solmaz F, Karataş H, Kandemir H, Solmaz A. Depression,
352. Programme for international student assessment (PISA): PISA loneliness and factors influencing in Syrian refugee children.
2018 database. Paris: Organisation for Economic Co-operation Int J Clin Pract. 2021;75(5):e14039. doi:10.1111/ijcp.14039.
and Development; 2018 ( [https://www.oecd.org/pisa/
365. Eiset AH, Loua AS, Kruse A, Norredam M. The health status
data/2018database/#d.en.516012; accessed 5 May 2022).
of newly arrived asylum-seeking minors in Denmark:
353. Obesity. In: Health topics. Geneva: World Health Organization; a nationwide register-based study. Int J Public Health.
2022 (https://www.who.int/health-topics/obesity#tab=tab_1, 2020;65(9):1763–72. doi:10.1007/s00038-020-01501-4.
366. Erausquin JT, Song E, Rhodes SD. Gender norms,
354. Dawson-Hahn E, Pak-Gorstein S, Matheson J, Zhou C, discrimination, acculturation, and depressive symptoms
Yun K, Scott K et al. Growth trajectories of refugee and among Latino men in a new settlement state. Ethn Dis.
nonrefugee children in the United States. Pediatrics. 2020;30(4):519–24. doi:10.18865/ed.30.4.519.
2016;138(6):e20160953. doi:10.1542/peds.2016-0953.
367. Kim I-H, Noh S. Racial/ethnic variations in the main and
355. Al-Thani M, Al-Thani A, Alyafei S, Al-Chetachi W, Khalifa buffering effects of ethnic and nonethnic supports on
SE, Ahmed A et al. The prevalence and characteristics of depressive symptoms among five ethnic immigrant groups in
overweight and obesity among students in Qatar. Public Toronto. Ethn Health. 2016;21(3):215–32. doi:10.1080/1355785
Health. 2018;160:143–9. doi:10.1016/j.puhe.2018.03.020. 8.2015.1061101.
356. Garemo M, Elamin A, Gardner A. Weight status and food habits 368. Sangalang CC, Becerra D, Mitchell FM, Lechuga-Peña S, Lopez
of preschool children in Abu Dhabi, United Arab Emirates: K, Kim I. Trauma, post-migration stress, and mental health:
NOPLAS project. Asia Pac J Clin Nutr. 2018;27(6):1302–14. a comparative analysis of refugees and immigrants in the
doi:10.6133/apjcn.201811_27(6).0018. United States. J Immigr Minor Health. 2019;21(5):909–19.
doi:10.1007/s10903-018-0826-2.
357. Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford
H, Saxena S. New WHO prevalence estimates of mental 369. Thomas J, Humeidan M, Barrack C, Huffman KL. Mindfulness,
disorders in conflict settings: a systematic review and meta- stress reactivity, and depressive symptoms among "third
analysis. Lancet. 2019;394(10194):240–8. doi:10.1016/S0140- culture kids" in the United Arab Emirates. J Cross-Cult
6736(19)30934-1. Psychol. 2021;52(2):192–208. doi:10.1177/0022022120987620.
358. Ao T, Shetty S, Sivilli T, Blanton C, Ellis H, Geltman PL et al. 370. Stevenson K, Alameddine R, Rukbi G, Chahrouri M, Usta J,
Suicidal ideation and mental health of Bhutanese refugees in Saab B et al. High rates of maternal depression amongst
the United States. J Immigr Minor Health. 2016;18(4):828–35. Syrian refugees in Lebanon - a pilot study. Sci Rep.
doi:10.1007/s10903-015-0325-7. 2019;9(1):11849. doi:10.1038/s41598-019-48247-5.
359. Meyerhoff J, Rohan KJ, Fondacaro KM. Suicide and suicide- 371. Eastwood J, Wang A, Khanlari S, Montgomery A, Yang JYH.
related behavior among Bhutanese refugees resettled in Psychosocial stratification of antenatal indicators to guide
the United States. Asian Am J Psychol. 2018;9(4):270–83. population-based programs in perinatal depression. BMC
doi:10.1037/aap0000125. Pregnancy Childbirth. 2021;21(1):277. doi:10.1186/s12884-
021-03722-8.
360. Kateri E, Kalaitzaki A, Karademas E. The role of self-esteem in
the relationship between anxiety and depression of Albanian
and Indian immigrants in Greece. Psychiatriki. 2021;32:23–33.
doi:10.22365/jpsych.2021.002.
172
372. Meyer SR, Steinhaus M, Bangirana C, Onyango-Mangen P, 383. Riley A, Varner A, Ventevogel P, Taimur Hasan MM,
Stark L. The influence of caregiver depression on adolescent Welton-Mitchell C. Daily stressors, trauma exposure,
mental health outcomes: findings from refugee settlements in and mental health among stateless Rohingya refugees
Uganda. BMC Psychiatry. 2017;17(1):405. doi:10.1186/s12888- in Bangladesh. Transcult Psychiatry. 2017;54(3):304–31.
017-1566-x. doi:10.1177/1363461517705571.
373. Sabry W, Mostafa N, Wahdan M. Screening for depression 384. Riley A, Akther Y, Noor M, Ali R, Welton-Mitchell C. Systematic
and anxiety symptoms among a sample of working Syrian human rights violations, traumatic events, daily stressors
refugees in Egypt. Egypt J Community Med. 2020;38(1):103– and mental health of Rohingya refugees in Bangladesh. Confl
11. doi:10.21608/EJCM.2020.68625. Health. 2020;14:60. doi:10.1186/s13031-020-00306-9.
374. Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, 385. Khan S, Haque S. Trauma, mental health, and everyday
Fitzgerald G et al. The prevalence of mental illness in refugees functioning among Rohingya refugee people living in short-
and asylum seekers: a systematic review and meta-analysis. and long-term resettlements. Soc Psychiatry Psychiatr
PLOS Med. 2020;17(9):e1003337. doi:10.1371/journal. Epidemiol. 2021;56(3):497–512. doi:10.1007/s00127-020-
pmed.1003337. 01962-1.
375. Henkelmann J-R, de Best S, Deckers C, Jensen K, Shahab M, 386. Kesornsri S, Sitthimongkol Y, Punpuing S, Vongsirimas N,
Elzinga B et al. Anxiety, depression and post-traumatic stress Hegadoren K. Mental health and related factors among
disorder in refugees resettling in high-income countries: migrants from Myanmar in Thailand. J Popul Soc Stud.
systematic review and meta-analysis. BJPsych Open. 2019;27(2):124–38. doi:10.25133/JPSSv27n2.008.
2020;6(4):e68. doi:10.1192/bjo.2020.54.
387. Meyer SR, Decker MR, Tol WA, Abshir N, Mar AA, Robinson
376. Björkenstam E, Helgesson M, Norredam M, Sijbrandij M, WC. Workplace and security stressors and mental health
de Montgomery CJ, Mittendorfer-Rutz E. Common mental among migrant workers on the Thailand–Myanmar border.
disorders among young refugees in Sweden: the role Soc Psychiatry Psychiatr Epidemiol. 2016;51(5):713–23.
of education and duration of residency. J Affect Disord. doi:10.1007/s00127-015-1162-7.
2020;266:563–71. doi:10.1016/j.jad.2020.02.015.
388. Poudel OP, Thapa B, Bhandary S. Pre-departure psychological
377. Priebe Rocha L, Soares C, McGregor A, Chen S, Kaplan A, distress and associated factors among migrant workers of
Rose RR et al. Understanding health priorities, behaviors, Nepal. Scientific Communication and Education; 2020 (http://
and service utilization among Brazilian immigrant women: biorxiv.org/lookup/doi/10.1101/2020.12.14.422661, accessed
implications for designing community-based interventions. J 2 April 2022).
Racial Ethn Health Disparities. 2022;9(1):135–45. doi:10.1007/
389. Regmi PR, Aryal N, van Teijlingen E, Simkhada P, Adhikary
s40615-020-00936-y.
P. Nepali migrant workers and the need for pre-departure
378. Im H, Swan LE, Warsame AH, Isse MM. Risk and protective training on mental health: a qualitative study. J Immigr Minor
factors for comorbidity of PTSD, depression, and anxiety Health. 2020;22(5):973–81. doi:10.1007/s10903-019-00960-z.
among Somali refugees in Kenya. Int J Soc Psychiatry.
390. Anjara SG, Nellums LB, Bonetto C, Van Bortel T. Stress, health
2022;68(10):134–46. doi:10.1177/0020764020978685.
and quality of life of female migrant domestic workers in
379. Akinyemi OO, Owoaje ET, Cadmus EO. In their own words: Singapore: a cross-sectional study. BMC Womens Health.
mental health and quality of life of West African refugees 2017;17(1):98. doi:10.1186/s12905-017-0442-7.
in Nigeria. J Int Migr Integr. 2016;17(1):273–87. doi:10.1007/
391. Miller R, Ong KIC, Choi S, Shibanuma A, Jimba M. Seeking
s12134-014-0409-6.
connection: a mixed methods study of mental well-being
380. Labys CA, Dreyer C, Burns JK. At zero and turning in and community volunteerism among international migrants
circles: refugee experiences and coping in Durban, in Japan. BMC Public Health. 2020;20(1):1272. doi:10.1186/
South Africa. Transcult Psychiatry. 2017;54(5–6):696–714. s12889-020-09381-2.
doi:10.1177/1363461517705570.
392. Chen W, Hall BJ, Ling L, Renzaho AM. Pre-migration and
381. Thela L, Tomita A, Maharaj V, Mhlongo M, Burns JK. post-migration factors associated with mental health in
Counting the cost of Afrophobia: post-migration adaptation humanitarian migrants in Australia and the moderation effect
and mental health challenges of African refugees in of post-migration stressors: findings from the first wave data
South Africa. Transcult Psychiatry. 2017;54(5–6):715–32. of the BNLA cohort study. Lancet Psychiatry. 2017;4(3):218–29.
doi:10.1177/1363461517745472. doi:10.1016/S2215-0366(17)30032-9.
382. Alfaro-Velcamp T, McLaughlin RH. Rape without remedy: 393. Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet
Congolese refugees in South Africa. Cogent Med. EJ, Cardoso G et al. Trauma and PTSD in the WHO World
2019;6(1):1697502. doi:10.1080/2331205X.2019.1697502. Mental Health Surveys. Eur J Psychotraumatol. 2017;8(suppl
5):1353383. doi:10.1080/20008198.2017.1353383.
173
394. Center for Substance Abuse Treatment (US). Trauma-informed 405. Scharpf F, Mkinga G, Masath FB, Hecker T. A socio-ecological
care in behavioral health services. Rockville (MD): Substance analysis of risk, protective and promotive factors for the
Abuse and Mental Health Services Administration; 2014 mental health of Burundian refugee children living in refugee
(Treatment Improvement Protocol series no. 57; https://www. camps. Eur Child Adolesc Psychiatry. 2021;30(10):1651–62.
ncbi.nlm.nih.gov/books/NBK207201/, accessed 2 April 2022). doi:10.1007/s00787-020-01649-7.
395. Al-Awaida W, Al-Ameer HJ, Al-Turk H, Al bawareed O, Khalil R, 406. Keller A, Joscelyne A, Granski M, Rosenfeld B. Pre-migration
Al Deek A et al. Psychological effects of quarantine on Syrian trauma exposure and mental health functioning among
refugees, compared to the Jordanian populations. Int Migr. Central American migrants arriving at the US border. PLOS
2022;60(1):219–27. doi:10.1111/imig.12847. One. 2017;12(1):e0168692. doi:10.1371/journal.pone.0168692.
396. Bajbouj M, Panneck P, Winter SM, Ajami C, Alabdullah J, 407. Rodin D, van Ommeren M. Commentary: explaining enormous
Burger MB et al. A central clearing clinic to provide mental variations in rates of disorder in trauma-focused psychiatric
health services for refugees in Germany. Front Public Health. epidemiology after major emergencies. Int J Epidemiol.
2021;9:635474. doi:10.3389/fpubh.2021.635474. 2009;38(4):1045–8. doi:10.1093/ije/dyp203.
397. Georgiadou E, Morawa E, Erim Y. High manifestations of 408. Al-Amin H, Singh R, Abdulrazzak M, Ghuloum S. Psychosocial
mental distress in Arabic asylum seekers accommodated in and clinical profiles of the cases visiting the emergency
collective centers for refugees in Germany. Int J Environ Res department due to accidental self-harm and suicide attempts
Public Health. 2017;14(6):612. doi:10.3390/ijerph14060612. in Doha, Qatar: a retrospective study. Community Ment Health
J. 2021;57(2):315–24. doi:10.1007/s10597-020-00650-3.
398. Solberg Ø, Vaez M, Johnson-Singh CM, Saboonchi F. Asylum-
seekers' psychosocial situation: a diathesis for post-migratory 409. Itani T, Jacobsen KH, Kraemer A. Suicidal ideation and
stress and mental health disorders? J Psychosom Res. planning among Palestinian middle school students living
2020;130:109914. doi:10.1016/j.jpsychores.2019.109914. in Gaza Strip, West Bank, and United Nations Relief and
Works Agency (UNRWA) camps. Int J Pediatr Adolesc Med.
399. Sareen J. Posttraumatic stress disorder in adults: impact,
2017;4(2):54–60. doi:10.1016/j.ijpam.2017.03.003.
comorbidity, risk factors, and treatment. Can J Psychiatry.
2014;59(9):460–7. doi:10.1177/070674371405900902. 410. Bukuluki P, Kisaakye P, Wandiembe SP, Besigwa S. Suicide
ideation and psychosocial distress among refugee
400. de Arellano MA, Andrews AR, Reid-Quiñones K, Vasquez
adolescents in Bidibidi settlement in West Nile, Uganda.
D, Doherty LS, Danielson CK et al. Immigration trauma
Discov Psychol. 2021;1(1):3. doi:10.1007/s44202-021-00003-5.
among Hispanic youth: missed by trauma assessments and
predictive of depression and PTSD symptoms. J Lat Psychol. 411. Joarder T, Sutradhar I, Hasan MI, Bulbul MMI. A record review
2018;6(3):159–74. doi:10.1037/lat0000090. on the health status of Rohingya refugees in Bangladesh.
Cureus. 2020;12(8):e9753. doi:10.7759/cureus.9753.
401. Schlaudt VA, Bosson R, Williams MT, German B, Hooper LM,
Frazier V et al. Traumatic experiences and mental health risk 412. Rahman MR, Faiz MA, Nu MY, Hassan MR, Chakrabarty AK,
for refugees. Int J Environ Res Public Health. 2020;17(6):1943. Kabir I et al. A rapid assessment of health literacy and
doi:10.3390/ijerph17061943. health status of Rohingya refugees living in Cox's Bazar,
Bangladesh following the August 2017 exodus from Myanmar:
402. Wright AM, Talia YR, Aldhalimi A, Broadbridge CL, Jamil H,
a cross-sectional study. Trop Med Infect Dis. 2020;5(3):110.
Lumley MA et al. Kidnapping and mental health in Iraqi
doi:10.3390/tropicalmed5030110.
refugees: the role of resilience. J Immigr Minor Health.
2017;19(1):98–107. doi:10.1007/s10903-015-0340-8. 413. Fischer L, Zarate A, Mozumder K, Elshazly M, Rosenbaum
S. Barriers, attitudes, confidence and knowledge of mental
403. Ainamani HE, Elbert T, Olema DK, Hecker T. Gender
health and psychosocial humanitarian staff in Cox's Bazar in
differences in response to war-related trauma and
responding to suicide risk. Intervention. 2021;19(2):242–8.
posttraumatic stress disorder - a study among the Congolese
doi:10.4103/INTV.INTV_53_20.
refugees in Uganda. BMC Psychiatry. 2020;20(1):17.
doi:10.1186/s12888-019-2420-0. 414. Björkenstam E, Helgesson M, Amin R, Mittendorfer-Rutz E.
Mental disorders, suicide attempt and suicide: differences
404. Haer R, Scharpf F, Hecker T. The social legacies of conflict: the
in the association in refugees compared with Swedish-born
mediating role of mental health with regard to the association
individuals. Br J Psychiatry. 2020;217(6):679–85. doi:10.1192/
between war exposure and social capital of Burundian
bjp.2019.215.
refugees. Psychol Violence. 2021;11(1):40–9. doi:10.1037/
vio0000348. 415. Sankaranarayanan A, Al-Amin H, Ghuloum S. Correlates
of near-fatal deliberate self-harm in Qatar: a retrospective
study of psychiatric admissions for suicidal behaviors. Crisis.
2020;41(2):121–7. doi:10.1027/0227-5910/a000613.
174
416. McMahon EM, Corcoran P, Keeley H, Cannon M, Carli V, 426. MacLean SA, Agyeman PO, Walther J, Singer EK, Baranowski
Wasserman C et al. Mental health difficulties and suicidal KA, Katz CL. Mental health of children held at a United States
behaviours among young migrants: multicentre study of immigration detention center. Soc Sci Med. 2019;230:303–8.
European adolescents. BJPsych Open. 2017;3(6):291–9. doi:10.1016/j.socscimed.2019.04.013.
doi:10.1192/bjpo.bp.117.005322.
427. Blackmore R, Gray KM, Boyle JA, Fazel M, Ranasinha S,
417. Tarricone I, D'Andrea G, Jongsma HE, Tosato S, Gayer- Fitzgerald G et al. Systematic review and meta-analysis: the
Anderson C, Stilo SA et al. Migration history and risk prevalence of mental illness in child and adolescent refugees
of psychosis: results from the multinational EU-GEI and asylum seekers. J Am Acad Child Adolesc Psychiatry.
study. Psychol Med. Epub 2021 Feb 10. doi:10.1017/ 2020;59(6):705–14. doi:10.1016/j.jaac.2019.11.011.
S003329172000495X.
428. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA.
418. Morgan C, Charalambides M, Hutchinson G, Murray Annual research review: a meta-analysis of the worldwide
RM. Migration, ethnicity, and psychosis: toward a prevalence of mental disorders in children and adolescents.
sociodevelopmental model. Schizophr Bull. 2010;36(4):655– J Child Psychol Psychiatry. 2015;56(3):345–65. doi:10.1111/
64. doi:10.1093/schbul/sbq051. jcpp.12381.
419. Terhune J, Dykxhoorn J, Mackay E, Hollander AC, Kirkbride JB, 429. Meyer SR, Yu G, Hermosilla S, Stark L. Latent class analysis of
Dalman C. Migrant status and risk of compulsory admission violence against adolescents and psychosocial outcomes in
at first diagnosis of psychotic disorder: a population-based refugee settings in Uganda and Rwanda. Glob Ment Health.
cohort study in Sweden. Psychol Med. 2020;52(2):362–71. 2017;4:e19. doi:10.1017/gmh.2017.17.
doi:10.1017/S0033291720002068.
430. Hirani K, Cherian S, Mutch R, Payne DN. Identification of
420. Dykxhoorn J, Hollander A-C, Lewis G, Magnusson C, Dalman health risk behaviours among adolescent refugees resettling
C, Kirkbride JB. Risk of schizophrenia, schizoaffective, and in Western Australia. Arch Dis Child. 2018;103(3):240–6.
bipolar disorders by migrant status, region of origin, and doi:10.1136/archdischild-2017-313451.
age-at-migration: a national cohort study of 1.8 million
431. Fernandez E, Lee J-S, McNamara P. "Uprooted from
people. Psychol Med. 2019;49(14):2354–63. doi:10.1017/
everything that attaches you": long-term outcomes of former
S0033291718003227.
child migrants in care in the twentieth century in Australia. Br
421. Brandt L, Henssler J, Müller M, Wall S, Gabel D, Heinz A. Risk of J Soc Work. 2019;49(2):523–45. doi:10.1093/bjsw/bcy070.
psychosis among refugees: a systematic review and meta-
432. Arega NT. Posttraumatic stress among Eritrean
analysis. JAMA Psychiatry. 2019;76(11):1133–40. doi:10.1001/
unaccompanied refugee minors in Ethiopia. Int J Migr Health
jamapsychiatry.2019.1937.
Soc Care. 2021;17(1):1–15. doi:10.1108/IJMHSC-02-2020-0016.
422. Maguire J, Mifsud N, Seiler N, Nguyen T, Sizer H, McGorry P et
433. Emedo M, Habeeb S, Joyce M, Anderson S, Lorek A. Adverse
al. Symptomatic, functional and service utilization outcomes
experiences of unaccompanied asylum seeking children and
of migrants with a first episode of psychosis. Soc Psychiatry
the impact on their emotional wellbeing and mental health
Psychiatr Epidemiol. 2021;56(8):1389–97. doi:10.1007/s00127-
needs. Arch Dis Child. 2018;103(1). doi:10.1136/archdischild-
020-02011-7.
2018-rcpch.4.
423. Beni Yonis O, Khader Y, Jarboua A, Al-Bsoul MM, Al-Akour
434. Jarlby F, Goosen S, Derluyn I, Vitus K, Jervelund SS. What
N, Alfaqih MA et al. Post-traumatic stress disorder among
can we learn from unaccompanied refugee adolescents'
Syrian adolescent refugees in Jordan. J Public Health.
perspectives on mental health care in exile? Eur J Pediatr.
2020;42(2):319–24. doi:10.1093/pubmed/fdz026.
2018;177(12):1767–74. doi:10.1007/s00431-018-3249-0.
424. Escot R, Mahfouz M, Feghaly Saade I, Varady CJ. Insights
435. Jensen TK, Skar A-MS, Andersson ES, Birkeland MS. Long-
into Syrian refugee children's mental health status & coping
term mental health in unaccompanied refugee minors:
mechanisms. Beirut: Caritas Lebanon Migrant Center; 2016
pre- and post-flight predictors. Eur Child Adolesc Psychiatry.
(https://reliefweb.int/sites/reliefweb.int/files/resources/Final-
2019;28(12):1671–82. doi:10.1007/s00787-019-01340-6.
Mental.pdf, accessed 2 April 2022).
436. Longobardi C, Veronesi TG, Prino LE. Abuses, resilience,
425. Shah SM, Al Dhaheri F, Albanna A, Al Jaberi N, Al Eissaee
behavioural problems and post-traumatic stress symptoms
S, Alshehhi NA et al. Self-esteem and other risk factors for
among unaccompanied migrant minors: an Italian
depressive symptoms among adolescents in United Arab
cross-sectional exploratory study. Psychiatr Psychol Klin.
Emirates. PLOS One. 2020;15(1):e0227483. doi:10.1371/
2017;17(2):87–92. doi:10.15557/PiPK.2017.0009.
175
437. Sarkadi A, Ådahl K, Stenvall E, Ssegonja R, Batti H, Gavra P 448. Tohme J, Egan JE, Stall R, Wagner G, Mokhbat J. HIV
et al. Teaching recovery techniques: evaluation of a group prevalence and demographic determinants of unprotected
intervention for unaccompanied refugee minors with anal sex and HIV testing among male refugees who have sex
symptoms of PTSD in Sweden. Eur Child Adolesc Psychiatry. with men in Beirut, Lebanon. AIDS Behav. 2016;20
2018;27(4):467–79. doi:10.1007/s00787-017-1093-9. (suppl 3):408–16. doi:10.1007/s10461-016-1484-9.
438. Jakobsen M, Meyer DeMott MA, Wentzel-Larsen T, Heir T. The 449. Gosselin A, Ravalihasy A, Pannetier J, Lert F, Desgrées du Loû
impact of the asylum process on mental health: a longitudinal A; Parcours Study Group. When and why? Timing of post-
study of unaccompanied refugee minors in Norway. BMJ migration HIV acquisition among sub-Saharan migrants in
Open. 2017;7(6):e015157. doi:10.1136/bmjopen-2016-015157. France. Sex Transm Infect. 2020;96(3):227–31. doi:10.1136/
sextrans-2019-054080.
439. Davies A, Basten A, Frattini C. Migration: a social determinant
of the health of migrants. Geneva: International Organization 450. Ndumbi P, del Romero J, Pulido F, Velasco Arribas M, Dronda
for Migration; 2009 (https://migrationhealthresearch.iom.int/ F, Blanco Ramos JR et al. Barriers to health care services
migration-social-determinant-health-migrants, accessed for migrants living with HIV in Spain. Eur J Public Health.
21 April 2022). 2018;28(3):451–7. doi:10.1093/eurpub/ckx225.
440. Gurrola MA, Ayón C. Immigration policies and social 451. Dana DP, Gumbie T, Grinker R. Access to HIV/AIDS health
determinants of health: is immigrants' health at risk? Race Soc services by refugees in the Eastern Cape, South Africa. South
Probl. 2018;10(3):209–20. doi:10.1007/s12552-018-9239-z. Africa: Eastern Cape Socio-Economic Consultative Council;
2018 (https://www.ecsecc.org/datarepository/documents/
441. Agu J, Lobo R, Crawford G, Chigwada B. Migrant sexual
ecsecc-wp-access-to-hiv-wp-22_95890.pdf, accessed
health help-seeking and experiences of stigmatization and
2 April 2022).
discrimination in Perth, Western Australia: exploring barriers
and enablers. Int J Environ Res Public Health. 2016;13(5):485. 452. Musumari PM, Chamchan C. Correlates of HIV testing
doi:10.3390/ijerph13050485. experience among migrant workers from Myanmar
residing in Thailand: a secondary data analysis. PLOS One.
442. Ziersch A, Walsh M, Baak M, Rowley G, Oudih E, Mwanri L. "It
is not an acceptable disease": a qualitative study of HIV-
related stigma and discrimination and impacts on health and 453. Thapa S, Bista N, Hannes K, Buve A, Vermandere M, Mathei
wellbeing for people from ethnically diverse backgrounds C. Vulnerability of wives of Nepalese labor migrants to HIV
in Australia. BMC Public Health. 2021;21(1):779. doi:10.1186/ infection: integrating quantitative and qualitative evidence.
s12889-021-10679-y. Women Health. 2016;56(7):745–66. doi:10.1080/03630242.201
5.1118726.
443. Khatoon S, Budhathoki SS, Bam K, Thapa R, Bhatt LP,
Basnet B et al. Socio-demographic characteristics and the 454. Correa-Agudelo E, Kim H-Y, Musuka GN, Mukandavire
utilization of HIV testing and counselling services among the Z, Akullian A, Cuadros DF. Associated health and social
key populations at the Bhutanese refugee camps in Eastern determinants of mobile populations across HIV epidemic
Nepal. BMC Res Notes. 2018;11(1):535. doi:10.1186/s13104- gradients in southern Africa. J Migr Health. 2021;3:100038.
018-3657-2. doi:10.1016/j.jmh.2021.100038.
444. Pinehas LN, van Wyk NC, Leech R. Healthcare needs of 455. Tohme J, Egan JE, Friedman MR, Stall R. Psycho-social
displaced women: Osire refugee camp, Namibia. Int Nurs Rev. correlates of condom use and HIV testing among MSM
2016;63(1):139–47. doi:10.1111/inr.12241. refugees in Beirut, Lebanon. AIDS Behav. 2016;20
(suppl 3):417–25. doi:10.1007/s10461-016-1498-3.
445. Steenberg B. Patients and personhood: perceptions of HIV
in Mozambican immigrants in South Africa. Med Anthropol. 456. Rebolledo-Ponietsky K, Munayco CV, Mezones-Holguín E.
2020;39(3):211–24. doi:10.1080/01459740.2019.1677646. Migration crisis in Venezuela: impact on HIV in Peru. J Travel
Med. 2019;26(2):tay155. doi:10.1093/jtm/tay155.
446. Steenberg B. HIV-positive Mozambican migrants in South
Africa: loneliness, secrecy and disclosure. Cult Health Sex. 457. Zhang Y, Liang B, Liu D, Wei G, Mo S, Nong A et al. Migrant
2020;22(1):48–63. doi:10.1080/13691058.2019.1571230. female sex workers working at the Sino-Vietnamese border
for a short time have a higher risk of HIV transmission: a
447. Ojikutu BO, Nnaji C, Sithole-Berk J, Masongo D, Nichols
consecutive cross-sectional study. AIDS Res Ther. 2020;17(1):4.
K, Weeks N et al. African born women living with HIV in
doi:10.1186/s12981-020-0260-0.
the United States: unmet needs and opportunities for
intervention. AIDS Care. 2018;30(12):1542–50. doi:10.1080/ 458. Tschirhart N, Thi SS, Swe LL, Nosten F, Foster AM. Treating the
09540121.2018.1497767. invisible: gaps and opportunities for enhanced TB control
along the Thailand–Myanmar border. BMC Health Serv Res.
2017;17(1):29. doi:10.1186/s12913-016-1954-9.
176
459. Infante C, Aggleton P, Pridmore P. Forms and determinants 470. Medland NA, Chow EPF, Read THR, Ong JJ, Chen M, Denham I
of migration and HIV/AIDS-related stigma on the Mexican- et al. Incident HIV infection has fallen rapidly in men who have
Guatemalan border. Qual Health Res. 2009;19(12):1656–68. sex with men in Melbourne, Australia (2013–2017) but not in
doi:10.1177/1049732309353909. the newly-arrived Asian-born. BMC Infect Dis. 2018;18(1):410.
doi:10.1186/s12879-018-3325-0.
460. HIV/AIDS surveillance in Europe 2020 (2019 data). Stockholm:
European Centre for Disease Prevention and Control; 2020 471. Blackshaw LCD, Chow EPF, Varma R, Healey L, Templeton DJ,
(https://www.ecdc.europa.eu/en/publications-data/hivaids- Basu A et al. Characteristics of recently arrived Asian men who
surveillance-europe-2020-2019-data, accessed 2 April 2022). have sex with men diagnosed with HIV through sexual health
services in Melbourne and Sydney. Aust N Z J Public Health.
461. Kerani RP, Satcher Johnson A, Buskin SE, Rao D, Golden
2019;43(5):424–8. doi:10.1111/1753-6405.12926.
MR, Hu X et al. The epidemiology of HIV among people born
outside the United States, 2010–2017. Public Health Rep. 472. Hu J, Gu X, Tao X, Qian Y, Babu GR, Wang G et al. Prevalence
2020;135(5):611–20. doi:10.1177/0033354920942623. and trends of HIV, syphilis, and HCV in migrant and resident
men who have sex with men in Shandong, China: results from
462. Demeke HB, Johnson AS, Wu B, Nwangwu-Ike N, King H,
a serial cross-sectional study. PLOS One. 2017;12(1):e0170443.
Dean HD. Differences between U.S.-born and non-U.S.-born
black adults reported with diagnosed HIV infection: United
States, 2008–2014. J Immigr Minor Health. 2019;21(1):30–8. 473. Nelson LE, Tharao W, Husbands W, Sa T, Zhang N, Kushwaha S
doi:10.1007/s10903-018-0699-4. et al. The epidemiology of HIV and other sexually transmitted
infections in African, Caribbean and Black men in Toronto,
463. Taylor TN, DeHovitz J, Hirshfield S. Intersectional stigma and
Canada. BMC Infect Dis. 2019;19(1):294. doi:10.1186/s12879-
multi-level barriers to HIV testing among foreign-born black
019-3925-3.
men from the Caribbean. Front Public Health. 2020;7:373.
doi:10.3389/fpubh.2019.00373. 474. Migrant health: access to HIV prevention, treatment and care
for migrant populations in EU/EEA countries. Stockholm:
464. Pannetier J, Ravalihasy A, Lydié N, Lert F, Desgrées du Loû
European Centre for Disease Prevention and Control, 2009
A, Parcours Study Group. Prevalence and circumstances
(https://www.ecdc.europa.eu/sites/default/files/media/en/
of forced sex and post-migration HIV acquisition in sub-
publications/Publications/0907_TER_Migrant_health_HIV_
Saharan African migrant women in France: an analysis of
Access_to_treatment.pdf, accessed 26 June 2022).
the ANRS-PARCOURS retrospective population-based study.
Lancet Public Health. 2018;3(1):e16–23. doi:10.1016/S2468- 475. Masebo W. Accessing ART in Malawi while living in South
2667(17)30211-6. Africa - a thematic analysis of qualitative data from
undocumented Malawian migrants. Glob Public Health.
465. Desgrees-du-Lou A, Pannetier J, Ravalihasy A, Le Guen
2019;14(5):621–35. doi:10.1080/17441692.2018.1524920.
M, Gosselin A, Panjo H et al. Is hardship during migration
a determinant of HIV infection? Results from the ANRS 476. Faturiyele I, Karletsos D, Ntene-Sealiete K, Musekiwa A, Khabo
PARCOURS study of sub-Saharan African migrants in France. M, Mariti M et al. Access to HIV care and treatment for migrants
AIDS. 2016;30(4):645–56. doi:10.1097/QAD.0000000000000957. between Lesotho and South Africa: a mixed methods study.
BMC Public Health. 2018;18(1):668. doi:10.1186/s12889-018-
466. Alvarez-del Arco D, Fakoya I, Thomadakis C, Pantazis N,
5594-3.
Touloumi G, Gennotte A-F et al. High levels of postmigration
HIV acquisition within nine European countries. AIDS. 477. Been SK, Vijver DAMC, Nieuwkerk PT, Is B, Stutterheim SE, Bos
2017;31(14):1979–88. doi:10.1097/QAD.0000000000001571. AER. Risk factors for non-adherence to cART in immigrants
with HIV living in the Netherlands: results from the ROtterdam
467. Ayuttacorn A, Tangmunkongvorakul A, Musumari PM,
ADherence (ROAD) Project. PLOS One. 2016;11(10):e0162800.
Srithanaviboonchai K, Jirattikorn A, Aurpibul L. Disclosure of
HIV status among Shan female migrant workers living with
HIV in Northern Thailand: a qualitative study. PLOS One. 478. Marukutira T, Yin D, Cressman L, Kariuki R, Malone B, Spelman
2019;14(5):e0216382. doi:10.1371/journal.pone.0216382. T et al. Clinical outcomes of a cohort of migrants and citizens
living with human immunodeficiency virus in Botswana:
468. Kwena Z, Nakamanya S, Nanyonjo G, Okello E, Fast P, Ssetaala
implications for Joint United Nation Program on HIV and AIDS
A et al. Understanding mobility and sexual risk behaviour
90-90-90 targets. Medicine (Baltimore). 2019;98(23):e15994.
among women in fishing communities of Lake Victoria in East
doi:10.1097/MD.0000000000015994.
Africa: a qualitative study. BMC Public Health. 2020;20(1):944.
doi:10.1186/s12889-020-09085-7. 479. Been SK, Yildiz E, Nieuwkerk PT, Pogány K, van de Vijver
DAMC, Verbon A. Self-reported adherence and pharmacy
469. Shannon K, Crago A-L, Baral SD, Bekker L-G, Kerrigan D,
refill adherence are both predictive for an undetectable viral
Decker MR et al. The global response and unmet actions
load among HIV-infected migrants receiving cART. PLOS One.
for HIV and sex workers. Lancet. 2018;392(10148):698–710.
doi:10.1016/S0140-6736(18)31439-9.
177
480. Kronfli N, Linthwaite B, Sheehan N, Cox J, Hardy I, Lebouché 491. Boyd AT, Cookson ST, Almashayek I, Yaacoub H, Qayyum MS,
B et al. Delayed linkage to HIV care among asylum seekers Galev A. An evaluation of a tuberculosis case-finding and
in Quebec, Canada. BMC Public Health. 2019;19(1):1683. treatment program among Syrian refugees - Jordan and
doi:10.1186/s12889-019-8052-y. Lebanon, 2013–2015. Confl Health. 2019;13(1):32. doi:10.1186/
s13031-019-0213-1.
481. Gray C, Lobo R, Narciso L, Oudih E, Gunaratnam P, Thorpe
R et al. Why I can't, won't or don't test for HIV: insights from 492. Global tuberculosis report 2021. Geneva: World Health
Australian migrants born in sub-Saharan Africa, Southeast Organization; 2021 (https://apps.who.int/iris/rest/
Asia and Northeast Asia. Int J Environ Res Public Health. bitstreams/1379788/retrieve, accessed 21 April 2022).
2019;16(6):1034. doi:10.3390/ijerph16061034.
493. Ali S, Rao MB, Sahly AA, Alfageeh A, Bakari A. A retrospective
482. Shakya P, Tanaka M, Shibanuma A, Jimba M. Nepalese study to investigate the impact of immigration on tuberculosis
migrants in Japan: What is holding them back in getting control program by DOTS strategy in Gazan Province, Saudi
access to healthcare? PLOS One. 2018;13(9):e0203645. Arabia. J Public Health. 2018;26(2):163–75. doi:10.1007/
doi:10.1371/journal.pone.0203645. s10389-017-0838-8.
483. Ryan KE, Wilkinson AL, Asselin J, Leitinger DP, Locke P, 494. van den Boogaard J, Slump E, Schimmel HJ, van der Hoek
Pedrana A et al. Assessment of service refinement and its W, van den Hof S, de Vries G. High incidence of active
impact on repeat HIV testing by client's access to Australia's tuberculosis in asylum seekers from Eritrea and Somalia in
universal healthcare system: a retrospective cohort study. J the first 5 years after arrival in the Netherlands. Emerg Infect
Int AIDS Soc. 2019;22(8):e25353. doi:10.1002/jia2.25353. Dis. 2020;26(4):675–81. doi:10.3201/eid2604.190123.
484. Ravicz M, Muhongayire B, Kamagaju S, Klabbers RE, Faustin Z, 495. Vo LNQ, Codlin AJ, Forse RJ, Nguyen HT, Vu TN, Van Truong
Kambugu A et al. Using intervention mapping methodology V et al. Tuberculosis among economic migrants: a cross-
to design an HIV linkage intervention in a refugee settlement sectional study of the risk of poor treatment outcomes
in rural Uganda. AIDS Care. 2022;34(4):446–58. doi:10.1080/ and impact of a treatment adherence intervention among
09540121.2021.1900532. temporary residents in an urban district in Ho Chi Minh City,
Viet Nam. BMC Infect Dis. 2020;20(1):134. doi:10.1186/s12879-
485. Gray RT, Watson J, Cogle AJ, Smith DE, Hoy JF, Bastian
020-4865-7.
LA et al. Funding antiretroviral treatment for HIV-positive
temporary residents in Australia prevents transmission and 496. Aldridge RW, Zenner D, White PJ, Muzyamba MC, Loutet
is inexpensive. Sex Health. 2018;15(1):13–19. doi:10. M, Dhavan P et al. Prevalence of and risk factors for active
1071/SH16237. tuberculosis in migrants screened before entry to the UK: a
population-based cross-sectional study. Lancet Infect Dis.
486. Global tuberculosis programme [website]. Geneva: World
2016;16(8):962–70. doi:10.1016/S1473-3099(16)00072-4.
Health Organization; 2020 (https://www.who.int/teams/
global-tuberculosis-programme/data, accessed 4 May 2022). 497. Benjumea-Bedoya D, Becker M, Haworth-Brockman M,
Balakumar S, Hiebert K, Lutz J-A et al. Integrated care for
487. Ali F, Shafee M, Akbar A, Khan N, Khetran MA, Rahman F et
latent tuberculosis infection (LTBI) at a primary health care
al. Frequency of pulmonary tuberculosis in Afghan assylum
facility for refugees in Winnipeg, Canada: a mixed-methods
seekers dwelling in Balochistan, Pakistan. Rawal Med J.
evaluation. Front Public Health. 2019;7:57. doi:10.3389/
2018;43(4):577–80.
fpubh.2019.00057.
488. Chan EYY, Chiu CP, Chan GKW. Medical and health risks
498. Tschirhart N, Sein T, Nosten F, Foster AM. Refugee and migrant
associated with communicable diseases of Rohingya
patient perspectives on travel and tuberculosis along the
refugees in Bangladesh 2017. Int J Infect Dis. 2018;68:39–43.
Thailand–Myanmar border: a qualitative study. PLOS One.
doi:10.1016/j.ijid.2018.01.001.
489. Aldridge RW, Zenner D, White PJ, Williamson EJ, Muzyamba
499. Pawlowski A, Jansson M, Sköld M, Rottenberg ME, Källenius
MC, Dhavan P et al. Tuberculosis in migrants moving from
G. Tuberculosis and HIV co-infection. PLOS Pathog.
high-incidence to low-incidence countries: a population
2012;8(2):e1002464. doi :10.1371/journal.ppat.1002464.
based cohort study. Lancet. 2016;388(10059):2510–18.
doi:10.1016/S0140-6736(16)31008-X. 500. Legesse T, Admenur G, Gebregzabher S, Woldegebriel E,
Fantahun B, Tsegay Y et al. Tuberculosis (TB) in the refugee
490. Tuberculosis surveillance and monitoring in Europe 2021:
camps in Ethiopia: trends of case notification, profile,
2019 data. Copenhagen: WHO Regional Office for Europe;
and treatment outcomes, 2014 to 2017. BMC Infect Dis.
2021 (https://apps.who.int/iris/handle/10665/340210,
2021;21(1):139. doi:10.1186/s12879-021-05828-y.
178
501. Ejeta E, Beyene G, Balay G, Bonsa Z, Abebe G. Factors 511. Al-Ghafli H, Varghese B, Enani M, Alrajhi A, Johani SA, Albarrak
associated with unsuccessful treatment outcome in A. Demographic risk factors for extra-pulmonary tuberculosis
tuberculosis patients among refugees and their surrounding among adolescents and adults in Saudi Arabia. PLOS One.
communities in Gambella Regional State, Ethiopia. PLOS One. 2019;14(3):e0213846. doi:10.1371/journal.pone.0213846.
512. Varghese B, Enani M, Alrajhi A, Al Johani S, Albarak A,
502. Confronting inequalities: lessons for pandemic responses from Althawadi S et al. Impact of Mycobacterium tuberculosis
40 years of AIDS. Global AIDS update. Geneva: UNAIDS; 2021 complex lineages as a determinant of disease phenotypes
(https://www.unaids.org/sites/default/files/media_asset/2021- from an immigrant rich moderate tuberculosis burden
global-aids-update_en.pdf, accessed 30 June 2022). country. Respir Res. 2018;19(1):259. doi:10.1186/s12931-
018-0966-x.
503. Orozco-Andrade I, Acosta-Loya JA, Bravo-Rodríguez G,
Martínez-Lozano FN, Espinoza-Hernández ME, Enríquez- 513. Hayward SE, Rustage K, Nellums LB, van der Werf MJ, Noori T,
Porras A et al. Patrones de farmacorresistencia en población Boccia D et al. Extrapulmonary tuberculosis among migrants
migrante con tuberculosis pulmonar [Drug resistance patterns in Europe, 1995 to 2017. Clin Microbiol Infect. 2021;27(9):1347.
in migrant population with pulmonary tuberculosis]. Neumol doi:10.1016/j.cmi.2020.12.006.
Cir Tórax. 2018;77(4):247–57 (in Spanish).
514. Dale KD, Trauer JM, Dodd PJ, Houben RMGJ, Denholm JT.
504. Pandey S, Lavu E, Congdon J, Moke R, Bainomugisa A, Coulter Estimating the prevalence of latent tuberculosis in a low-
C. Characterization of pncA mutations in multi-drug and incidence setting: Australia. Eur Respir J. 2018;52(6):1801218.
pyrazinamide resistant Mycobacterium tuberculosis isolates doi:10.1183/13993003.01218-2018.
cultured from Queensland migrants and Papua New Guinea
515. Yap P, Tan KHX, Lim WY, Barkham T, Tan LWL, Chen MI-C
residents. Tuberculosis. 2018;111:109–13. doi:10.1016/j.
et al. Prevalence of and risk factors associated with latent
tube.2018.06.006.
tuberculosis in Singapore: a cross-sectional survey. Int J Infect
505. Helbling P, Kröger S, Haas W, Brusin S, Cirillo DM, Groenheit R Dis. 2018;72:55–62. doi:10.1016/j.ijid.2018.05.004.
et al. Screening of migrants for tuberculosis identifies patients
516. Kawatsu L, Uchimura K, Ohkado A. Trend and treatment
with multidrug-resistant tuberculosis but is not sufficient.
outcomes of latent tuberculosis infection among migrant
Clin Microbiol Infect. 2018;24(8):918–19. doi:10.1016/j.
persons in Japan: retrospective analysis of Japan tuberculosis
cmi.2018.03.015.
surveillance data. BMC Infect Dis. 2021;21(1):42. doi:10.1186/
506. Riccardi N, Pontarelli A, Alagna R, Saderi L, Ferrarese M, s12879-020-05712-1.
Castellotti P et al. Epidemiology and treatment outcome
517. Dara M, Solovic I, Sotgiu G, D'Ambrosio L, Centis R, Tran R et al.
of MDR and pre-XDR TB in international migrants at two
Tuberculosis care among refugees arriving in Europe: a ERS/
reference centers in the north of Italy: a cross-sectional
WHO Europe Region survey of current practices. Eur Respir J.
study coordinated by Stop TB Italia Onlus. Public Health.
2016;48(3):808–17. doi:10.1183/13993003.00840-2016.
2020;180:17–21. doi:10.1016/j.puhe.2019.10.022.
518. Public health guidance on screening and vaccination for
507. Jensenius M, Winje BA, Blomberg B, Mengshoel AT, von der
infectious diseases in newly arrived migrants within the EU/
Lippe B, Hannula R et al. Multidrug-resistant tuberculosis in
EEA. Stockholm: European Centre for Disease Prevention and
Norway: a nationwide study, 1995–2014. Int J Tuberc Lung
Control; 2018 (https://www.ecdc.europa.eu/sites/default/
Dis. 2016;20(6):786–92. doi:10.5588/ijtld.15.0895.
files/documents/Public%20health%20guidance%20on%20
508. Ködmön C, Zucs P, van der Werf MJ. Migration-related screening%20and%20vaccination%20of%20migrants%20
tuberculosis: epidemiology and characteristics of tuberculosis in%20the%20EU%20EEA.pdf, accessed 30 June 2022).
cases originating outside the European Union and European
519. Latent tuberculosis infection: updated and consolidated
Economic Area, 2007 to 2013. Euro Surveill. 2016;21(12).
guidelines for programmatic management. Geneva: World
doi:10.2807/1560-7917.ES.2016.21.12.30164.
509. Furukawa NW, Haider MZ, Allen SJ, Carlson SL, Lindquist handle/10665/260233, accessed 2 April 2022).
SW. Resistance to first-line antituberculosis drugs in
520. Pampaloni A, Locatelli ME, Rullo EV, Alaimo S, Cosentino F,
Washington state by region of birth and implications for latent
Marino A et al. "Diagnosis on the Dock" project: a proactive
tuberculosis treatment among foreign-born individuals. Am J
screening program for diagnosing pulmonary tuberculosis in
Trop Med Hyg. 2017;96(3):543–49. doi:10.4269/ajtmh.16-0662.
disembarking refugees and new SEI model. Int J Infect Dis.
510. Ali M, Howady F, Munir W, Karim H, Al-Suwaidi Z, Al-Maslamani 2021;106:98–104. doi:10.1016/j.ijid.2021.03.032.
M et al. Drug-resistant tuberculosis: an experience from Qatar.
521. Pittalis S, Piselli P, Contini S, Gualano G, Alma MG, Tadolini
Libyan J Med. 2020;15(1):1744351. doi:10.1080/19932820.
M et al. Socioeconomic status and biomedical risk factors in
2020.1744351.
migrants and native tuberculosis patients in Italy. PLOS One.
179
522. Campbell JR, Johnston JC, Cook VJ, Sadatsafavi M, Elwood 533. Izri A, Cojean S, Leblanc C, Cohen Y, Bouchaud O, Durand R.
RK, Marra F. Cost-effectiveness of latent tuberculosis Plasmodium vivax severe imported malaria in two migrants in
infection screening before immigration to low-incidence France. Malar J. 2019;18(1):422. doi:10.1186/s12936-019-3067-5.
countries. Emerg Infect Dis. 2019;25(4):661–71. doi:10.3201/
534. Roggelin L, Tappe D, Noack B, Addo MM, Tannich E, Rothe
eid2504.171630.
C. Sharp increase of imported Plasmodium vivax malaria
523. Hargreaves S, Nellums LB, Johnson C, Goldberg J, Pantelidis seen in migrants from Eritrea in Hamburg, Germany. Malar J.
P, Rahman A et al. Delivering multi-disease screening 2016;15:325. doi:10.1186/s12936-016-1366-7.
to migrants for latent TB and blood-borne viruses in an
535. Pérez-Molina JA, López-Polín A, Treviño B, Molina I,
emergency department setting: a feasibility study. Travel Med
Goikoetxea J, Díaz-Menéndez M et al. 6-year review of +Redivi:
Infect Dis. 2020;36:101611. doi:10.1016/j.tmaid.2020.101611.
a prospective registry of imported infectious diseases in
524. Öhd JN, Lönnroth K, Abubakar I, Aldridge RW, Erkens C, Spain. J Travel Med. 2017;24(5). doi:10.1093/jtm/tax035.
Jonsson J et al. Building a European database to gather
536. Boga JA, Casado L, Fernàndez-Suarez J, Moran N, Rodríguez-
multi-country evidence on active and latent TB screening
Perez M, Martínez-Sela M et al. Screening program for
for migrants. Int J Infect Dis. 2019;80S:S45–9. doi:10.1016/j.
imported diseases in immigrant women: analysis and
ijid.2019.02.041.
implications from a gender-oriented perspective. Am J Trop
525. Trauer JM, Williams B, Laemmle-Ruff I, Horyniak D, Caplice Med Hyg. 2020;103(1):480–4. doi:10.4269/ajtmh.19-0687.
LVS, McBryde ES et al. Tuberculosis in migrants to Australia:
537. Jovanovic S, Dakic Z, Lavadinović L, Poluga J, Malinic J, Karić
outcomes of a national screening program. Lancet Reg Health
U et al. Changing trend of imported Plasmodium malaria
West Pac. 2021;10:100135. doi:10.1016/j.lanwpc.2021.100135.
cases by origins and species in Serbia. J Infect Public Health.
526. Peghin M, Rodriguez-Pardo D, Sanchez-Montalva A, Pellisé F, 2020;13:365–6. doi:10.1016/j.jiph.2020.01.161.
Rivas A, Tortola T et al. The changing epidemiology of spinal
538. Brindicci G, Santoro CR, Loconsole D, Martinelli D, Prato R,
tuberculosis: the influence of international immigration in
Lonero G et al. A cluster of cryptic Plasmodium falciparum
Catalonia, 1993–2014. Epidemiol Infect. 2017;145(10):2152–60.
malaria in African migrants in southern Italy, October 2017.
doi:10.1017/S0950268817000863.
Vector Borne Zoonotic Dis. 2020;20(12):927–31. doi:10.1089/
527. Broderick C, Hopkins S, Mack DJF, Aston W, Pollock R, Skinner vbz.2019.2607.
JA et al. Delays in the diagnosis and treatment of bone and
539. Iqbal J, Al-Awadhi M, Ahmad S. Decreasing trend of imported
joint tuberculosis in the United Kingdom. Bone Joint J.
malaria cases but increasing influx of mixed P. falciparum
2018;100-B(1):119–24. doi:10.1302/0301-620X.100B1.BJJ-
and P. vivax infections in malaria-free Kuwait. PLOS One.
2017-0357.R1.
528. Kentley J, Ooi JL, Potter J, Tiberi S, O'Shaughnessy T,
540. Al-Rumhi A, Al-Hashami Z, Al-Hamidhi S, Gadalla A, Naeem
Langmead L et al. Intestinal tuberculosis: a diagnostic
R, Ranford-Cartwright L et al. Influx of diverse, drug resistant
challenge. Trop Med Int Health. 2017;22(8):994–9. doi:10.1111/
and transmissible Plasmodium falciparum into a malaria-free
tmi.12908.
setting in Qatar. BMC Infect Dis. 2020;20(1):413. doi:10.1186/
529. Doğru S, Döner P. Frequency and outcomes of new patients s12879-020-05111-6.
with pulmonary tuberculosis in Hatay province after Syrian
541. Alshahrani AM, Abdelgader TM, Saeed I, Al-Akhshami A,
civil war. Indian J Tuberc. 2017;64(2):83–8. doi:10.1016/j.
Al-Ghamdi M, Al-Zahrani MH et al. The changing malaria
ijtb.2016.11.034.
landscape in Aseer region, Kingdom of Saudi Arabia: 2000–
530. El Guamri Y, Amahmid O, Zenjari K, Bouhout S, Ait Mouh M, Ait 2015. Malar J. 2016;15(1):538. doi:10.1186/s12936-016-1581-2.
Melloul A et al. [Imported malaria in the region of Marrakech-
542. Yang C, Zhang H, Zhou R, Qian D, Liu Y, Zhao Y et al.
Safi, Morocco, between 1996 and 2016]. Bull Soc Pathol Exot.
Polymorphisms of Plasmodium falciparum k13-propeller
2018;111(2):104–8. doi:10.3166/bspe-2018-0014.
gene among migrant workers returning to Henan Province,
531. Farag E, Bansal D, Chehab MAH, Al-Dahshan A, Bala M, China from Africa. BMC Infect Dis. 2017;17(1):560. doi:10.1186/
Ganesan N et al. Epidemiology of malaria in the State s12879-017-2634-z.
of Qatar, 2008–2015. Mediterr J Hematol Infect Dis.
543. Smith JL, Ghimire P, Rijal KR, Maglior A, Hollis S, Andrade-
2018;10(1):e2018050. doi:10.4084/MJHID.2018.050.
Pacheco R et al. Designing malaria surveillance strategies for
532. Ismail KA, Abdelwahab MM, Rezk HM, Khalifa AM. Hyalournan mobile and migrant populations in Nepal: a mixed-methods
role in pathophysiology of different species of Plasmodium. study. Malar J. 2019;18(1):158. doi:10.1186/s12936-019-2791-1.
Infect Dis Clin Pract. 2016;24(5):280–2. doi:10.1097/
IPC.0000000000000412.
180
544. Wen S, Harvard KE, Gueye CS, Canavati SE, Chancellor A, 554. Tatem AJ, Jia P, Ordanovich D, Falkner M, Huang Z, Howes
Ahmed B-N et al. Targeting populations at higher risk for R et al. The geography of imported malaria to non-endemic
malaria: a survey of national malaria elimination programmes countries: a meta-analysis of nationally reported statistics.
in the Asia Pacific. Malar J. 2016;15(1):271. doi:10.1186/ Lancet Infect Dis. 2017;17(1):98–107. doi:10.1016/S1473-
s12936-016-1319-1. 3099(16)30326-7.
545. Kheang ST, Lin MA, Lwin S, Naing YH, Yarzar P, Kak N et al. 555. Rakprasit J, Nakamura K, Seino K, Morita A. Healthcare
Malaria case detection among mobile populations and use for communicable diseases among migrant workers in
migrant workers in Myanmar: comparison of 3 service comparison with Thai workers. Ind Health. 2017;55(1):67–75.
delivery approaches. Glob Health Sci Pract. 2018;6(2):384–9. doi:10.2486/indhealth.2016-0107.
doi:10.9745/GHSP-D-17-00318.
556. Inkochasan M, Gopinath D, Vicario E, Lee A, Duigan P. Access
546. Ariza-Abril JS, Marcela-Cifuentes Á, Calderón-Jaramillo to health care for migrants in the Greater Mekong Subregion:
M, Rivera D, Rivillas-García JC. Uso de servicios de salud policies and legal frameworks and their impact on malaria
y enfermedades transmisibles de la población migrante control in the context of malaria elimination. WHO South-
y refugiada Venezolana [Use of health services and East Asia J Public Health. 2019;8(1):26–34. doi:10.4103/2224-
communicable diseases in the Venezuelan migrant and 3151.255346.
refugee population]. Salud UIS. 2020;52(4):392–401 (in
557. Molnarova S, Wolf S, Tenna M. Highland malaria at the Kiziba
Spanish). doi:10.18273/revsal.v52n4-2020006.
UNHCR refugee camps (1950 m.a.s.). Clin Soc Work Health
547. Refugee health report Uganda, June 2019. Ministry of Health Interv. 2016;7(3):19–24. doi:10.22359/cswhi_7_3_05.
Knowledge Management Portal. Kampala: Ministry of Health
558. Aschale Y, Mengist A, Bitew A, Kassie B, Talie A. Prevalence
of Uganda; 2019 (http://library.health.go.ug/publications/
of malaria and associated risk factors among asymptomatic
refugees/refugee-health-report-uganda-june-2019, accessed
migrant laborers in West Armachiho District, Northwest
3 April 2022).
Ethiopia. Res Rep Trop Med. 2018;9:95–101. doi:10.2147/
548. Ahmed A, Mulatu K, Elfu B. Prevalence of malaria and RRTM.S165260.
associated factors among under-five children in Sherkole
559. Camuset G, Lafarge S, Borgherini G, Gerber A, Pouderoux
refugee camp, Benishangul-Gumuz region, Ethiopia. A cross-
N, Foucher A et al. Leprosy on Reunion Island, 2005–
sectional study. PLOS One. 2021;16(2):e0246895. doi:10.1371/
2013: situation and perspectives. PLOS Negl Trop Dis.
549. Coldiron ME, Lasry E, Bouhenia M, Das D, Okui P, Nyehangane
560. Ostera G, Blum J, Cornejo C, Burgula S, Jeun R, Bryan PE
D et al. Intermittent preventive treatment for malaria among
et al. Strongyloidiasis in Latin American immigrants: a
children in a refugee camp in Northern Uganda: lessons
pilot study. J Helminthol. 2017;91(2):262–6. doi:10.1017/
learned. Malar J. 2017;16(1):218. doi:10.1186/s12936-017-
S0022149X16000213.
1869-x.
561. Humphrey JM, Al-Absi ES, Hamdan MM, Okasha SS, Al-
550. iRHIS: integrated refugee health information system [website].
Trmanini DM, El-Dous HG et al. Dengue and chikungunya
Geneva: Office of the United Nations High Commissioner for
seroprevalence among Qatari nationals and immigrants
Refugees; 2022 (https://his.unhcr.org/home, accessed
residing in Qatar. PLOS One. 2019;14(1):e0211574.
4 May 2022).
551. Standardised expanded nutrition survey: data dashboard
562. Crawshaw AF, Pareek M, Were J, Schillinger S, Gorbacheva O,
[website]. Geneva: Office of the United Nations High
Wickramage KP et al. Infectious disease testing of UK-bound
Commissioner for Refugees; 2022 (https://sens.unhcr.org/
refugees: a population-based, cross-sectional study. BMC
data-dashboard/, accessed 4 May 2022).
Med. 2018;16:143. doi:10.1186/s12916-018-1125-4.
552. Canavati SE, Quintero CE, Lawford HLS, Yok S, Lek D, Richards
563. Cooper CL, Read D, Vachon M-L, Conway B, Wong A, Ramji A
JS et al. High mobility, low access thwarts interventions
et al. Hepatitis C virus infection characteristics and treatment
among seasonal workers in the Greater Mekong Sub-region:
outcomes in Canadian immigrants. BMC Public Health.
lessons from the malaria containment project. Malar J.
2020;20(1):1345. doi:10.1186/s12889-020-09464-0.
2016;15(1):434. doi:10.1186/s12936-016-1491-3.
564. Klok S, van Dulm E, Boyd A, Generaal E, Eskander S, Joore
553. Population mobility and malaria. Geneva: World Health
IK et al. Hepatitis B virus (HBV), hepatitis C virus (HCV) and
Organization; International Organization for Migration; 2017
human immunodeficiency virus (HIV) infections among
(http://apps.who.int/iris/handle/10665/255816, accessed
undocumented migrants and uninsured legal residents in the
3 April 2022).
Netherlands: a cross-sectional study, 2018–2019. PLOS One.
181
565. Kim JU, Ingiliz P, Shimakawa Y, Lemoine M. Improving care 576. Zanjirani Farahani L, Mohebali M, Akhoundi B, Saghafipour
of migrants is key for viral hepatitis elimination in Europe. A, Kakooei Z. Seroepidemiological study on visceral
Bull World Health Organ. 2021;99(4):280–6. doi:10.2471/ leishmaniasis in an endemic focus of central Iran during 2017.
BLT.20.260919. J Parasit Dis. 2019;43(1):22–7. doi:10.1007/s12639-018-1049-0.
566. Nazareth J, Baggaley RF, Divall P, Pan D, Martin CA, Volik M 577. Abdalla NM, Abdelgani AM, Osman AA, Mohamed MN.
et al. What is the evidence on existing national policies and Demographical and population dynamics impact on public
guidelines for delivering effective tuberculosis, HIV and viral health of cutaneous leishmaniasis in Al-Madinah Almonawra,
hepatitis services for refugees and migrants among Member Saudi Arabia. Afr Health Sci. 2019;19(3):2421–30. doi:10.4314/
States of the WHO European Region? Copenhagen: WHO ahs.v19i3.16.
578. Alarfaj YY, Alghanim NI, Alkhalifah RH, Balghonaim MS, Ali MB.
handle/10665/352055/, accessed 26 April 2022).
Incidence of cutaneous leishmaniasis in Al-Ahsa, Saudi Arabia
567. Nasrallah GK, Al-Absi ES, Ghandour R, Ali NH, Taleb S, Hedaya from 2011 to 2013. Indo Am J Pharm Sci. 2019;6(1):801–7.
L et al. Seroprevalence of hepatitis E virus among blood doi:10.5281/zenodo.2537605.
donors in Qatar (2013-2016). Transfusion. 2017;57(7):1801–7.
579. Yentur Doni N, Gurses G, Dikme R, Aksoy M, Yildiz Zeyrek
doi:10.1111/trf.14116.
F, Simsek Z et al. Cutaneous leishmaniasis due to three
568. Bizri AR, Fares J, Musharrafieh U. Infectious diseases in the era Leishmania species among Syrian refugees in Sanliurfa,
of refugees: hepatitis A outbreak in Lebanon. Avicenna J Med. southeastern Turkey. Acta Parasitol. 2020;65(4):936–48.
2018;8(4):147–52. doi:10.4103/ajm.AJM_130_18. doi:10.2478/s11686-020-00227-w.
569. Al Mahtab M, Akbar SMF, Takahashi K, Adnan ABM, Alam 580. Lindner AK, Richter J, Gertler M, Nikolaus M, Equihua Martinez
MA, Noor-E-Alam SM et al. Alarming levels of hepatitis C G, Müller K et al. Cutaneous leishmaniasis in refugees from
virus prevalence among Rohingya refugees in Bangladesh: Syria: complex cases in Berlin 2015–2020. J Travel Med.
emergency national and international actions warranted. 2020;27(7):taaa161. doi:10.1093/jtm/taaa161.
Euroasian J Hepatogastroenterol. 2019;9(1):55–6. doi:10.5005/
581. Meymandi SK, Forsyth CJ, Soverow J, Hernandez S, Sanchez
jp-journals-10018-1297.
D, Montgomery SP et al. Prevalence of Chagas disease in the
570. Ayele A, Abera D, Hailu M, Birhanu M, Desta K. Prevalence Latin American-born population of Los Angeles. Clin Infect
and associated risk factors for hepatitis B and C viruses Dis. 2017;64(9):1182–8. doi:10.1093/cid/cix064.
among refugees in Gambella, Ethiopia. BMC Public Health.
582. Basile L, Jansa JM, Carlier Y, Salamanca DD, Angheben A,
2020;20(1):721. doi:10.1186/s12889-020-08893-1.
Bartoloni A et al. Chagas disease in European countries:
571. Robotin MC, Wallace J, Gallego G, George J. Hepatitis B and the challenge of a surveillance system. Euro Surveill.
liver cancer: community awareness, knowledge and beliefs of 2011;16(37):19968. doi:10.2807/ese.16.37.19968-en.
Middle Eastern Migrants in Sydney, Australia. Int J Environ Res
583. González Sanz M, De Sario M, García-Mingo D, Dawood N,
Public Health. 2021;18(16):8534. doi:10.3390/ijerph18168534.
Álvarez-Martínez MJ, Daly R et al. Chagas disease in the
572. Özbilgin A, Gencoglan G, Tunali V, Çavuş İ, Yıldırım A, Gündüz United Kingdom: a review of cases managed at the Hospital
C et al. Refugees at the crossroads of continents: a molecular for Tropical Diseases London 1995–2018. The current state of
approach for cutaneous leishmaniasis among refugees in detection of Chagas disease in the UK. Travel Med Infect Dis.
Turkey. Acta Parasitol. 2020;65(1):136–43. doi:10.2478/s11686- 2020;36:101760. doi:10.1016/j.tmaid.2020.101760.
019-00139-4.
584. Aith FMA, Forsyth C, Shikanai-Yasuda MA. Chagas disease and
573. Amr ZS, Kanani K, Shadfan B, Hani RB. Cutaneous healthcare rights in the Bolivian immigrant community of São
leishmaniasis among Syrian refugees in Jordan: a Paulo, Brazil. Trop Med Infect Dis. 2020;5(2):62. doi:10.3390/
retrospective study. Bull Soc Pathol Exot . 2018;111(5):295– tropicalmed5020062.
300. doi:10.3166/bspe-2019-0057.
585. Luna EJ, Furucho CR, Silva RA, Wanderley DM, Carvalho NB,
574. de Lima Junior MM, Rodrigues GA, de Lima MR. Evaluation Satolo CG et al. Prevalence of Trypanosoma cruzi infection
of emerging infectious disease and the importance of SINAN among Bolivian immigrants in the city of São Paulo, Brazil.
for epidemiological surveillance of Venezuelans immigrants Mem Inst Oswaldo Cruz. 2017;112(1):70–4. doi:10.1590/
in Brazil. Braz J Infect Dis. 2019;23(5):307–12. doi:10.1016/j. 0074-02760160384.
bjid.2019.07.006.
586. Requena-Méndez A, Aldasoro E, Lazzari E, Sicuri E, Brown
575. Aschale Y, Ayehu A, Worku L, Tesfa H, Birhanie M, Lemma W. M, Moore DA et al. Prevalence of Chagas disease in Latin-
Malaria-visceral leishmaniasis co-infection and associated American migrants living in Europe: a systematic review
factors among migrant laborers in West Armachiho district, and meta-analysis. PLOS Negl Trop Dis. 2015;9(2):e0003540.
North West Ethiopia: community based cross-sectional study. doi:10.1371/journal.pntd.0003540.
BMC Infect Dis. 2019;19(1):239. doi:10.1186/s12879-019-3865-y.
182
587. Cobo F, Salas-Coronas J, Cabezas-Fernández MT, Vázquez- 597. Muga GO, Onyango-Ouma W, Sang R, Affognon H. Indigenous
Villegas J, Cabeza-Barrera MI, Soriano-Pérez MJ. Infectious knowledge of Rift Valley fever among Somali nomadic
diseases in immigrant population related to the time of pastoralists and its implications on public health delivery
residence in Spain. J Immigr Minor Health. 2016;18(1):8–15. approaches in Ijara sub-County, north eastern Kenya. PLOS
doi:10.1007/s10903-014-0141-5. Negl Trop Dis. 2021;15(2):e0009166. doi:10.1371/journal.
pntd.0009166.
588. Romay-Barja M, Boquete T, Martinez O, Benito A, Blasco-
Hernández T. Factors associated with Chagas screening 598. Sanders AM, Abdalla Z, Elshafie BE, Nute AW, Long EF,
among immigrants from an endemic country in Madrid, Aziz N et al. Prevalence of trachoma within refugee camps
Spain. PLOS One. 2020;15(3):e0230120. doi:10.1371/journal. serving South Sudanese refugees in White Nile State, Sudan:
pone.0230120. results from population-based surveys. PLOS Negl Trop Dis.
589. Vargas-Machuca R, Rojas-Dávila CE, Jiménez MM, Piscoya-
Magallanes CR, Razuri H, Ugaz ME. Situación nutricional de 599. Mathur R, Rentsch CT, Morton CE, Hulme WJ, Schultze A,
los niños migrantes venezolanos a su ingreso al Perú y las MacKenna B et al. Ethnic differences in SARS-CoV-2 infection
acciones emprendidas para proteger su salud y nutrición and COVID-19-related hospitalisation, intensive care unit
[Nutritional situation of Venezuelan migrant children admission, and death in 17 million adults in England: an
upon entry into Peru and the actions taken to protect their observational cohort study using the OpenSAFELY platform.
health and nutrition]. Rev Peru Med Exp Salud Publica. Lancet. 2021;397(10286):1711–24. doi:10.1016/S0140-
2019;36(3):504–10. doi:10.17843/rpmesp.2019.363.4676. 6736(21)00634-6.
590. Mekonnen GK, Mengistie B, Sahilu G, Kloos H, Mulat W. 600. Fabiani M, Mateo-Urdiales A, Andrianou X, Bella A, Del
Etiologies of diarrhea and drug susceptibility patterns of Manso M, Bellino S et al. Epidemiological characteristics of
bacterial isolates among under-five year children in refugee COVID-19 cases in non-Italian nationals notified to the Italian
camps in Gambella Region, Ethiopia: a case control study. BMC surveillance system. Eur J Public Health. 2021;31:37–44.
Infect Dis. 2019;19(1):1008. doi:10.1186/s12879-019-4599-6. doi:10.1093/eurpub/ckaa249.
591. Kisera N, Luxemburger C, Tornieporth N, Otieno G, Inda J. 601. Giorgi Rossi P, Marino M, Formisano D, Venturelli F, Vicentini
A descriptive cross-sectional study of cholera at Kakuma M, Grilli R et al. Characteristics and outcomes of a cohort of
and Kalobeyei refugee camps, Kenya in 2018. Pan Afr Med J. COVID-19 patients in the Province of Reggio Emilia, Italy. PLOS
2020;37:197. doi:10.11604/pamj.2020.37.197.24798. One. 2020;15(8):e0238281. doi:10.1371/journal.pone.0238281.
592. Mekonnen GK, Alemu BM, Mulat W, Sahilu G, Kloos H. Risk 602. COVID-19-epidemien: kunnskap, situasjon, prognose, risiko
factors for acute childhood diarrhea: a cross-sectional study og respons i Norge etter uke 51. Oslo: Norwegian Institute
comparing refugee camps and host communities in Gambella of Public Health; 2020 (in Norwegian; https://www.fhi.no/
Region, Ethiopia. Travel Med Infect Dis. 2019;31:101385. contentassets/c9e459cd7cc24991810a0d28d7803bd0/
doi:10.1016/j.tmaid.2019.02.003. vedlegg/covid-19-epidemien-kunnskap-situasjon-prognose-
risiko-og-respons-i-norge-etter-uke-51-publisert-21.12.2020.
593. Watts NS, Mizinduko MM, Barnett ED, White LF, Hochberg NS.
pdf, accessed 4 May 2022).
Association between parasitic infections and tuberculin skin
test results in refugees. Travel Med Infect Dis. 2017;16:35–40. 603. Demographic description of confirmed COVID-19
doi:10.1016/j.tmaid.2017.03.007. cases in Sweden from 13 March to 7 May. Stockholm:
Swedish Public Health Agency; 2020 (in Swedish;
594. Boughattas S, Behnke JM, Al-Sadeq D, Ismail A, Abu-Madi M.
https://www.folkhalsomyndigheten.se/contentassets/
Cryptosporidium spp., prevalence, molecular characterisation
d6538f6c359e448ba39993a41e1116e7/covid-19-demografisk-
and socio-demographic risk factors among immigrants in
beskrivning-bekraftade-covid-19-fall.pdf, accessed
Qatar. PLOS Negl Trop Dis. 2019;13(10):e0007750. doi:10.1371/
4 May 2022).
journal.pntd.0007750.
604. COVID-19 og herkomst - opdateret fokusrapport. Copenhagen:
595. Chernet A, Kling K, Sydow V, Kuenzli E, Hatz C, Utzinger J et
Statens Serum Institut; 2020 (in Danish; https://files.ssi.dk/
al. Accuracy of diagnostic tests for Schistosoma mansoni
COVID19-og-herkomst-oktober-2020, accessed 4 May 2022).
infection in asymptomatic Eritrean refugees: serology and
point-of-care circulating cathodic antigen against stool 605. Hayward SE, Deal A, Cheng C, Crawshaw A, Orcutt M,
microscopy. Clin Infect Dis. 2017;65(4):568–74. doi:10.1093/ Vandrevala TF et al. Clinical outcomes and risk factors for
cid/cix366. COVID-19 among migrant populations in high-income
countries: a systematic review. J Migr Health. 2021;3:100041.
596. Global leprosy strategy 2016−2020: accelerating towards a
doi:10.1016/j.jmh.2021.100041.
leprosy-free world. Geneva: World Health Organization; 2016
(https://apps.who.int/iris/handle/10665/208824, accessed
3 April 2022).
183
606. Pan H, Fokkema T, Switsers L, Dury S, Hoens S, De Donder L. 617. Least protected, most affected: migrants and refugees
Older Chinese migrants in coronavirus pandemic: exploring facing extraordinary risks during the COVID-19 pandemic.
risk and protective factors to increased loneliness. Eur J Geneva: International Federation of Red Cross and Red
Ageing. 2021;18(2):207–15. doi:10.1007/s10433-021-00625-7. Crescent Societies; 2021 (https://www.ifrc.org/document/
least-protected-most-affected-migrants-and-refugees-facing-
607. A claim to dignity: ageing on the move. New York: Office of
extraordinary-risks-during, accessed 3 April 2022).
the United Nations High Commissioner for Refugees; 2021
(https://www.acnur.org/60ad9f544, accessed 21 April 2022). 618. Åhlberg M. No viable alternatives: social (in)security and risk
of labour exploitation during COVID-19. London: Independent
608. Reducing COVID-19 transmission and strengthening
Workers Union of Great Britain and United Voices of the
vaccine uptake among migrant populations in the EU/EEA.
World; 2021 (https://www.labourexploitation.org/sites/
Stockholm: European Centre for Disease Prevention and
default/files/publications/Full%20report_Social%20
Control; 2021 (https://www.ecdc.europa.eu/sites/default/
Insecurity_Final.pdf, accessed 3 April 2022).
files/documents/covid-19-reducing-transmission-and-
strengthening-vaccine-uptake-in-migrants.pdf, accessed 619. The impact of the COVID-19 pandemic on jobs and incomes in
3 April 2022). G20 economies. Geneva: International Labour Organization;
2020 (https://www.ilo.org/wcmsp5/groups/public/---
609. Guidance on infection prevention and control of COVID-19 in
dgreports/---cabinet/documents/publication/wcms_756331.
migrant and refugee reception and detention centres in the
pdf, accessed 3 April 2022).
EU/EEA and the UK. Stockholm: European Centre for Disease
Prevention and Control; 2020 (https://www.ecdc.europa.eu/ 620. Refugees and migrants in times of COVID-19: mapping trends
sites/default/files/documents/COVID-19-guidance-refugee- of public health and migration policies and practices. Geneva:
asylum-seekers-migrants-EU.pdf, accessed 3 April 2022). World Health Organization; 2021 (https://apps.who.int/iris/
610. Epidemiological surveillance in points of care for refugees/
migrants: weekly report: week 19/2020 (04/05 to 10/05). 621. Hajjar MS, Abu-Sittah GS. The multidimensional burden
Athens: Ministry of Health of Greece; 2020 (https://eody.gov. of COVID-19 on Syrian refugees in Lebanon. J Glob Health.
gr/wp-content/uploads/2020/05/Surveillance-refugees- 2021;11:05003. doi:10.7189/jogh.11.05003.
weekly-EN-2020-19.pdf, accessed 3 April 2022).
622. Benton M, Batalova J, Davidoff-Gore S, Schmidt T. COVID-19
611. Preparedness, prevention and control of coronavirus and the state of global mobility in 2020. Geneva: International
disease (COVID-19) for refugees and migrants in non-camp Organization for Migration; 2021 (https://publications.iom.int/
settings: interim guidance, 17 April 2020. Geneva: World books/covid-19-and-state-global-mobility-2020, accessed
Health Organization; 2020 (https://apps.who.int/iris/ 3 April 2022).
623. Kumar K, Mehra A, Sahoo S, Nehra R, Grover S. The
612. Sisti LG, Di Napoli A, Petrelli A, Rossi A, Diodati A, Menghini psychological impact of COVID-19 pandemic and lockdown
M et al. COVID-19 impact in the Italian reception system on the migrant workers: a cross-sectional survey. Asian J
for migrants during the nationwide lockdown: a national Psychiatry. 2020;53:102252. doi:10.1016/j.ajp.2020.102252.
observational study. Int J Environ Res Public Health.
624. Mukumbang FC, Ambe AN, Adebiyi BO. Unspoken inequality:
2021;18(23):12380. doi:10.3390/ijerph182312380.
how COVID-19 has exacerbated existing vulnerabilities of
613. Hamadah H, Alahmad B, Behbehani M, Al-Youha S, Almazeedi asylum-seekers, refugees, and undocumented migrants in
S, Al-Haddad M et al. COVID-19 clinical outcomes and South Africa. Int J Equity Health. 2020;19(1):141. doi:10.1186/
nationality: results from a nationwide registry in Kuwait. s12939-020-01259-4.
625. ApartTogether survey: preliminary overview of refugees
09490-y.
and migrants self-reported impact of COVID-19. Geneva:
614. Tan IB, Tan C, Hsu LY, Dan YY, Aw A, Cook AR et al. Prevalence World Health Organization; 2020 (https://apps.who.int/iris/
and outcomes of SARS-CoV-2 infection among migrant handle/10665/337931, accessed 3 April 2022).
workers in Singapore. JAMA. 2021;325(6):584–5. doi:10.1001/
626. From insights to action: gender equality in the wake of
jama.2020.24071.
COVID-19. New York: United Nations Entity for Gender Equality
615. Zhang M, Gurung A, Anglewicz P, Yun K. COVID-19 and and the Empowerment of Women (UN Women); 2020 (https://
immigrant essential workers: Bhutanese and Burmese www.unwomen.org/en/digital-library/publications/2020/09/
refugees in the United States. Public Health Rep. gender-equality-in-the-wake-of-covid-19, accessed
2021;136(1):117–23. doi:10.1177/0033354920971720. 3 April 2022).
616. COVID-19 dashboard. WHO Cox's Bazar data hub. Geneva:
World Health Organization; 2022 (https://cxb-epi.netlify.app/
post/covid-19-dashboard/, accessed 3 April 2022).
184
627. The impact of COVID-19 on refugee and migrant women in 636. Bukuluki P, Mwenyango H, Kato F, Kyamulabi A, Bagabo
Tunisia. Mixed Migration Centre; 2021 (https://reliefweb.int/ A. Chapter 4 – The psychosocial effect of COVID-19 on
report/tunisia/impact-covid-19-refugee-and-migrant-women- urban refugees: narratives from Congolese refugees
tunisia, accessed 3 April 2022). living in Kampala. In: Moustafa AA, editor. Mental health
effects of COVID-19. New York: Academic Press; 2021
628. Impact of COVID-19 on gender-based violence: refugee and
(https://www.sciencedirect.com/science/article/pii/
migrant response. New York: United Nations Children's Fund;
B9780128242896000064, accessed 3 April 2022).
2021 (https://www.unicef.org/eca/media/15751/file, accessed
3 April 2022). 637. Bukuluki P, Mwenyango H, Katongole SP, Sidhva D, Palattiyil
G. The socio-economic and psychosocial impact of COVID-19
629. COVID-19 pandemic worsening gender inequalities for
pandemic on urban refugees in Uganda. Soc Sci Humanit
refugee women and girls. Geneva: Office of the United Nations
Open. 2020;2(1):100045. doi:10.1016/j.ssaho.2020.100045.
High Commissioner for Refugees; 2021 (https://www.unhcr.
org/news/press/2021/3/604524674/covid-19-pandemic- 638. Kizilhan JI, Noll-Hussong M. Psychological impact of
worsening-gender-inequalities-refugee-women-girls.html, COVID-19 in a refugee camp in Iraq. Psychiatry Clin Neurosci.
accessed 3 April 2022). 2020;74(12):659–60. doi:10.1111/pcn.13142.
630. A web of insecurity: gendered risks and vulnerabilities for 639. Rees S, Fisher J. COVID-19 and the mental health of people
children on the move during the COVID-19 pandemic. New from refugee backgrounds. Int J Health Serv. 2020;50(4):
York: United Nations Children's Fund; 2021 (https://data. 415–17. doi:10.1177/0020731420942475.
unicef.org/resources/a-web-of-insecurity-gendered-risks-
640. The impact of COVID-19 on mental, neurological and
vulnerabilities-children-on-the-move-covid-19/, accessed
substance use services: results of a rapid assessment. Geneva:
3 April 2022).
631. 10 million additional girls at risk of child marriage due to handle/10665/335838, accessed 3 April 2022).
COVID-19. New York: United Nations Childrens Fund; 2021
641. Manirambona E, Uwizeyimana T, Uwiringiyimana E, Reddy
(https://www.unicef.org/press-releases/10-million-additional-
H. Impact of the COVID-19 pandemic on the food rations
girls-risk-child-marriage-due-covid-19, accessed
of refugees in Rwanda. Int J Equity Health. 2021;20(1):107.
25 June 2022).
doi:10.1186/s12939-021-01450-1.
632. Lusambili AM, Martini M, Abdirahman F, Asante A, Ochieng S,
642. Karim MR, Islam MT, Talukder B. COVID-19's impacts on
Guni JN et al. "We have a lot of home deliveries." A qualitative
migrant workers from Bangladesh: in search of policy
study on the impact of COVID-19 on access to and utilisation
intervention. World Dev. 2021;136:105123. doi:10.1016/j.
of reproductive, maternal, newborn and child health care
worlddev.2020.105123.
among refugee women in urban Eastleigh, Kenya. J Migr
Health. 2020;2:100025. doi:10.1016/j.jmh.2020.100025. 643. Chowdhury MB, Chakraborty M. The impact of
COVID-19 on the migrant workers and remittances flow
633. Landini C. Child marriage in the context of COVID-19:
to Bangladesh. South Asian Surv. 2021;28(1):38–56.
analysis of trends, programming and alternative approaches
doi:10.1177/0971523121995365.
in the Middle East and North Africa. New York: United
Nations Population Fund; 2021 (https://resourcecentre. 644. Alemi Q, Stempel C, Siddiq H, Kim E. Refugees and COVID-19:
savethechildren.net/document/child-marriage-context- achieving a comprehensive public health response.
covid-19-analysis-trends-programming-and-alternative- Bull World Health Organ. 2020;98(8):510. doi:10.2471/
approaches/, accessed 3 April 2022). BLT.20.271080.
634. Ubeysekara I. Sri Lankan women migrant workers: more risks, 645. IOM Myanmar COVID-19 response situation report 3. Geneva:
more trafficking during COVID-19. Colombo: Helvetas Sri International Organization for Migration; 2020 (https://
Lanka; 2020 (https://www.shareweb.ch/site/Migration/focus- reliefweb.int/report/myanmar/iom-myanmar-covid-19-
area/Pages/Sri-Lankan-women-migrant-workers--more- response-situation-report-3-1-may-2020, accessed
risks%2C-more-trafficking-during-COVID-19.aspx, accessed 3 April 2022).
3 April 2022).
646. Chung RY-N, Li MM. Anti-Chinese sentiment during the 2019-
635. Gender-based violence risk assessment Azraq Camp. Geneva: nCoV outbreak. Lancet. 2020;395(10225):686–7. doi:10.1016/
Office of the United Nations High Commissioner for Refugees; S0140-6736(20)30358-5.
2021 (https://reliefweb.int/sites/reliefweb.int/files/resources/
647. Devakumar D, Shannon G, Bhopal SS, Abubakar I. Racism
DJ3_SGBV%20Risk%20Assessment_Azraq_Final.pdf,
and discrimination in COVID-19 responses. Lancet.
2020;395(10231):1194. doi:10.1016/S0140-6736(20)30792-3.
185
648. Adhanom Ghebreyesus T. WHO Director-General's opening 659. Bozorgmehr K, Hintermeier M, Razum O, Mohsenpour
remarks at the media briefing on COVID-19. Geneva: World A, Biddle L, Oertelt-Prigione S et al. SARS-CoV-2 in
Health Organization; 2020 (https://www.who.int/director- aufnahmeeinrichtungen und gemeinschaftsunterkünften
general/speeches/detail/who-director-general-s-opening- für geflüchtete: epidemiologische und normativ-rechtliche
remarks-at-the-media-briefing-on-covid-19---11-march-2020, aspekte. Competence Network Public Health COVID‐19;
accessed 3 April 2022). 2020 (in German; https://www.public-health-covid19.de/
images/2020/Ergebnisse/FactSheet_PHNetwork-COVID19_
649. Connor P. More than nine-in-ten people worldwide live in
Aufnahmeeinrichtungen_v1_inkl_ANNEX.pdf,
countries with travel restrictions amid COVID-19. Washington
(DC): Pew Research Center; 2020 (https://www.pewresearch.
org/fact-tank/2020/04/01/more-than-nine-in-ten-people- 660. Gilman RT, Mahroof-Shaffi S, Harkensee C, Chamberlain
worldwide-live-in-countries-with-travel-restrictions-amid- AT. Modelling interventions to control COVID-19 outbreaks
covid-19/, accessed 3 April 2022). in a refugee camp. BMJ Glob Health. 2020;5(12):e003727.
doi:10.1136/bmjgh-2020-003727.
650. International migration 2020 highlights. New York: United
Nations Department of Economic and Social Affairs, 661. Easton-Calabria E. A restriction of responsibility-sharing:
Population Division; 2021 (https://www.un.org/en/desa/ exploring the impact of COVID-19 on the global compact
international-migration-2020-highlights, accessed on refugees. Copenhagen: Danish Refugee Council; 2020
21 April 2022). (https://reliefweb.int/report/world/restriction-responsibility-
sharing-exploring-impact-covid-19-global-compact-refugees,
651. International Migration Outlook 2020. Paris: Organisation for
www.oecd-ilibrary.org/social-issues-migration-health/ 662. Alkhamis MA, Youha SA, Khajah MM, Haider NB, Alhardan S,
international-migration-outlook-2021_29f23e9d-en, Nabeel A et al. Spatiotemporal dynamics of the COVID-19
accessed 3 April 2022). pandemic in the State of Kuwait. Int J Infect Dis. 2020;98:153–
60. doi:10.1016/j.ijid.2020.06.078.
652. 2020 annual international migration and forced displacement
trends and policies report to the G20. Paris: Organisation for 663. Measures to contain the COVID-19 outbreak in migrant worker
Economic Co-operation and Development; 2021 (https:// dormitories. Singapore Ministry of Health; 2020 (https://www.
www.oecd.org/els/mig/FINAL-2020-OECD-ILO-UNHCR-IOM- moh.gov.sg/news-highlights/details/measures-to-contain-
G20-report.pdf, accessed 3 April 2022). the-covid-19-outbreak-in-migrant-worker-dormitories,
653. COVID-19 impact on stranded migrants Return and
Reintegration Platform. Geneva: International Organization 664. Chersich MF, Gray G, Fairlie L, Eichbaum Q, Mayhew S,
for Migration; 2020 (https://returnandreintegration.iom.int/ Allwood B et al. COVID-19 in Africa: care and protection for
en/resources/report/covid-19-impact-stranded-migrants, frontline healthcare workers. Global Health. 2020;16(1):46.
accessed 3 April 2022). doi:10.1186/s12992-020-00574-3.
654. Labor migration in Asia: impacts of the COVID-19 crisis and 665. Reid A, Ronda‐Perez E, Schenker MB. Migrant workers,
the post-pandemic future. Paris: Organisation for Economic essential work, and COVID‐19. Am J Ind Med. 2021;64(2):73–7.
Co-operation and Development; 2021 (https://www.oecd- doi:10.1002/ajim.23209.
ilibrary.org/social-issues-migration-health/labor-migration-
666. Editorial. The plight of essential workers during the COVID-19
in-asia_a5d6e6aa-en, accessed 3 April 2022).
pandemic. Lancet. 2020;395(10237):1587. doi:10.1016/S0140-
655. Laczko F. COVID-19 and migration in 2020: five key trends. 6736(20)31200-9.
Migr Policy Pract. 2021;XI(1):5–9 (https://publications.iom.int/
667. Kerwin D, Warren R. US foreign-born workers in the global
system/files/pdf/mpp-44.pdf, accessed 3 April 2022).
pandemic: essential and marginalized. J Migr Hum Secur.
656. Greenaway C, Hargreaves S, Barkati S, Coyle CM, Gobbi F, 2020;8(3):282–300. doi:10.1177/2331502420952752.
Veizis A et al. COVID-19: exposing and addressing health
668. Migration data relevant for the COVID-19 pandemic. Migration
disparities among ethnic minorities and migrants. J Travel
data portal. Global Migration Data Analysis Centre; 2021
Med. 2020;27(7):taaa113. doi:10.1093/jtm/taaa113.
(https://www.migrationdataportal.org/themes/migration-
657. Redditt V, Wright V, Rashid M, Male R, Bogoch I. Outbreak of data-relevant-covid-19-pandemic, accessed 3 April 2022).
SARS-CoV-2 infection at a large refugee shelter in Toronto,
669. Contribution of migrant doctors and nurses to tackling
April 2020: a clinical and epidemiologic descriptive analysis.
COVID-19 crisis in OECD countries. Paris: Organisation for
CMAJ Open. 2020;8(4):E819–24. doi:10.9778/cmajo.20200165.
Economic Development and Co-operation; 2020 (https://
658. Subbaraman N. "Distancing is impossible": refugee www.oecd-ilibrary.org/social-issues-migration-health/
camps race to avert coronavirus catastrophe. Nature. contribution-of-migrant-doctors-and-nurses-to-tackling-
2020;581(7806):18. doi:10.1038/d41586-020-01219-6. covid-19-crisis-in-oecd-countries_2f7bace2-en, accessed
21 April 2022).
186
670. Mutambudzi M, Niedzwiedz C, Macdonald EB, Leyland A, Mair 680. Remote assessment COVID-19: Venezuelan migrants in
F, Anderson J et al. Occupation and risk of severe COVID-19: Colombia, Ecuador and Peru. In: ReliefWeb [website].
prospective cohort study of 120 075 UK Biobank participants. New York: United Nations Office for the Coordination of
Occup Environ Med. 2020;78(5):307–14. doi:10.1136/ Humanitarian Affairs; 2020 (https://reliefweb.int/report/
oemed-2020-106731. colombia/remote-assessment-covid-19-venezuelan-migrants-
colombia-ecuador-and-peru, accessed 29 March 2022).
671. Gholizadeh P, Sanogo M, Oumarou A, Mohamed MN, Cissoko
Y, Sow MS et al. Fighting COVID-19 in west Africa after 681. Del Monte JA, Irwin RM. Personas migrantes en Tijuana
experiencing the Ebola epidemic. Health Promot Perspect. frente al COVID-19: impactos y consecuencias de las medidas
2021;11(1):5–11. doi:10.34172/hpp.2021.02. sanitarias desde la perspectiva de los actores [Migrants in
Tijuana facing COVID-19: impacts and consequences of health
672. Onoma AK. The making of dangerous communities: the "Peul-
measures from the perspective of the actors]. Tijuana: Colegio
Fouta" in Ebola-weary Senegal. Afr Spectr. 2017;52(2):29–51.
de la Frontera Norte; 2020 (in Spanish; https://www.colef.
doi:10.1177/000203971705200202.
mx/wp-content/uploads/2020/06/8_Personasmigrantes.pdf,
673. Onoma AK. Xenophobia's contours during an Ebola epidemic: accessed 3 April 2022).
proximity and the targeting of Peul migrants in Senegal. Afr
682. Ulrich MR, Crosby SS. Title 42, asylum, and politicising public
Stud Rev. 2020;63(2):353–74. doi:10.1017/asr.2019.38.
health. Lancet Reg Health - Am. 2022;7:100124. doi:10.1016/j.
674. Al-Ghalib Alsharif FL, Malit FT. Migration and the lana.2021.100124.
COVID-19 pandemic in the Gulf Report No. 15. Bonn:
683. Bojorquez-Chapela I, Infante C, Larrea-Schiavon S,
Konrad Adenauer Stiftung; 2020 (https://www.kas.de/
Vieitez-Martinez I. In-transit migrants and asylum seekers:
documents/286298/8668222/Policy+Report+No+15+M
inclusion gaps in Mexico's COVID-19 health policy response.
igration+and+The+COVID-19+Pandemic+in+the+Gulf.
Health Aff (Millwood). 2021;40(7):1154–61. doi:10.1377/
pdf/87dd88bd-ed47-41c7-be23-48c5a5eb8d7c?version=1.0
hlthaff.2021.00085.
&t=1603448109241, accessed 3 April 2022).
684. Alabdulla M, Reagu SM, Al-Khal A, Elzain M, Jones RM.
675. Alsharif F. Undocumented migrants in Saudi Arabia:
COVID-19 vaccine hesitancy and attitudes in Qatar: a
COVID-19 and amnesty reforms. Int Migr. 2022;60(1):188–204.
national cross-sectional survey of a migrant-majority
doi:10.1111/imig.12838.
population. Influenza Other Respir Viruses. 2021;15(3):361–70.
676. Rahman MM. COVID-19 and migrants in the GCC States: doi:10.1111/irv.12847.
challenges, responses and key lessons. Doha: Qatar
685. Crawshaw AF, Deal A, Rustage K, Forster AS, Campos-Matos
University Gulf Studies Center; 2021 (Working Paper 1; http://
I, Vandrevala T et al. What must be done to tackle vaccine
www.qu.edu.qa/static_file/qu/research/Gulf%20Studies/
hesitancy and barriers to COVID-19 vaccination in migrants? J
documents/Working%20paper%201%20-%20Mizanur%20
Travel Med. 2021;28(4):taab048. doi:10.1093/jtm/taab048.
Rahman%20-%202021.pdf, accessed 26 April 2022).
686. Priebe Rocha L, Rose R, Hoch A, Soares C, Fernandes A, Galvão
677. WHO Country Office: Libya: annual report 2020. Cairo: WHO
H et al. The impact of the COVID-19 pandemic on the Brazilian
Regional Office for the Eastern Mediterranean; 2021 (https://
immigrant community in the U.S: results from a qualitative
applications.emro.who.int/docs/9789290225959-eng.
study. Int J Environ Res Public Health. 2021;18(7):3355.
pdf?ua=1, accessed 26 April 2022).
doi:10.3390/ijerph18073355.
678. Riggirozzi P, Grugel J, Cintra N. Perspective on migrants'
687. COVID-19 situation reports. Cairo: WHO Regional Office for
right to health in Latin America during COVID-19.
the Eastern Mediterranean; 2020 (http://www.emro.who.int/
London: University College London–Lancet Commission
health-topics/corona-virus/situation-reports.html, accessed
on Migration and Health; 2020 (https://1bec58c3-
3 April 2022).
8dcb-46b0-bb2a-fd4addf0b29a.filesusr.com/
ugd/188e74_543cbb0400824084abcea99479dfa124.pdf, 688. Knipper M, Sedas AC, Keshavjee S, Abbara A, Almhawish N,
accessed 3 April 2022). Alashawi H et al. The need for protecting and enhancing
TB health policies and services for forcibly displaced and
679. Fernández-Niño JA, Cubillos-Novella A, Bojórquez L,
migrant populations during the ongoing COVID-19 pandemic.
Rodríguez M. Recommendations for the response against
Int J Infect Dis. 2021;113(suppl 1):S22–7. doi:10.1016/j.
COVID-19 in migratory contexts under a closed border: the
ijid.2021.03.047.
case of Colombia. Biomedica. 2020;40:68–72. doi:10.7705/
biomedica.5512. 689. The COVID-19 vaccines and undocumented migrants:
what are European countries doing? Brussels: Platform for
International Cooperation on Undocumented Migrants
(PICUM); 2021 (https://picum.org/covid-19-vaccines-
undocumented-migrants-europe/, accessed 3 April 2022).
187
690. Spiegel PB, Hering H, Paik E, Schilperoord M. Conflict-affected 694. Wickramage K, Gostin LO, Friedman E, Prakongsai P,
displaced persons need to benefit more from HIV and malaria Suphanchaimat R, Hui C et al. Missing: where are the migrants
national strategic plans and Global Fund grants. Confl Health. in pandemic influenza preparedness plans? Health Hum
2010;4(1):2. doi:10.1186/1752-1505-4-2. Rights. 2018;20(1):251–8. PMID:30008567.
691. WHO SAGE roadmap for prioritizing uses of COVID-19 695. The COVAX Humanitarian Buffer. New York: Inter-
vaccines. Geneva: World Health Organization; 2021 (https:// Agency Standing Committee; 2022 (https://
apps.who.int/iris/rest/bitstreams/1406385/retrieve, interagencystandingcommittee.org/inter-agency-standing-
accessed 3 April 2022). committee/covax-humanitarian-buffer, accessed
25 June 2022).
692. Sköld N. UNHCR calls for inclusion of refugees in vaccination
plans. UNHCR Nordic and Baltic Countries. Geneva: Office of 696. Over 1.6 million COVID-19 vaccines delivered to Islamic
the United Nations High Commissioner for Refugees; 2021 Republic of Iran to increase protection of Afghan refugees.
(https://www.unhcr.org/neu/51787-unhcr-calls-for-inclusion- Tehran: United Nations Children's Fund; 2021 (http://www.
of-refugees-in-vaccination-plans.html, accessed 3 April 2022). emro.who.int/iran/news/over-16-million-donated-covid-
19-vaccines-land-in-islamic-republic-of-iran-to-increase-
693. UNHCR COVID-19 response [website]. Geneva:
protection-of-afghan-refugees.html, accessed 25 June 2022).
Office of the United Nations High Commissioner
for Refugees; 2021 (https://reporting.unhcr.org/
document/925#_ga=2.174892007.43253892.1639994982-
1175060295.1621948336, accessed 3 April 2022).
Although health is at the core of any ministry of health,
the multifaceted nature of health and migration necessitates
working not only across government agencies but also with
many other national sectors to ensure effective and quality
health services for all refugees and migrants. It also entails
adopting a regional perspective, connecting migrants to
health services along migration routes within and between
countries. As a Minister, I also need to consider three
specific dimensions: the long term of infrastructure,
the medium term of policy and the short term of politics.
Migration can occur regularly yet go unnoticed over decades

but can also be unexpected and rapid as a result of major
weather events, outbreak of conflict or war, or ethnic
cleansing. All can displace tens of thousands in a short
timespan, which places great stress on host health systems.
This report demonstrates that the most efficient way to

meet the health needs of refugees and migrants in the short,
medium and long term is by integrated health systems
and by including refugees and migrants within systems
that serve the host communities. In spite of the significant
resources and technical improvements this may require,
a more inclusive health system has proven to be hugely
beneficial for all, refugees, migrants and host communities
alike. To make this happen, those in charge need to work
in synergy with other sectors of government and society.
Midori de Habich,
Former Minister of Health, Peru
CHAPTER 4
Refugee- and
migrant-
sensitive
health systems
190
A nurse at a Severe Acute Respiratory Infection Isolation and Treatment Center (SARI ITC) in Cox’s Bazar, Bangladesh, supporting
COVID-19 preparedness and response for vulnerable Rohingya refugees and host communities. © WHO / Blink Media – Fabeha Monir
Refugee- and migrant-sensitive health systems
191
4.1 Introduction
This chapter is structured according to the six building blocks of health systems
defined by WHO: service delivery; the health workforce; access to medical
products, vaccines and technologies; HIS; financing; and leadership and
governance (Fig. 4.1). These building blocks are used to describe opportunities
and challenges for a health system that is sensitive to the needs of refugees and
migrants (1), in line with UHC, including PHC. As described in the 2010 global
consultation on migrant health, "sensitive health systems and programmes" seek
to systematically integrate the needs of refugees and migrants "into all aspects of
health services financing, policy, planning, implementation, and evaluation" (2).
For health systems to be sensitive to the needs of refugees and migrants, these
populations need to be included in the system not only as patients but also as
providers, decision-makers and facilitators. Moreover, making health systems
sensitive to the needs of refugees and migrants is part of the process of health
systems strengthening, which also benefits the host population.
Aerial view of the entrance of the new site of Moria reception and identification centre for asylum seekers and refugees on Lesvos, Greece,
in September 2020. It replaced the previous centre that burned down in a catastrophic fire. © WHO
192
Fig. 4.1. WHO health systems building blocks applied to refugee and migrant health
LEADERSHIP AND GOVERNANCE FINANCING
• Policies and regulations that are inclusive of • E

ligibility and enrolment in health insurance schemes
refugees and migrants and other alternative health financing schemes
• Ensuring whole-of-government and whole-of-society • C

ross-border health and social insurance schemes
approaches, working with all relevant ministries,
stakeholders and sectors, not just health • D
edicated finances to achieve refugee- and migrant-
inclusive universal health coverage
SERVICE DELIVERY ACCESS TO MEDICAL

PRODUCTS, VACCINES
• Services that are adapted to AND TECHNOLOGIES
(language, culture, administrative,
proximity, health-seeking • A
vailability of and access to essential
behaviour) and appropriate for the medicines and technologies for
refugee and migrant population Refugee- and refugee and migrant patients
migrant-sensitive
• Essential health packages
health systems
• E
vidence-based and cost-effective use
accessible for refugees and of services such as health screening
migrants, regardless of legal status
HEALTH INFORMATION SYSTEMS HEALTH WORKFORCE
• Inclusion of refugees and migrants in health • C

apacity building and training on aspects such
information systems as competencies to provide people-centred and
culturally sensitive health services to refugees
• Inclusion of essential variables in data collection tools and migrants, and address the health conditions
to facilitate disaggregation by migratory status and associated with migration and displacement
comparability of data
• A
ddition of roles such as interpreters and cultural
• Ensuring data confidentiality and protection of refugee mediators to health workforce
and migrant health data
• I nclusion of refugees and migrants in the health
• Availability of anonymized data for research purposes workforce
• Timely availability of evidence for policy-making and
public health interventions
Source: Adapted with permission from Legido-Quigley et al. (1).

193
4.2 Service delivery (1,3,4). Although the use of health services

varies significantly across and within regions,
by types of service and by migrant group,
• Refugees and migrants face many of thematic barriers are generally similar across
the same barriers in accessing health regions and include institutional or
services as the local population, administrative, language, cultural,
although these may be intensified by
discrimination and transport barriers.
their migratory status.
• T
he most common barriers include Institutional barriers. Navigating an
institutional and administrative, unfamiliar health system in another country
language and cultural, provider
is challenging for refugees and migrants, who
discrimination, transportation and
may not be able to access or understand
financial factors. Direct and indirect
health costs also present major barriers. coverage and registration instructions. This is
exacerbated by, for example, health policies
• Several regions report a lack of health
that are not inclusive of refugees and migrants
services tailored to the particular
and inadequate training of the health care
needs of refugees and migrants.
professionals who interact with refugee and
migrant populations. For example, studies
in sub-Saharan African countries highlighted
Good-quality health services – those that administrative and organizational barriers,
deliver effective, safe, personal and non- such as a lack of proper paperwork or
personal health interventions to those documentation (5). Similarly, lack of awareness
who need them, when and where needed, of health system processes and their navigation,
with minimum waste of resources – are as well as a low level of health literacy, are
integral to achieving UHC. Strengthening notable barriers that increase difficulties in
health service delivery is key in ensuring accessing health services. An example is the
better health outcomes for all, including lack of awareness among some refugees and
refugee and migrant populations, whether migrants as to when and how to seek primary
in camps, communities, detention centres or preventive care services. A qualitative study
or elsewhere. Improving the health and with sub-Saharan African migrant women
well-being of refugees and migrants
ultimately means ensuring they have access
to health services and addressing barriers
to their use. This section also highlights
good practices and the models for service
For health systems to be sensitive
delivery required to meet the health needs of to the needs of refugees and
refugee and migrant health across regions.
migrants, these populations
4.2.1 Common barriers need to be included in the
Refugees and migrants may face many of the system not only as patients but
same barriers in accessing health services as the
local population, including cost, proximity and also as providers, decision-
general gaps in the health systems. However, makers and facilitators.
they also face barriers specific to their migratory
status, or limited recognition of their status
194
in the Basque Country, Spain, revealed that their patients at least once per year, and 30%
the perception of institutional barriers was reported that this occurred once per week (23).
compounded by other major barriers to access. In Kenya, providers of SGBV-related health
These included difficulties in fulfilling the legal services struggled to communicate directly with
conditions for access, a lack of documentation, refugees, which had negative effects on service
poor communication with health centre staff provision; health care providers reported a need
and perceptions of negative staff attitudes for skills in relevant languages or sign language,
or stereotypes (6). A qualitative study with as well as for access to interpreters (10).
asylum seekers in Denmark found that Refugees with visual or hearing impairments
unfamiliarity with the health system, combined or other disabilities faced reduced access to
with interpersonal miscommunication and the health system, and may even have been
perceived cultural insensitivity among health excluded from health system research and data
professionals, undermined trust in the health collection, according to research from the WHO
system and reduced their motivation to seek African and European regions. Improving this
health services (7). A qualitative study with would require participatory design as well as
Syrian refugees in Jordan showed that given tools such as personal assistants, sign language,
the complexity and fragmentation of care Braille documents and the creation of supporter
(i.e. across government, NGO and private roles for the process (24,25).
services), refugees faced barriers in access
to health services (8). Many of these barriers Cultural barriers. In addition to language
are created or exacerbated, instead of barriers, miscommunication may be caused by
addressed, by policies and practices that cultural barriers. For example, health providers
do not include refugees and migrants. in industrialized countries may mistakenly
This is discussed further in section 4.7. conclude that refugees and migrants from
developing countries have low levels of health
Language and communication barriers. literacy, when in fact the differences are cultural
Language barriers when communicating with (26). For example, a study based in the United
health service providers are a widespread States concluded that African-born women
problem across WHO regions for refugees were three times less likely to have attended a
and various types of migrants (9–21). For clinic for a cervical smear test in the past three
example, studies in the WHO South-East years than African-American women born in the
Asia Region noted that language influenced United States, highlighting the need for further
access to health services among refugees research on educational and cultural aspects
and migrants; communication difficulties and of care (27). Providing culturally sensitive
misunderstandings during medical treatment and adaptive care for refugees and migrants
were reported as a significant barrier to is especially important in SRH, for SGBV
seeking health services (16,22). In the United survivors (28–31), and for mental health and
States, Spanish-speaking patients with poor psychosocial support services (32–36), areas
English-language skills were less likely than in which sensitivities or stigma exist. In a study
English speakers to receive an appointment conducted in Italy, the lack of cultural mediators
that matched their needs, especially in and interpreters was reported to contribute to
emerging destinations within the country the communication barriers faced by refugees
(17). In Switzerland, more than 90% of the 599 at service points; many refugees, including
PHC providers in a nationwide cross-sectional survivors of sexual violence, cited this as
study reported facing language barriers with having deterred them from accessing care (31).
195
Evidence on acceptable low-intensity group hospital staff, including racial discrimination,

psychological interventions for Syrian refugees and that their migratory status further affected
indicated that previously recommended the inequities they faced when seeking health
relaxation techniques, such as yoga, should care (47). A nationally representative survey
be replaced with more culturally appropriate in France found that the occurrences of
activities, such as listening to music or reporting discrimination by health services
prayer (34). and deciding to forego care in the 12 months
prior to the survey were highest among women
Discrimination. Discrimination by health (migrant and non-migrant), children born to
providers towards refugees and migrants, or a migrants in host countries (second-generation
lack of sensitivity from other personnel within migrants), migrants from Africa (northern
the health system, is reported as a key barrier and sub-Saharan countries) or overseas
to good-quality and acceptable care, as well territories, and Muslim populations (48).
as to health-seeking behaviour across regions
(3,13,36–39). In two countries in the WHO A longitudinal study in Ontario, Canada,
Region of the Americas, refugees and migrants found that migrants from Bangladesh, China,
reported being dissatisfied with the delivery India, Pakistan and Sri Lanka in the last 6
of health services by providers during medical months of their lives were more likely to
encounters; the reasons reported included receive invasive and aggressive care and to
miscommunication as a result of cultural die in intensive care units compared with
and language gaps, discrimination, lack of the general population (49). Afghan refugee
trust, dissatisfaction regarding recommended women received suboptimal maternal
treatments or referrals to specialists, and care in comparison to non-migrant women
dissatisfaction related to short, impersonal in a neighbouring host country (50).
appointments (40,41). In many countries in
the WHO Region of the Americas (38,42,43) Restrictive immigration policies. Restrictive
and WHO European Region (39,44), refugees entry and integration policies have been
and migrants experienced discrimination from linked to poor refugee and migrant health
health professionals who were not aware of, outcomes, thereby creating a dynamic in which
doubted or even disregarded their right to migrants face disincentives and barriers to
access health services. accessing and utilizing health care. Migrants,
especially irregular migrants, reported a fear
HIV-positive migrants reported discrimination of repatriation or deportation resulting from
because of their nationality or language and, accessing health services, high health care
as a result, preferred to return to their country costs compared with local populations, and
of origin for their HIV medication (45). A study employer gatekeeping of health care across
on barriers to adherence to TB treatment multiple WHO regions (9), including the Region
for non-nationals found that refugees and of the Americas (51), the European Region
migrants blamed their non-national status (52,53) and the Western Pacific Region (3). The
for the discrimination that they experienced detection of certain communicable diseases,
when seeking care (46). A qualitative study such as HIV, STIs or TB, in foreign residents
exploring the experiences of African migrant can sometimes lead to cancellation of their
workers in a country in the WHO Eastern residence permit and deportation (54–56).
Mediterranean Region found that the workers However, since 2015, several countries have
faced interpersonal discrimination from made progress in lifting HIV-related travel
196
restrictions, including Belarus, Lithuania, the isolation of their work (60). Sri Lankan Tamil
Republic of Korea and Uzbekistan (57,58). refugees in India live in remote and rural camps
that are distant from health services; they also
Even where policies to support access to health reported delays in receiving benefits from health
services exist, fear of deportation because of coverage schemes because of complicated
insufficient documentation and lack of trust application procedures (61).
in the health system may still prevent refugees
and migrants from using health services, as was 4.2.2 Service models to meet
the case among Chinese migrants in Kenya (9) refugee and migrant
and migrants living in Sweden (53). In research health needs
across 14 countries of the WHO European As is the case with culturally sensitive care,
Region, migrants reported poorer health in several regions report a lack of quality health
countries with exclusionist or assimilationist services tailored to the requirements of refugees
policies than in countries that were more and migrants. Studies from the WHO South-
multicultural (59). East Asia (62,63) and Eastern Mediterranean
(33,64) regions acknowledged the need for
Transportation barriers. Difficulties with specialized service models, including increased
transportation or geographical barriers also health services for those who have experienced
affect access to health services. In Australia and conflict and insecurity. A train-the-trainer model
New Zealand, agricultural migrant workers from in Greece improved the use of trauma-informed
Pacific Island countries were deterred from practices of care among refugees (65).
seeking treatment because of language and
cultural barriers, as well as the geographical The literature on delivering refugee- and
migrant-sensitive health services focuses
on interventions promoting good-quality,
patient-centred care and patient satisfaction,
in which the priorities, preferences and
perspectives of refugees and migrants are
used to improve health service delivery (66).
Refugees and migrants may face The 2018 WHO European Region scoping
many of the same barriers in review on communication barriers for

refugees and migrants in health service
accessing health services as the settings identified four key strategies: cultural
local population, including cost, mediation, interpretation, translation of health
information, and guidance and training for
proximity and general gaps in the health care providers (18). A cross-sectional
health systems. study of 251 migrant patients in South Africa
revealed the importance of incorporating their
They also face barriers specific perceptions of the health system into national
to their migratory status, such as planning for UHC (67). The study found that
migrant patients' satisfaction with nurses
out-of-pocket expenses or limited depended on being given information about
recognition of their status. their condition, receiving polite treatment,
the time spent in the facility and whether they
received prescribed medicines.
197
In Italy, the results of a participatory research were designed to promote culturally and
project with the Chinese community, many linguistically relevant solutions to gaps in
of whom hold irregular status, suggested the health system for migrants. The most
that direct participation in health promotion common interventions involved providing
efforts may improve their engagement with health education and access to information
health interventions such as screening for regarding the overall health system and
hypertension (68). its specific services, and improving health
literacy. For example, a Canadian health
Research reviewed in the WHO Region of the education programme improved navigation
Americas and South-East Asia Region focused and knowledge of the Canadian health
on key public health approaches, including system among refugees and migrants (70). In
health education, access to information and the United States, an intervention reduced
improving health literacy (63,69). unnecessary visits to emergency departments
for young Spanish-speaking children through
In the literature on the WHO Region of the Spanish-language text messages aimed
Americas, many interventions and initiatives at parents (71). In Chile, a 2016 programme
were identified as having culturally sensitive focused on promoting migrants' access to
approaches for migrants or refugees. Some of health care and adherence to medical follow-
these were specifically designed to improve up by providing them with information on the
the relevance and acceptability of services Chilean health system and their right to
or health information materials, and others health (72).
Bew, a 45-year-old migrant worker from Myanmar, is vaccinated against COVID-19 in Mae Sot, Thailand, in November 2021. The vaccination
campaign, which followed a survey exercise carried out by the Ministry of Public Health, aimed to ensure that migrant workers returning to
Thailand were protected against COVID-19 as the country reopened its borders. © WHO / Anat Duangjan
198
Governmental agencies in Canada, Chile, One study addressing cross-border care

Honduras, the United States and other between Libya and Tunisia identified "how four
countries, often acting in partnership with key geopolitical periods shaped medical travel
community organizations, have developed to [Sfax]: initial diasporic exchanges facilitated
websites to provide migrants with key by bilateral agreements; an emerging medical
information about how to access health tourism industry within private health services
services. Other initiatives in Canada and the arising from the United Nations embargo on
United States demonstrated the effectiveness Libya; the 2011 political crisis and arrival of
of community-based health promotion war-wounded; and therapeutic circulations
models, for example, that targeted sites and emerging transnational spaces of care
frequented by refugees or migrants, such as a resulting from the context of war" (78). Cross-
Sikh temple (73), Asian-migrant churches (74), border health care provision also arose in the
or specific supermarkets or media outlets, as WHO African Region, ensuring continuity of
well as those using various communication care for HIV-positive migrants between South
technologies (75). In Amsterdam, faith-based Africa and Lesotho (45).
organizations were reported to be important
settings for the implementation of public In 2018 the European Centre for Disease
health programmes for African migrants; Prevention and Control developed evidence-
migrant community leaders were also based guidance on preventing priority
crucial players in initiating and supporting infectious diseases among newly arrived
community-based health awareness and migrants, including active TB and LTBI, HIV,
health promotion programmes (76). HBV infection, HCV infection, schistosomiasis,
strongyloidiasis and VPDs (79).
An emerging area of research in the WHO
Eastern Mediterranean Region focuses on Significant variations in data collection within
continuity of care and cross-border health care the WHO European Region exist, including in
provision, including the migration of patients approaches to TB control. Consequently, TB
for health care purposes when health systems elimination targets for the Region will not be
collapse as a result of conflict in the Region (77). met unless discrepancies in access to screening
and treatment of refugees and migrants are
addressed (80). Various studies have also
demonstrated the effectiveness and cost–
effectiveness of screening adult and adolescent
refugees and migrants for active TB and LTBI
and for other key infectious diseases, particularly
when targeting those from high-incidence
countries, making clear the importance of
linking HIS to public health outcomes (81).
Studies of surveillance data on outbreaks of
cholera in refugee camps in Uganda (82) and
of measles in refugee camps in Cameroon (83)
both demonstrated the importance of early
detection, treatment and rapid response to
contain the spread within refugee settlements
and local communities.
199
4.3 Health workforce migration (2). This section explores the findings
of regional literature on sufficient health
workforce staffing levels, training and resources
• Across every WHO region, efforts are for culturally competent care, and support for
under way to strengthen the capacities the use of refugee and migrant health workers.
of the health workforce to serve
refugees and migrants, including by 4.3.1 Sufficient staffing levels,
ensuring sufficient staffing levels,
training and resources
training and resources.
Efforts to strengthen the capacities of the
• To deliver refugee- and migrant- health workforce to serve refugees and
sensitive health services, the health
migrants are under way across every region.
workforce must be able to provide
They include specific training on cultural
culturally competent care and
address health issues associated with competencies, and on the staffing, support
displacement and migration; however, and resources the workforce will need if it is
resources are often insufficient. to provide sustained, good-quality care to
refugee and migrant populations (14,69,84–88).
• Even in high-income countries, there
are not enough health professionals In a qualitative study in Jordan, local health
with the necessary skills to provide care providers for Syrian refugees with cancer
culturally sensitive care to refugees described the "moral distress" of feeling
and migrants. they could not uphold their duty of care and
• On a project level, some health humanitarian values given funding and other
workforces have successfully constraints (89). Another study addressed the
integrated refugees and migrants, impact of the Syrian refugee crisis on nursing
including as cultural mediators, in Lebanon, with the nurses and nursing
thereby both making services more directors interviewed citing fatigue, burnout
effective and relieving staff shortages. and depleted capacity for compassionate
• The literature notes three key issues care at individual level; rationing and stressed
for migrant health care workers: the
impact of displacement on the health
workforce, the need for mechanisms
to incorporate refugee and migrant
health professionals, and the case Refugee and migrant patients
of countries where large parts of the
health workforce are migrants. will experience patient-centred
care when, despite cultural
differences, health professionals
A well performing health workforce is one that
works in ways that are responsive, fair and
take the time to explain procedures,
efficient to achieve the best health outcomes include culturally relevant
possible, given the available resources and
circumstances. To deliver health services that
references, appreciate the needs
are sensitive to the needs of refugees and of the patients and involve
migrants, the health workforce must be able to patients in decision-making.
provide culturally competent care and address
health issues associated with displacement and
200
interpersonal relationships at practice clinics in Jordan led to significant improvement

level; and shortages in resources and poor in the knowledge assessments and clinical
performance at health system level (86). checklist scores of trainees; trainees also
reported high satisfaction with the training
Experiences in the WHO European Region (97). The Operational Refugee and Migrant
highlight that movement of large populations Maternal Approach project developed cultural
requires swift recruitment and deployment of competence training for health professionals
human resources, including all types of health and midwives to help provide perinatal care
professionals. Although ad hoc recruitment for migrant women in Greece, the Netherlands
can address the immediate health and and the United Kingdom; a key aspect of the
humanitarian needs of arriving refugees curriculum involved follow-up training sessions
and migrants, a report found that this over many months, recognizing that it takes
must be weighed against challenges to the time to change attitudes (94). Research from the
sustainability and quality of service provision WHO Eastern Mediterranean Region focused
(85). The report concluded that adequate on cultural competency training for the migrant
training and intercultural mediation was health workforce, especially migrant nurses,
necessary to facilitate people-centred care in to enable them to provide quality services to
multicultural displacement contexts and even the host population; this issue was particularly
in settings of rapid service provision, such as relevant in Saudi Arabia and the United Arab
during mass arrivals. Emirates (98–100).
Many guidance documents and tools have been In border areas of Myanmar and Thailand,
developed to support health care providers strengthening the health workforce by using
across refugee and migrant groups and regions. village malaria workers has proven to be more
The existing health workforce should be trained effective in reaching migrant populations
in health coverage eligibility and migratory than other methods of malaria control, such
status, as well as in delivering cross-cultural as mobile malaria clinics and screening
health service to reduce discrimination (90). checkpoints for migrants. Such workers can
Training in cultural competence can strengthen reach hard-to-access malaria-endemic villages
the ability of providers to connect with refugee with a higher malaria prevalence, enabling
and migrant groups; this provider connection them to test more community members and
and attitude can have a positive influence resulting in high rates of case-finding. These
on the trust and health-seeking behaviour strategies are particularly important given the
of refugees and migrants (69,91–95). More diversity of malaria knowledge in this region,
specifically, refugee and migrant patients will where only half of short-term migrants are
experience patient-centred care when, despite aware of the disease (101).
cultural differences, health professionals
take the time to explain procedures, include In the United States, studies collating the
culturally relevant references, appreciate the perspectives of providers highlighted the lack
needs of the patients and involve patients in of adequate resources, support and training
decision-making (96). required to deliver acceptable care to refugee
and migrant populations, such as the need for
A low-cost training, skill-building, practice and multilingual health education materials and
feedback programme designed to improve interpretive services (102). Providers of health
the capacity of physicians working at UNRWA services for refugees in the United States
201
felt unable to fill structural gaps that require Canada and the United States, where third-
policy change; this impeded access to and party medical consultants were used: providers
the delivery of adequate and acceptable care did not always trust interpreters to translate
(103). In other WHO regions, inefficiencies in without moral, cultural or gender bias; there
the health system, such as weak infrastructure, were disruptions linked to interpreting via
lack of staff or staff support, and work overload phone; and some hired interpreters may have
were identified by providers as barriers to had limited knowledge of medical terms (118).
providing migrant-sensitive care (104–106). An innovative approach used in Türkiye was
found to increase the number of primary care
4.3.2 Supporting refugee and consultations among Syrian refugees living
migrant health workers there. The Ministry of Health of Türkiye worked
In every WHO region, studies present evidence together with WHO to select, train and deploy
highlighting the importance of including Syrian doctors, nurses and medical translators
cultural liaisons, intercultural mediators, among the Syrian refugee population to serve
peer educators, CHWs, or volunteers from in primary health care services for Syrian
refugee and migrant communities (107–112). refugees (119).
Thailand's health system has included
interpretation and cultural services since In the WHO Eastern Mediterranean Region,
2003 to reduce language and cultural barriers evidence has highlighted that migrant health
between health personnel and refugee and care professionals need adequate training to
migrant populations. This is conducted provide culturally sensitive care to the host
through migrant health workers and populations. In the United Arab Emirates,
volunteers in public health facilities, as well as expatriate nurses working in palliative care were
through CHWs within migrant communities required to develop their skills in advanced
who serve as cultural mediators and provide communication and spiritual practices, in
basic health education (107). addition to acquiring knowledge of local
cultural and religious norms (120). Migrant
In Italy, a national referral centre for nurses in the Region expressed communication
transcultural mediation in the health system challenges and a lack of cultural awareness,
was established by law in 2013 (113). In Brazil, partly the result of the unavailability of cultural
Bolivian health agents were deployed to education, indicating the need for education
reach Bolivian migrants who faced barriers and orientation programmes, particularly
in accessing health services (114). In the those relating to end-of-life care, cultural values
United States, peer counsellors and CHWs and family matters (98,99). The provision of
were used to promote vaccination (108) and such educational programmes for migrant
colorectal cancer screening (115) among health care professionals is critical as, among
Asian migrant communities. For Spanish- non-Muslim expatriate nurses in Saudi Arabia,
speaking populations, promotoras were widely cultural competency has been found to
deployed, for example, to prevent NCDs positively correlate with patient-centred
through lifestyle changes (116). In Chile, cross- care (100).
cultural facilitators reduced communication
gaps caused by cultural and linguistic Refugee community workers were used in the
differences between mostly Creole-speaking Dadaab Refugee Complex in Kenya, working
Haitian patients and their health providers under the supervision of professional SGBV
(117). By comparison in projects based in service providers to provide support
202
to SGBV survivors (111). Experiences from this skilled health care personnel may be working
humanitarian context showed that refugee elsewhere. The refugee and migrant health
community workers had tense relationships workforce abroad face various physical,
with the professional service providers, low pay, emotional and professional hardships in
opposition from some community members terms of displacement and migration and
and a lack of preparedness for the task ahead, of work transition before they can operate
as well as a lack of personal security because effectively within a new health system:
of subregional conflict and violence. training and language capacities are required
for acculturation to take place (123–126).
Intercultural mediators are employed to Studies of refugee and migrant nurses and
perform a variety of functions, e.g. linguistic doctors employed in Australia have indicated
facilitation and interpretation; bridging both positive experiences (mostly related
sociocultural gaps; preventing conflict and to income and autonomy) and negative
supporting resolution between health providers experiences (a lack of cultural awareness
and patients; supporting integration and or linguistic abilities) (126,127). As more
empowerment and providing advocacy to refugee and migrant health professionals
refugees and migrants about social and health are recruited and fill gaps in the health
services and their rights and entitlements to workforce, understanding these challenges
these services; building trust and facilitating is important to support their work transition
the therapeutic relationship for services; and needs as professionals (128). The WHO
providing psychosocial support, health South-East Asia Region is also one from
education and counselling; and, depending which health care workers primarily migrate.
on the situation, providing intercultural Research conducted within the WHO Eastern
mediation versus interpretation (109). They Mediterranean Region addresses the health
have had a positive impact on health systems of expatriate health workers, especially their
in 17 Member States of the WHO European mental health (121,129–136).
Region. However, the positive impact may be
limited by a lack of resources and processes for The literature raises three overarching issues
gaining professional qualification, insufficient related to the topic of migrant health care
training and the inconsistent implementation workers: the impact of displacement of the
of intercultural mediation programmes. In health workforce, the need for mechanisms to
2016 the Government of Türkiye enacted a law leverage the use of refugee and migrant health
allowing Syrian health professionals to work professionals, and the case of countries where
in the Turkish health system, with training large proportions of the health workforce
supported by WHO. This was designed to are migrants.
integrate Syrian professionals into the health
system and to ensure that Syrian refugees 4.3.3 Impact of migration
were able to receive health care without Although migration can have a detrimental
encountering language or cultural barriers (121). effect on health systems, it can also bring
opportunities. For example, as a result of
Many countries of the WHO Western Pacific advances in information and communication
Region have experienced shortages of health technologies, such as using telehealth and
care workers in remote and underserved other digital health technologies, migration
areas, where international migrants may can allow the possibility of a diaspora health
reside (122): this is partly because highly workforce to contribute from a distance
203
to health care in their country of origin face the problem of not having evidence of
(131–133,137). The literature highlights the their diplomas and other accreditation. This
economic benefits and also the excess problem is recognized in the literature in many
mortality costs associated with physician regions (140–142).
migration and the absence of policies to
prevent intraregional brain drain from low- Migrant nurses and doctors can experience
and middle-income countries to higher- prolonged processes to obtain visas and
income countries (132,133). Economic validate their medical qualifications, leading
modelling indicates that the countries them to accept less-skilled work in the interim
incurring the greatest economic cost as (143). Such workers may also have migrated or
a result of physician migration are India, been displaced for other reasons, and they may
Nigeria, Pakistan and South Africa, with the not be entitled to work legally in their profession
WHO African Region experiencing the greatest in their host countries. In such circumstances,
effect of all WHO regions (132,137,138). they may practice informally to fill gaps in their
communities, for example, Syrian refugee health
On an individual level, migrants may also face providers in Lebanon (144). In another example,
numerous challenges upon returning to their a nursing school has been created in the
home countries. Migrant health care workers setting of Sahrawi refugee camps as a means
returning to Botswana from high-income of mobilizing their limited resources to address
countries reported family ties and missing the lack of health care professionals serving the
home as reasons for returning, but some refugee populations (145). As part of the Triple
said that they had experienced difficulties Win project, Germany is recruiting nurses from
in reintegrating into the health system (139). countries such as Bosnia and Herzegovina, the
Migrant nurses from Indonesia who worked Philippines, Serbia and Tunisia, which educate a
as caregivers in Japan reported a variety of larger number of nurses than can be employed
challenges upon returning home, including within their respective labour markets (143).
deskilling and struggling to re-enter the
field of nursing (134). The diaspora of health 4.3.5 Countries with a large migrant
care providers from Sudan is reported to health workforce
have built links to overseas institutions and Migrant health care workers often play important
specialist clinical services, and has provided roles in countries in which migrants are a
physical and monetary donations to public significant component of the health workforce,
facilities (131). Health care providers choose although host country governments may have
their destination countries based on factors varying reactions to this reliance and may
such as an ageing population, a better school not collect adequate information to monitor
system, good remuneration and lower rates of it (Box 4.1). Evidence from the WHO Eastern
unemployment (137,138). Mediterranean Region documents the impact of
government-induced efforts to encourage the
4.3.4 Better use of health employment of nationals in health care sectors
professionals that have been largely dominated by migrants.
The literature indicates that ways need to In Oman, a labour localization programme
be found to improve the use of refugee and known as Omanization aims to promote the
migrant health professionals in various employment of nationals in the nursing field,
contexts. When establishing themselves in host which has raised concerns about the job security
countries, refugee and migrant health workers of migrant health workers (152).
204
Box 4.1.
Global patterns of health worker migration
Many countries do not have a dedicated policy or plan regarding health worker migration. Monitoring
health worker migration, and the resulting impact on the composition of the health workforce, is
key to ensuring sufficient national capacity to provide adequate and efficient health services. This
is recognized by instruments such as World Health Assembly resolutions WHA63.16 and WHA69.19
(146,147), the WHO global code of practice on the international recruitment of health personnel (148) and
the Global strategy on human resources for health (149).
Tools such as the National Reporting Instrument and National Health Workforce Accounts (NHWA)
contribute to monitoring the migration of global health workers and generating evidence for policy dialogue
(150). NHWA provides a standardized mechanism to strengthen health workforce information systems in
countries, thereby building capacity and stakeholder cooperation at the national level with regards to health
workforce data. NHWA also facilitates the improvement of health workforce data at global level. Since its
adoption 5 years ago, more than 170 countries have been engaged in implementation of the NHWA.
Although there are various approaches to monitoring health worker migration, they are built on the
main concepts of foreign-trained and foreign-born health workers. As shown in Fig. 4.2, the proportion
of migrant doctors employed by the health systems of countries in the Organisation for Economic
Co-operation and Development has risen during the past two decades (151). Around two thirds of
all foreign-born or foreign-trained doctors originated from within the OECD area and upper-middle-
income countries, whereas lower-middle-income countries and low-income countries accounted for
around 30% and 3–4%, respectively, of foreign-born doctors.
However, unpublished data collected by WHO show that the presence of foreign-trained health
personnel is not restricted to any particular region and varies for each health occupation and between
WHO regions. The WHO Eastern Mediterranean Region has the highest proportion of foreign-trained
health workers. All regions show a higher percentage of foreign-trained medical doctors than of
foreign-trained nursing personnel. Note that some countries do not have medical training facilities
and, therefore, send their nationals to train abroad; this may be understood as having health workers
that are all foreign-trained but not necessarily as health worker movement or brain drain. Some other
countries actively recruit foreign-born, foreign-trained health workers to deliver health services. Adding
to this mix is the voluntary movement of health workers seeking better career opportunities and the
subsequent movement of health workers as a result of the migration of entire families. These points all
highlight the fact that health worker mobility is difficult to measure using any single metric.
In Saudi Arabia the "Saudization" of the country's including physical therapists (64,154). Some
pharmacy workforce has also been considered, countries have had to rely on their migrant health
given that less than 20% of pharmacists are workforce, particularly during the COVID-19
Saudi nationals and the country has an unmet pandemic. Australia, where more than half of
need to train and retain nationals as pharmacists doctors and more than one third of nurses are
(153). Such a disparity is also apparent among born elsewhere, strengthened its reliance on
other health care professions in Saudi Arabia, migrant health workers during the pandemic
205
Fig. 4.2. Foreign-born doctors working within the OECD countries during 2000–2001, 2010–2011 and 2015–2016
42.9
Australia 52.8
53.9
14.6
Austria 16.9
14.2
Belgium 15.7
35.1
Canada 34.1
38.5
Czechia 8.8
9.7
10.9
Denmark 19.1
21.0
Estonia 18.0
14.0
4.0
Finland 7.7
9.5
16.9
France 19.5
15.7
11.1
Germany 15.7
20.2
Greece 7.3
4.2
11.0
Hungary 13.3
11.2
35.3
Ireland 46.6
41.1
Israel 49.2
48.7
Italy 5.0
4.3
Country
Latvia 17.4
30.2
Luxembourg 40.0
55
Mexico 1.5
16.7
Netherlands 14.6
17.1
46.9
New Zealand 54.3
16.6
Norway 22.7
22.7
Poland 3.2
2.7
19.7
Portugal 16.4
9.9
Slovakia 1.2
Slovenia 18.1
7.5
Spain 10.3
13.7
22.9
Sweden 29.8
30.5
28.1
Switzerland 41.6
47.1
Türkiye 6.2
2.9
33.7
United Kingdom 35.4
33.1
24.4
United States 26.4
30.2
0 10 20 30 40 50 60
% of foreign-born doctors
2000–2001 2010–2011 2015–2016
Source: Socha-Dietrich & Dumont (151).

206
by lifting its restrictions on working hours for migrant access to good-quality and affordable
international nursing students: the burden on medicines and vaccinations.
the health workforce was reduced by allowing
nursing students to work for more than 40 h per 4.4.1 Access to good-quality and
week; this practice should be monitored to avoid affordable medicines
any negative effects (112,137). The Maldives, Refugees and migrants may have limited access
which is still developing its national medical to medication. One study in Australia showed
education, has relied heavily on expatriates in that resettled refugees had limited health
building its health workforce (155). literacy, were at a greater risk of mismanaging
their medication than their host population,
and faced difficulties in accessing medicine
4.4 Access to medical products, and pharmacy services (156). Literature related
vaccines and technologies to the WHO Region of the Americas is scarce.
Migrants from Latin American countries in the
United States reported feeling that options
• Refugees and migrants have limited for pharmaceutical pain management were
access to medications in some camp not offered because the provider may have
settings and informal settlements, often assumed they were unable to pay for them;
as a result of supply chain difficulties,
in such cases, migrants may have borrowed
cost, lack of adequate diagnostics and
medication from other migrants (41). A study
medication, and discrimination.
shows that Nicaraguan migrants in Costa Rica
• Limited access to essential medications reported using the black market for medication
may lead refugees and migrants to
because of the various barriers to accessing
resort to self-medication or to use
health services (157).
non-prescribed medicines, such
as antibiotics, resulting in possible
antimicrobial resistance. Different refugee settings may present different
barriers to medicine access. There are
• Vaccination coverage policies
indications that at the onset of the emergency,
for refugees and migrants vary
widely and lack clarity, and are Rohingya refugees in camps in Cox's Bazar,
sometimes complicated by limitations Bangladesh, experienced very low levels of
and challenges connected to access to essential medicines for both acute
migratory status. and chronic conditions because, among other
• In many places, screening services factors, mobile clinics in the camps lacked
urgently require improvement to diagnostic and refrigeration infrastructure (158).
protect both people on the move Among Rohingya refugees with serious health
and local communities in countries conditions, evidence indicates that 70% were
of transit or destination. prescribed ineffective pain treatments that
were largely ineffective; no nearby pharmacy
was found to have morphine available and
A correctly functioning health system ensures only 1 out of 17 had suitable oral opioids (159).
equitable access to essential medical products, Although there is a significant lack of basic pain
vaccines and technologies of assured quality, medicines at health facilities and pharmacies,
safety, efficacy and cost–effectiveness, and additional barriers include health care providers
their scientifically sound and cost-effective being unaware of how to use pain medicine,
use. This section addresses refugee and believing they can be misused, or displaying
207
reluctance to prescribe them. Pharmacies may included in the 2015–2020 UNHCR health
also employ staff with very little to no formal access and utilization surveys. As shown
training in the field of pharmacy (160). in Fig. 4.3, the proportion of Syrian
respondents reporting access to care or
In another example, an evaluation of a medication for chronic conditions increased
pharmacist-delivered home medication from 2016 to 2017, and then gradually
management service for Syrian refugees decreased to 68% in 2020 (163–168).
in Jordan found that the programme was
effective on several levels: it decreased The idea that refugees and migrants may
treatment-related problems, physician self-medicate because of barriers to accessing
approval rates of pharmacist recommendations medicines is discussed in regional research.
were high and satisfaction rates among Obstacles including perceived barriers and
refugees were high (161). An evaluation of cost may lead refugees and migrants to
community-based primary care for NCDs seek medicines elsewhere if they cannot
delivered to Syrian refugees in Lebanon and acquire them through the health system.
Lebanese nationals showed satisfaction with Among Chinese migrants in Australia, the
the programme among patients and health use of non-prescribed antibiotics was
providers; the greatest problems experienced influenced by their experiences with PHC
were interruptions in the supply of medicines access; one study showed that migrants
(162). In a vulnerability assessment of Syrian with positive experiences and perceptions
refugees in Lebanon, the cost of medicines was of health services were at a lower risk of
cited as a barrier for 77% of the respondents using non-prescribed antibiotics (169).
Fig. 4.3. Proportion of Syrian refugees in non-camp settings who accessed care or medication for a chronic
condition during the 3 months prior to survey, 2015–2020
100
90
64 64 79 78 77 68
80
70
% of Syrian refugees
60
50
40
30
20
10
2015 2016 2017 2018 2019 2020
Year

208
Using non-prescribed antibiotics contributes to 4.4.2 Access to vaccines

antimicrobial resistance. In the WHO South-East Vaccination is an important public health
Asia Region, artemisinin-resistant malaria was measure and service for refugees and migrants
present but migrants living near the Thailand– because vaccines protect both them and
Myanmar border had low levels of awareness local communities in countries of transit or
of the disease (101). In the WHO Eastern destination, and also prevent outbreaks and
Mediterranean Region, a study of methicillin- the spread of VPDs. In some cases, vaccination
resistant Staphylococcus aureus found no services may be the first contact with the
statistically significant differences in its carrier health system for a refugee or migrant.
rate between the Iraqi host community and (See section 3.8.10 for details of COVID-19
Syrian refugees (170). A study of antimicrobial vaccination programmes for refugees
resistance to cholera in the Islamic Republic and migrants).
of Iran showed that most cases were detected
among male migrants aged 16–30 years from Many recent surveys in the WHO European
Afghanistan and Pakistan who had travelled Region assessed the seroprevalence of VPDs
without work authorization to Iran for job and of non-vaccine-preventable infections
opportunities (171). It is important to build in refugees and migrants (173–177). One
awareness among refugees and migrants study in Swiss hospitals found that refugee
regarding the rational and safe use of such and migrant children older than 5 years
medicines. In Uganda, records documented from certain countries in the WHO Eastern
inappropriate antibiotic-prescribing practices Mediterranean Region were mostly seronegative
in a refugee setting: these practices included for hepatitis A and at risk of clinical infection
the excessive use of antibiotics and a failure by (178). Two Italian studies showed heterogeneity
health workers to diagnose (27%) and prescribe in vaccination coverage from VPDs among
(47%) in line with treatment guidelines (172). children born to migrant women, although this
varied according to the geographical context,
antigen, birth cohort and area of origin
(179,180). Two other Italian studies showed that
adult migrants at risk for influenza-related
complications had lower influenza vaccination
coverage than Italian citizens (181,182).
Vaccination is an important health Across the WHO European Region, there

is a lack of clarity and consistency in
service for refugees and migrants national guidelines and policies for access
because vaccines protect both to immunization programmes by refugees
and migrants (183). Comprehensive national
them and local communities in immunization plans exist in 42 Member States
countries of transit or destination, in the Region but, as of 2017, only 11 Member
and also prevent outbreaks States have included recommendations in
their plans for refugees and migrants (184). This
and the spread of vaccine- lack of coordination across the Region could
preventable diseases. lead to confusion among some health care
professionals about whether to immediately
vaccinate refugees and migrants who have an
209
unknown or unclear vaccination history or to successful strategies presented, notably the

first conduct serological testing (185). There is establishment of permanent vaccination
also a lack of clarity about which vaccinations points coupled with timely intervention and
to prioritize upon arrival (186). To address these coordination (192). A study of the spatial
challenges, the Region identified three critical heterogeneity of measles vaccination coverage
elements that are applicable beyond the Region in 10 sub-Saharan African countries identified
to ensure high vaccination coverage among clusters of low levels of coverage linked to
refugees and migrants: (i) the provision of border areas with highly mobile transborder
appropriate vaccination services to new arrivals, populations. Such clustering was associated
(ii) the delivery of immunization services to with low levels of health education and limited
refugees and migrants as part of mainstream access to health services (193). According to
health services, and (iii) the provision of targeted a study based in the WHO African Region, the
and culturally appropriate immunization recognized need for improved and accessible
services to reach particular refugee and migrant systems for serological immunoassays in
communities (184). remote settings is being addressed (194).
In the WHO Region of the Americas, a report
IOM is partnering with various countries in on 10 Caribbean island countries and
the WHO Western Pacific Region and beyond territories (Antigua and Barbuda, Bahamas,
in a comprehensive vaccination programme Barbados, Dominica, Grenada, Jamaica,
for arriving migrants (187). This programme Saint Kitts and Nevis, Saint Lucia, Saint
is facilitated by the IOM's migration health Vincent and the Grenadines, and Trinidad
assessment centres for more than 15 VPDs. and Tobago) indicated an interest in ensuring
The National Immunization Programme in that migrants entering the countries received
Thailand is a good example of providing the required vaccinations; however, current
vaccinations to hard-to-reach migrant screening processes are weak, hindering the
populations, with migrant children near the effectiveness of the programme (195).
Thailand–Myanmar border receiving timely
and appropriate vaccines at the following In the United States, vaccination rates for
rates: 92.3% for TB (bacille Calmette–Guérin, refugees and migrants are lower than for those
BCG); 85.3% for three doses of oral poliovirus born in the country (109,196,197), with the
vaccine (OPV); 63.8% for diphtheria, tetanus exception of influenza and hepatitis A and B
and pertussis vaccine; 72.2% for three doses among specific age subgroups and among
of hepatitis B vaccine; and 90.9% for measles people with NCDs (198). Refugees and migrants
vaccine (188). However, the same data suggest from various eastern African countries living in
that overall vaccine coverage in migrant Australia indicated that they had limited access
populations is low. to immunizations, mostly because of language
barriers; this could be addressed by increasing
Literature published by the WHO African community-led information dissemination
Region suggests strengthening cross- and reminders about immunizations to these
border vaccination and seasonal migration groups (199). In New Zealand, less than 50% of
surveillance, including permanent vaccination migrant children were found to have at least
points at transit points and vaccination one recorded vaccination event in the National
on market days (189–191). With a focus on Immunisation Register; even among migrant
polio outbreaks in the Horn of Africa and children who had been in New Zealand for
Kenya, responses have been evaluated and at least 2 years, only 60% had a record in the
210
register (200). Similarly, children born in China which summarizes UNHCR health access and
to refugees from the Democratic People's utilization survey data for Lebanon) (203). The
Republic of Korea had lower immunization same study noted that although household
rates than both the host population and surveys may be the most reliable way of
other migrant children (201). Inequities in assessing need, they are limited by information
vaccine access can affect the prevalence of bias (e.g. absent or unreadable vaccination
VPDs; in New Zealand, children from refugee cards, or recall bias of mothers) and a lack of
backgrounds experienced a higher incidence sampling frames for mobile populations. The
of VPD-related hospitalizations than the host study recommended conducting research
population (202). on the validity of recall methods and on links
between campaigns and routine immunization
A study estimating vaccine coverage among programmes and that vaccine access for hard-
refugee populations in Jordan and Lebanon to-reach populations be improved. Another
found that only about 35% of Syrian refugee study in Lebanon reported that although
children in Jordan and less than 15% in Lebanese children had higher levels of antigens
Lebanon were fully immunized through than Syrian children at baseline for a vaccination
routine vaccination services (see Fig. 4.4, programme, this difference was substantially
Fig. 4.4. Proportion of Syrian refugee children in Lebanon who received oral polio vaccination and injectable vaccines
100
90 88 87
84 84
80 83
83 82 83
70 69
60
% of children
50
40
30
20
10
0
2016 2017 2018 2019 2020
Year
Proportion of children who received oral Proportion of children who received

poliovirus vaccine injectable vaccines

211
reduced by the campaign (204). UNHCR systematically collected and comparable data
health access and utilization survey data for through national HIS or common reporting
Lebanon (163–168) confirmed these gaps in full frameworks. There are some comparable data
vaccination coverage (Fig. 4.4). The proportion from major household surveys, but these
of children who received oral poliovirus vaccine data have their own challenges (Chapter 5).
increased from 69% in 2016 to 83% in 2017, A comprehensive set of information and
and the proportion of children who received data from HIS around the world and their
injectable vaccines fluctuated between 84% thorough analysis is essential to gain in-depth
and 88% from 2017 to 2020 (Fig. 4.4). knowledge of refugee and migrant health
(Box 4.2; Chapters 5 and 6).
4.5 Health information systems 4.5.1 Data collection on refugee

and migrant health
Data collection related to epidemiological
• Significant limitations to refugee and surveillance and screening and migratory
migrant health data exist in HIS, such status has been reported across several WHO
as an absence of epidemiological data, regions. Because there is a need to collect
a lack of standardization of data within
epidemiological data effectively in cross-border
countries and regions, comparability
areas among highly mobile populations who
across databases or time of data
collection, and an inability to have difficulties completing treatment, research
disaggregate data by migratory status. on HIS in the WHO South-East Asia Region was
based on the coordination of malaria and TB
• Data collection efforts may also
surveillance. One of the major issues for
place too great an emphasis on
monitoring for infectious diseases, TB control in Thai border areas is incomplete
while neglecting comprehensive public surveillance data as a result of migrant patient
health monitoring. mobility and loss to follow-up, which can lead
to multidrug-resistant TB (209). Initiatives for
• The protection and privacy of refugee
and migrant health data are major multicountry coordination around malaria
concerns. The inappropriate data collection and information-sharing
sharing of data can have serious platforms include the WHO Mekong Malaria
consequences, such as limiting access Elimination Programme (210) and the Asia
to health care and other services, Pacific Malaria Elimination Network (211).
or even deportation. The Mekong Programme has helped many
participating countries move towards their
malaria elimination objectives. The Asia Pacific
Correctly functioning HIS ensure the programme is an example of an effective
production, analysis, dissemination and mechanism for gathering country-specific
use of reliable and timely information and information on high-risk populations to target
data on health determinants, health systems patterns of displacement and migration and
performance and health status. Data and other data from 21 partner countries (211).
evidence for a report on health should Identifying the health needs of refugees and
predominantly come from HIS; however, migrants during the reception pathway, while
this report predominantly uses information respecting human rights and confidentiality,
from peer-reviewed and grey literature requires effective and efficient screening
from around the world because of a lack of systems that are integrated with HIS and health
212
Box 4.2.
Global frameworks and regional guidelines that support harmonized data for refugee
and migrant health
Although global frameworks and regional guidelines are not binding, they are useful in mobilizing
countries to actively collect and harmonize data on displacement and migration health. These
frameworks and guidelines are examples of how such documents could facilitate the disaggregation of
health data by migratory status and integration with HIS.
Global indicator framework for the Sustainable Development Goals (SDGs)

The Inter-Agency and Expert Group on SDG Indicators developed a set of 231 unique indicators in 2017
(205), to be refined and reviewed annually: 24 indicators should be disaggregated by migratory status
(e.g. 1.1, 3.2, 3.c and 5.5); several indicators are directly related to migration (4.b.1, 10.7.1, 10.7.2, 10.7.3,
10.7.4, 10.c.1 and 16.2.2); and two indicators explicitly require disaggregation by migratory status
(8.8.1 and 8.8.2).
The WHO Strategy and action plan for refugee and migrant health in the WHO European Region
The strategy and action plan was presented to the WHO Regional Committee for Europe in 2016 to
"promote the inclusion of migrant [and refugee] variables in existing data collection systems" (206). A
progress report in 2020 found that most Member States that do not currently collect information about
variables related to displacement and migration had plans to incorporate such data into their routine HIS.
This encouraging trend highlights how guidelines can support better integration of data on displacement
and migration health (207).
The WHO Global action plan on promoting the health of refugees and migrants, 2019–2023
The global action plan advises the strengthening of HIS to ensure that standardized and comparable
records on refugee and migrant health are available at the global, regional and country levels (208).
care delivery (212). For example, border children (Greece, Portugal and Spain), and
health-check procedures must be evidence insufficient information was retrieved in health
based with data shared across countries, risk assessments in three other countries (France,
specific and include a guaranteed treatment Liechtenstein and Luxembourg).
linkage to the national health system in the
case that a disease is detected (213). However, Some of the major gaps in HIS across most
national policies on screening and identifying regions include the absence of epidemiological
the health needs of refugees and migrants data, lack of standardization, comparability
differ among countries, creating challenges issues across locations or time, and the
across the EU, EEA and other regions (214). inability to disaggregate data by migratory
Of the 30 countries for which data were status (4,89,122,215–217). The WHO European
collected, three reported no systematic Region notes that region-wide indicators
health assessments for newly arrived migrant generally do not exist, so there are no
213
comparable data to use in a regional overview status (122). Research identified several key
of refugee and migrant health. Health Evidence challenges across the Region – fragmented
Network synthesis report 66 examined HIS in and independent information systems, limited
the Region and found that the lack of clear availability of data, insufficient disaggregation
regional and national strategies prevents the of data, and poor data quality and reliability –
collection of relevant data and that existing that would remain even if migratory status
data collection processes favour infectious was captured.
disease monitoring over comprehensive
public health monitoring (4). In 2020 a task An article on the SRH of migrants in the
force on the collection and integration of data United States identified 29 publicly available
on refugee and migrant health in the Region sources of national, state and local data on
developed various national and regional immigration, race and ethnicity; SRH; and
policy recommendations, including ensuring health service use (216). Key challenges
adequate personnel for HIS, financing, included restricted access to disaggregated
logistics and information technology, as well data, variations in the type of information
as regulatory and legislative components collected over time across sources, changes
(Box 4.3). Data protection and privacy, as in race and ethnicity categories or measures
well as the ethical use of data, are special of immigration, and a lack of detailed data on
considerations for refugee and migrant both migration and SRH.
populations; firewalls are necessary for sharing
data between governmental bodies that could Literature published in the WHO Region of
affect legal status or deportation (207). the Americas describes the implementation
of electronic health records (EHR) and other
A recent WHO report highlighted differences HIS technologies in migrant health contexts.
in the capacity of HIS between high- and One study focused on implementing EHR
low-income countries: although low-income to promote hypertension management in
countries have weaker HIS, these are migrant-serving primary care practices in New
the countries in which most refugees are York City (219). The intervention focused on
hosted (Chapter 1) (218). The management training staff to generate routine hypertension
of health data in refugee-hosting districts of registry reports, as well as to develop and
Uganda highlights the multiple challenges implement medical alerts and order sets
of integrating refugee stakeholder data at (i.e. treatment guidelines). This would require
national level, including collection, analysis implementing standardized and mandatory
and reporting (215). The Ugandan model seeks fields within the EHR for race and ethnicity
to integrate the UNHCR Integrated Refugee subgroup documentation, training in the
Health Information System with the Ugandan codes used for billing and improving reporting
National Health Management Information practices. The intervention succeeded in
System by streamlining data to inform policy improving health outcomes for migrant
and programming in the field. Countries patients, and participating primary care
in the WHO Western Pacific Region have practices reported both satisfaction with and
established a regional monitoring framework adherence to the implementation of EHR.
for UHC and the SDGs, which includes making This successful intervention can inform future
improvements to civil registration, vital interventions to implement EHR in other
statistics and surveillance systems; however, settings in the Region. Another study in the
the data collected do not yet include migratory United States used a multicomponent health
214
Box 4.3.
An interoperable health information system for refugees and migrants
SAVe (Support Asylum and Vulnerabilities through e-health, or electronic health) software is an
electronic health information system developed by the Italian National Institute for Health, Migration
and Poverty in 2019 (207). It allows national health system staff, including those working in the
reception system, to enter and access data about the health of migrants, even those whose status is
irregular and who are not registered with the national health service.
SAVe is designed both for rapid initial health assessment at or just after arrival and for later phases of
the reception path. It provides tools to investigate traumas, mental health needs and vulnerabilities.
The system is now being implemented by local health authorities in those Italian regions where more
than 14 000 migrants are hosted, and further rollout to all first-reception centres and hotspots is
planned. The health records of a single patient can be saved on demand to external storage devices,
facilitating continuity of care even if the patient moves to another country. The system is compliant
with rules on personal data protection and privacy.
A unique migrant identifier code included within the SAVe system will allow the files to be linked to
the electronic health record. Data from the SAVe system are anonymous and will be made available
only for epidemiological and research purposes, permitting the regular release of data sheets and
epidemiological reports on the status of migrant health.
information technology screening tool for the regulation and referrals among refugees from
diagnosis and treatment of major depressive occupied Palestinian territory, including east
disorder and PTSD in primary care settings Jerusalem, in Lebanon (221). However, service
among migrant patients from Cambodia (220). delivery methods that rely on technology or
The tool is programmed to use evidence-based mobile devices, such as smart phones and
clinical algorithms and guidelines to facilitate digital applications, were considered expensive
evidence-based care. It helped to improve the by Syrian refugees accessing electronic mental
diagnosis and treatment of migrant patients health services (222).
suffering from both disorders, and will be
used to inform future interventions based
on information systems to enhance mental
health services for migrant patients. HIS-based
low-cost tools – electronic health (e-health)
and mobile health (m-health) – are used in
refugee settings, particularly for data collection
related to NCDs, and have proven effective
for diabetes and hypertension detection,
215
4.5.2 Dissemination and use of 4.6 Financing

refugee and migrant
health data
Standardized, good-quality data must be • D
irect and indirect health costs are
collected and then shared across government major barriers to accessing health care
entities at the national and global levels in all WHO regions, especially where
refugees and migrants are not covered
to inform evidence-based policies and
by national health systems or by social
programmes (207). The grey literature across
security or insurance schemes.
WHO regions includes examples of extensive
reports on various issues related to refugee • R
efugees and migrants often cannot
afford the out-of-pocket costs of
and migrant health status and access to health
accessing health services, and so
care. These reports use national databases
spend less overall on health care than
or registrations, or were commissioned host populations.
by research institutions and international
• S
ome countries have successfully
organizations, including United Nations
integrated refugees and migrants into
agencies (122,195,210,215,207,223–225). Such
their public health and social protection
reports are used to inform policy-makers strategies and services.
and to develop guidance and programmes
• A
lthough many countries might
for practitioners that promote health among
perceive a lack of incentives to include
refugee and migrant populations. For example,
refugees and migrants in UHC, evidence
a report on the potentially harmful effects of clearly indicates that it may actually
migratory status on the health of migrants be more costly to exclude them from
in Mexico, including exposure to poor living health coverage.
conditions and insecurity as well as risks
related to sexual exploitation and human
trafficking, provided key information for policy-
makers (226). An effective health financing system raises
adequate funds for health in ways that
IOM and UNHCR conducted various types ensure that people can use the services
of data collection activities and household they require but are protected from the
surveys with refugees and migrants in the financial catastrophe or impoverishment
WHO Region of the Americas and other WHO associated with having to pay for them.
regions, including information relevant for This section discusses the mechanisms
health systems such as the Displacement for and challenges of financing a health
Tracking Matrix (227). For example, IOM system inclusive of refugees and migrants. It
collected, analysed and shared information includes public, private and mixed systems,
on human mobility in these countries through as well as information about the health costs
the Northern Triangle Migration Management and expenditures for refugee and migrant
Information Initiative, which covers El populations and estimated costs for the host
Salvador, Guatemala and Honduras (228). country health systems.
Issues related to collecting and synthesizing
better-quality refugee and migrant health data 4.6.1 Refugee and migrant
are discussed in Chapter 5. expenditure
The out-of-pocket costs or financial burden of
accessing health services are often prohibitive
216
for refugees and migrants (3,229–233). Even health services were indeed more accessible
when refugees or migrants are legally entitled than higher-level services, but that structural
to certain health services, there are often and financial barriers limited their access (234).
hidden costs (e.g. transportation or hiring
translators) or co-payments that hinder In some contexts, refugee and migrant
seeking or accessing care. For example, populations spend less overall on health
among non-camp Syrian refugees in Jordan services. A study in the United States showed
with chronic health conditions such as that out-of-pocket spending by migrants on
hypertension and diabetes, only 84.7% health services was significantly lower than
received treatment; the gap was linked to the that of the host population with equivalent
out-of-pocket payments necessary in seeking health needs, mostly attributable to less
care (232). However, the host community also spending on private insurance (235). Similarly,
reported high out-of-pocket payments; these a study in Colombia focusing on health-related
were sometimes higher than those of the expenditure among migrants and non-
refugee population because, in some cases, migrants living with HIV (and in contact with
refugees received financial aid from agencies a medical facility) found that the average per
such as UNHCR. This study illustrates the capita expenditure was lower for migrants,
importance of financial protection for health at US$ 859, than for non-migrants, at
equity between host and migrant population US$ 1796, when adjusted for age and clinical
groups. Another study of Syrian refugees in characteristics (236). This trend holds among
Jordan found that preventive and primary refugees and migrants in Kuwait, whose out-of-
pocket expenses on health consultations were
generally lower than those of nationals, mostly
because refugees and migrants tend to
seek more care at public (i.e. lower-cost)
facilities (237).
Identifying the health needs of
These results do not mean that refugees and
refugees and migrants during the migrants have fewer health care needs. As
reception pathway, while respecting indicated in section 4.2.1, there exist several
barriers that prevent access to health care
human rights and confidentiality, systems. This is the case for Venezuelan migrants
requires effective and efficient who, lacking refugee status, do not have access
to public health services. Many in Colombia
screening systems that are and Peru reported seeking alternatives, such as
integrated with health information telemedicine, local pharmacies and extra-legal
systems and health care delivery. care networks, the costs of which then affect their
ability to pay for their basic needs such as food
and housing (238).
Although low-income countries have 4.6.2 Public health coverage
weaker HIS, these are the countries Insufficient financing of health systems that
in which most refugees are hosted. cover refugees and migrants can create
significant barriers to access (239), leading
to inadequate health services and health
217
promotion or to a lack of training among acute conditions decreased from 2015 to 2017,
providers and CHWs. Financial constraints are followed by a steady increase to 2020. These
the primary challenge towards meeting the results take into account the multiple political
health care needs of refugees and migrants and economic crises faced by the Lebanese
in many countries. At the same time, existing population in recent years.
national health policies also carry implications
for addressing the health needs of refugees Despite differences within and between
and migrants. For instance, in Malaysia, countries, several countries in the WHO
medical fees for migrants have been noted Western Pacific Region have enacted policies
to have increased, influencing their access to to provide health service entitlements to
health services (239). Except for Sri Lanka migrants, specifically migrant workers (249).
and Thailand, most other countries in the EU countries on the periphery of the WHO
WHO South-East Asia Region do not have European Region, which are often the first
specific policies for the health of refugees countries of arrival, face disproportionate
and migrants, and these groups are excluded financial costs to cover the health needs of
from health insurance programmes. The asylum seekers. A study concluded that given
health service card possessed by migrants widespread political controversies about
in Thailand is used most often by those with national security and economic austerity,
poorer health or those seeking treatment among other issues, countries in the EU lacked
for chronic illness, many of whom face high incentives to honour health as a human right
costs for health services (Box 4.4). Sri Lanka and to provide UHC for people who have been
has enacted multiple policies such as the forcibly displaced (250).
2009 National Labour Law, which provides
HIV and reproductive health care to labour A 2015 study in Germany concluded that the
migrants; the 2013 National Migration cost of excluding refugees and asylum seekers
Health Policy, which promotes the health of from public health coverage was higher
outbound and inbound migrants; and the overall than that of allowing regular access
Child Health Protection Plan, which covers the (251). However, a 2018 study following up on
children of migrant workers and emphasizes the rapid acceptance of more than 1 million
psychological and mental health needs (210). refugee applications in Germany during the
Syrian refugee crisis showed that the average
Although Syrian refugees in Jordan have expenditure by refugees was 10% higher
access to public health services for children, than for the regularly insured; although these
nearly half reported paying out-of-pocket increased costs were mostly because of higher
fees for either the consultation or medication, hospital expenditure and a lack of awareness
possibly because they lacked awareness of of outpatient and preventive care, they were
subsidized care (232). As shown in Fig. 4.5, reported to quickly decrease with increasing
the proportion of Syrian refugee households time living in Germany (252).
in Lebanon who reported knowing that
subsidized services were available at public Removing legal restrictions to health coverage
health centres sharply declined from 75% in may improve access to and use of PHC by
2015 to 57% in 2016, and then fluctuated until refugees and migrants, particularly for irregular
it reached 68% in 2020 (163–168). Knowledge migrants (253), thereby reducing their reliance
of free access to vaccinations for children at on or need for more costly emergency care
public health centres and free medications for or hospitalization (254). A study in Cameroon
218
Box 4.4.
Inclusion of refugees and migrants in Thailand's health system as a part of UHC
All workers in formal industries in Thailand have mandatory health coverage through the national
social security scheme, which is financed by workers, employers and the state. However, for many years
irregular migrant workers were not eligible for state social security schemes and had to either forego
health services or pay out of pocket for them. In 2001, the acute need for migrant labour led the Thai
Ministry of Public Health to introduce a new public insurance scheme that included irregular migrants
from neighbouring Cambodia, Lao People's Democratic Republic and Myanmar. The voluntary health
insurance card scheme (HICS) is funded by an annual premium paid by workers, enabling access to
public health care facilities and reduced catastrophic health expenses. However, with no contribution
from employers or government, it was not possible to make it mandatory, some migrant workers
remain outside both schemes (240–244).
Some of the major barriers faced by migrant workers in accessing migrant health insurance schemes
include their irregular status, nationality verification, the voluntary or semivoluntary nature of health
insurance schemes, administrative delays in enrolment, poorly responsive services, lack of portability
with respect to employer or location, and the resistance of employers to hiring migrants. The voluntary
nature of the scheme encouraged the participation of those who were ill, while healthy migrants tended
to abstain, given the extra cost to the household. Nationality verification and enrolment in insurance
schemes require effective communication and coordination among various ministries, such as the
Ministry of the Interior, Ministry of Labour and Ministry of Health, but deficiencies in communication
and coordination were among the major bureaucratic hurdles that reduced the uptake of health
insurance by workers. The low levels of enrolment by migrants inhibited large pooling of risks, which
affected the financial viability of the scheme (242,243).
Despite these barriers, enrolment increased. In 2011, less than 10% of migrants in Thailand were
insured. However, this number had increased to 64.0% by 2019. One of the major reasons was the
inclusion of health volunteers, who were recruited from migrant communities and workplaces (245,246).
While a one-size-fits-all service was introduced to simplify migrants' access to health insurance, several
challenges persist, such as ambiguous policy messages from other government departments and
authorities, and slow progress of nationality verification. However, Thailand is one of the few countries
to have made remarkable progress in financing migrant health: the HICS significantly reduced the
costs of inpatient care and out-of-pocket expenditures for migrant workers (247). Some of the factors
that helped reduce these expenses were insurance status, residence close to facilities and a history of
visiting health facilities after 2013 (when the HICS expanded its benefit package); conversely, severe
illness and advanced age increased inpatient care and out-of-pocket costs (245).
The Migrant Fund is another mechanism that provides protection to migrant workers who are not
covered by existing government insurance schemes: this voluntary, non-profit health insurance scheme
has been operating along the Thailand–Myanmar border since 2017. It was especially important for
irregular migrants who were otherwise excluded from insurance schemes as a result of unclear policies
(245). Other low-cost insurance schemes for migrants on the Thailand–Myanmar border also exist (248).
219
Fig. 4.5. Awareness of available subsidized PHC services within Syrian refugee households in Lebanon, 2015–2020
80
75
71
70 68
65
62
59 59 67
60 57
55 60
% of households
50 48 48
42 42
40 39
34
30
20
10
0
2015 2016 2017 2018 2019 2020
Year
Knowledge of access to subsidized Knowledge of free vaccinations for children Knowledge of free medicines for chronic
services at public health facilities < 12 years at public health facilities conditions from public health facilities
found that MCH service indicators did not Mexico and the United States are examples
deteriorate with the inclusion of refugees of countries with health systems that are
into the health system (255). Globally, more divided between the public and private
research is needed on the economic costs sectors. Although compulsory or voluntary
of including refugees and migrants in public prepaid insurance schemes are an important
health systems. component of health system financing in Chile,
in 2017 18% of migrants in Chile reported
4.6.3 Mixed or private health no health insurance coverage, a proportion
insurance coverage
A variety of factors affect access to public
insurance, most notably migratory status
and whether a person is recognized as a
refugee. Social health insurance is often
linked to employment status and therefore A variety of factors affect access to
individuals without the legal right to work
cannot access insurance. Populations in
public insurance, notably migratory
vulnerable situations, such as elderly migrants, status and whether a person is
may be excluded from health insurance, and recognized as a refugee.
lack of awareness about how to enrol can
be an obstacle for migrants of all ages. Chile,
220
more than four times higher than that of the host communities in Lebanon, accessed more
Chilean-born population (256). Evidence in by host communities than by Syrian refugees
Chile showed that migrants do not enjoy in Jordan, and accessed more by Syrian
sufficient public sector health coverage and refugees than by both host communities and
lack the opportunity to access private health IDPs in the Kurdistan region. Disparities were
coverage, mostly because of migratory status, also apparent between refugees living inside
employment status and lack of financial and outside of camps. In the Kurdistan region,
resources (257). Children born in the United Syrian refugees living outside of camps were
States to Mexican parents who then returned more likely to use private health care facilities
to Mexico were significantly more likely to be than those living in camps. In Jordan, camp
uninsured than Mexican-born children (39% residents were more likely to report receiving
versus 13%). Such children were also less likely external financial assistance, such as from
to be affiliated to any of the public schemes, the United Nations or NGOs, for medical
a disparity that decreased over time (258). visits than refugees living outside camps. This
Within the mixed health system of the United demonstrates that both public and private
States, some policy-makers have called for health care services are used by refugees
limits on access to public health coverage by and host populations, underscoring the vital
migrants, particularly to Medicaid. Irregular importance of integrating health services and
migrants in the United States were found to avoiding parallel systems.
have contributed US$ 2.2–3.8 billion more to
the Medicare Trust Fund than they withdrew
annually during 2000–2011, generating a total 4.7 Leadership and governance
surplus of US$ 35.1 billion (259).
Singapore requires employers of documented • A

cross the WHO regions, innovations in
migrant workers to provide health insurance service and financing show that health
for them under the Employment of Foreign systems can be made more inclusive and
effective for populations on the move.
Manpower Act and to cover health care costs
resulting from work-related injuries through • L evels of health coverage for refugees
the Work Injury Compensation Act (14). Despite and migrants vary among WHO regions.
these worker insurance schemes, gaps still In some, levels of coverage are similar
to those of the host population.
exist in access to health services among
Although data in several regions are
migrant workers. Some schemes cover only
scarce, they seem to indicate that equal
labour-related health costs, and various other access is not the norm.
perceived barriers discourage migrant workers
• A
number of solutions exist that could
from using insurance schemes (3).
strengthen health systems and help to
deliver UHC that includes refugees
A study in Jordan, the Kurdistan region of Iraq, and migrants.
and Lebanon found that Syrian refugees and
the host community (as well as IDPs in the
Kurdistan region) relied on both the public and
private sectors for health services, although Leadership and governance involve ensuring
with significant variation across the three that strategic policy frameworks exist and are
settings (260). Public health services were combined with effective oversight, coalition
accessed roughly equally by refugees and their building, the provision of appropriate
221
regulations and incentives, attention to system Similarly, but covering the wider field of
design, and accountability. Leadership and refugees and migrants, the IOM's Migration
governance at all levels of the health system Governance Framework provides a set of
play a critical role in enacting the political or Migration Governance Indicators (MGIs) to help
institutional changes necessary to improve the countries to assess the comprehensiveness
delivery of care to refugees and migrants. of their migration governance structures
(Box 4.5). The MGIs aim to offer insight on
4.7.1 Legal access and entitlement: policy measures and advance the conversation
national policies on migration governance by clarifying what
A critical issue is the right to access health well-governed migration might look like in the
services through legal entitlements. At national context of SDG Target 10.7 (facilitate orderly,
level, policies, plans and resource allocation safe, and responsible migration and mobility of
must meet the health needs of refugees people, including through the implementation
and migrants. Ideally, these would address of planned and well-managed migration
multisectoral needs that acknowledge the policies) (265).
determinants of health by involving sectors
such as employment, education, housing Using data from the Migrant Integration
and immigration. Subnationally, local Policy Index (MIPEX) Health Strand for 2015,
governments and community leaders have a 2018 report from the WHO European Region
key roles in service delivery across all sectors (266) showed significant variation in levels of
and in promoting the effective integration and entitlement to health services over 34 Member
well-being of refugees and migrants within States. Recent changes to these entitlements
communities (2). were largely associated with a change of
government. MIPEX 2020 reported increased
Literature on access to and the use of health involvement of migrants in information
services by refugees and migrants is often provision and health service design and
limited or inconsistent in most WHO regions. delivery in some countries in the region (267).
Tracking access to and use by refugees and Box 4.6 summarizes the MIPEX findings for the
migrants is particularly challenging in highly WHO European Region; this level of aggregated
fragmented public and private health systems. regional data on refugee and migrant
However, several initiatives have been set up entitlement to health services is not available
to collect data on the migration policies of for other WHO regions (268).
countries, including the UNHCR Public Health
Services Survey, which examines the inclusion In 2020, Ireland carried out a COVID-19
of refugees within national health services, assessment from a migration governance
policies and financing. The 2020 survey perspective, for which the MGI team developed
collected data on a wide range of issues, such a set of questions specific to COVID-19 to be
as the inclusion of refugees in national health added to standard MGI assessments. The
plans, plans for nutrition and WASH, and resultant report revealed that all migrants have
the financing of and access to public health access to all government-funded health services
services. Of the 47 countries (out of the 48 under the same conditions as nationals,
included in the survey) that have a national including migrants in irregular situations.
health policy or plan, 29 reported that refugees This includes access to COVID-19-related
were included in their policy or plan and one health services, such as testing, treatment
reported that coverage was only partial (261). and vaccinations, with access to vaccinations
222
Box 4.5.
Assessing migration health policies using the Migration Governance Indicators
The International Organization for Migration (IOM) developed its Migration Governance Framework in
2015, accompanied by a set of 94 Migration Governance Indicators (MGIs) (262).
The MGIs are divided into six domains: the rights of migrants; whole-of-government approach; partnerships;
well-being of migrants; mobility dimensions of crises; and safe, orderly and dignified migration. The first
assesses the adherence of countries to international standards and fulfilment of the rights of migrants,
using indicators related to access to certain social services by refugees and migrants, particularly whether all
migrants have the same status as citizens in accessing government-funded health services.
Data collected in 84 countries between 2018 and 2021 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 (Fig. 4.6). In just over one third of the countries, access depends on
migratory status; in 8% of countries, migrants have access only to emergency health care services; and
in 5% of countries they have no access to any government-funded health services (263).
Also assessed is the extent to which in a non-discriminatory manner migrants can access social
security, equal pay, unemployment benefits, old-age pension, invalidity benefits, maternity leave, family
benefits and social assistance. In 32% of the countries, all migrants have access to social protection.
In comparison, in 38% of countries, social protection is available for long-term residents and residents
on family reunion permits or for certain categories of residents on temporary work permits. In 12% of
countries, social protection is available only for long-term residents, while in 18% no migrants have
access to social protection (IOM, unpublished data, 2022).
In addition to these aggregate data, country examples of MGI data can highlight the connection between
migration governance and health issues, including in the context of COVID-19. In Cambodia, the MGI
process influenced the development of a new migration health policy, making clear how important it is for
all refugees and migrants to access essential health care. The policy addresses the well-being of migrants and
their rights in accessing health care services (264).
Fig. 4.6. Do refugees and migrants have the same status as citizens in accessing government health services?
Information from 84 countries, 2018–2021
60
50
50
37
% of countries
40
30
20
8
10 5
0
Access to all services Access to all services Access to emergency No access to any
regardless of migration status dependent on migration status health care services only health care services
Source: IOM, unpublished data.

223
Box 4.6.
Measuring health policies and the integration of migrants
The Migrant Integration Policy Index (MIPEX) has measured the level of integration of refugees and migrants within
policies in countries across six continents since 2004. Its research covers eight policy areas of integration: labour
market mobility, family reunification, education, political participation, permanent residence, access to nationality,
antidiscrimination protections and health (268).
The 2020 edition (268) noted that:

[t]he inclusion of migrants into the health system of destination countries is coming to be seen as an essential component of
their integration… How governments treat refugees and migrants strongly influences how well refugees and migrants feel both
in terms of their mental and physical health. Under inclusive integration policies, refugees and migrants and host populations
end up with similar health outcomes in terms of their reported health, chronic illnesses, elderly diabetes and frailty and, even,
mortality. Under restrictive policies, refugees and migrants are much more likely than the host population to suffer from these
poor health outcomes. For refugees' and migrants' health, a country's overall approach to integration seems more determinant
than any specific area of integration policy.
Key findings on access to health care have been published on the following topics.
Entitlements. (i) For migrants with valid residence permit/visa, conditions vary significantly across countries: in
some countries, legal residents may have unconditional entitlements but be limited only to emergency care, while
in others they have conditional access to the same range of services as for national citizens. Beyond these legal
conditions, 27 MIPEX countries present no administrative barriers to migrants with a valid residence permit or visa (the
corresponding figures for asylum seekers and irregular migrants are 15 and 2, respectively). (ii) For asylum seekers,
conditions of coverage may include remaining in an assigned location or having inadequate financial resources. As
per MIPEX data, Germany imposes the condition that entitlement to more than emergency care is granted only to
asylum seekers or refugees who have been in the country for longer than 15 months. Only 15 countries impose no
administrative barriers for asylum seekers. (iii) Irregular migrants face the greatest legal and administrative barriers
to obtaining coverage. Although not all aspects of their entitlements were measured in 2019, there are few signs that
these have improved since 2015. Only two countries – Chile and Switzerland – do not impose any administrative
barriers for irregular migrants. Where coverage for this group is limited to emergency care, a barrier always exists in the
form of a discretionary judgement about whether the health problem constitutes an emergency.
Accessibility of health services. Refugees and migrants are regularly reached with targeted information about
entitlements and use of health services in only 19 of the 56 MIPEX countries. In 23 countries, all three groups are
regularly reached with targeted information about health education and health promotion.
Responsive services. Qualified interpretation services for patients with inadequate proficiency in the official language
(or languages) are provided free of charge in 19 countries, but are not available in 20 countries. In the other 17 countries,
interpretation can be arranged, but the individual using the service must pay for it. In 31 countries, migrant patients
and communities are involved to some extent in designing and providing health information and services; community
involvement is greatest in Australia, Austria, Czechia, Ireland, New Zealand, Spain and the United Kingdom.
Policies to promote change. Most countries (44/56) have funding bodies that have supported refugee and
migrant health research in the last 5 years. The most extensive support is found in western European and traditional
destination countries. Comprehensive policies to include refugees and migrants within health care services have
emerged in Australia, Ireland, Norway, Sweden, the United Arab Emirates, the United Kingdom and the United States,
whereas in 33 countries the health system does not systematically address migrant or ethnic minority health issues.
224
supported by the translation of resources into or curative care (272). However, as discussed
several languages (269). in section 4.2, there exist barriers to accessing
care for refugees and migrants, even when
The United Kingdom has unconditional they are entitled to receive such care.
inclusion in health services for asylum seekers.
Since 2017, many services have been free to Entitlement to health services for migrant
all migrants, including sexual health, family children (including UASC) is also well
planning, primary health care, emergency documented in the WHO European Region.
departments and walk-in centres, and the The report of the European Commission
treatment of mental and physical conditions (273) compared the entitlements of migrant
caused by torture, FGM, and domestic children with those of children from the host
or sexual violence (270,271). By law, Italy population and compared entitlements across
guarantees health care to all migrants with or the different categories of migrant children.
without regular status, and irregular migrants In 20 countries, child asylum seekers are
are entitled to urgent and essential preventive entitled to the same level of care as children
A South Sudanese refugee and community leader lives in an "open area" settlement on the outskirts of Khartoum. The cost of transport
to the nearest hospital means that, despite the fact that refugees are entitled to equal access to health services in Sudan, health is out of
reach for many in his camp. Transport to the nearest cemetery is also prohibitively expensive. "We can't even afford to bury our dead," he
said. © WHO / Lindsay Mackenzie
225
from the host population. They are enrolled health of migrants in Chile (278), based on a
in the national health system, which includes series of community dialogues undertaken
emergency, primary and secondary health during the drafting process. In another
services. However, in a few countries, such example of inclusive policy in the Region,
as Germany and Slovakia, entitlements are Costa Rica developed a framework for the
restricted compared with those of nationals. right to health of migrants, guaranteed by the
The document also reported entitlements Ministry of Health (279). In Peru, Secretarial
for children of irregular migrants (and Resolution No. 266-2020 established the
the migrants themselves) and compared Functional Health Unit for Migrant and Border
them with those of children from the host Populations, attached for oversight to the
population. In 11 countries, children of Vice-Ministerial Office of Public Health (280).
irregular migrants are generally entitled by law
to the same health services as children from In the United States, health system policy
the host population, with some differences reforms have been adopted on a state-by-
in the level of specific entitlements. In 15 state basis to expand public health coverage
countries (Austria, Bulgaria, Czechia, Finland, (Medicaid) for citizens and non-citizens
Germany, Hungary, Ireland, Latvia, Lithuania, (those deemed lawfully present and children
Luxembourg, the Netherlands, Poland, of irregular migrant parents). The results in
Slovakia, Slovenia and the United Kingdom), states that have expanded coverage have been
entitlements for children of irregular migrants positive, with increased access to health care
are more restricted than those of national observed among racial and ethnic minorities
children. In most of these countries, anything (281). However, the policy reforms do not
beyond emergency care is available only at full include irregular migrants. A 2020 cross-
cost. In a different report, a longitudinal cohort sectional study found that 47.1% of irregular
study of children and adolescent refugees migrants in the United States were uninsured,
in Germany showed that unaccompanied or a proportion three times higher than that
separated children had a greater need for PHC of documented migrants and eight times
services than other refugee children (274). higher than that of the host population (282).
In the WHO Region of the Americas, levels According to another study, migrant children
of health coverage are generally lower for in the United States had lower levels of
refugees and migrants than for the host health insurance coverage than non-migrant
population. This is especially true for children (283).
more recently arrived migrants, irregular
migrants and those in transit (275,276). In However, the governance mechanisms
Chile, however, health coverage for various needed to ensure that policies and
vulnerable migrant groups has steadily frameworks lead to full or greater access to
expanded in recent decades. This began health care are not always in place. In Canada,
with providing prenatal care for irregular for example, the Interim Federal Health
migrants, followed by emergency care for Program provides temporary limited benefits
labour migrants and their families (277). In to specific groups not covered by provincial,
2016, a landmark decree provided coverage territorial or private health services. However,
for irregular migrants by the public health in practice, access to health for asylum seekers
insurance system (257). Chile launched the is subject to political discretion; claimants
International Migrant Health Policy in 2018 to from a country deemed safe by the
provide strategic guidelines to promote the government may have restricted access (284).
226
In addition to general guarantees of health including migrants in its UHC system, but
services for the migrant population in it still faces issues of low utilization and
Colombia, the government issued a specific inadequate financing (242). Most literature
decree in 2018 guaranteeing access to published on refugees within the Region
health services for both documented and involves Rohingya refugees in Bangladesh.
irregular Venezuelan refugees and migrants Although government, international and
(285). However, in another example of policy national organizations have supported
not being converted to practice, restrictive and coordinated health service provision
migration policies hinder the ability of to Rohingya refugees, the health situation
irregular migrants to access health care in Rohingya refugee camps remains
services in Colombia (286). suboptimal: service delivery is poor,
mainly because of a lack of resources and
In the WHO Western Pacific Region, countries inadequate health facilities; accessing
with a high proportion of migrants, including health services and essential medicines is
Australia, New Zealand, the Republic of Korea difficult because of a lack of finances, low
and Singapore, have implemented systems levels of health literacy and sociocultural
and laws to grant refugees and migrants barriers; and the refugees experience poor-
access to national health systems. For quality overall living conditions (289).
example, the Republic of Korea's Employment
Permit System provides universal national Evidence is similarly limited in the WHO African
health insurance and industrial accident Region, although the need for health services
compensation to migrant workers (287,288). In and facilities in refugee and humanitarian
Singapore, the Work Injury Compensation Act contexts is clear. A study from Rwanda
and the Employment of Foreign Manpower reported that refugee access to palliative care
Act are two policies that facilitate access to services was extremely limited in this refugee-
health care for migrant workers. The former hosting country, and research on refugee
requires employees to cover health care camps in South Sudan has highlighted the
costs for injuries sustained during work, need for the integration of comprehensive
while the latter mandates employers of low- neonatal interventions within national policies
wage migrant workers with a Work Permit (290,291). A policy review of documents
or S Pass to cover the costs of their medical addressing access to health care services
treatment (14). The Seasonal Workers Program for refugees in South Africa found policies
in Australia and New Zealand's Recognised to be contradictory or not implemented,
Seasonal Employer scheme are required to or to contain ambiguous language. Only
provide seasonal migrant workers with health 5 of 12 reviewed policy documents outlining
insurance (60). The New Zealand scheme has services for refugees were found to have been
recently expanded coverage to provide a more implemented and were in operation (292).
comprehensive insurance option for workers,
offering wide-ranging medical treatments. 4.7.2 Refugee-hosting contexts
Leadership and governance should ensure
In the WHO South-East Asia Region, that the inclusion both of the ideals of the
information about access to health services UNHCR Comprehensive Refugee Response
for refugees and migrants is limited. Thailand Framework (293) and of refugee needs in
is one of the few countries in the Region national policies lead to improvements
to make significant progress towards in health services and health outcomes.
227
Although Uganda has an integrated refugee 4.7.3 Regional leadership

policy that includes refugees in public health and strategies
interventions, ethnographic research in There exist many examples of regional
western Uganda highlighted that, in reality, strategies and frameworks designed to
implementation of these interventions improve access to inclusive health services
inadvertently resulted in excluding refugees by refugees and migrants.
from programming and disease surveillance,
in this case around African sleeping sickness Two publications for sub-Saharan African
(human African trypanosomiasis) (294). countries indicated the need to develop
Some of the implementation challenges migration-aware governance responses to
leading to the exclusion of refugees were HIV (300,301). Focus areas for future research
donor pressure to reduce the scope of the and intervention on HIV and migration in the
programme, challenges in building local subregion include recognition of population
supervision capacity, barriers to using rapid movements related to improved livelihoods,
diagnostic tests, and high staff turnover. urbanization and conflict, and access to
Additionally, studies in South Africa treatment and care. In addition, they recognized
documented the importance of multisectoral the need to build the governance and capacity
and multilevel (including local) approaches of health systems to respond to both HIV and
for delivering coordinated responses to migration with standardized, multisectoral and
refugee and migrant health (295,296). evidence-informed approaches.
The current war in Syria and subsequent At subregional level, the ministries of health
refugee crisis have provided important of six Andean countries – Plurinational State
insights into the international support of Bolivia, Chile, Colombia, Ecuador, Peru
required for greater inclusion of refugees and the Bolivarian Republic of Venezuela –
in the health systems of refugee-hosting established the Andean health plan for migrants
countries. Such support includes governance 2019–2022, which aims to ensure good-quality
mechanisms to ensure that international aid and coordinated health services for migrants
translates into inclusive policies and that who transit through those countries (302). The
the policies themselves lead to increased Central American Integration System of 2019 –
access to health services for refugees (297). which includes Belize, Costa Rica, Dominican
Republic, El Salvador, Guatemala, Honduras,
In February 2019, the Ethiopian Government Nicaragua and Panama – provides strategic
approved a new Refugees Proclamation (No. guidelines for comprehensive health care
1110/2019) that provides access to health and public health surveillance for migrants in
services for refugees and asylum seekers transit, returnees and fragmented families in
(298). In addition, the Federal Ministry of the subregion (303). Many similar examples of
Health in Ethiopia signed a memorandum regional strategies exist, although evaluations
of understanding with the Administration of the effectiveness of these regional efforts are
for Refugee and Returnee Affairs, UNHCR not well documented.
and UNICEF to ensure that all refugees
and migrants have the right to basic health In the WHO South-East Asia Region, the Safe
services and to be treated in the same way and Fair programme (2018–2022) supported
as members of the host community (299). by the United Nations Entity for Gender
Equality and Empowerment of Women and
228
the ILO has been implemented, representing preparedness and response, strengthening
a partnership between several countries health systems and their resilience, preventing
with large numbers of citizens migrating for communicable and noncommunicable
work, namely Cambodia, the Lao People's diseases, ensuring ethical and effective health
Democratic Republic, Malaysia, the Philippines screening and assessment, and improving
and Viet Nam. The initiative aims to ensure health information and communication
that the rights of migrants are enforced and to systems (206). Developed in response to the
end violence against female migrant workers in 2030 Agenda for Sustainable Development
particular (304). (205), this strategy and action plan also
includes clear considerations for follow-up and
The Strategy and action plan for refugee and monitoring of its implementation (206,266).
migrant health in the WHO European Region
and subsequent progress reports provide a The most recent example of responsive
framework for collaborative regional action, leadership in the WHO Eastern Mediterranean
focusing on, as priorities, advocating for Region is the inclusion of refugees and
the right to health, addressing the social migrants in the COVID-19 vaccination scheme
determinants of health, achieving public health in Jordan (Box 4.7).
Box 4.7.
Leadership by example: Jordan includes refugees and migrants in COVID-19 vaccination
In mid-January 2021, at a public health clinic in the town of Irbid, Jordan became one of the first
countries in the world to offer COVID-19 vaccinations to refugees and migrants (305). This initiative – at
a time when 313 557 cases and 4137 deaths attributed to the disease had been reported in the country
(306) – was a striking example of leadership in providing equitable access to health care regardless of
migratory status and of decisive action in the face of a health crisis (307).
At the onset of the COVID-19 pandemic, and with the support of WHO, the Jordanian Ministry of Health
rapidly produced the National COVID-19 Preparedness and Response Plan (308). The Plan emphasized
a whole-of-society approach, with beneficiaries including Jordanians and non-Jordanians residing in
both host communities and refugee camps. This was followed in December 2020 by the multisectoral
COVID-19 National Deployment and Vaccination Plan (308), which was designed to extend free-of-charge,
equitable access to all individuals in Jordan.
The challenge facing Jordan was a daunting one. Approximately two fifths of Jordan's resident
population are migrants (309); in 2021, the Office of the United Nations High Commissioner for Refugees
had registered a total of 658 000 Syrian refugees in the country (310). According to the United Nations
Relief and Works Agency for Palestine Refugees in the Near East, more than 2 million registered refugees,
including those recently displaced from the Syrian Arab Republic as well as the majority who have lived
there for decades (311), reside in Jordan, which also hosts tens of thousands of refugees from other
countries such as Iraq, Sudan and Yemen (310).
229
In the WHO Western Pacific Region, many and migrants, especially upon arrival in their
frameworks have made advances towards host countries or in border areas, while their
achieving both UHC and the SDGs, taking immunization rates have often been found to
into consideration disadvantaged groups be lower than those of host communities.
such as refugees and migrants. Examples
of such frameworks include the Regional The collection and processing of accurate
action agenda on achieving the Sustainable and relevant health information is essential
Development Goals in the Western Pacific for delivering high-quality health services to
(312), the Regional framework for urban health refugees and migrants. However, the literature
in the Western Pacific 2016–2020 (313), the indicates widespread gaps in HIS, including the
Western Pacific regional framework for action absence of epidemiological data (both from
for disaster risk management for health (314) general surveillance and from arrival or border
and Universal health coverage: moving towards screening), a lack of standardization of data
better health – action framework for the within countries and regions, comparability
Western Pacific Region (315). issues across locations or time of data
collection, and an inability to disaggregate
data by migratory status.
4.8 Summary
Direct and indirect health costs are major
There are major and widespread gaps in the barriers to accessing health care across
six building blocks covered in this chapter, but regions, and refugees and migrants often
solutions do exist that can help to deliver UHC cannot afford the out-of-pocket costs. As
that includes refugees and migrants. a result, they tend to spend less overall on
health services than host populations. Some
Refugees and migrants may face many of the studies, however, show that it costs more to
same barriers to accessing health services exclude refugees and migrants from health
as the local population, including cost, coverage than to include them, an area that
proximity and general gaps in health systems. requires more research.
However, they also face barriers specific to
their migratory status, such as out-of-pocket Finally, leadership and governance play an
expenses or limited recognition of their status. essential role by providing the necessary policy
frameworks and adjusting them as required to
When refugees and migrants do access health deliver health care to refugees and migrants.
services, they may face a workforce that is
insufficiently trained to deliver health services
that are sensitive to refugee and migrant
health; efforts to strengthen these capacities
are now under way across every WHO region.
Refugees and migrants often have limited

access to essential medication and may
resort to self-medication or the use of non-
prescribed medicines, such as antibiotics,
resulting in possible antimicrobial resistance.
Vaccination coverage varies widely for refugees
230
References 10. Jemutai J, Muraya K, Che PC, Mulupi S. A situation analysis

of access to refugee health services in Kenya: gaps and
recommendations: a literature review. York: Centre for Health
Economics; 2021 (CHE Research Paper no. 178; https://www.
york.ac.uk/media/che/documents/papers/researchpapers/
1. Legido-Quigley H, Pocock N, Tan ST, Pajin L, Suphanchaimat CHERP178_refugee_health_services_kenya.pdf, accessed
R, Wickramage K et al. Healthcare is not universal if 7 April 2022).
undocumented migrants are excluded. BMJ. 2019;366:14160.
11. Hunter-Adams J, Rother H-A. A qualitative study of language
doi:10.1136/bmj.14160.
barriers between South African health care providers and
2. Health of migrants: the way forward: report of a global cross-border migrants. BMC Health Serv Res. 2017;17(1):97.
consultation, Madrid, Spain, 3–5 March 2010. Geneva: World doi:10.1186/s12913-017-2042-5.
Health Organization; 2011:3–5 (https://apps.who.int/iris/
12. Zihindula G, Meyer-Weitz A, Akintola O. Lived experiences
of Democratic Republic of Congo refugees facing medical
3. Rajaraman N, Yip TW, Kuan BYH, Lim JFY. Exclusion of migrant xenophobia in Durban, South Africa. J Asian Afr Stud.
workers from national UHC systems: perspectives from 2015;52(4):458–70. doi:10.1177/0021909615595990.
HealthServe, a non-profit organisation in Singapore. Asian
13. Takbiri A, Takian A, Foroushani AR, Jaafaripooyan E. The
Bioeth Rev. 2020;12(3):363–74. doi:10.1007/s41649-020-
challenges of providing primary health care to Afghan
00138-y.
immigrants in Tehran: a key global human right issue. Int
4. Bozorgmehr K, Biddle L, Rohleder S, Puthoopparambil SJ, J Hum Rights Healthc. 2020;13(3):259–73. doi:10.1108/
Jahn R. What is the evidence on availability and integration IJHRH-06-2019-0042.
of refugee and migrant health data in health information
14. Ang JW, Koh CJ, Chua BW, Narayanaswamy S, Wijaya L, Chan
systems in the WHO European Region? Copenhagen:
LG et al. Are migrant workers in Singapore receiving adequate
WHO Regional Office for Europe; 2019 (Health Evidence
healthcare? A survey of doctors working in public tertiary
Network Synthesis report no. 66; https://apps.who.int/iris/
healthcare institutions. Singapore Med J. 2020;61(10):540–7.
doi:10.11622/smedj.2019101.
5. Chekero T, Ross FC. “On paper” and “having papers”:
15. Inci MG, Kutschke N, Nasser S, Alavi S, Abels I, Kurmeyer C et
Zimbabwean migrant women’s experiences in accessing
al. Unmet family planning needs among female refugees and
healthcare in Giyani, Limpopo province, South Africa.
asylum seekers in Germany - is free access to family planning
Anthropol South Afr. 2018;41(1):41–54. doi:10.1080/23323256.
services enough? Results of a cross-sectional study. Reprod
2018.1442729.
Health. 2020;17(1):115. doi:10.1186/s12978-020-00962-3.
6. Pérez-Urdiales I, Goicolea I, San Sebastián M, Irazusta
16. Jeffries R, Abdi H, Ali M, Bhuiyan ATMRH, El Shazly M, Harlass
A, Linander I. Sub-Saharan African immigrant women’s
S et al. The health response to the Rohingya refugee crisis
experiences of (lack of) access to appropriate healthcare in
post August 2017: reflections from two years of health
the public health system in the Basque Country, Spain. Int J
sector coordination in Cox’s Bazar, Bangladesh. PLOS One.
Equity Health. 2019;18(1):59. doi:10.1186/s12939-019-0958-6.
7. Barghadouch A, Norredam M. Psychosocial responses to
17. Nathenson RA, Saloner B, Richards MR, Rhodes KV. Spanish-
healthcare: a study on asylum-seeking families’ experiences
speaking immigrants’ access to safety net providers and
in Denmark. J Immigr Minor Health. 2022;24(2):551–5.
translation services across traditional and emerging US
doi:10.1007/s10903-021-01183-x.
destinations. Milbank Q. 2016;94(4):768–99. doi:10.1111/1468-
8. McNatt ZZ, Freels PE, Chandler H, Fawad M, Qarmout S, Al- 0009.12231.
Oraibi AS et al. “What’s happening in Syria even affects the
18. McGarry O, Hannigan A, De Almeida MM, Severoni S,
rocks”: a qualitative study of the Syrian refugee experience
Puthoopparambil J, MacFarlane A. What strategies to
accessing noncommunicable disease services in Jordan.
address communication barriers for refugees and migrants in
Confl Health. 2019;13(1):26. doi:10.1186/s13031-019-0209-x.
health care settings have been implemented and evaluated
9. Qiu J, Song D, Nie J, Su M, Hao C, Gu J et al. Utilization of across the WHO European Region? Copenhagen: WHO
healthcare services among Chinese migrants in Kenya: a Regional Office for Europe; 2018 (https://apps.who.int/iris/
qualitative study. BMC Health Serv Res. 2019;19(1):995. handle/10665/326238, accessed 7 April 2022).
doi:10.1186/s12913-019-4846-y.
19. Yelland J, Riggs E, Szwarc J, Casey S, Duell-Piening P,
Chesters D et al. Compromised communication: a qualitative
study exploring Afghan families and health professionals’
experience of interpreting support in Australian maternity
care. BMJ Qual Saf. 2016;25(4):e1–e1. doi:10.1136/
bmjqs-2014-003837.
231
20. Sampson AK, Hassani-Mahmooei B, Collie A. Lack of English 31. Chynoweth SK, Buscher D, Martin S, Zwi AB. A social
proficiency is associated with the characteristics of work- ecological approach to understanding service utilization
related injury and recovery cost in the Victorian working barriers among male survivors of sexual violence in three
population. Work. 2020;67(3):741–52. doi:10.3233/ refugee settings: a qualitative exploratory study. Confl Health.
WOR-203323. 2020;14(1):43. doi:10.1186/s13031-020-00288-8.
21. Shakya P, Tanaka M, Shibanuma A, Jimba M. Nepalese 32. Tol WA, Augustinavicius J, Carswell K, Brown FL, Adaku A, Leku
migrants in Japan: what is holding them back in getting MR et al. Translation, adaptation, and pilot of a guided self-
access to healthcare? PLOS One. 2018;13(9):e0203645. help intervention to reduce psychological distress in South
doi:10.1371/journal.pone.0203645. Sudanese refugees in Uganda. Glob Ment Health. 2018;5:e25.
doi:10.1017/gmh.2018.14.
22. Adhikary P, Aryal N, Dhungana RR, Kc RK, Regmi PR,
Wickramage KP et al. Accessing health services in India: 33. Yassin N, Taha AA, Ghantous Z, Atoui MM, Forgione F.
experiences of seasonal migrants returning to Nepal. BMC Evaluating a mental health program for Palestinian refugees
Health Serv Res. 2020;20(1):992. doi:10.1186/s12913-020- in Lebanon. J Immigr Minor Health. 2018;20(2):388–98.
05846-7. doi:10.1007/s10903-017-0657-6.
23. Jaeger FN, Pellaud N, Laville B, Klauser P. The migration- 34. Akhtar A, Engels M, Bawaneh A, Bird M, Bryant R, Cuijpers P et
related language barrier and professional interpreter use in al. Cultural adaptation of a low-intensity group psychological
primary health care in Switzerland. BMC Health Serv Res. intervention for Syrian refugees. Intervention. 2021;19(1):48–
2019;19(1):429. doi:10.1186/s12913-019-4164-4. 57. doi:10.4103/INTV.INTV_38_20.
24. The risks that refugees with disabilities face in Turkey: how to 35. Noubani A, Diaconu K, Ghandour L, El Koussa M, Loffreda G,
mitigate risks and challenges to shape an apt humanitarian Saleh S. A community-based system dynamics approach for
response. York: Euro-Mediterranean for Human Rights understanding factors affecting mental health and health
Monitor, York University; 2020 (https://euromedmonitor.org/ seeking behaviors in Beirut and Beqaa regions of Lebanon.
uploads/reports/pwden.pdf, accessed 7 April 2022). Glob Health. 2020;16(1):28. doi:10.1186/s12992-020-00556-5.
25. Tanabe M, Pearce E, Krause SK. “Nothing about us, without 36. Kesornsri S, Sitthimongkol Y, Punpuing S, Vongsirimas N,
us”: conducting participatory action research among and with Hegadoren KH. Mental health and related factors among
persons with disabilities in humanitarian settings. Action Res. migrants from Myanmar in Thailand. J Popul Soc Stud. 2019
2018;16(3):280–98. doi:10.1177/1476750316685878. Mar 28;27(2):124–38. doi:10.25133/JPSSv27n2.008.
26. Khuu BP, Lee HY, Zhou AQ, Shin J, Lee RM. Healthcare 37. Radi S. Hospital interactions in Morocco: access to health
providers’ perspectives on parental health literacy and care policies from a patient perspective. Mondes Dev.
child health outcomes among Southeast Asian American 2019;187(3):71–84. doi:10.3917/med.187.0071.
immigrants and refugees. Child Youth Serv Rev. 2016;67:220–
38. Llanes-García YE, Ghys T. Barriers to access healthcare for
9. doi:10.1016/j.childyouth.2016.06.006.
Middle American migrants during transit in Mexico. Política
27. Forney-Gorman A, Kozhimannil KB. Differences in cervical Glob Ciudad. 2021;7(13):182–204. doi:10.29105/10.29105/
cancer screening between African-American versus African- pgc7.13-7.
born black women in the United States. J Immigr Minor
39. Borrell C, Palència L, Bartoll X, Ikram U, Malmusi D. Perceived
Health. 2016;18(6):1371–7. doi:10.1007/s10903-015-0267-0.
discrimination and health among immigrants in Europe
28. Lugova H, Samad N, Haque M. Sexual and gender-based according to national integration policies. Int J Environ
violence among refugees and internally displaced persons in Res Public Health. 2015;12(9):10687–99. doi:10.3390/
the Democratic Republic of the Congo: post-conflict scenario. ijerph120910687.
Risk Manag Healthc Policy. 2020;13:2937–48. doi:10.2147/
40. Guruge S, Sidani S, Illesinghe V, Younes R, Bukhari H,
RMHP.S283698.
Altenberg J et al. Healthcare needs and health service
29. Lilleston P, Winograd L, Ahmed S, Prime DS, Alam DA, utilization by Syrian refugee women in Toronto. Confl Health.
Stoebenau K et al. Evaluation of a mobile approach to gender- 2018;12(1):46. doi:10.1186/s13031-018-0181-x.
based violence service delivery among Syrian refugees in
41. Torres CA, Thorn BE, Kapoor S, DeMonte C. An examination
Lebanon. Health Policy Plan. 2018;33(7):767–76. doi:10.1093/
of cultural values and pain management in foreign-born
heapol/czy050.
Spanish-speaking Hispanics seeking care at a federally
30. Gausman J, Othman A, Dababneh A, Dabobe M, Hamad I, qualified health center. Pain Med. 2017;18(11):2058–69.
Daas I et al. A social-ecological examination into the research, doi:10.1093/pm/pnw315.
policy and health service delivery environment related to
early marriage and sexual and gender-based violence among
youth in Jordan. BMC Int Health Hum Rights. 2020;20(1):16.
doi:10.1186/s12914-020-00234-y.
232
42. Arrieta JDR. Banca, salud y estímulo del empleo: servicios 53. Kalengayi FNK, Hurtig A-K, Ahlm C, Krantz I. Fear of
públicos desde la óptica de los refugiados y solicitantes en deportation may limit legal immigrants’ access to HIV/AIDS-
Costa Rica [Banking, health and employment stimulus: public related care: a survey of Swedish language school students in
services from the perspective of refugees and asylum seekers northern Sweden. J Immigr Minor Health. 2012;14(1):39–47.
in Costa Rica]. Rev Cienc Soc. 2017;155:111–29 (in Spanish). doi:10.1007/s10903-011-9509-y.
doi:10.15517/RCS.V0I155.30258.
54. Mikhaylova YuV, Nechaeva OB, Shikina IB, Sorokin VN.
43. Gurrola MA, Ayón C. Immigration policies and social Influence of migration factor on TB and HIV epidemic
determinants of health: is immigrants’ health at risk? Race Soc situation in Russia. Social Asp Popul Health. 2018;(62):4.
Probl. 2018;10(3):209–20. doi:10.1007/s12552-018-9239-z. doi:10.21045/2071-5021-2018-62-4-4.
44. Dzúrová D, Winkler P, Drbohlav D. Immigrants’ access to 55. Kiyutin v. Russia, 2700/10. Strasbourg: European Court
health insurance: no equality without awareness. Int J of Human Rights; 2011 (https://hudoc.echr.coe.int/
Environ Res Public Health. 2014;11(7):7144–53. doi:10.3390/ Eng#{%22itemid%22:[%22001-103904%22]}, accessed
ijerph110707144. 16 April 2022).
45. Faturiyele I, Karletsos D, Ntene-Sealiete K, Musekiwa A, Khabo 56. Kashnitsky D, Richter JM. ‘In short, we will deport you’:
M, Mariti M et al. Access to HIV care and treatment for migrants disrupted temporalities of migrants with HIV in Russia. Glob
between Lesotho and South Africa: a mixed methods study. Public Health. 2021;11:1–13. doi:10.1080/17441692.
BMC Public Health. 2018;18(1):668. doi:10.1186/s12889-018- 2021.2002923.
5594-3.
57. Deported, denied access, discriminated against because of
46. Lohiniva AL, Mokhtar A, Azer A, Elmoghazy E, Kamal E, their HIV status. Geneva: Joint United Nations Programme
Benkirane M et al. Qualitative interviews with non-national on HIV/AIDS; 2019 (https://www.unaids.org/en/resources/
tuberculosis patients in Cairo, Egypt: understanding the presscentre/featurestories/2019/june/20190627_deported,
financial and social cost of treatment adherence. Health Soc accessed 7 April 2022).
Care Community. 2016;24(6):e164–72. doi:10.1111/hsc.12280.
58. UNAIDS and UNDP call on 48 countries and territories
47. Fernandez B. Health inequities faced by Ethiopian migrant to remove all HIV-related travel restrictions. Geneva:
domestic workers in Lebanon. Health Place. 2018;50:154–61. Joint United Nations Programme on HIV/AIDS; 2019
doi:10.1016/j.healthplace.2018.01.008. (https://www.unaids.org/en/resources/presscentre/
pressreleaseandstatementarchive/2019/june/20190627_hiv-
48. Rivenbark JG, Ichou M. Discrimination in healthcare as
related-travel-restrictions, accessed 7 April 2022).
a barrier to care: experiences of socially disadvantaged
populations in France from a nationally representative survey. 59. Malmusi D. Immigrants’ health and health inequality by type
BMC Public Health. 2020;20(1):31. doi:10.1186/s12889-019- of integration policies in European countries. Eur J Public
8124-z. Health. 2015;25(2):293–9. doi:10.1093/eurpub/cku156.
49. Yarnell CJ, Fu L, Bonares MJ, Nayfeh A, Fowler RA. Association 60. Bailey R. Health care management in Australia’s and New
between Chinese or South Asian ethnicity and end-of-life care Zealand’s seasonal worker schemes. Canberra: Department
in Ontario, Canada. CMAJ. 2020;192(11):E266–74. doi:10.1503/ of Pacific Affairs (Working Paper 2020/2; https://dpa.
cmaj.190655. bellschool.anu.edu.au/sites/default/files/publications/
attachments/2020-03/dpa_working_paper_2020_2_bailey_
50. Mohammadi S, Gargari SS, Fallahian M, Källestål C, Ziaei
final.pdf, accessed 7 April 2022).
S, Essén B. Afghan migrants face more suboptimal care
than natives: a maternal near-miss audit study at university 61. Maneesh P, Divyarani R, Remya S, Nisha P, Vilvijayan C,
hospitals in Tehran, Iran. BMC Pregnancy Childbirth. Dhinakaran D. Barriers to healthcare for Sri Lankan Tamil
2017;17(1):64. doi:10.1186/s12884-017-1239-2. refugees in Tamil Nadu, India. Turk J Comput Math Educ.
2021;12:4075–83 (https://www.turcomat.org/index.php/
51. Yu M, Kelley AT, Morgan AU, Duong A, Mahajan A, Gipson JD.
turkbilmat/article/download/8213/6416/14730, accessed
Challenges for adult undocumented immigrants in accessing
7 April 2022).
primary care: a qualitative study of health care workers in Los
Angeles County. Health Equity. 2020;4(1):366–74. doi:10.1089/ 62. Riley A, Varner A, Ventevogel P, Hasan MMT, Welton-
heq.2020.0036. Mitchell C. Daily stressors, trauma exposure, and
mental health among stateless Rohingya refugees in
52. Müllerschön J, Koschollek C, Santos-Hövener C, Kuehne A,
Bangladesh. Transcult Psychiatry. 2017;54(3):304–31.
Müller-Nordhorn J, Bremer V. Impact of health insurance
doi:10.1177/1363461517705571.
status among migrants from sub-Saharan Africa on access to
health care and HIV testing in Germany: a participatory cross-
sectional survey. BMC Int Health Hum Rights. 2019;19(1):10.
doi:10.1186/s12914-019-0189-3.
233
63. Tarannum S, Elshazly M, Harlass S, Ventevogel P. Integrating 74. Choi YJ, Orpinas P, Kim I, Ko KS. Korean clergy for healthy
mental health into primary health care in Rohingya refugee families: online intervention for preventing intimate
settings in Bangladesh: experiences of UNHCR. Intervention. partner violence. Glob Health Promot. 2019;26(4):25–32.
2019;17(2):130–9. doi:10.4103/INTV_INTV_34_19. doi:10.1177/1757975917747878.
64. Alghadir AH, Zafar H, Iqbal ZA. Experiences of overseas trained 75. Lee H, Ghebre R, Le C, Jang YJ, Sharratt M, Yee D. Mobile
physical therapists working in Saudi Arabia: an observational phone multilevel and multimedia messaging intervention
study. Int J Environ Res Public Health. 2020;17(10):3406. for breast cancer screening: pilot randomized controlled
doi:10.3390/ijerph17103406. trial. JMIR mHealth uHealth. 2017;5(11):e154. doi:10.2196/
mhealth.7091.
65. Fragkiadaki E, Ghafoori B, Triliva S, Sfakianaki R. A pilot
study of a trauma training for healthcare workers serving 76. Agyemang C, Meeks K, Boateng R, Beune E. Your health is your
refugees in Greece: perceptions of feasibility of task-shifting wealth: faith-based community action on the health of African
trauma informed care. J Aggress Maltreatment Trauma. migrant communities in Amsterdam. J Epidemiol Community
2020;29(4):442–60. doi:10.1080/10926771.2019.1662866. Health. 2018;72(5):409–12. doi:10.1136/jech-2017-209130.
66. Al-Rousan T, Schwabkey Z, Jirmanus L, Nelson BD. Health 77. Dewachi O, Skelton M, Nguyen V-K, Fouad FM, Sitta GA, Maasri
needs and priorities of Syrian refugees in camps and urban Z et al. Changing therapeutic geographies of the Iraqi and
settings in Jordan: perspectives of refugees and health Syrian wars. Lancet. 2014;383(9915):449–57. doi:10.1016/
care providers. East Mediterr Health J. 2018;24(3):243–53. S0140-6736(13)62299-0.
doi:10.26719/2018.24.3.243.
78. Rouland B, Jarraya M. From medical tourism to regionalism
67. White JA, Levin J, Rispel LC. Migrants’ perceptions of from the bottom up: emerging transnational spaces
health system responsiveness and satisfaction with health of care between Libya and Tunisia. J Ethn Migr Stud.
workers in a South African province. Glob Health Action. 2020;46(20):4248–63. doi:10.1080/1369183X.2019.1597475.
2020;13(1):1850058. doi:10.1080/16549716.2020.1850058.
79. Public health guidance on screening and vaccination for
68. Modesti PA, Calabrese M, Marzotti I, Bing H, Malandrino D, infectious diseases in newly arrived migrants within the EU/
Boddi M et al. Prevalence, awareness, treatment, and control EEA. Stockholm: European Centre for Disease Prevention and
of hypertension among Chinese first-generation migrants Control; 2018 (https://www.ecdc.europa.eu/sites/default/
and Italians in Prato, Italy: the CHIP study. Int J Hypertens. files/documents/Public%20health%20guidance%20on%20
2017;2017:6402085. doi:10.1155/2017/6402085. screening%20and%20vaccination%20of%20migrants%20
in%20the%20EU%20EEA.pdf, accessed 7 April 2022).
69. McMichael C, Healy J. Health equity and migrants in
the Greater Mekong Subregion. Glob Health Action. 80. Hargreaves S, Rustage K, Nellums LB, Powis J, Milburn J,
2017;10(1):1271594. doi:10.1080/16549716.2017.1271594. Severoni S et al. What constitutes an effective and efficient
package of services for the prevention, diagnosis, treatment
70. Ghahari S, Burnett S, Alexander L. Development and pilot
and care of tuberculosis among refugees and migrants in the
testing of a health education program to improve immigrants’
WHO European Region? Copenhagen: WHO Regional Office
access to Canadian health services. BMC Health Serv Res.
for Europe; 2018 (Health Evidence Network synthesis report
2020;20(1):321. doi:10.1186/s12913-020-05180-y.
56; https://apps.who.int/iris/handle/10665/326256, accessed
71. DeCamp LR, Godage SK, Araujo DV, Cortez JD, Wu L, Psoter 7 April 2022).
KJ et al. A texting intervention in Latino families to reduce ED
81. Shedrawy J, Deogan C, Öhd JN, Hergens M-P, Bruchfeld J,
use: a randomized trial. Pediatrics. 2020;145(1):e20191405.
Jonsson J et al. Cost–effectiveness of the latent tuberculosis
doi:10.1542/peds.2019-1405.
screening program for migrants in Stockholm Region. Eur
72. Chepo M, Astorga-Pinto S, Cabieses B. Atención inicial de J Health Econ. 2021;22(3):445–54. doi:10.1007/s10198-021-
migrantes en Chile: iniciativa en atención primaria de salud 01265-5.
a un año de su implementación [Initial care for migrants in
82. Bwire G, Orach CG, Aceng FL, Arianitwe SE, Matseketse D,
Chile: status of a primary health care initiative after one year
Tumusherure E et al. Refugee settlements and cholera risks in
of implementation]. 2019;43:e71 (in Spanish). doi:10.26633/
Uganda, 2016–2019. Am J Trop Med Hyg. 2021;104(4):1225–31.
RPSP.2019.71.
doi:10.4269/ajtmh.20-0741.
73. Agarwal G, Bhandari M, Pirrie M, Angeles R, Marzanek F.
83. Ndombo PK, Ndze VN, Mbarga FD, Anderson R, Acho A, Chia
Feasibility of implementing a community cardiovascular
JE et al. Molecular characterisation of measles virus strains
health promotion program with paramedics and
among refugees from Central African Republic in Cameroon
volunteers in a South Asian population. BMC Public Health.
in 2014. Epidemiol Infect. 2018;146(3):319–23. doi:10.1017/
2020;20(1):1618. doi:10.1186/s12889-020-09728-9.
S0950268817002990.
234
84. Isadru VR, Nanyonga RC, Alege JB. Health facilities’ 94. Fair F, Soltani H, Raben L, van Streun Y, Sioti E, Papadakaki M
readiness to manage hypertension and diabetes cases et al. Midwives’ experiences of cultural competency training
at primary health facilities in Bidibidi refugee settlement, and providing perinatal care for migrant women a mixed
Yumbe District, Uganda. J Trop Med. 2021;2021:e1415794. methods study: operational refugee and migrant maternal
doi:10.1155/2021/1415794. approach (ORAMMA) project. BMC Pregnancy Childbirth.
2021;21(1):340. doi:10.1186/s12884-021-03799-1.
85. Gottlieb N, Weinstein T, Mink J, Ghebrezghiabher HM, Sultan
Z, Reichlin R. Applying a community-based participatory 95. Bapolisi A, Crabtree K, Jarolimova J, Kelly C, Kentoffio K, Patel
research approach to improve access to healthcare for P et al. Assessment of attitudes and targeted educational
Eritrean asylum-seekers in Israel: a pilot study. Isr J Health needs for refugee care providers in a Ugandan hospital. Int J
Policy Res. 2017;6(1):61. doi:10.1186/s13584-017-0185-9. Med Educ. 2018;9:221–5. doi:10.5116/ijme.5b64.9630.
86. Dumit NY, Honein-AbouHaidar G. The impact of the Syrian 96. Richter S, Vallianatos H, Green J, Obuekwe C. Intersection
refugee crisis on nurses and the healthcare system in of migration and access to health care: experiences and
Lebanon: a qualitative exploratory study. J Nurs Scholarsh. perceptions of female economic migrants in Canada. Int J
2019;51(3):289–98. doi:10.1111/jnu.12479. Environ Res Public Health. 2020;17(10):3682. doi:10.3390/
ijerph17103682.
87. Veliz-Rojas L, Bianchetti-Saavedra AF, Silva-Fernández
M. Competencias interculturales en la atención primaria 97. Al Shdaifat A, Zink T. Pilot study to build capacity for family
de salud: un desafío para la educación superior frente a medicine with abbreviated, low-cost training programme
contextos de diversidad cultural [Intercultural skills in primary with minimal impact on patient care for a cohort of 84 general
health care: a challenge for higher education in contexts of practitioners caring for Palestinian refugees in Jordan. BMJ
cultural diversity]. Cad Saúde Publica. 2019;35(1):e00120818 Open. 2019;9(8):e028240. doi:10.1136/bmjopen-2018-028240.
(in Spanish). doi:10.1590/0102-311x00120818.
98. Abudari G, Hazeim H, Ginete G. Caring for terminally ill
88. Mengesha ZB, Perz J, Dune T, Ussher J. Preparedness Muslim patients: lived experiences of non-Muslim nurses.
of health care professionals for delivering sexual and Palliat Support Care. 2016;14(6):599–611. doi:10.1017/
reproductive health care to refugee and migrant women: S1478951516000249.
a mixed methods study. Int J Environ Res Public Health.
99. Brunton M, Cook C, Kuzemski D, Brownie S, Thirlwall A.
2018;15(1):174. doi:10.3390/ijerph15010174.
Internationally qualified nurse communication: a qualitative
89. Marzouk M, Kelley M, Fadhil I, Slama S, Longuere KS, Ariana cross country study. J Clin Nurs. 2019;28(19–20):3669–79.
P et al. “If I have a cancer, it is not my fault I am a refugee”: doi:10.1111/jocn.14968.
a qualitative study with expert stakeholders on cancer care
100. Albougami AS, Alotaibi JS, Alsharari AF, Albagawi BS, Almazan
management for Syrian refugees in Jordan. PLOS One.
JU, Maniago JD et al. Cultural competence and perception of
patient-centered care among non-Muslim expatriate nurses
90. McHenry MS, Nutakki K, Swigonski NL. Effectiveness of cross- in Saudi Arabia: a cross sectional study. Pak J Med Health
cultural education for medical residents caring for Burmese Sci. 2019;13(3):933–8 (https://www.pjmhsonline.com/2019/
refugees. Educ Health. 2016;29(3):250–4. doi:10.4103/1357- july_sep/pdf/933.pdf, accessed 8 April 2022).
6283.204217.
101. Kheang ST, Lin MA, Lwin S, Naing YH, Yarzar P, Kak N.
91. Gagliardi AR, Kim C, Jameel B. Physician behaviours that Malaria case detection among mobile populations and
optimize patient-centred care: focus groups with migrant migrant workers in Myanmar: comparison of 3 service
women. Health Expect. 2020;23(5):1280–8. doi:10.1111/ delivery approaches. Glob Health Sci Pract. 2018;6(2):384–9.
hex.13110. doi:10.9745/GHSP-D-17-00318.
92. Fellmeth G, Plugge E, Fazel M, Nosten S, Oo MM, 102. Alpern JD, Davey CS, Song J. Perceived barriers to success for
Pimanpanarak M et al. Perinatal depression in migrant resident physicians interested in refugee and migrant health.
and refugee women on the Thai–Myanmar border: does BMC Med Educ. 2016;16:178. doi:10.1186/s12909-016-0696-z.
social support matter? Philos Trans R Soc B Biol Sci.
103. Reece MJ, Rubin S. Qualitative pilot study: challenges for
2021;376(1827):20200030. doi:10.1098/rstb.2020.0030.
primary healthcare providers caring for refugees in Northeast
93. Young S, Guo KL. Cultural diversity training: the necessity of Ohio. Cureus. 2021;13(1):e12572. doi:10.7759/cureus.12572.
cultural competence for health care providers and in nursing
104. de Arruda-Barbosa L, Sales AFG, de Souza ILL. Reflexos da
practice. Health Care Manag. 2016;35(2):94–102. doi:10.1097/
imigração venezuelana na assistência em saúde no maior
HCM.0000000000000100.
hospital de Roraima: análise qualitativa [The impact of
Venezuelan immigration on health care in Roraima's largest
hospital: qualitative analysis]. Saúde Soc. 2020;29(2):e190730
(in Portuguese). doi:10.1590/S0104-12902020190730.
235
105. Schininá G, Nunes N, Birot P, Giardinelli L, Kios G. 114. Losco LN, Gemma SFB. Health subjects, territory agents: the
Mainstreaming mental health and psychosocial support community health agent in immigrant primary care. Interface.
in camp coordination and camp management. The 2019;23:e180589. doi:10.1590/Interface.180589.
experience of the International Organization for Migration
115. Nguyen TT, Tsoh JY, Woo K, Stewart SL, Le GM, Burke A et al.
in the north east of Nigeria and South Sudan. Intervention.
Colorectal cancer screening and Chinese Americans: efficacy
2016;14(3):232–44 (https://www.interventionjournal.com/
of lay health worker outreach and print materials. Am J Prev
sites/default/files/Mainstreaming_mental_health_and_
Med. 2017;52(3):e67–76. doi:10.1016/j.amepre.2016.10.003.
psychosocial.7.pdf, accessed 8 April 2022).
116. Ross SET, Gibbs BB, Documet PI, Pate RR. ANDALE Pittsburgh:
106. Abbott KL, Woods CA, Halim DA, Qureshi HA. Pediatric care
results of a promotora-led, home-based intervention to
during a short-term medical mission to a Syrian refugee
promote a healthy weight in Latino preschool children. BMC
camp in northern Jordan. Avicenna J Med. 2017;7(4):176–81.
Public Health. 2018;18(1):360. doi:10.1186/s12889-018-5266-3.
doi:10.4103/ajm.AJM_100_17.
117. Sepúlveda C, Cabieses B. Rol del facilitador intercultural
107. Kosiyaporn H, Julchoo S, Phaiyarom M, Sinam P, Kunpeuk
para migrantes internacionales en centros de salud chilenos:
W, Pudpong N et al. Strengthening the migrant-friendliness
perspectivas de cuatro grupos de actores clave [Role of the
of Thai health services through interpretation and cultural
intercultural facilitator for international migrants in Chilean
mediation: a system analysis. Glob Health Res Policy.
health centres: perspectives from four groups of key actors].
2020;5(1):53. doi:10.1186/s41256-020-00181-0.
Rev Peru Med Exp Salud Publica. 2019;36(4):592–600 (in
108. Juon H-S, Strong C, Kim F, Park E, Lee S. Lay health worker Spanish). doi:10.17843/rpmesp.2019.364.4683.
intervention improved compliance with hepatitis B
118. MacFarlane A, Huschke S, Pottie K, Hauck FR, Griswold
vaccination in Asian Americans: randomized controlled
K, Harris MF. Barriers to the use of trained interpreters in
trial. PLOS One. 2016;11(9):e0162683. doi:10.1371/journal.
consultations with refugees in four resettlement countries: a
pone.0162683.
qualitative analysis using normalisation process theory. BMC
109. Verrept H. What are the roles of intercultural mediators in Fam Pract. 2020;21(1):259. doi:10.1186/s12875-020-01314-7.
health care and what is the evidence on their contributions
119. Ursu P, Nitzan D, Şener S, Sucaklı B, Şimşek M, Beqiri M et
and effectiveness in improving accessibility and quality of
al. Protracted emergency in Turkey: supporting provision
care for refugees and migrants in the WHO European Region?
of essential health services to Syrians under temporary
Copenhagen: WHO Regional Office for Europe; 2019 (https://
protection. Public Health Panor. 2018;04(01):120–5 (https://
apps.who.int/iris/handle/10665/327321, accessed 8 April 2022).
apps.who.int/iris/handle/10665/325072, accessed
110. Naal H, Mendelsohn R, Brome D, Noubani A, Nabulsi D, 8 April 2022).
Muhieddine D et al. Evaluating a capacity building program on
120. Oakley S, Grealish L, Coyne E. Telling their story: a qualitative
women’s health for displaced community health workers in
descriptive study of the lived experience of expatriate
fragile settings in Lebanon. Hum Resour Health. 2021;19(1):37.
palliative care nurses in the United Arab Emirates. Eur J Oncol
doi:10.1186/s12960-021-00585-0.
Nurs. 2020;48:101793. doi:10.1016/j.ejon.2020.101793.
111. Izugbara C, Muthuri S, Muuo S, Egesa C, Franchi G, McAlpine
121. World Refugee Day: WHO training enables Syrian doctors and
A et al. “They say our work is not halal”: experiences and
nurses to provide health care in Turkey. Copenhagen: WHO
challenges of refugee community workers involved in gender-
Regional Office for Europe; 2017 (https://www.euro.who.int/
based violence prevention and care in Dadaab, Kenya. J Refug
en/countries/turkey/news/news/2017/06/world-refugee-day-
Stud. 2020;33(3):521–36. doi:10.1093/jrs/fey055.
who-training-enables-syrian-doctors-and-nurses-to-provide-
112. Asia‐Pacific migration report 2020: assessing implementation health-care-in-turkey, accessed 8 April 2022).
of the global compact for migration. Bangkok: United Nations
122. Primary health care in the Western Pacific Region: looking
Economic and Social Commission for Asia and the Pacific;
back and future directions. Manila: WHO Regional Office
2020 (https://www.unescap.org/resources/asia-pacific-
for the Western Pacific; 2018 (https://apps.who.int/iris/
migration-report-2020, accessed 8 April 2022).
113. Regolamento recante disposizioni sul funzionamento e
123. Healee D, Inada K. Working with difference: thematic concepts
l’organizzazione dell’Istituto Nazionale per la promozione
of Japanese nurses working in New Zealand. Nurs Health Sci.
della salute delle popolazioni migranti e per il contrasto delle
2016;18(1):91–6. doi:10.1111/nhs.12246.
malattie della poverta [Regulation outlining provisions on
the functioning and organisation of the National Institute for 124. Jenkins B, Huntington A. “We are the international nurses”: an
Health Promotion of Migrant Populations and for combating exploration of internationally qualified nurses’ experiences of
poverty-related diseases]. Rome: Ministero della Salute; transitioning to New Zealand and working in aged care. Nurs
2013 (in Italian; https://www.inmp.it/index.php/ita/content/ Prax N Z. 2016;32(2):9–20. doi:10.36951/ngpxnz.2016.006.
download/14884/119029/file/Decreto%2022%20febbraio%20
2013%20n.%2056.pdf, accessed 8 April 2022).
236
125. Joseph B, Olasoji M, Moss C, Cross W. Transition 136. Efendi F, Oda H, Kurniati A, Hadjo SS, Nadatien I, Ritonga
experiences of Indian nurses into Australian mental IL. Determinants of nursing students’ intention to migrate
health system. J Transcult Nurs. 2022;33(1):41–8. overseas to work and implications for sustainability: the case
doi:10.1177/10436596211026373. of Indonesian students. Nurs Health Sci. 2021;23(1):103–12.
doi:10.1111/nhs.12757.
126. Timilsina Bhandari KK, Xiao LD, Belan I. Job satisfaction of
overseas-qualified nurses working in Australian hospitals. Int 137. Contribution of migrant doctors and nurses to tackling
Nurs Rev. 2015;62(1):64–74. doi:10.1111/inr.12146. COVID-19 crisis in OECD countries. Paris: Organisation for
127. Aggar C, Shinners L, Thomas T, Stockhausen L. Experiences
www.oecd-ilibrary.org/social-issues-migration-health/
of internationally qualified registered nurses enrolled in
contribution-of-migrant-doctors-and-nurses-to-tackling-
a bridging program in Australia: a pilot study. Collegian.
covid-19-crisis-in-oecd-countries_2f7bace2-en, accessed
2020;27(3):298–303. doi:10.1016/j.colegn.2019.09.003.
8 April 2022).
128. Marcus K, Purwaningrum F, Short S. Towards more effective
138. Botezat A, Ramos R. Physicians’ brain drain - a gravity model
health workforce governance: the case of overseas‐trained
of migration flows. Glob Health. 2020;16(1):7. doi:10.1186/
doctors. Aust J Rural Health. 2021;29(1):52–60. doi:10.1111/
s12992-019-0536-0.
ajr.12692.
139. Motlhatlhedi K, Nkomazana O. Home is home:
129. Wells R, Abo-Hilal M, Steel Z, Hunt C, Plested B, Hassan M et
Botswana’s return migrant health workers. PLOS One.
al. Community readiness in the Syrian refugee community
in Jordan: a rapid ecological assessment tool to build
psychosocial service capacity. Am J Orthopsychiatry. 140. WHO guideline on health workforce development, attraction,
2020;90(2):212–22. doi:10.1037/ort0000404. recruitment and retention in rural and remote areas: a
summary. Geneva: World Health Organization; 2021 (https://
130. Gatter M. Preserving order: narrating resilience as threat in
Jordan’s Azraq refugee camp. Territ Polit Gov. 2021;1:1–17.
8 April 2022).
doi:10.1080/21622671.2020.1860812.
141. Recognition of qualifications and competences of migrants.
131. Abdalla FM, Omar MA, Badr EE. Contribution of Sudanese
medical diaspora to the healthcare delivery system in
(https://publications.iom.int/system/files/pdf/recognition_
Sudan: exploring options and barriers. Hum Resour Health.
qualifications_competencesofmigrants.pdf, accessed
2016;14:28. doi:10.1186/s12960-016-0123-x.
16 April 2022).
132. Saluja S, Rudolfson N, Massenburg BB, Meara JG, Shrime
142. What a waste: ensure migrants and refugees’ qualifications
MG. The impact of physician migration on mortality in low
and prior learning are recognized. Paris: United Nations
and middle-income countries: An economic modelling
Educational, Scientific and Cultural Organization; 2018
study. BMJ Glob Health. 2020;5(1):e001535. doi:10.1136/
(https://unesdoc.unesco.org/ark:/48223/pf0000366312,
bmjgh-2019-001535.
133. Policy brief for the global policy advisory council: the Gulf
143. Human mobility, shared opportunities: a review of the 2009
Cooperation Council (GCC) and health worker migration.
human development report and the way ahead. New York:
Washington (DC): Aspen Institute; 2008 (https://www.
United Nations Development Programme; 2020 (https://www.
aspeninstitute.org/wp-content/uploads/files/content/
undp.org/sites/g/files/zskgke326/files/publications/UNDP-
images/GCC%20and%20HWM%20Policy%20Brief.pdf,
IOM-Human-Mobility-Shared-Opportunities.pdf, accessed
8 April 2022).
134. Kurniati A, Chen C-M, Efendi F, Ogawa R. A deskilling and
144. Honein-Abouhaidar G, Noubani A, El Arnaout N, Ismail S,
challenging journey: the lived experience of Indonesian nurse
Nimer H, Menassa M et al. Informal healthcare provision in
returnees. Int Nurs Rev. 2017;64(4):494–501. doi:10.1111/
Lebanon: an adaptive mechanism among displaced Syrian
inr.12352.
health professionals in a protracted crisis. Confl Health.
135. Tangcharoensathien V, Travis P, Tancarino AS, Sawaengdee K, 2019;13(1):40. doi:10.1186/s13031-019-0224-y.
Chhoedon Y, Hassan S et al. Managing in- and out-migration
145. López-Entrambasaguas OM, Martínez-Linares JM, Linares-
of health workforce in selected countries in South East
Abad M, Calero-García MJ. Is it possible to become a
Asia region. Int J Health Policy Manag. 2018;7(2):137–43.
nurse in a refugee camp? Int J Environ Res Public Health.
doi:10.15171/ijhpm.2017.49.
2019;16(18):3414. doi:10.3390/ijerph16183414.
237
146. Resolution WHA63.16. WHO global code of practice on the 157. Fouratt CE, Voorend K. Esquivando al estado: prácticas
international recruitment of health personnel. In: Sixty-third privadas en el uso de los servicios de salud entre inmigrantes
World Health Assembly, Geneva, 17–21 May 2010. Resolutions nicaragüenses en Costa Rica [Evading the state: private
and decisions, annexes. Geneva: World Health Organization; practices in the use of health services among Nicaraguan
2010:31 (WHA63/2010/REC/1; https://apps.who.int/gb/ migrants in Costa Rica]. Anu Estud Centroam. 2019;45:373–
ebwha/pdf_files/WHA63-REC1/WHA63_REC1-en.pdf). 403 (in Spanish). doi:10.15517/aeca.v45i0.36863.
147. Resolution WHA69.19. Global strategy on human resources for 158. Saiyed S, Siddiqui F, Gunja A. Providing healthcare in the camps
health: workforce 2030. In: Sixty-ninth World Health Assembly, of the Rohingya. London: British Medical Association; 2018
Geneva, 23–28 May 2016. Resolutions and decisions, (https://blogs.bmj.com/bmj/2018/12/31/providing-healthcare-
annexes. Geneva: World Health Organization; 2016:43–46 in-the-camps-of-the-rohingya/, accessed 8 April 2022).
(WHA69/2016/REC/1; https://apps.who.int/gb/ebwha/pdf_
159. Doherty M, Power L, Petrova M, Gunn S, Powell R, Coghlan R
files/WHA69-REC1/A69_2016_REC1-en.pdf#page=1).
et al. Illness-related suffering and need for palliative care in
148. WHO global code of practice on the international recruitment Rohingya refugees and caregivers in Bangladesh: a cross-
of health personnel. Geneva: World Health Organization; sectional study. PLOS Med. 2020;17(3):e1003011. doi:10.1371/
2021 (https://www.who.int/publications/m/item/nri-2021, journal.pmed.1003011.
160. Doherty M, Khan F. Neglected suffering: The unmet need for
149. Global strategy on human resources for health: workforce palliative care in Cox’s Bazar. London: World Child Cancer;
2030. Geneva: World Health Organization; 2016 (https://apps. 2018 (https://reliefweb.int/sites/reliefweb.int/files/resources/
who.int/iris/handle/10665/250368/, accessed 16 April 2022). Neglected%20Suffering.pdf, accessed 8 April 2022).
150. National health workforce accounts: a handbook. Geneva: 161. Al Alawneh M, Nuaimi N, Basheti IA. Pharmacists in
World Health Organization; 2017 (https://apps.who.int/iris/ humanitarian crisis settings: assessing the impact of
handle/10665/259360, accessed 16 April 2022). pharmacist-delivered home medication management review
service to Syrian refugees in Jordan. Res Soc Adm Pharm.
151. Socha-Dietrich K, Dumont JC. International migration and
2019;15(2):164–72. doi:10.1016/j.sapharm.2018.04.008.
movement of doctors to and within OECD countries - 2000 to
2018: developments in countries of destination and impact 162. Sethi S, Jonsson R, Skaff R, Tyler F. Community-based
on countries of origin. Paris: Organisation for Economic noncommunicable disease care for Syrian refugees
Co-operation and Development; 2021 (OECD Health in Lebanon. Glob Health Sci Pract. 2017;5(3):495–506.
Working Papers no. 126; https://www.oecd-ilibrary.org/ doi:10.9745/GHSP-D-17-00043.
social-issues-migration-health/international-migration-and-
163. At a glance: health access and utilization survey among non-
movement-of-doctors-to-and-within-oecd-countries-2000-to-
camp refugees in Lebanon – November 2015. Geneva: Office
2018_7ca8643e-en, accessed 16 April 2022).
of the United Nations High Commissioner for Refugees, Public
152. Ennis CA, Walton-Roberts M. Labour market regulation Health; 2015 (https://reliefweb.int/report/lebanon/glance-
as global social policy: the case of nursing labour health-access-and-utilization-survey-among-non-camp-
markets in Oman. Glob Soc Policy. 2018;18(2):169–88. refugees-lebanon-november, accessed 29 April 2022).
doi:10.1177/1468018117737990.
164. At a glance: health access and utilization survey among Syrian
153. AlRuthia Y, Alsenaidy MA, Alrabiah HK, AlMuhaisen A, Alshehri refugees in Lebanon – September 2016. Geneva: Office of
M. The status of licensed pharmacy workforce in Saudi Arabia: the United Nations High Commissioner for Refugees, Public
a 2030 economic vision perspective. Hum Resour Health. Health; 2016 (https://reliefweb.int/report/lebanon/glance-
2018;16(1):28. doi:10.1186/s12960-018-0294-8. health-access-and-utilization-survey-among-syrian-refugees-
lebanon-september, accessed 29 April 2022).
154. Gillani SW, Rahman SA, Mohammad Abdul MI, Sulaiman
SAS. Assessment of community pharmacists’ perceptions of 165. Health access and utilization survey among Syrian refugees
healthcare services in Saudi Arabia. J Pharm Health Serv Res. in Lebanon – November 2017. Geneva: Office of the United
2017;8(4):269–74. doi:10.1111/jphs.12183. Nations High Commissioner for Refugees, Public Health;
155. Usman SK, Moosa S, Abdullah AS. Navigating the health
system in responding to health workforce challenges of the
COVID-19 pandemic: the case of Maldives (short case). Int J
Health Plann Manage. 2021;36(suppl 1):182–9. doi:10.1002/ 166. Health access and utilization survey among Syrian refugees
hpm.3136. in Lebanon – December 2018. Geneva: Office of the United
Nations High Commissioner for Refugees, Public Health;
156. Bellamy K, Ostini R, Martini N, Kairuz T. Insights from the
coalface: barriers to accessing medicines and pharmacy
services for resettled refugees from Africa. Aust J Prim Health.
december-2018, accessed 29 April 2022).
2019;25(2):118–24. doi:10.1071/PY18092.
238
167. Health access and utilization survey among Syrian refugees 177. Marek E, D’Cruz G, Katz Z, Szilard I, Berenyi K, Feiszt Z.
in Lebanon – November 2019. Geneva: Office of the United Improving asylum seekers’ health awareness in a Hungarian
Nations High Commissioner for Refugees, Public Health; refugee reception centre. Health Promot Int. 2019;34(5):e35–
2019 (https://reliefweb.int/report/lebanon/health-access- 46. doi:10.1093/heapro/day066.
178. Fahrni O, Posfay-Barbe KM, Nm W. Immunisation against
hepatitis A in migrant children: three vaccination strategies,
168. United Nations High Commissioner for Refugees: Health a retrospective study. Pediatr Infect Dis J. 2020;39(2):164–9.
access and utilization survey among Syrian refugees in doi:10.1097/INF.0000000000002526.
Lebanon (October 2020). Geneva: Office of the United
179. Spadea T, Fano V, Piovesan C, Rusciani R, Salamina G, Greco
Nations High Commissioner for Refugees, Public Health; 2020
G et al. Early childhood vaccination coverage and timeliness
(https://reliefweb.int/report/lebanon/unhcr-health-access-
by macro-area of origin in children born to foreign women
residing in Italy. Public Health. 2021;196:138–45. doi:10.1016/j.
october-2020, accessed 29 April 2022).
puhe.2021.05.025.
169. Hu J, Wang Z. Non-prescribed antibiotic use and general
180. Fabiani M, Fano V, Spadea T, Piovesan C, Bianconi E, Rusciani
practitioner service utilisation among Chinese migrants in
R et al. Comparison of early childhood vaccination coverage
Australia. Aust J Prim Health. 2016;22(5):434–9. doi:10.
and timeliness between children born to Italian women and
1071/PY15076.
those born to foreign women residing in Italy: a multi-centre
170. Rasheed NA, Hussein NR. Methicillin-resistant staphylococcus retrospective cohort study. Vaccine. 2019;37(16):2179–87.
aureus carriage rate and molecular characterization of the doi:10.1016/j.vaccine.2019.03.023.
staphylococcal cassette chromosome mec among Syrian
181. Fabiani M, Di Napoli A, Riccardo F, Gargiulo L, Declich S,
refugees in Iraq. Int J Infect Dis. 2020;91:218–22. doi:10.1016/j.
Petrelli A. [Differences in influenza vaccination coverage
ijid.2019.12.006.
among subgroups of adult immigrants residing in Italy at risk
171. Masoumi-Asl H, Gouya MM, Rahbar M, Sabourian R. The for complications (2012–2013)]. Epidemiol Prev. 2017;41(3-4
epidemiology and antimicrobial resistance of cholera suppl 1):50–6 (in Italian). doi:10.19191/EP17.3-4S1.P050.065.
cases in Iran during 2013. Iran J Microbiol. 2016;8(4):232–7.
182. Fabiani M, Riccardo F, Napoli AD, Gargiulo L, Declich S, Petrelli
PMID:28210461.
A. Differences in influenza vaccination coverage between
172. Bonniface M, Nambatya W, Rajab K. An evaluation of adult immigrants and Italian citizens at risk for influenza-
antibiotic prescribing practices in a rural refugee settlement related complications: a cross-sectional study. PLOS One.
district in Uganda. Antibiotics. 2021;10(2):172. doi:10.3390/ 2016;11(11):e0166517. doi:10.1371/journal.pone.0166517.
antibiotics10020172.
183. De Vito E, de Waure C, Specchia ML, Ricciardi W. Public health
173 Freidl GS, Tostmann A, Curvers M, Ruijs WLM, Smits G, Schepp aspects of migrant health: a review of the evidence on health
R et al. Immunity against measles, mumps, rubella, varicella, status for undocumented migrants in the European region.
diphtheria, tetanus, polio, hepatitis A and hepatitis B among Copenhagen: WHO Regional Office for Europe; 2015 (Health
adult asylum seekers in the Netherlands, 2016. Vaccine. Evidence Network synthesis report 42; https://apps.who.int/
2018;36(12):1664–72. doi:10.1016/j.vaccine.2018.01.079. iris/handle/10665/326342, accessed 8 April 2022).
174. Napolitano F, Gualdieri L, Santagati G, Angelillo IF. Knowledge 184. De Vito E, Parente P, de Waure C, Poscia A, Ricciardi W.
and attitudes toward HPV infection and vaccination among A review of evidence on equitable delivery, access and
immigrants and refugees in Italy. Vaccine. 2018;36(49):7536– utilization of immunization services for migrants and refugees
41. doi:10.1016/j.vaccine.2018.10.050. in the WHO European Region. Copenhagen: WHO Regional
Office for Europe; 2017 (Health Evidence Network synthesis
175. Jablonka A, Solbach P, Wöbse M, Manns MP, Schmidt RE,
report 53; https://apps.who.int/iris/handle/10665/326288,
Wedemeyer H et al. Seroprevalence of antibodies and
antigens against hepatitis A-E viruses in refugees and asylum
seekers in Germany in 2015. Eur J Gastroenterol Hepatol. 185. Jablonka A, Happle C, Grote U, Schleenvoigt BT, Hampel
2017;29(8):939–45. doi:10.1097/MEG.0000000000000889. A, Dopfer C. Measles, mumps, rubella, and varicella
seroprevalence in refugees in Germany in 2015. Infection.
176. Hvass AMF, Norredam M, Sodemann M, Thomsen MK,
2016;44(6):781–7. doi:10.1007/s15010-016-0926-7.
Christian W. Are refugees arriving in Denmark an under-
immunised group for measles? A cross-sectional serology 186. Hargreaves S, Nellums LB, Ramsay M, Saliba V, Majeed A,
study. Vaccine. 2020;38(13):2788–94. doi:10.1016/j. Mounier-Jack S et al. Who is responsible for the vaccination
vaccine.2020.02.025. of migrants in Europe? Lancet. 2018;391(10132):1752–4.
doi:10.1016/S0140-6736(18)30846-8.
239
187. Migration health annual report 2017. Geneva: International 198. Williams WW, Lu P-J, O’Halloran A, Kim DK, Grohskopf LA,
Organization for Migration; 2017 (https://publications.iom.int/ Pilishvili T et al. Surveillance of vaccination coverage among
system/files/pdf/mhd_ar2017.pdf, accessed 8 April 2022). adult populations: United States, 2015. MMWR Surveill Summ.
2017;66(11):1–28. doi:10.15585/mmwr.ss6611a1.
Charatrueangrongkun R et al. Immunisation coverage in 199. Abdi I, Menzies R, Seale H. Barriers and facilitators of
migrant school children along the Thailand-Myanmar border. immunisation in refugees and migrants in Australia: an east-
J Immigr Minor Health. 2016;18(5)1038–45. doi:10.1007/ African case study. Vaccine. 2019;37(44):6724–9. doi:10.1016/j.
s10903-015-0294-x. vaccine.2019.09.025.
189. Harvey B, Dalal W, Amin F, McIntyre E, Ward S, Merrill 200. Charania NA, Paynter J, Lee AC, Watson DG, Turner NM.
RD et al. Planning and implementing a targeted polio Exploring immunisation inequities among migrant and
vaccination campaign for Somali mobile populations refugee children in New Zealand. Hum Vaccines Immunother.
in northeastern Kenya based on migration and 2018;14(12):3026–33. doi:10.1080/21645515.2018.1496769.
settlement patterns. Ethn Health. 2022;27(4):817–32. doi:
201. Chung HJ, Han SH, Kim H, Finkelstein JL. Childhood
10.1080/13557858.2020.1838455.
immunisations in China: disparities in health care access in
190. Positioning demand generation in national EPI planning and children born to North Korean refugees. BMC Int Health Hum
implementation process: a quick guide to assist immunization Rights. 2016;16(1):13. doi:10.1186/s12914-016-0085-z.
and communication planners and managers. Brazzaville:
202. Charania NA, Paynter J, Lee AC, Watson DG, Turner NM.
WHO Regional Office for Africa; 2018 (https://apps.who.int/
Vaccine-preventable disease-associated hospitalisations
iris/handle/10665/273314, accessed 8 April 2022).
among migrant and non-migrant children in New Zealand. J
191. Masters NB, Wagner AL, Carlson BF, Muuo SW, Mutua MK, Immigr Minor Health. 2020;22(2):223–31. doi:10.1007/s10903-
Boulton ML. Childhood vaccination in Kenya: socioeconomic 019-00888-4.
determinants and disparities among the Somali ethnic
203. Roberton T, Weiss W, Doocy S; Jordan Health Access
community. Int J Public Health. 2019;64(3):313–22.
Survey Team; Lebanon Health Access Survey Team.
doi:10.1007/s00038-018-1187-2.
Challenges in estimating vaccine coverage in refugee and
192. Okiror S, Toure B, Davis B, Hydarov R, Ram B, Nwogu C displaced populations: results from household surveys in
et al. Lessons learnt from interregional and interagency Jordan and Lebanon. Vaccines. 2017;5(3):22. doi:10.3390/
collaboration in polio outbreak response in the Horn of Africa. vaccines5030022.
J Immunol Sci. 2021;Special Issue(2):40–7. doi:10.29245/2578-
204. Rossi R, Assaad R, Rebeschini A, Hamadeh R. Vaccination
3009/2021/S2.1112.
coverage cluster surveys in middle Dreib – Akkar, Lebanon:
193. Brownwright TK, Dodson ZM, van Panhuis WG. Spatial comparison of vaccination coverage in children aged 12–59
clustering of measles vaccination coverage among children months pre- and post-vaccination campaign. PLOS One.
in sub-Saharan Africa. BMC Public Health. 2017;17(1):957. 2016;11(12):e0168145. doi:10.1371/journal.pone.0168145.
doi:10.1186/s12889-017-4961-9.
205. SDG indicators: global indicator framework for the
194. Ng AHC, Fobel R, Fobel C, Lamanna J, Rackus DG, Summers Sustainable Development Goals and targets of the 2030
A et al. A digital microfluidic system for serological Agenda for Sustainable Development. New York: United
immunoassays in remote settings. Sci Transl Med. Nations Department of Economic and Social Affairs (https://
2018;10(438):eaar6076. doi:10.1126/scitranslmed.aar6076. unstats.un.org/sdgs/indicators/indicators-list/, accessed
30 April 2022).
195. Migration governance in the Caribbean: report on the island
states of the commonwealth Caribbean. Geneva: International 206. Strategy and action plan for refugee and migrant health in the
Organization for Migration; 2018 (https://caribbeanmigration. WHO European Region. In: Sixty-sixth Regional Committee for
org/sites/default/files/repository/regional_report_on_ Europe: Copenhagen, 12–15 September 2016. Copenhagen:
migration_governance_in_the_island_states_of_the_ WHO Regional Office for Europe; 2016 (EUR/RC66/8; https://
commonwealth_caribbean.pdf, accessed 8 April 2022). apps.who.int/iris/handle/10665/338085, accessed
9 April 2022).
196. Allen EM, Lee HY, Pratt R, Vang H, Desai JR, Dube A et al.
Facilitators and barriers of cervical cancer screening and 207. Collection and integration of data on refugee and migrant
human papilloma virus vaccination among Somali refugee health in the WHO European Region. Copenhagen: WHO
women in the United States: a qualitative analysis. J Transcult Regional Office for Europe; 2020 (https://apps.who.int/iris/
Nurs. 2019;30(1):55–63. doi:10.1177/1043659618796909. handle/10665/337694, accessed 9 April 2022).
197. Mitchell T, Dalal W, Klosovsky A, Yen C, Phares C, Burkhardt
M et al. An immunization program for US-bound refugees:
development, challenges, and opportunities 2012–present.
Vaccine. 2021;39(1):68–77. doi:10.1016/j.vaccine.2020.10.047.
240
208. Global action plan on promoting the health of refugees 219. Lopez PM, Divney A, Goldfeld K, Zanowiak J, Gore R, Kumar
and migrants, 2019–2023. In: Seventy-second World Health R et al. Feasibility and outcomes of an electronic health
Assembly, Geneva, 20–28 May 2019. Resolutions and record intervention to improve hypertension management
decisions, annexes. Geneva: World Health Organization; in immigrant-serving primary care practices. Med Care.
2019:Annex 5 (WHA72/2019/REC/1; https://apps.who.int/gb/ 2019;57:S164–71. doi:10.1097/MLR.0000000000000994.
ebwha/pdf_files/WHA72-REC1/A72_2019_REC1-en.pdf).
220. Sorkin DH, Rizzo S, Biegler K, Sim SE, Nicholas E, Chandler
209. Tschirhart N, Thi SS, Swe LL, Nosten F, Foster AM. Treating the M et al. Novel health information technology to aid
invisible: gaps and opportunities for enhanced TB control provider recognition and treatment of major depressive
along the Thailand-Myanmar border. BMC Health Serv Res. disorder and posttraumatic stress disorder in primary care.
2017;17(1):29. doi:10.1186/s12913-016-1954-9. Med Care. 2019;57(suppl 6 suppl 2):S190–6. doi:10.1097/
MLR.0000000000001036.
210. Health of refugees and migrants: regional situation analysis,
practices, experiences, lessons learned and ways forward. 221. Saleh S, Alameddine M, Farah A, Arnaout NE, Dimassi H,
New Delhi: WHO Regional Office for South-East Asia; 2018 Muntaner C et al. eHealth as a facilitator of equitable access to
(https://www.who.int/docs/default-source/documents/ primary healthcare: the case of caring for non-communicable
publications/health-of-refugees-and-migrants-searo-2018. diseases in rural and refugee settings in Lebanon. Int J Public
pdf?sfvrsn=b7c1ad1f_1, accessed 29 April 2022). Health. 2018;63(5):577–88. doi:10.1007/s00038-018-1092-8.
211. Wen S, Harvard KE, Gueye CS, Canavati SE, Chancellor A, 222. Burchert S, Alkneme MS, Bird M, Carswell K, Cuijpers P,
Ahmed B-N et al. Targeting populations at higher risk for Hansen P et al. User-centered app adaptation of a low-
malaria: a survey of national malaria elimination programmes intensity e-mental health intervention for Syrian refugees.
in the Asia Pacific. Malar J. 2016;15(1):271. doi:10.1186/ Front Psychiatry. 2019;9:663. doi:10.3389/fpsyt.2018.00663.
s12936-016-1319-1.
223. Personas migrantes en Tijuana frente al COVID-19: impactos y
212. Zenner D, Méndez AR, Schillinger S, Val E, Wickramage K. consecuencias de las medidas santiarias desde la perspectiva
Health and illness in migrants and refugees arriving in Europe: de los actors [Migrants in Tijuana facing COVID-19: impacts
analysis of the electronic Personal Health Record system. J and consequences of health measures from the perspective
Travel Med. 2022;2:taac035. doi:10.1093/jtm/taac035. of the actors]. Tijuana: El Colegio de la Frontera Norte; 2020 (in
Spanish; https://www.colef.mx/wp-content/uploads/2020/06/8_
213. I controlli alla frontiera: a frontiera dei controlli. Controlli
Personasmigrantes.pdf, accessed 15 April 2022).
sanitari all’arrivo e percorsi di tutela per i migranti ospiti nei
centri di accoglienza [Border controls: health checks on arrival 224. Kitabayashi H, Chiang C, Al-Shoaibi AAA, Hirakawa Y, Aoyama
and protection routes for migrants in reception centres]. A. Association between maternal and child health handbook
Rome: National Institute for Health, Migration and Poverty; and quality of antenatal care services in Palestine. Matern
2017 (in Italian; https://www.epicentro.iss.it/migranti/pdf/ Child Health J. 2017;21(12):2161–8. doi:10.1007/s10995-017-
LG_Migranti-web.pdf, accessed 8 April 2022). 2332-x.
214. Hjern A, Stubbe Østergaard L, Nörredam M-L. Health 225. Dahleez KA, Bader I, Aboramadan M. E-health system
examinations of child migrants in Europe: screening or characteristics, medical performance and healthcare quality
assessment of healthcare needs? BMJ Paediatr Open. at UNRWA-Palestine health centers. J Enterp Inf Manage.
2019;3(1):e000411. doi:10.1136/bmjpo-2018-000411. 2021;34(4):1004–36. doi:10.1108/JEIM-01-2019-0023.
215. Kyozira C, Kabahuma C, Mpiima J. Integration of the UNHCR 226. Arellano L. Diagnóstico sobre acceso a servicios de salud
refugee health information system into the national health para personas migrantes, solicitantes de asilo y refugiadas
information management system for Uganda. Health Inf [Assessment of access to health services for migrants, asylum
Manag. 2021;50(3):149–56. doi:10.1177/1833358319887817. seekers and refugees]. Mexico City: Sin Fronteras; 2014 (in
Spanish; https://sinfronteras.org.mx/agendamigracioncdmx/
216. Tapales A, Desai S, Leong E. Data opportunities for
assets/diagnostico_acceso_servicios_de_salud.pdf, accessed
studying the sexual and reproductive health of immigrants
15 April 2022).
in the United States. J Health Care Poor Underserved.
2019;30(2):560–86. doi:10.1353/hpu.2019.0031. 227. Displacement tracking matrix [website]. Geneva: International
Organization for Migration; 2019 (https://dtm.iom.int/,
217. Mercado CEG, Ekapirat N, Dondorp AM, Maude RJ. An
assessment of national surveillance systems for malaria
elimination in the Asia Pacific. Malar J. 2017;16(1):127. 228. Migration management information initiative launched in
doi:10.1186/s12936-017-1774-3. Central American northern triangle [website]. El Salvador:
International Organization on Migration; 2016 (https://www.
218. SCORE for health data technical package: essential interventions.
iom.int/news/migration-management-information-initiative-
Geneva: World Health Organization; 2020 (https://apps.who.int/
launched-central-american-northern-triangle#, accessed
iris/handle/10665/334005, accessed 16 April 2022).
9 April 2022).
241
229. Guo P, Alajarmeh S, Alarja G, Alrjoub W, Al-Essa A, Abusalem 240. Khongthanachayopit S, Laohasiriwong W. Accessibility to
L et al. Compounded trauma: a qualitative study of the health services among migrant workers in the northeast
challenges for refugees living with advanced cancer. Palliat of Thailand. F1000Res. 2017;6:972. doi:10.12688/
Med. 2021;35(5):916–26. doi:10.1177/02692163211000236. f1000research.11651.1.
230. Heydari A, Amiri R, Nayeri ND, AboAli V. Afghan refugees’ 241. Thailand [website]. Bangkok: International Organization for
experience of Iran’s health service delivery. Int J Hum Rights Migration Thailand; 2022 (https://thailand.iom.int/, accessed
Healthc. 2016;9(2):75–85. doi:10.1108/IJHRH-06-2015-0020. 9 April 2022).
231. Jamil R, Kumar R. Culture, structure, and health: narratives 242. Kunpeuk W, Teekasap P, Kosiyaporn H, Julchoo S, Phaiyarom
of low-income Bangladeshi migrant workers from the United M, Sinam P et al. Understanding the problem of access to
Arab Emirates. Health Commun. 2021;36(11):1297–308. doi:10. public health insurance schemes among cross-border migrants
1080/10410236.2020.1750773. in Thailand through systems thinking. Int J Environ Res Public
Health. 2020;17(14):5113. doi:10.3390/ijerph17145113.
232. Lyles E, Burnham G, Chlela L, Spiegel P, Morlock L, Doocy S
et al. Health service utilisation and adherence to medication 243. Tangcharoensathien V, Thwin AA, Patcharanarumol W.
for hypertension and diabetes among Syrian refugees and Implementing health insurance for migrants, Thailand.
affected host communities in Lebanon. J Diabetes Metab Bull World Health Organ. 2017;95(2):146–51. doi:10.2471/
Disord. 2020;19(2):1245–59. doi:10.1007/s40200-020-00638-6. BLT.16.179606.
233. Hussain AHME, Ahmed M, Vincent JE, Islam J, Sapkota YD, 244. Suphanchaimat R, Putthasri W, Prakongsai P,
Das T et al. Rapid assessment of avoidable blindness and Tangcharoensathien V. Evolution and complexity of government
cataract surgery coverage among forcibly displaced Myanmar policies to protect the health of undocumented/illegal migrants
nationals (Rohingya refugees) in Cox’s Bazar, Bangladesh. in Thailand: the unsolved challenges. Risk Manag Healthc Policy.
PLOS One. 2020;15(12):e0243005. doi:10.1371/journal. 2017;10:49–62. doi:10.2147/RMHP.S130442.
pone.0243005.
245. Pudpong N, Durier N, Julchoo S, Sainam P, Kuttiparambil
234. Ay M, González PA, Delgado RC. The perceived barriers of B, Suphanchaimat R. Assessment of a voluntary non-
access to health care among a group of non-camp Syrian profit health insurance scheme for migrants along the
refugees in Jordan. Int J Health Serv. 2016;46(3):566–89. Thai–Myanmar border: a case study of the migrant fund in
doi:10.1177/0020731416636831. Thailand. Int J Environ Res Public Health. 2019;16(14):2581.
doi:10.3390/ijerph16142581.
235. Tarraf W, Jensen GA, González HM. Impact of Medicare age
eligibility on health spending among US and foreign-born 246. Thailand migration report 2019. Bangkok: United Nations
adults. Health Serv Res. 2016;51(3):846–71. doi:10.1111/1475- Thematic Working Group on Migration in Thailand; 2019
6773.12402. (https://thailand.un.org/sites/default/files/2020-06/Thailand-
Migration-Report-2019.pdf, accessed 1 July 2022).
236. Castillo-Cañón JC, Bojorquez-Chapela I, Fernández-Niño J,
Valbuena-Garcia AM, Acuña-Merchan L. Healthcare-related 247. Suphanchaimat R, Kunpeuk W, Phaiyarom M, Nipaporn S. The
expenditures among immigrants and non-immigrants effects of the health insurance card scheme on out-of-pocket
living with HIV in Colombia. Health Soc Care Community. expenditure among migrants in Ranong Province, Thailand.
2021;29(6):1887–95. doi:10.1111/hsc.13302. Risk Manag Healthc Policy. 2019;12:317–30. doi:10.2147/
RMHP.S219571.
237. Burney NA, Alenezi M, Al-Musallam N, Al-Khayat A. The
demand for medical care services: evidence from Kuwait 248 Saito M, Keereevijit A, San TD, Thein YY, Gilder ME, McGready
based on households’ out-of-pocket expenses. Appl Econ. R. Challenges to primary healthcare services in the
2016;48(28):2636–50. doi:10.1080/00036846.2015.1128073. management of non-communicable diseases in marginalised
populations on the Thailand–Myanmar border: a pilot survey.
238. Zambrano-Barragán P, Ramírez Hernández S, Freier LF, Luzes
Trop Doct. 2018;48(4):273–7. doi:10.1177/0049475518786853.
M, Sobczyk R, Rodríguez A et al. The impact of COVID-19 on
Venezuelan migrants’ access to health: a qualitative study in 249. Loganathan T, Rui D, Pocock NS. Healthcare for migrant
Colombian and Peruvian cities. J Migr Health. 2020;3:100029. workers in destination countries: a comparative qualitative
doi:10.1016/j.jmh.2020.100029. study of China and Malaysia. BMJ Open. 2020;10(12):e039800.
doi:10.1136/bmjopen-2020-039800.
239. Legido-Quigley H, Chuah FLH, Howard N. Southeast Asian
health system challenges and responses to the ‘Andaman 250. Biddle L, Mladovsky P, Bozorgmehr K. Health financing for
Sea refugee crisis’: a qualitative study of health-sector asylum seekers in Europe: three scenarios towards responsive
perspectives from Indonesia, Malaysia, Myanmar, and financing systems. In: Bozorgmehr K, Roberts B, Razum O,
Thailand. PLOS Med. 2020;17(11):e1003143. doi:10.1371/ Biddle L, editors. Health policy and systems responses to
journal.pmed.1003143. forced migration. Cham: Springer International Publishing;
2020:77–98.
242
251. Bozorgmehr K, Razum O. Effect of restricting access to health 262. Migration governance indicators: a global perspective.
care on health expenditures among asylum-seekers and Geneva: International Organization for Migration; 2019
refugees: a quasi-experimental study in Germany, 1994–2013. (https://publications.iom.int/system/files/pdf/mgi-a-global-
PLOS One. 2015;10(7):e0131483. doi:10.1371/journal. perspective.pdf, accessed 3 May 2022).
pone.0131483.
263. Migration data relevant for the COVID-19 pandemic.
252. Bauhoff S, Göpffarth D. Asylum-seekers in Germany differ In: Migration data portal [website]. Berlin: IOM’s Global
from regularly insured in their morbidity, utilizations and costs Migration Data Analysis Centre; 2022 (https://www.
of care. PLOS One. 2018;13(5):e0197881. doi:10.1371/journal. migrationdataportal.org/themes/migration-data-relevant-
pone.0197881. covid-19-pandemic, accessed 3 May 2022).
253. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, 264. The migration governance indicators: success stories.
Stuckler D et al. Financial crisis, austerity, and health in Geneva: International Organization for Migration; 2021
Europe. Lancet. 2013;381(9874):1323–31. doi:10.1016/S0140- (https://publications.iom.int/system/files/pdf/MGI-SUCCESS-
6736(13)60102-6. STORIES.pdf, accessed 9 April 2022).
254. Rosano A, Dauvrin M, Buttigieg SC, Ronda E, Tafforeau J, Dias 265. Migration governance framework (MiGOF). Geneva:
S. Migrant’s access to preventive health services in five EU International Organization for Migration; 2020 (https://www.
countries. BMC Health Serv Res. 2017;17(1):588. doi:10.1186/ iom.int/sites/g/files/tmzbdl486/files/about-iom/migof_
s12913-017-2549-9. brochure_a4_en.pdf, accessed 9 April 2022).
255. Tatah L, Delbiso TD, Rodriguez-Llanes JM, Cuesta JG, 266. Report on the health of refugees and migrants in the WHO
Guha-Sapir D. Impact of refugees on local health systems: a European Region: no public health without refugees and
difference-in-differences analysis in Cameroon. PLOS One. migrant health. Copenhagen: WHO Regional Office for Europe;
2016;11(12):e0168820. doi:10.1371/journal.pone.0168820. 2018 (https://apps.who.int/iris/handle/10665/311347,
256. Cabieses B, Chepo M, Obach A, Espinoza M. Towards universal
coverage for international migrants in Chile: accessibility 267. Indicator: health. In: Migration integration policy index
and acceptability indicators from a multi-methods study. (MIPEX) [online database]. Barcelona: Barcelona Centre for
Medical Research Archives. 2019;7(1):1–20. doi:10.18103/mra. International Affairs; Belgium: Migration Policy Group; 2020
v7i1.1889. (https://www.mipex.eu/health, accessed 9 April 2022).
257. Ortega CMF, Valderrama CG, Melis RP. Políticas públicas 268. Policy indicators: key findings. In: Migration integration policy
y salud en materia de inmigración: puntos críticos en la index (MIPEX) [online database]. Barcelona: Barcelona Centre
accesibilidad del sistema público chileno [Public policies and for International Affairs; Belgium: Migration Policy Group; 2020
immigration health: critical issues in the accessibility of the (https://www.mipex.eu/key-findings, accessed 9 April 2022).
Chilean public system]. Acciones Investig Soc. 2017;37:61–93
269. IOM Ireland rapid policy survey report: the Irish Government’s
(in Spanish). doi:10.26754/ojs_ais/ais.2017372188.
policy response to COVID-19 from a migration governance
258. Wassink JT. Out of sight and uninsured: access to healthcare lens, March 2020 – August 2020. Dublin: International
among US-born minors in Mexico. J Immigr Minor Health. Organization for Migration Ireland; 2020 (https://publications.
2020;22(3):448–55. doi:10.1007/s10903-020-00997-5. iom.int/system/files/pdf/iom-ireland-rapid-policy-survey-
report.pdf, accessed 9 April 2022).
259. Zallman L, Wilson FA, Stimpson JP, Bearse A, Arsenault L,
Dube B et al. Unauthorized immigrants prolong the life of 270. Roche R, Simmons R, Crawshaw AF, Fisher P, Pareek M, Morton
Medicare’s trust fund. J Gen Intern Med. 2016;31(1):122–7. W et al. What do primary care staff know and do about blood
doi:10.1007/s11606-015-3418-z. borne virus testing and care for migrant patients? A national
survey. BMC Public Health. 2021;21(1):336. doi:10.1186/
260. Krishnan N. Coping with the influx: service delivery to Syrian
s12889-020-10068-x.
refugees and hosts in Jordan, Lebanon, and Kurdistan, Iraq.
Washington (DC): World Bank; 2020 (Policy Research Working 271. Hospital treatment for overseas visitors. In: NHS Liverpool
Paper no. 9326; https://openknowledge.worldbank.org/ University Hospitals [website]. Liverpool: NHS Royal Liverpool
handle/10986/34172, accessed 9 April 2022). Hospitals, Royal Liverpool and Broadgreen University
Hospitals Trust; 2022 (https://www.rlbuht.nhs.uk/about-
261. Public health services survey: inclusion of refugees into
the-trust/trust-statements/hospital-treatment-for-overseas-
national health systems [online database]. Geneva: Office of
visitors/, accessed 9 April 2022).
the United Nations High Commissioner for Refugees; 2020
(https://app.powerbi.com/view?r=eyJrIjoiMWQ0OGM4YW 272. Cities of rights: ensuring health care for undocumented
EtNzYxZS00MTVlLTk4ZTItMjk4YzU5NTkwYjhhIiwidCI6ImU residents. Brussels: Platform for International Cooperation
1YzM3OTgxLTY2NjQtNDEzNC04YTBjLTY1NDNkMmFmOD on Undocumented Migrants; 2017 (https://picum.org/wp-
BiZSIsImMiOjh9&pageName=ReportSection, content/uploads/2017/11/CityOfRights_Health_EN.pdf,
accessed 9 April 2022). accessed 9 April 2022).
243
273. Hjern A, Østergaard LS. Migrant children in Europe: 282. Wilson FA, Zallman L, Pagán JA, Ortega AN, Wang Y,
entitlements to health care. Brussels: Models of Child Tatar M. Comparison of use of health care services and
Health Appraised Consortium; European Commission; spending for unauthorized immigrants vs authorized
2016 (https://ec.europa.eu/research/participants/ immigrants or US citizens using a machine learning model.
documents/downloadPublic?documentIds= JAMA Netw Open. 2020;3(12):e2029230. doi:10.1001/
080166e5ac79c440&appId=PPGMS, accessed 9 April 2022). jamanetworkopen.2020.29230.
274. Happle C, Dopfer C, Ernst D, Kleinert E, Vakilzadeh A, Hellms 283. Jarlenski M, Baller J, Borrero S, Bennett WL. Trends in
S et al. Pediatric healthcare utilisation in a large cohort of disparities in low-income children’s health insurance coverage
refugee children entering western Europe during the migrant and access to care by family immigration status. Acad Pediatr.
crisis. Int J Environ Res Public Health. 2019;16(22):4415. 2016;16(2):208–15. doi:10.1016/j.acap.2015.07.008.
doi:10.3390/ijerph16224415.
284. La Spina E. Categorías de exclusión en el acceso a la
275. Rodrígez-Vargas JM, López Jaramillo AM, Vargas-Valle ED. asistencia sanitaria de las personas migrantes en Canadá:
La afiliación al sistema de salud de personas migrantes una perspectiva comparada [Categories of exclusion in
venezolanas en Colombia [The affiliation to the health access to health care for migrants in Canada: a comparative
system among Venezuelan migrants in Colombia]. Rev Poblac perspective]. Rev Derecho Político. 2019;1(105):197–224 (in
Salud En Mesoamérica. 2021;18(2):181–214 (in Spanish). Spanish). doi:10.5944/rdp.105.2019.25271.
doi:10.15517/psm.v18i2.42795.
285. Santacruz JSR, Georg RR, Cubillos AF, Valverde JR, Wiesner
276. Bojorquez-Chapela I, Infante C, Larrea-Schiavon S, MLR, Rodriguez AYR. Realidades migratorias actuales: una
Vieitez-Martinez I. In-transit migrants and asylum seekers: mirada frente a la recepción de la población de venezolanos
inclusion gaps in Mexico’s COVID-19 health policy response. en el contexto Colombiano y sus efectos en la salud [Current
Health Aff (Millwood). 2021;40(7):1154–61. doi:10.1377/ migratory realities: integration of Venezuelan migrants to
hlthaff.2021.00085. the Colombian context and its health impacts]. In: Pardo
MF, editor. América Latina en las dinámicas de la migración
277. Rosa DL, Valdés BC. Acceso a salud de la población migrante
internacional: perspectivas críticas [Latin America and the
internacional en situación irregular: la respuesta del sector salud
dynamics of international migration: critical perspectives].
en Chile [Access to health services for international migrant
Bogotá: Universidad Externo de Colombia; 2019 (in Spanish).
populations in irregular situations: health sector response in
Chile]. Cuad Méd Soc. 2018;58(4):97–108 (in Spanish; https://cms. 286. Jaramillo Vélez LD, García-Juan L. Retos actuales de la
colegiomedico.cl/wp-content/uploads/2019/04/Cuad-Med-Soc- atención sanitaria de la población inmigrante irregular
Chile-2018-58-4-97-108.pdf, accessed 15 April 2022). en Colombia [Current challenges in the health care of
the irregular immigrant population in Colombia]. Rev
278. Política de salud de migrantes internacionales [International
Castell-Manchega Cienc Soc. 2019;25:15–31 (in Spanish).
migrant health policy]. Santiago: Ministry of Health, Chile;
doi:10.20932/barataria.v0i25.472.
2018 (in Spanish; https://www.minsal.cl/wp-content/
uploads/2015/09/2018.01.22.POLITICA-DE-SALUD-DE- 287. Yang S. The public employment service in the Republic of
MIGRANTES.pdf, accessed 15 April 2022). Korea. Geneva: International Labour Organization; 2015
(Employment Working Paper no. 192.
279. Marco de acciones rectoras para el derecho a la salud de las
personas migrantes [Framework of guiding actions for the 288. Cho Y, Denisova A, Yi S, Khadka U. Bilateral arrangement of
right to health of migrants]. San José: Ministry of Health, Costa temporary labor migration: lessons from Korea’s employment
Rica; 2016 (in Spanish; https://www.saludymigracion.org/ permit system. Washington (DC): World Bank; 2018 (https://
system/files/repositorio/4-_marco_de_acciones_rectoras_-_ openknowledge.worldbank.org/handle/10986/30471,
ministerio_de_salud_2016.pdf, accessed 15 April 2022). accessed 9 April 2022).
280. Secretarial Resolution No. 266-2020. Lima: Ministry of Health, 289. Alam N, Kenny B, Maguire JE, McEwen S, Sheel M, Tolosa
Peru; 2020 (in Spanish; https://cdn.www.gob.pe/uploads/ MX. Field epidemiology in action: an Australian perspective
document/file/1399875/RS%20266-2020.pdf.pdf, accessed of epidemic response to the Rohingya health emergencies
15 April 2022). in Cox’s Bazar, Bangladesh. Glob Biosecurity. 2019;1(1).
doi:10.31646/gbio.14.
281. Angier H, Hoopes M, Marino M, Huguet N, Jacobs EA,
Heintzman J et al. Uninsured primary care visit disparities 290. de Laat S, Wahoush O, Jaber R, Khater W, Musoni E, Abu Siam
under the Affordable Care Act. Ann Fam Med. 2017;15(5):434– I et al. A case analysis of partnered research on palliative care
42. doi:10.1370/afm.2125. for refugees in Jordan and Rwanda. Confl Health. 2021;15(1):2.
doi:10.1186/s13031-020-00333-6.
244
291. Sami S, Amsalu R, Dimiti A, Jackson D, Kenyi S, Meyers J et al. 302. Heredia N, Jemio J, Lagos G. Plan Andino de salud personas
Understanding health systems to improve community and migrantes 2019–2022 [Andean Health Plan for Migrants
facility level newborn care among displaced populations in 2019–2022]. Lima: Organismo Andino de Salud Convenio
South Sudan: a mixed methods case study. BMC Pregnancy Hipólito Unanue; 2019 (in Spanish; https://pesquisa.bvsalud.
Childbirth. 2018;18(1):325. doi:10.1186/s12884-018-1953-4. org/portal/resource/pt/biblio-1119476?lang=en, accessed
9 April 2022).
292. Zihindula G, Akintola O, Meyer-Weitz A. How do policy
documents relevant to refugees address issues relating to 303. Republic of Nicaragua profile 2021: migration governance
refugee’s access to health care services in South Africa? Afr indicators. Geneva: International Organization for Migration;
Popul Stud. 2017;31(1). doi:10.11564/31-1-956. 2021 (https://publications.iom.int/system/files/pdf/MGI-%20
Nicaragua-2021.pdf, accessed 1 July 2022).
293. Comprehensive refugee response network [website].
Geneva: Office of the United Nations High Commissioner for 304. South-East Asia/ASEAN Region: annual narrative progress
Refugees (https://www.unhcr.org/uk/comprehensive-refugee- report. Geneva: International Labour Organization; New York:
response-framework-crrf.html, accessed 30 April 2022). United Nations Entity for Gender Equality and Empowerment
of Women; 2019 (https://www.spotlightinitiative.org/
294. Palmer JJ, Robert O, Kansiime F. Including refugees in
sites/default/files/publication/AR2019_SAFEANDFAIR_
disease elimination: challenges observed from a sleeping
spotlightinitiative_FINAL.pdf, accessed 9 April 2022).
sickness programme in Uganda. Confl Health. 2017;11(1):22.
doi:10.1186/s13031-017-0125-x. 305. Refugees receive COVID-19 vaccinations in Jordan. Amman:
Office of the United Nations High Commissioner for Refugees;
295. Masuku S, Rama S. A case study of government and civil
2022 (https://www.unhcr.org/ph/22405-refugees-covid-
societies’ collaboration and challenges in securing the
vaccinations-jordan.html, accessed 16 April 2022).
rights of Congolese refugees living in Pietermaritzburg,
KwaZulu-Natal, South Africa. S Afr J Sci. 2020;116(3–4):6210. 306. COVID-19: WHO EMRO biweekly situation report #1: epi weeks
doi:10.17159/sajs.2020/6210. 1–2 (3–16 January 2021) [website]. Cairo: WHO Regional Office
for the Eastern Mediterranean; 2021 (http://www.emro.who.
296. Vearey J, Thomson K, Sommers T, Sprague C. Analysing local-
int/images/stories/coronavirus/documents/covid_19_bi_
level responses to migration and urban health in Hillbrow:
weekly_sitrep_one.pdf?ua=1, accessed 3 May 2022).
the Johannesburg Migrant Health Forum. BMC Public Health.
2017;17(suppl 3):427. doi:10.1186/s12889-017-4352-2. 307. Bellizzi S, Aidyralieva C, Alsawhala L, Al-Shaikh A, Santoro
A, Profili MC. Vaccination for SARS-CoV-2 of migrants and
297. Lupieri S, Doetter LF. Transnational interdependency and
refugees, Jordan. Bull World Health Organ. 2021;99(9):611.
healthcare system change: the role of humanitarian and
doi:10.2471/BLT.21.285591.
development aid in shaping health policy in Jordan. Glob Soc
Policy. 2020;20(2):192–214. doi:10.1177/1468018119896465. 308. Al-Shaikh A, Muthu N, Aidyralieva C, Profili MC, Bellizzi S.
COVID-19 vaccine roll-out in middle-income countries:
298. Ethiopia: Proclamation No. 11102019. Addis Ababa:
lessons learned from the Jordan experience. Vaccine.
House of People’s Representatives; 2019 (ETH-
2021;39(34):4769–71. doi:10.1016/j.vaccine.2021.06.078.
2019-L-109317; https://www.ilo.org/dyn/natlex/docs/
ELECTRONIC/109317/135566/F-1190510897/ETH109317.pdf, 309. IOM Jordan [website]. Amman: International Organization
accessed 20 June 2022). for Migration; 2021 (https://jordan.iom.int/, accessed
16 April 2022).
299. Ethiopia profile 2019: migration governance indicators.
Geneva: International Organization for Migration; 2019 310. UNHCR continues to support refugees in Jordan
(https://publications.iom.int/system/files/pdf/mgi_ throughout 2019. Amman: Office of the United Nations High
ethiopia_2019.pdf, accessed 9 April 2022). Commissioner for Refugees; 2019 (https://www.unhcr.org/
jo/12449-unhcr-continues-to-support-refugees-in-jordan-
300. Vearey J. Moving forward: why responding to migration,
throughout-2019.html, accessed 16 April 2022).
mobility and HIV in South(ern) Africa is a public health
priority. J Int AIDS Soc. 2018;21(suppl 4):e25137. doi:10.1002/ 311. Where we work: Jordan. Ammam: United Nations Relief and
jia2.25137. Works Agency for Palestine refugees in the Near East; 2022
(https://www.unrwa.org/where-we-work/jordan, accessed
301. Vearey J. Mobility, migration and generalised HIV epidemics: a
3 May 2022).
focus on sub-Saharan Africa. In: Thomas F, editor. Handbook
of migration and health. Cheltenham: Edward Elgar 312. Regional action agenda on achieving the Sustainable
Publishing; 2016. Development Goals in the Western Pacific. Manila: WHO
Regional Office for the Western Pacific; 2017 (https://apps.
who.int/iris/handle/10665/254663, accessed 29 April 2022).
245
313. Regional framework for urban health in the Western Pacific 315. Universal health coverage: moving towards better health.
2016–2020: healthy and resilient cities. Manila: WHO Regional Action framework for the Western Pacific Region. Manila: WHO
Office for the Western Pacific; 2016 (https://apps.who.int/iris/ Regional Office for the Western Pacific; 2016 (http://apps.who.
handle/10665/208321, accessed 29 April 2022). int/iris/handle/10665/246420, accessed 29 April 2022).
314. Western Pacific regional framework for action for disaster
risk management for health. Manila: WHO Regional Office
for the Western Pacific; 2015 (https://apps.who.int/iris/rest/
bitstreams/1246887/retrieve, accessed 29 April 2022).
CHAPTER 5
Mapping progress
towards global
health goals:
an exploratory
review
248
A Ugandan refugee and trained yoga instructor teaches refugees and Kenyans in Kakuma refugee camp alternative ways to maintain
their physical and mental well-being. © UNHCR / Samuel Otieno
Mapping progress towards global health goals: an exploratory review
249
• Data on health care for refugees and migrants are of poor quality because
they are not disaggregated by migratory status, not systematically
collected, not representative of the refugee and migrant populations, and
often are not comparable across countries and over time.
• More and better quality data are urgently needed to monitor the health of
refugees and migrants if many health and health-related SDGs and targets
are to be met.
• Household surveys have improved the methodology and quality of data
over the decades, but clearer definition of “migrants”, more systematic
data collection and data from representative samples are still needed.
5.1 Introduction
"What gets measured, gets done" is an oft-quoted management maxim (1).
When designing the 2030 Agenda for Sustainable Development, global leaders
were mindful that the goals of the 2000 United Nations Millennium Declaration
had lacked clear paths for measuring progress. They, therefore, embedded into
the SDGs not only goals and targets but also the requirement for a follow-up and
review process, or monitoring system (2,3). This gave rise to the SDG indicator
framework (4), developed during 2016–2017 and adopted at the United Nations
General Assembly on 6 July 2017 (5).
Paragraph 75 of the SDG framework clearly articulated this requirement and

entrusted an Inter-Agency and Expert Group on SDG Indicators to develop the
review process and be its custodian. To expedite equitable progress towards all
SDG targets, overarching SDG Target 17.18 calls for countries to undertake data
disaggregation by 2020 in order to fulfil the mandate in the 2030 Agenda for
Target 17.18 (5):
enhance capacity-building support to developing countries, including

for least developed countries and small island developing States, to
increase significantly the availability of high-quality, timely and reliable
data disaggregated by income, gender, age, race, ethnicity, migratory
status, disability, geographic location and other characteristics relevant
in national contexts.
250
When the 2030 Agenda was adopted in the Global Partnership for Sustainable
2015, it set a 2020 deadline for Target 17.18 Development" (5), this must be carried out with
to emphasize the urgency of the issue. It national and international partners.
was intended to allow for 10 years – from
2020 to 2030 – of effective monitoring using This chapter aims to provide illustrative
disaggregated data. examples and focuses on international migrants
as this report is intended to cover this group.
The 2020 deadline came and went, and the However, the analyses in this chapter are limited
world, including high-income countries, because high-quality comparable data are still
missed the target (6). The COVID-19 pandemic lacking, and many policies and programmes
clearly brought additional constraints and are ad hoc and not evidence based. This
limitations to data collection, not least by chapter calls on national and international
seriously disrupting the 2020 round of censuses policy-makers to change the current narrative
and household surveys (7,8). With eight years by moving from small-scale, unrepresentative
remaining until the SDG target date of 2030, and non-comparable data sets to robust,
an unprecedented acceleration of progress comparable and high-quality data, which would
and focused attention are needed to be able allow appropriate decisions to be taken at the
to monitor the health and health-related SDGs local, national, regional and global levels. This
in terms of migratory status. As with all targets move can be made only by understanding
for SDG 17, which are meant to "strengthen the challenges and pitfalls so that they can
the means of implementation and revitalize be addressed and avoided. The examples
In Suriname, following the near elimination of malaria in village communities, the Ministry of Health Malaria Programme has a focused on
malaria transmission in remaining risk populations and areas, including irregular migrants from Brazil working in gold mining areas.
© WHO / PAHO
251
highlighted in this chapter make a convincing

case for strengthening systems for data
collection, evidence gathering and monitoring. Still fewer data are available about
Such strengthening will not only help to meet hard-to-reach populations, such
SDG Target 17.18, albeit late, but also create an
enabling environment to fulfil the promises of as irregular migrants, refugees
the 2030 Agenda and meet all SDG targets, for not living in camps, victims of
all people, including refugees and migrants, and
ensure that no one is left behind. trafficking, deportees, stateless
individuals and people perpetually
5.2 The challenge to meet on the move.
This chapter is both a reminder and a wake-up
call for governments, for national, regional
and international organizations, and for
researchers. Urgent, practical steps need to be harmonizing and analysing data about
taken (9–12). In particular, this chapter makes the health of refugees and migrants; and
the case not only for more data but also for • to discuss potential measures that can
better-quality and more robust data that are be taken.
comparable within and across countries and
over time, encompassing health status and Great strides have been made by household
also the determinants of health. surveys during the past 40 years in generating
comparable data across countries and
With this chapter, WHO aimed to explore and over time, and this chapter highlights the
analyse key data sets to reveal the progress potential for using these data sets to monitor
that has been made towards reaching the SDG the progress made by countries towards
targets for refugees and migrants. However, achieving the many health and health-related
the review underscored a number of gaps and SDG targets.
inconsistencies that made it nearly impossible
to assess this progress. This chapter also provides a strong justification
for why such comprehensive data are essential
Nonetheless, it does mark the first attempt by to monitor progress towards achieving global
WHO to conduct an exploratory review with and national health goals and to promote
the following objectives: the health of refugees and migrants through
an inclusive public health approach. While
• t o disaggregate data from five key the analyses do not provide baseline data for
international surveys1 by health and any specific indicator or target, nonetheless
migratory status in the context of the SDGs; valuable lessons have been learned about
• t o use SDG indicators and reporting the work required to meet the goals and
frameworks as examples to illustrate the aspirations of the global community, including
benefits and challenges of collecting, refugees and migrants.
1
The surveys analysed included both internal and international migrants, but this chapter only covers the data for international migrants.
252
The chapter concludes with a discussion of for all at all ages), widely known as the health
how the availability and usefulness of such SDG, at least nine others are directly related to
data might be increased in preparation for health (Table 5.1).
essential tasks, such as formulating policies
and designing programmes (Box 5.1). 5.2.2 The SDGs and population
movement
5.2.1 Making the health of refugees The impact of population movement on
and migrants visible in major development is widely recognized, yet there
data sets remains a dearth of routinely collected
As described in Box 5.1, disaggregating data systematic and representative data and
into smaller units allows underlying trends, evidence about the health of refugees and
patterns and inequities to be analysed migrants at local, national, regional and
with greater precision and clarity (13). The global levels (15–17). Therefore, refugees
benefits of disaggregation range from more and migrants are largely invisible in official
accurately monitoring progress, which allows data relating to the SDGs that are relevant to
interventions to be targeted towards attaining health. As 2030 approaches, little is known
goals, to conducting health situation analyses about whether efforts to meet SDG 3 are
for subgroups in a population, to timely improving the health of refugee and migrant
problem detection and to improved targeting populations or to what extent they are being
of resources and improved implementation left behind (18). Still fewer data are available
and evaluations of programmes. about hard-to-reach populations, such as
irregular migrants, refugees not living in
The 17 SDGs in the 2030 Agenda are interlinked camps, victims of trafficking, deportees,
and interdependent across the spectrum of stateless individuals and people perpetually
development needs (14). In addition to SDG 3 on the move.
(ensure healthy lives and promote well-being
Box 5.1.
Big picture versus full picture
When data are aggregated, they provide a big picture.
The focus on the promise in the 2030 Agenda for Sustainable Development to leave no one behind has
highlighted a problem: the big picture does not always portray the full picture. That is, the actual living
conditions of vulnerable people are hidden, such as people with disabilities, people living with precarious
health conditions (e.g. HIV or AIDS), indigenous peoples, undocumented (or irregular) migrants, religious
minorities, refugees, the uninsured, elderly people, those who are internally displaced and those who
are in vulnerable working conditions, among others; sometimes the oversight is inadvertent, but at other
times, it occurs deliberately, such as through information suppression.
Source: Asian Development Bank (13).

253
Table 5.1. The SDGs most directly related to global healtha
Interlinkages between SDG 3 and other Interlinkage between SDGs and targets and
SDG 3 SDGs within the current framework indicators within the current framework
Ensure healthy lives and promote 1. No poverty 1.1, 1.2, 1.3, 1.4, 1.5, 1.a, 1.b
well-being for all at all ages
2. Zero hunger 2.1, 2.2
4. Quality education 4.1, 4.2, 4.3, 4.7
5. Gender equality 5.1, 5.2, 5.3, 5.6, 5.c
6. Clean water and sanitation 6.1, 6.2, 6.3, 6.4, 6.a, 6.b
7. Affordable and clean energy 7.1
8. Decent work and economic growth 8.1, 8.3, 8.5, 8.6, 8.7, 8.8
9. Industry, innovation and infrastructure 9.1, 9.c
10. Reduced inequalities 10.1, 10.2, 10.3, 10.4, 10.7
11. Sustainable cities and communities 11.1, 11.2, 11.3, 11.5, 11.6, 11.7, 11.b
12. Responsible consumption and

12.4
production
13. Climate action 13.1, 13.3
14. Life below water 14.1, 14.2
16.1, 16.2, 16.3, 16.4, 16.6, 16.7, 16.9,

16. Peace, justice and strong institutions
16.10, 16.a
17. Partnerships for the goals 17.13, 17.16, 17.18
a
Red indicates indirect interlinkage.
Source: Inter-Agency and Expert Group on Sustainable Development Goal Indicators (14).
The 2030 Agenda makes clear that refugees through the implementation of planned and
and migrants are included in the overall well-managed migration policies). However,
principle of leaving no one behind (5). Target 17.18 applies specific SDG targets to all
Paragraph 29 acknowledges the importance populations, making all outcome indicators
of migrants in global development, while relevant to all groups, including refugees
paragraph 23 recognizes the vulnerability of and migrants.
"refugees and internally displaced persons
and migrants" (5). However, only two targets 5.2.3 Moving forward on
in the SDG framework can be directly tied to disaggregation
improving the health of refugees and migrants: The indicators set out in Target 17.18 were
Target 8.8 (protect labour rights and promote revised during the 2020 comprehensive
safe and secure working environments for review by the United Nations Statistical
all workers, including migrant workers, in Commission (19), which focused on national
particular women migrants, and those in capacities, legislation and plans and
precarious employment) and Target 10.7 introduced 36 major changes to the 2017
(facilitate orderly, safe, regular and responsible framework (4). The need for improvements
migration and mobility of people, including was also emphasized by the Global compact
254
on refugees and the Global compact for safe, (18), the IOM builds on the work of its Global
orderly and regular migration (11,12). Migration Data Analysis Centre, highlighting
the case for identifying migrants within
WHO supports monitoring of the SDG targets large data sets and exploring how to work
through the Inter-Agency and Expert Group on with specific indicators, including data
SDG Indicators. sources. The potential for digging deep
into large data sets was demonstrated by
In the IOM's 2020 institutional strategy on disaggregating data on migratory status from
migration and sustainable development data in IPUMS, a large, accessible database
and its migration data strategy (17,20), containing census and other population
the Organization provides guidance on data from more than 100 countries (21). This
disaggregating SDG indicators by migratory study disaggregated information about SDG
status. These publications are intended to help Indicator 8.6.1 (the proportion of youth not
governments and institutions to take practical, in employment, education or training) from
low-cost steps to disaggregate data across census data using the variables "nativity",
sectors by migratory status; the strategies "native-born" or "foreign-born" as indicators
provide examples and highlight special of migratory status. Although the study
considerations relevant to the health-related was not focused directly on health but on
SDG targets. determinants of health, it illustrates the
potential for disaggregating data relevant to
In a pilot study, Leave no migrant behind: determinants of health from large databases.
the 2030 Agenda and data disaggregation
Two nurses go over patient files in the labour ward of Mama Lucy Kibaki Hospital in Nairobi, Kenya. © WHO / Khadija Farah
255
5.3 Review methodology further analysis when this review was carried
out. However, for reasons related to data
The review conducted for this chapter began validity and representativeness (Annex), only
by considering which large data sets to 28 countries could be included fully in the
explore. The Multiple Indicator Cluster Survey review. However, six that had been excluded
(MICS) round 6 (MICS6) and the Demographic because their survey provided data only for
and Health Survey (DHS) phase VII (DHS-VII) female respondents (but satisfied all other
were clear choices because these global data criteria) were included in Tables 5.7–5.10,
sets allow for intercountry comparability and which discuss gender-specific issues (Box 5.2).
offer the potential to disaggregate outcomes Although the review generated a number of
about health and various determinants of detailed data tables, only those are shown
health by migratory status. The review also for which it is possible to present clearly the
included data from the European Social potentials and limitations of the data.
Survey (ESS), the Programme for International
Student Assessment (PISA) and the Other data sources were also considered, such
Household Survey Databank (Banco de Datos as censuses, civil registration and vital statistics
de Encuestas de Hogares; BADEHOG), all of systems and the administrative data produced
which provide sociodemographic details that by national HIS. However, these often have
constitute key determinants of health. PISA issues related to accessibility and comparability
provides self-reported data related to mental across countries and over time. Additionally,
health, and the ESS includes self-reporting on some presented problems regarding privacy
health and limiting long-term illness. – particularly concerns that data collected by
tracking health information using migratory
A more detailed discussion of the review status could be misused – and data security,
methodology, including its limitations and as well as a lack of disaggregation of health
potential, is presented in the Annex. information and concerns about interoperability
across national and global levels and between
5.3.1 Criteria for inclusion various agencies and organizations (22,23).
The following criteria were used to determine
which countries and surveys would be Nonetheless, a comprehensive review of
included in this review; to be included: all major data sets from across the world
• survey data and documentation needed to can shed light on health and migration,
be available in English; whether about determinants, health status
• the survey reference period had to be from or health systems, and this is of paramount
2015 and onwards, to capture the most importance to get a true picture of the health
recent trends; of refugees and migrants: their health issues,
• the percentage of international migrants the challenges they face and how to overcome
in the total sample (of internal and them. Such studies are time and resource
international migrants) had to be at intensive but must be prioritized to develop
least 1%, in order to conduct meaningful a robust data and monitoring framework for
analyses. health and migration. Only the development of
such a framework will permit decision-makers
A total of 77 candidate countries had to confidently address the issues, determine
conducted MICS6 and DHS-VII and had which policies need introducing or changing,
data available online for downloading for and which types of intervention are needed.
256
Box 5.2.
Countries included in the exploratory review, by WHO region
African Region Region of the Americas Additional countries added

Benin Guyana to gender-specific analyses
Burundi Suriname Argentina
Cameroon Chile
Central African Republic South-East Asia Region Colombia
Chad Indonesia Costa Rica
Ethiopia Nepal Dominican Republic
Gambia Thailand Ecuador
Ghana
Guinea European Region
Guinea-Bissau Armenia
Lesotho Kosovoa
Liberia Montenegro
Malawi
Mali Eastern Mediterranean Region
Sao Tome and Principe Jordan
Sierra Leone
Togo Western Pacific Region
Zimbabwe Tonga
a
All references to Kosovo in this document should be understood to be in the context of the United Nations Security Council resolution 1244 (1999).
5.3.2 Data limitations over time and across countries. However,

The tables are presented only for illustrative questions on migratory status were added
purposes, and they should be reviewed only relatively recently, since the New York
with close attention paid to the caveats declaration for refugees and migrants of 2016
and limitations of the data, such as in terms (10), and they present a number of limitations.
of sample size, representativeness and
definitional and other issues. Note also that The DHS and MICS are the largest surveys and
the numbers in the tables do not always sum are not carried out in the countries that are
to 28 or 34 (28 plus 6) because data for some the most typical destinations for international
of the chosen indicators were not available for migrants – that is, those higher-income
all 28 countries. nations from which the greatest amount of
research on refugees and migrants is available
None of the surveys was originally designed (Chapter 1, Table 1.2). Some of these nations
to investigate population movement, but all, are included in the BADEHOG, ESS and PISA
in different ways, strive to provide important surveys. However, the health and health-
information about international migration. In related variables available in these surveys are
particular, questions in the DHS and MICS have relatively sparse compared with those in the
been refined and harmonized to be comparable MICS and DHS.
257
Data in some of the tables may reflect results

that are not fully aligned with the findings
reported in Chapters 2–4, which are based Alternative data collection
on a global literature review. It is difficult to approaches might also need to be
provide a comprehensive explanation for the
lack of alignment because of the limited data considered. For example, if refugees
available from global surveys and a lack of are living in camps, then data
information about how international migrants
were sampled and recruited for the DHS and might need to be collected directly
MICS. The majority of the studies in the global from the camps and not through
literature review were from the high-income
countries that are the traditional destinations
household surveys.
(Annex, Fig. A.1), whereas the majority of the
data analysed in this chapter are not from these
destination countries. This could be why the
results are not completely aligned with those in Survey completeness poses another
Chapters 2–4. However, because of the limited challenge. It is only recently that surveys have
data, it is not possible to conclude whether started to collect data that specifically track
such inconsistencies are the result of data- international migration – and such data are
quality issues or are an accurate reflection of the not collected in all countries. When the data
health of refugees and migrants residing in the are collected, surveys may not yield a sample
countries presented in the tables. The definitive size that is statistically valid and representative
answers to such questions need to be explored of the refugee and migrant populations
through further research and data that are residing in a country. Statistical validity is
collected systematically and routinely. even harder to achieve when disaggregating
by migratory status and by other dimensions,
Similarly, the proportion of international such as disability or occupation. The
migrants in the included surveys does not unknowns associated with irregular migration
always reflect the actual proportions as also add an element of difficulty to ensuring
reported in the global estimates produced by data are complete.
UNDESA. Since 1990 UNDESA has published
periodic estimates of the total number of The questions asked in the two major
international migrants ("stock") by country household surveys may obscure some
or area of destination and origin and by age dimensions of migration due to a lack of
and sex. Most of the data used by UNDESA clarity (see the definitions in section 5.3.3).
to estimate the total number of migrants by However, these data are still interesting, since
country or area are obtained from population respondents have been migrants recently.
censuses, but population registers and Consequently, the DHS and MICS present
nationally representative surveys are also used a good global data set if the focus is on the
(24). In some countries, such as Gambia and experience of migration and not current
Togo, the proportion of international migrants migratory status, which has implications for
reported in the MICS6 and DHS-VII is higher than access to health care and social services. No
that reported by UNDESA. However, for most information about when migration might
countries, UNDESA reports lower proportions of have occurred is collected. Neither survey
international migrants. provides consistent representation from all
258
regions. Despite these challenges, the MICS Overall, the populations and data covered by the
and DHS present the largest global data set MICS6, DHS-VII, ESS, PISA and BADEHOG surveys
that includes international migrants. (A more are wide and diverse (Table 5.2). The greatest
detailed discussion of the sampling strategies representation of countries in the WHO African
of the two surveys is presented in Box 5.3.) Region is in the MICS6 and DHS-VII surveys,
which include 18 sub-Saharan countries.
Box 5.3.
Sampling in the Multiple Indicator Cluster Survey and Demographic and Health Survey
and ways to ensure that refugees and migrants are included
The Multiple Indicator Cluster Survey (MICS) and Demographic and Health Survey (DHS) household
sample surveys have become key sources of data on social phenomena since the 1980s. They are
among the most flexible methods of data collection. In theory, almost any population-based topic can
be investigated through household surveys. It is common for households to be used as second-stage
sampling units in most area-based sampling strategies. In sample surveys, part of the population is
selected and observations are made or data are collected, and then inferences are made from this
part to the whole population. Because sample surveys entail smaller workloads for interviewers and
allow more time for data collection, most topics can be covered in greater detail than in censuses (25).
A probability sample can be drawn only from an existing sampling frame that contains a complete
list of statistical units in the target population. Since constructing a new sampling frame is likely to be
expensive, household surveys should use an adequate pre-existing sampling frame that is officially
recognized. This is possible where there has recently been a population census. Census frames generally
provide the best sampling frame in terms of coverage, cartographic materials and organization. In the
absence of a census frame, a household survey can use an alternative, such as a complete list of villages
or communities in the country that includes a measure of population size (e.g. number of households)
and all necessary identification information or a master sample that is large enough to support the
survey design (26). However, this is an expensive alternative. The sampling frame used for the global
surveys is often not representative of all population groups. Additionally, migrants are a heterogeneous
group (e.g. in terms of migratory status, country of origin, reason for migration) and that heterogeneity
needs to be reflected in a sampling frame in order to address their health needs adequately.
If a representative sample of refugees and migrants is not included in the traditional sampling frame,
then a different frame must be generated from untraditional sources, such as estimates and data from
immigration authorities. Alternative data collection approaches might also need to be considered. For
example, if refugees are living in camps, then data might need to be collected directly from the camps and
not through household surveys. Similarly, for irregular migrants and other migrant groups, oversampling
or purposive sampling should be integrated into the survey design, as often these groups are missing
from the census frame. Surveys of populations that are hard to identify or are not willing or able to take
part in surveys, or both, have been the object of methodological reflection (27). Various methods aimed at
producing a sample that can be extrapolated from these populations have been proposed, such as time–
space or time–location sampling, respondent-driven sampling and the capture–recapture method (28).
259
Table 5.2. Data from the DHS-VII, MICS6, ESS, PISA and BADEHOG surveys
Survey (years covered) Area Survey population
DHS-VII, MICS6 (2015 to 2020) World Households
ESS (every 2 years from 2002 to 2018) Europe and central Asia People aged ≥15 years who live in a private
household, regardless of their nationality,
citizenship, primary language or legal status
PISA (2018) World Students aged 15 years and 3 (completed)

months and 16 years and 2 (completed)
months at the start of the survey period,
who are attending educational institutions
located within the country and are in
grade 7 or higher
BADEHOG (2018 to 2019) United Nations Economic Commission Households

for Latin America
The high-income countries that are often definition is statistical and aimed at bringing
the destination for international migrants clarity to data collection and analysis (30,31).
normally do not conduct household surveys, IOM's definition of a migrant as "a person
but they use other methods, and health data who moves away from his or her place of
usually come from administrative records. usual residence, whether within a country or
Since data from administrative records often across an international border, temporarily
are not comparable across countries and or permanently, and for a variety of reasons"
over time, this report did not consider these. focuses on movement, regardless of the
Future reports should consider both types of geography, time or reason for migration (30).
data set, as well as innovative data sources. UNDESA focuses on movement from a person's
This chapter is intended to demonstrate "usual residence" and provides separate
the power of household surveys to elicit definitions for short-term and long-term
information about health and migration. migrants (31). National statistical professionals
across the world have not yet come to a clear
5.3.3 Definitions consensus on these important definitions.
Identifying a person as a international migrant
is challenging for global surveys since people The questions used by the surveys featured in
on the move may be defined differently by this illustrative review to identify and define
different countries and organizations. While migratory status also vary significantly.
refugee status is clear due to its definition in
the 1951 Geneva Convention (Chapter 1), there The MICS6 and DHS-VII classify two types
is no global consensus on the definition of of migratory status: international migrant
migrant (29). and non-migrant (which includes internal
migrants). For MICS, international migrants
The definitions used by IOM and UNDESA refer to those who choose "overseas/outside
provide good examples. The IOM's definition of country" in response to the variable "place
is an operational aid for discussing and of living prior to moving to current place" and
raising the challenges connected to migration "province prior to moving to current place". In
and gathering information; the UNDESA the DHS, international migrants are those who
260
choose "abroad" in response to the variable The ESS uses the variable "citizen of country"
"region of previous residence". The surveys use to classify international and non-international
different variables to identify non-migrants: migrants. However, further disaggregation is not
the MICS uses "duration of living in current possible because both internal migrants and
place" and the DHS uses "years lived in place non-migrants are referred to as non-migrants.
of residence". In the MICS, respondents who
answer "always/since birth" are included BADEHOG indicators vary slightly between
as non-migrants. Time is not considered as survey countries in Latin America and the
a variable in all classifications. One of the Caribbean. Most ask "Where were you born?",
ambiguities that arises in the way that the with values that include terms such as
DHS and MICS record migratory status can be bordering country, other country or outside
seen in the DHS survey question, "Before you of the country. Uruguay's ongoing household
moved here, which [province/region/state] survey of 2019 (known as ECH 2019) takes a
did you live in?" The equivalent question in different approach in question E37, seeking to
the MICS is, "Before you moved here, in which determine the "immediate place of residence
region did you live?" It is possible for this after birth" and offering the choice "foreign
indicator to capture people who are currently residence at birth". While this establishes
not international migrants, such as returning respondents’ migratory status, it does not
citizen migrants – that is, people who are necessarily reflect their citizenship.
citizens of the country where they are staying
or people who acquired citizenship in the One major survey, Afrobarometer, could not be
country where they are residing. included in this review because of the unclear
question regarding migratory status: "During
PISA includes an indicator of migratory status the past three years, have you or anyone in
with the values "native, second generation, your household gone to live in another country
first generation". In this review, native has been outside [name of country] for more than three
changed to non-migrant to ensure consistency months?" A yes answer to this question would
in reporting the results from various surveys. capture both returning citizens and left-behind
First-generation migrant students are foreign- families who have or had an international
born students whose parents are both also migrant household member.
foreign born. Second-generation migrant
students are born in the country where they The term host population in Tables 5.4–5.11
sat the PISA test and whose parents are both includes individuals who are not
foreign born. Information on citizenship is not international migrants (internal migrants,
collected in the survey. For the purposes of where data available, and individuals that
this review, second-generation students are are not migrants).
not considered migrants since they have not
moved across a border, although they may not Table 5.3 summarizes the questions used by
necessarily be citizens of the country where the surveys featured in this illustrative review
they live. (In a related issue, even if second- to identify and define migratory status.
generation migrants – that is, descendants of
migrants – are citizens, they may continue to
face challenges similar to those suffered by their
migrant peers, such as discrimination.)
261
Table 5.3. Questions and variables used in surveys to identify migratory status
Variable name or number, Response used to

Survey label and question Response choices assess migratory status
MICS6 WB15/MW15: Duration of living in current place No. of years Always/since birth
Question: How long have you been 95 = Always/since birth (to identify non-migrants)
continuously living in [name of current city, 99 = No response
town or village of residence]?
WB16/MW16: Place of living prior to moving to 1 = City/urban Overseas/outside of country

current place 2 = Town (international migrants)
Question: Just before you moved here, did you 3 = Rural area City/town in the country
live in a city, in a town or in a rural area? Overseas/outside of (internal migrants)
(Note: used only by Gambia and Togo; other country
countries or areas used WB17/MWB17)
WB17/MWB17: Province prior to moving to Places in the country Overseas/outside of country

current place 96 = Outside of (country), (international migrants)
Question: Before you moved here, which specify/overseas Places in the country
region did you live in? (internal migrants)
DHS-VII V104/MV104: Years lived in place of residence No. of years Always

Question: How long have you been living 95 = Always (non-migrants)
continuously in [name of current city, town or 96 = Visitor
village of residence]? 97 = Inconsistent
98 = Don't know
V105A/MV105A: Region of previous residence Regions of the country Abroad

Question: Before you moved here, which 96 = Abroad (international migrants)
[province/region/state] did you live in? Regions of the country
(internal migrants)
ESS Ctzcntr: Citizen of country Yes Yes (non-international migrant)

No No (international migrant)
PISA IMMIG: Index immigration status Native, second generation, Native (non-immigrant)
first generation First- and second-generation
(international migrant)
Examples of surveys included in BADEHOG
Argentina (EPH 2019) CH15: Where were you born? Bordering country/other Born outside of the country
country
Colombia (GEIH 2019) P756S3: Where were you born? Other countries Born outside of the country
Uruguay (ECH 2019) E37: Immediate place of residence after birth Other country Foreign residence at birth

ECH: Continuous Household Survey (Encuesta Continua de Hogares); EPH: Permanent Household Survey (Encuesta Permanente de Hogares); GEIH: Comprehensive Survey of
Household (Gran Encuesta Integrada de Hogares).
5.4 Review results The review found useful data regarding four
categories of key socioeconomic determinants:
Major determinants of refugee and migrant housing, access to health insurance, access
health include a number of factors, from the to health care services and WASH. These
environment (e.g. air quality and water quality) determinants touch directly on SDGs 1 (poverty),
to the migratory status of these populations 3 (health), 4 (education), 6 (water and sanitation)
as defined by national legislation (Chapter 2). and 11 (sustainable cities and communities).
262
5.4.1 Housing Caribbean covered by the surveys, a relatively

As discussed in Chapter 2, housing conditions larger proportion of international migrants
are critical to the health outcomes of refugees tended to live in households where three
and migrants, with determinants ranging or more people shared a bedroom. In a few
from construction quality to forms of tenure countries, this proportion is strikingly higher
and numbers of people sharing dwellings for international migrants. However, two
(32,33). There is also a significant gender countries, Panama and Paraguay, showed
consideration, given the location- and the opposite pattern: a higher proportion of
building-related risks of violence to women non-migrants lived in households where three
and girls and the difficulty of finding safe or more people shared a bedroom. Additional
private places for managing menstruation research is needed to determine whether this
when living in tents, multihousehold dwellings, reflects reality or issues with sampling, as
unfinished buildings or communal spaces (34). highlighted above.
The BADEHOG surveys ask about over- Table 5.4 shows that, generally, a higher
crowding as measured by the number of proportion of international migrants experience
people sleeping in a single bedroom overcrowding than their host counterparts
(Table 5.4). This can be important as do. In Chile, international migrants experience
overcrowding can increase the risk of overcrowding more frequently than the local
transmission of communicable diseases, population, in addition to residing in smaller
lead to greater levels of violence and living quarters with few security measures (38).
mental health issues, and generally reduce Violence is compounded by overcrowding,
the quality of life (36,37). In seven of the and migrants, especially international migrant
nine countries in Latin America and the women, face a higher risk of violence as well
Table 5.4. Percentages of households with three or more people per bedroom in the BADEHOG studies, by
migratory status, 2017, 2018 and 2019
% of households with ≥3 people/bedroom, both sexes
Country or area Survey year International migrant Host population
Argentina 2019 31.1 29.1
Chile 2017 18.3 4.1
Colombia 2019 51.4 20.5
Costa Rica 2018 15.5 6.0
Dominican Republic 2019 49.3 12.4
Ecuador 2019 29.5 25.0
Panama 2019 14.8 21.7
Paraguay 2018 18.7 33.5
Uruguay 2019 13.5 10.0
Source: United Nations Economic Commission for Latin America and the Caribbean (35).
263
Girls play outside their cabin at a centre for migrants in Sweden. © WHO / Malin Bring
as unsuitable housing conditions than non- 5.4.2 Health insurance

migrant populations (39). Such conditions are Health financing arrangements vary from
linked to poor health outcomes, and findings country to country, with a vast range of public,
from Peru indicate overcrowding (defined as private and mixed systems. They control
four or more people living in one room) among people's access to needed treatment and
Venezuelan migrants is linked to poor quality of services, with some providing shelter from
life, relapse of chronic diseases and a variety of financial catastrophe in the event of accident
mental health issues (40). In Costa Rica, a high or disease (46). In many countries, health care
proportion of international migrants experience is largely paid for out of pocket.
overcrowding, and this is a top risk factor for TB
among them (41). Irregular migrant workers are in a particularly
vulnerable situation because their access
Globally, migrant workers often live in to social security can be reduced by
dormitories or camps established by their their migratory status, lack of freedom
employers, while refugees may live in crowded of association, isolation, exclusion and
camps, and these conditions increase the risk xenophobia. The only international instrument
of transmission of communicable diseases explicitly referring to the right of irregular
(42–44). Farmworkers in the United States, migrants to social security is ILO Convention
for example, often live in family or communal No. 143 (Article 9.1), which stipulates that
dwellings judged to have poor conditions irregular migrant workers shall have the same
(including overcrowding, mould, mildew and rights as other groups of migrant workers
structural deficiencies) or in encampments, concerning social security benefits arising from
and both of these living situations are linked to past employment (47).
adverse health outcomes (45).
264
Among the surveys reviewed and analysed, Malaysia, Myanmar and Thailand (52). The
the health insurance variable was found to be 2019 data from the MCIS6 in Nepal highlighted
a good proxy for the financial risk protection the low coverage of health insurance among
indicator in SDG Target 3.8. Despite welcome host and migrant populations alike. Further,
examples of UHC, notably in Thailand the literature indicates that more recently
(Chapter 4), in 15 of 25 countries covered by these figures are likely to have been impacted
the MICS6 and DHS-VII surveys, international by the COVID-19 pandemic, especially
migrants were considerably less likely to considering that Nepal is a country that sends
have health insurance coverage than the host large numbers of migrant workers abroad.
populations. This was also true in eight of the Roughly 1 million Nepalese workers sought
nine selected Latin America and Caribbean to return from their host countries during the
countries in the BADEHOG databank pandemic, placing a strain on Nepal's health
(Table 5.5). The higher coverage among system as the demand for services increased
international migrants in some countries with the sudden influx of returned migrants
might be a result of health insurance being (53,54). In Thailand, the national Government
required as part of a visa application in which communicated publicly that all migrants,
employers or migrants themselves have to pay regardless of their legal status, could access
for a visa or residence permit (48,49). COVID-19 testing and treatment without
financial barriers; however, this messaging was
As indicated in Chapter 4, there are a variety of inconsistent due to limitations that included
reasons for lower coverage among migrants, a lack of coordination and communication
including the need for nationality verification, between departments and across HIS (55).
ambiguous policy messages, administrative
delays in the enrollment process, resistance of In Latin America, similar to the findings from
employers to hiring migrants and the voluntary the household surveys, research shows that
or semivoluntary nature of a health insurance lower proportions of migrants have health
system. Some of these factors may be beyond insurance than do non-migrants. Several
the control of migrants (e.g. nationality countries, including Chile, Colombia and
verification requires communication between Mexico, have fragmented health systems that
various ministries). Even when policy measures are divided between the public and private
are in place to provide health insurance and sectors, leaving many migrants insufficiently
ensure UHC, gaps in coverage may remain. covered by the public sector through barriers
This should be taken into consideration by such as a lack of employment and financial
countries that already have policies and resources, and migratory status (56–59).
by countries that are planning to integrate
additional measures. A strategy to close these Data from 2018 indicate that only 24.5%
coverage gaps includes having migrants of Venezuelan migrants in Colombia were
volunteer as health communicators directly affiliated with the health insurance system
in their communities to promote and increase compared with 93% of those born in
health insurance coverage (46,50,51). Colombia, and this trend was stronger among
recently arrived migrants (60).
A study conducted among health sector
representatives identified financial constraints In Chile, migrants are 7.5 times more likely to
as a primary challenge to meeting the health report not having health insurance than the
needs of international migrants in Indonesia, Chilean-born population (61). Social factors
265
Table 5.5. Health insurance coverage, by migratory status
% with health insurance coverage
Country or area Survey Year(s) International migrants Host population
Argentina BADEHOG 2019 57.7 68.7
Armenia DHS-VII 2015–2016 8.4 8.3
Benin DHS-VII 2017–2018 1.1 1.3
Burundi DHS-VII 2016–2017 21.6 23.2
Cameroon DHS-VII 2018 6.6 3.0
Central African Republic MICS6 2018–2019 1.6 0.7
Chad MICS6 2019 3.3 0.3
Chile BADEHOG 2017 68.7 73.6
Colombia BADEHOG 2019 13.4 46.3
Costa Rica BADEHOG 2018 63.0 83.6
Dominican Republic BADEHOG 2019 17.9 46.9
Ecuador BADEHOG 2019 27.7 36.1
Ethiopia DHS-VII 2016 6.2 4.8
Gambia MICS6 2018 1.3 2.0
Ghana MICS6 2017–2018 43.2 53.2
Guinea DHS-VII 2018 3.0 1.6
Guinea-Bissau MICS6 2018–2019 0.8 0.8
Guyana MICS6 2019–2020 14.6 19.9
Indonesia DHS-VII 2017 50.5 61.3
Kosovo a
MICS6 2019–2020 13.3 6.8
Liberia DHS-VII 2019–2020 3.5 4.6
Malawi DHS-VII 2015–2016 1.7 1.6
Mali DHS-VII 2018 5.2 5.1
Nepal MICS6 2019 3.6 5.8
Panama BADEHOG 2019 28.3 47.2
Paraguay BADEHOG 2018 26.5 27.0
Sao Tome and Principe MICS6 2019 7.7 1.3
Sierra Leone DHS-VII 2019 3.8 5.3
Suriname MICS6 2018 52.6 71.5
Thailand MICS6 2019 41.9 98.0
Togo MICS6 2017 2.3 5.3
Tonga MICS6 2019 69.5 79.4
Uruguay BADEHOG 2019 82.0 80.9
Zimbabwe MICS6 2019 5.3 6.0
a
266
may also influence how migrants seek health coverage but also an effective marker
insurance while in host countries, potentially indicating that vital health services are not
explaining part of the gap between health reaching populations most at risk. Data from
insurance coverage among migrants and 8 of 15 countries or areas indicate that the
non-migrants. In Costa Rica, perceptions percentage of international migrant children
in the migrant community of not being who received measles vaccine was lower
members of or being disaffiliated from society than that of children in the host
are challenges to accessing health care, population (Table 5.6).
highlighting the role that social integration
and community building play (62). Migrant children often are faced with less
consistent and less timely access to vaccines
5.4.3 Health and access to compared with non-migrant children. The
health care services obstacles include weak vaccine coverage
As a measure of progress made in pursuit of assessmen upon entry into a country, living in
the SDGs, access to health care services covers border areas with highly mobile transborder
a number of dimensions. This review looked populations, incomplete migrant-specific data
at four of these dimensions: child health, in immunization registers, language barriers and
nutrition, maternal care and FGM, and low levels of health literacy among caregivers or
mental health. lack of knowledge about how to access vaccines
(63–65). Policies and immunization programmes
Children's health: access to vaccines. This in some countries in the WHO European
report discusses the health of migrant children Region, for example, may also lack specific
in selected countries using the major indicator recommendations for immunizing migrants
of access to vaccines. This corresponds most (66). Among displaced and mobile populations,
closely to SDG 2 (end hunger, achieve food estimating vaccine coverage is particularly
security and improved nutrition and promote challenging, as is providing accessible routine
sustainable agriculture) and SDG 3 (ensure vaccination services in hard-to-reach areas
healthy lives and promote well-being for all (67,68). However, high immunization coverage
at all ages). has been possible in such contexts, as
evidenced by the Thai National Immunization
Immunization of children plays a key role in Programme, which has delivered high
ensuring healthy lives and well-being, and vaccination rates for children in hard-to-reach
in protecting communities. It is pivotal to border regions, including with BCG, three doses
achieving the SDGs, especially in low- and of OPV and measles vaccines (69).
middle-income countries. The MICS6 and
DHS-VII surveys provide data on five vaccines A specific barrier for irregular migrants and
received by children who are international their children may be a lack of firewalls
migrants and children in host populations in between the data systems of service providers
countries for which data are available. Measles and those of immigration authorities. If
vaccination coverage provides a good example. families are in an irregular migration situation,
they may fear arrest, detention or deportation
Measles is caused by one of the world's most if they are detected by the authorities. For
contagious human viruses, and measles this reason, they may avoid service providers,
transmission within a community is not only including approaching health providers for
a clear indicator of poor measles vaccination routine immunization (70).
267
5.4.4 Health services and Contraception. The data from the global
protective interventions surveys indicate that a slightly greater
SDG 5 aims to "achieve gender equality and proportion of female international migrants
empower all women and girls", emphasizing in the surveyed countries used traditional
caring for mothers and ensuring the ability of methods of contraception (e.g. periodic
females aged 15–49 years to make informed abstinence, withdrawal or folk remedies)
decisions about their SRH. compared with non-migrant women, whereas
Table 5.6. Percentage of children who received measles vaccine, by migratory status
% of children receiving measles vaccine
Country or area Surveya Year(s) International migrants Host population
Benin DHS-VII 2017–2018 45.0 47.5
Burundi DHS-VII 2016–2017 63.0 69.3
Cameroon DHS-VII 2018 32.7 49.9
Central African Republicb MICS6 2018–2019 55.6 54.2
Ethiopia DHS-VII 2016 39.7 41.3
Gambiab MICS6 2018 86.7 85.0
Guinea DHS-VII 2018 37.1 30.5
Indonesia DHS-VII 2017 68.9 59.3
Jordan DHS-VII 2017–2018 54.5 55.3
Liberia DHS-VII 2019–2020 56.3 51.1
Malawi DHS-VII 2015–2016 65.9 68.8
Mali DHS-VII 2018 57.4 49.4
Nepal MICS6 2019 92.9 85.6
Sierra Leone DHS-VII 2019 54.8 56.6
Togo MICS6 2017 62.7 65.5
a
DHS data refer to children born in the past 3 years who ever received measles vaccine. Children are considered to have received the vaccine if vaccination was noted on their
vaccination card or reported by the mother. For MICS, the data refer to children ever given measles and rubella vaccine.
b
Please note that the cell count is between 25 and 49.
ND: no data.
268
the proportions using modern contraceptive evidence presented in Chapter 2 indicating

methods are similar among the different that migrants consistently use traditional
groups (Table 5.7). For example, in Burundi, contraceptive methods as opposed to more
23% of female international migrants used modern or effective methods, particularly
traditional methods compared with 18% of when compared with non-migrants (71–73).
the host population. This is in line with the The literature highlights that among refugees
Table 5.7. Percentage of women using traditional or modern methods of contraception, by migratory status
% using type of contraceptiona
Modern Traditionala
International Host International Host

Country or area Survey Year(s) migrants population migrants population
Central African Republicb MICS6 2018–2019 71.0 80.8 29.0 18.3
Chadb MICS6 2019 75.9 75.5 24.1 23.3
Ethiopiab DHS-VII 2016 93.3 96.3 6.7 3.0
Gambia MICS6 2018 98.5 97.5 0.5 0.1
Ghana MICS6 2017–2018 87.5 88.5 10.9 9.6
Guineab DHS-VII 2018 96.8 93.4 3.2 2.3
Guinea-Bissau MICS6 2018–2019 96.4 96.5 3.6 3.0
Indonesia DHS-VII 2017 53.6 44.4 13.8 11.0
Jordan DHS-VII 2017–2018 67.6 70.8 32.4 29.2
Kosovoc MICS6 2019–2020 17.0 14.3 83.0 85.4
Kyrgyzstan MICS6 2018 100.0 95.8 0.0 4.0
Lesotho b
MICS6 2018 94.9 97.9 5.1 0.9
Liberia DHS-VII 2019–2020 94.6 96.8 4.5 2.9
Malawi DHS-VII 2015–2016 94.7 97.8 2.6 1.5
Mali DHS-VII 2018 93.7 94.8 4.8 2.6
Montenegro MICS6 2018 60.9 53.9 36.2 45.1
Nepal MICS6 2019 96.1 92.4 3.9 7.4
Sierra Leone DHS-VII 2019 96.6 97.9 3.4 0.7
Surinameb MICS6 2018 100.0 98.4 0.0 0.8
Thailand MICS6 2019 98.3 95.7 1.1 4.2
Togo MICS6 2017 85.7 88.6 14.3 10.7
Tongab MICS6 2019 96.0 78.6 4.0 13.8
Zimbabweb DHS-VII 2015 100.0 98.1 0.0 1.7
a
Traditional methods of birth control include periodic abstinence and withdrawal.
b
c
269
and international migrants in some low- and Similar proportions of international

middle-income countries in Africa and Asia, migrant and non-migrant women had ANC
for example, only small proportions use visits in Jordan, as shown in Table 5.8,
long-acting reversible contraception, while and as reported by women in Lebanon,
Venezuelan migrants in Brazil report there two countries in the WHO Eastern
is limited availability of these methods in Mediterranean Region. The literature review
health centres (74–76). The reasons given for presented in Chapter 3 regarding ANC visits
not using modern contraceptive methods consistently showed that refugees and
include limited knowledge of and access migrants complete fewer visits than host
to family planning services, unsupportive populations, although evidence varied
sexual partners and concerns about side- regarding the size of the gap. For example,
effects (77,78). In Australia, a study conducted a nationally representative MICS in the
among Japanese migrant women noted that occupied Palestinian territory, including east
the migrants preferred the contraceptive Jerusalem, in 2019–2020 indicated that ANC
practice of sotodashi (i.e. the combined use coverage was lower among refugees (88.2%)
of condoms and withdrawal), and Chinese than among non-refugees (95.9%) (84).
migrants cited beliefs about hormonal
contraception causing side-effects, such Although Table 5.8 shows that the
as disrupting their inner balance (79,80). proportions of migrants and host populations
Even in some countries in the EU, where in Thailand that have four or more ANC visits
contraception is available and free, language are similar (88.5% and 90.6%, respectively),
barriers and a lack of knowledge pose migrant women along the Thailand–Myanmar
challenges to migrants accessing family border face barriers in attending ANC
planning services (81–83). However, in visits. Evidence indicates that international
13 of 33 countries or areas, a lower proportion migrant women along this border delay
of female international migrants used their visits until the third trimester, citing
traditional methods compared with non- the long distances that must be travelled
migrant women. For example, in Armenia, as a major challenge (85). Women delaying
49.3% of female international migrants used visits until the third trimester had to travel
traditional methods, compared with 57.1% 46% further compared with women who
of women in the host population. The attended visits during their first trimester (85).
reasons for this need to be further explored
in relation to education and other Women and girls who have undergone
socioeconomic factors. FGM. SDG Target 5.3 aims to eliminate
the practice of FGM by 2030. FGM is a
Number of antenatal care visits. The review violation of human rights because there is
suggested that pregnant women in host no medical justification for damaging or
populations have better access to ANC, as removing healthy, normal tissue, especially
indicated by the number of ANC visits. In the for a procedure that prevents the natural
majority of countries surveyed by the MICS6 functions of women's bodies (86).
and DHS-VII, pregnant international migrants
have at most three ANC visits compared
with four or more for women in host
populations (Table 5.8).
Table 5.8. Percentage of women attending ANC, by number of visits and migratory status
270
% attending for each number of ANC
0 1 2–3 ≥4
International Host International Host International Host International Host

Country or area Survey Year(s) migrants population migrants population migrants population migrants population
Armeniaa DHS-VII 2015–2016 0.0 0.3 0.0 0.1 0.0 2.4 97.6 95.8
Benin DHS-VII 2017–2018 10.0 11.5 6.4 6.2 28.9 28.4 51.7 51.2
Burundi DHS-VII 2016–2017 0.0 0.7 2.4 2.0 53.4 47.6 44.2 49.6
Cameroon DHS-VII 2018 18.4 12.7 0.0 2.3 20.8 20.0 59.2 64.0
Central African Republica MICS6 2018–2019 0.0 0.0 7.3 7.0 34.1 33.4 56.1 55.0
Ethiopia DHS-VII 2016 13.7 34.7 4.1 4.7 32.9 24.2 47.9 36.1
Gambia MICS6 2018 0.0 0.0 2.5 1.7 24.3 21.4 72.8 76.6
Ghana MICS6 2017–2018 0.0 0.0 1.3 2.0 12.7 10.1 86.1 87.3
Guinea DHS-VII 2018 8.4 14.5 5.3 11.3 28.2 37.2 52.7 34.3
Guinea-Bissau MICS6 2018–2019 0.0 0.0 2.5 1.6 15.1 17.1 82.4 81.2
Indonesia DHS-VII 2017 6.2 3.3 0.0 1.3 6.2 6.7 86.3 88.2
Jordan DHS-VII 2017–2018 3.3 2.6 1.6 2.1 6.1 2.9 88.6 91.6
Kosovoa,b MICS6 2019–2020 0.0 0.0 0.0 0.7 16.7 3.1 83.3 95.5
Liberia DHS-VII 2019–2020 1.4 2.2 0.9 1.7 6.1 9.4 89.7 84.8
Malawi DHS-VII 2015–2016 1.3 1.7 5.7 1.9 42.7 45.1 50.3 50.8
Mali DHS-VII 2018 10.4 22.9 1.0 5.8 28.7 27.7 57.4 41.8
Montenegro MICS6 2018 0.0 0.0 4.3 0.6 1.4 1.7 94.2 97.8
Nepal MICS6 2019 0.0 0.0 6.1 2.0 17.3 15.4 76.5 82.7
Table 5.8 contd
% attending for each number of ANC
0 1 2–3 ≥4
International Host International Host International Host International Host

Country or area Survey Year(s) migrants population migrants population migrants population migrants population
Sierra Leone DHS-VII 2019 1.6 1.4 2.5 0.8 4.9 7.0 77.0 79.5
Surinamea MICS6 2018 0.0 0.0 2.6 1.3 5.3 3.8 76.3 77.3
Thailand MICS6 2019 0.0 0.0 1.9 1.1 3.8 3.1 88.5 90.6
Togo MICS6 2017 0.0 0.0 3.2 3.7 39.4 38.1 57.3 57.9
Zimbabwea MICS6 2019 0.0 0.0 5.4 2.1 18.9 22.2 75.7 75.0
a
b
271
272
The proportions of women and their daughters The data in Table 5.9 contrast with research
who had undergone FGM in the selected findings from the WHO Eastern Mediterranean
countries is similar between international Region. In Saudi Arabia, Saudi nationals
migrants and non-migrants in 9 out of 11 were less likely to have experienced FGM
countries in sub-Saharan Africa for which compared with migrants from countries
MICS6 and DHS-VII survey data were available such as Egypt, Somalia and Yemen (89).
(Table 5.9). However, in Guinea-Bissau and Togo,
the proportions of women and their daughters Literature from the WHO European Region
experiencing FGM is higher among migrants. has identified the presence of FGM among
refugees and international migrants
Evidence that was based on the country of originating from countries in eastern Africa
birth and that compared Somali refugees and the Middle East. Social factors influence
in Kenya with local populations found these decisions, including the duration of
little difference between those who had stay in the host country and cultural norms.
experienced FGM and those who had not. Evidence suggests that a longer stay in a
However, the literature does highlight that host country where FGM is not promoted
living separately from a parent, especially or allowed is positively associated with
a mother, is significantly associated with rejecting FGM (90). The data analysed in this
being less likely to experience FGM (87). This chapter do not provide information on the
finding may support other research showing duration of stay, but the prevalence of FGM
that the custom of FGM might be influenced seems to be at comparable levels between
by a mother's assumptions that FGM will host and international migrant populations.
increase her daughter's marriageability (88). Further research suggests that gender-
Table 5.9. Percentage of women (15–49 years) and their daughters (0 months to 14 years) in the WHO African
Region who have experienced FGM, by migratory status
% experiencing FGM
Women Daughters
International Host International Host

Country or area Survey Year(s) migrants population migrants population
Central African Republic MICS6 2018–2019 30.4 34.3 3.3 2.2

Chad MICS6 2019 46.9 45.4 8.4 10.9
Ethiopia DHS-VII 2016 65.7 69.7 17.5 24.7
Gambia MICS6 2018 62.2 75.8 38.7 50.2
Ghana MICS6 2017–2018 9.3 11.8 0.6 0.6
Guinea DHS-VII 2018 96.8 96.0 52.2 41.4
Guinea-Bissau MICS6 2018–2019 70.0 51.6 33.1 25.8
Liberia DHS-VII 2019–2020 38.7 38.4 ND ND
Mali DHS-VII 2018 80.5 84.9 70.5 69.5
Sierra Leone DHS-VII 2019 88.5 89.2 14.9 10.0
Togo MICS6 2017 11.7 7.1 0.8 0.0
ND: no data.
273
related concepts about men's virility and There is widespread evidence that female
sexual pleasure influence the acceptance of refugees and international migrants experience
medicalized defibulation among women from high levels of sexual violence (94–97). Studies
some African countries living in a European in the WHO Eastern Mediterranean Region
country (91). Estimating the prevalence found evidence of increased IPV and forced
of FGM among international migrants in pregnancy among refugees in several settings
Europe is difficult; however, a combination (98,99). Research in the United States indicated
of direct and indirect methods can be used. that migrant women from Latin American
Direct methods include collecting data countries faced forms of SGBV and IPV linked
through surveys conducted among the target not only to social conditions in their country
population, while indirect methods could of origin but also to changing power dynamics
include utilizing secondary data sources (92). related to migration and acculturation (96,100).
The evidence regarding women subjected to
Intimate partner violence against physical or sexual violence by their current
women. SDG Target 5.2 aims to "eliminate husband or partner is mixed in the data from
all forms of violence against all women DHS-VII (Table 5.10). In some countries, such
and girls in the public and private spheres", as Cameroon and Nepal, migrant women
while for SDG 16, which aims to promote reported experiencing more violence than
peaceful and inclusive societies, Targets non-migrant women did; this contrasted with
16.1 and 16.2 seek to reduce all forms of other countries, such as Sierra Leone and
violence and violence-related deaths (93). Zimbabwe, where they reported experiencing
less violence than non-migrant women.
Table 5.10. Percentage of women (15–49 years) subjected to physical or sexual violence by a husband or partner
during the previous 12 months, by migratory status
% of women experiencing physical or sexual violence
International migrants Host population
Physical Sexual Physical Sexual

Country or area Survey Year(s) violencea violence violence violence
Armenia DHS-VII 2015–2016 3.0b 0.0b 3.1 0.3b

Benin DHS-VII 2017–2018 9.4 5.6b 11.7 5.6
Burundi DHS-VII 2016–2017 16.6 21.9 b
18.0 18.6
Cameroon DHS-VII 2018 25.9b
11.8 b
15.3 6.0
Ethiopia DHS-VII 2016 5.5b
3.6 b
14.3 5.6
Jordan DHS-VII 2017–2018 7.5 1.2 b
10.1 2.7
Liberia DHS-VII 2019–2020 35.5 6.6 b
33.7 6.9
Malawi DHS-VII 2015–2016 16.2b
16.2 b
16.3 14.3
Mali DHS-VII 2018 14.6b
9.0 b
15.2 5.4
Nepal DHS-VII 2016 12.0 6.7 b
9.8 5.3
Sierra Leone DHS-VII 2019 20.5b
3.8 b
36.1 6.1
Zimbabwe DHS-VII 2015 10.0b
4.3 b
15.9 7.7
a
The definitions of different types of spousal violence are detailed in Croft et al. (101).
b
Due to a small sample size (< 25), caution should be used in interpreting these data.
274
5.4.5 Mental health assimilationist (i.e. they promote societal

The need to improve mental health is covered participation and citizenship irrespective
by SDG 3, which aims to ensure healthy lives of labour-market attachment, but with an
and promote well-being for all, and SDG 16, emphasis on sociopolitical conformity) or
which aims to promote peaceful and inclusive exclusionist (i.e. access to welfare support and
societies for sustainable development, services are conditional on labour-market
among other goals. The literature reviewed in attachment, and opportunities for citizenship
Chapter 3 suggested there were higher rates of are scarce). International migrants living in
depression and anxiety among certain groups countries termed exclusionist are more likely to
of refugees and migrants during different report mental health issues, such as depressive
phases of migration, resulting from factors symptoms, to report social discrimination
such as family separation, community and and to have poorer self-rated health than
workplace stressors, and social exclusion migrants in multicultural countries (105–107).
(102). PTSD has been observed among Also, migrants who experience restrictive entry
forced migrants, such as refugees affected by policies (e.g. they have only temporary visa
conflict and war, particularly among youth status or are put in detention) or integration
and adolescents (103), and there is recent policies (e.g. there is limited welfare eligibility,
evidence indicating that social disadvantages and there are documentation requirements)
experienced before and after migration are have been found to be at increased risk for
significantly associated with psychosis (104). poorer self-rated health and mental health
(108). Health inequalities are most common
The surveys reviewed do not provide data directly in countries in the exclusionist category, even
pertinent to mental health but instead collect after adjusting for a migrant's SES (105). The
self-reported (i.e. subjective) information. The impact of government policies, particularly
relevant indicators are found in MICS6 as well as in those that are restrictive and exclusionist in
the PISA surveys, and include self-assessments nature, goes beyond self-reported health
of health and feelings of discrimination. status, as there may be an association between
such policies and increased mortality (106).
Self-reported health. Self-reported health
provides an indication of how individuals The literature identifies other factors
perceive their health and well-being. beyond national migration policies that
Evidence from the literature indicates that have been associated with self-rated
international migrants who report poorer health. Lower levels of social cohesion and
health status than host populations may perceived discrimination against refugees
do so in part due to their host country's and international migrants have also been
migration policies, attitudes towards associated with poorer health outcomes
migrants and the social environment. among refugees and international migrants
living in several high-income countries and
MIPEX, discussed in Chapter 4, uses a three- some middle-income countries (109–111).
category framework that describes national Individual factors, such as age, gender and
policies as inclusive (i.e. they promote societal country of origin, also influence perceptions
participation and citizenship irrespective of of health and well-being (112–115). Self-rated
labour-market attachment, and cultural and health can decline with increasing age, while
political tolerance, which earlier versions gender inequalities may have an impact
of the framework termed multicultural), on girls' perceptions of their well-being.
275
The identified literature explored the Feelings of discrimination or harassment

complexity of assessing illness, particularly due to ethnicity or migratory status.
mental illness, among refugees and migrants. Feelings and experiences of discrimination
Not all refugees and migrants are exposed to and harassment can contribute to depression
the same risks, leading to varying prevalences and other health problems, including self-
of mental disorders (102,116,117). Depending harm and suicide (87,93,123,124). In all
on the host population's prevalence of mental of the nine selected countries surveyed
illness, refugees and migrants may have lower, (Fig 5.1) in the MICS6, higher percentages
similar or higher prevalence (118). Additionally, of both male and female international
European doctors may struggle with properly migrants reported having felt discrimination
classifying mental health disorders in refugees and harassment compared with the host
if they are using conventional diagnostic population. This pattern is consistent
categories (119–121). Mental health issues are with studies carried out in various WHO
often highly stigmatized, and self-stigmatization regions. International migrants reported
can be higher in migrant groups (122). discrimination or harassment due to their
Fig. 5.1. Percentage of males and females who self-reported discrimination or harassment due to their ethnicity or
migratory statusa, 2015–2020
40 40
36.1
35 35
33.8
29.4
30 30
28.0
28.2
25.6
25.0
25 25
% famale
% male
19.1
20 20
17.4
17.0
16.2
15 15
11.4
12.0
10.3
10.6
10 10
9.1
7.9
7.8
7.2
8
6.9
6.9
6.1
6.3
6.3
6.9
5.4
4.7
5 5
4.1
2.7
2.4
2.7
3.0
2.1
2.1
0.9
0 0
Central African Republic
Chad
Guyana
Lesotho
Montenegro
Thailand
Tonga
Zimbabwe
Central African Republic
Chad
Guyana
Kosovob
Lesotho
Montenegro
Thailand
Tonga
Zimbabwe
Kosovo
Host population International migrants
a
Ethnicity and migratory status are not the same. However, the choice available to respondents in the Multiple Indicator Cluster Survey 6, section VT22 was “Ethnic or
immigration origin”, so the results are reported together here.
b
Source: UNICEF (132).

276
ethnicity or migratory status in a variety of geography. For example, migrants working as

settings in their host country, including the long-distance truck drivers in Zambia often
workplace, during health care visits and in resort to using bushes as toilets, given the lack
social settings; these feelings were often of sanitation services along the road (133).
linked to poor or worsening mental health Somali refugee women living in rural northern
(125–131). Often, these experiences are Kenya lack improved sanitation services, and
compounded by additional factors, including 96% report using bushes as toilets due to the
facing discrimination due to their legal status, lack of latrines in their households. Notably,
disability, gender, HIV status and engagement personal safety is highlighted as a major
in sex work, among others (125–131). These concern of open defecation in bushes, rather
intersecting identities highlight the various than hygiene. Somali women reported worries
challenges international migrants may face, about safety, including fears of physical and
often at higher rates than non-migrants. sexual violence, the risk of encountering
wild animals, and privacy concerns (134).
5.4.6 Drinking-water, sanitation
and hygiene as a health
determinant 5.5 Summary
SDG 6, which aims to ensure the availability
and sustainable management of water and As the deadline for meeting the SDGs
sanitation for all, focuses on WASH as a approaches, there is still time to meet
major determinant of global health. WASH- their goals and targets, but only if practical
related data disaggregated by migratory steps are taken urgently. Refugees and
status are available from the countries migrants are largely invisible in official
surveyed by the MICS6 and DHS-VII. Similar data relating to the health SDGs because
to other data presented in this chapter, of the lack of disaggregated data. Even
this subject needs further investigation. fewer data are available for hard-to-reach
populations, hampering efforts to leave no
The MICS6 and DHS-VII surveys indicate that one behind. It is, therefore, hard to understand
international migrants in a majority of the and address the needs of refugees and
selected countries have better toilet facilities migrants, develop inclusive public health
compared with the host population. In 18 approaches and track progress towards
out of the 27 countries, a larger percentage national and global goals. This invisibility
of international migrants had access to in data also may make decision-makers
flush toilets than in the host population and health systems oblivious to the public
(Table 5.11). Data from the MICS6 and DHS- health challenges within their borders.
VII surveys indicate that lower percentages
of international migrants in rural areas have This chapter has highlighted the difficulties
access to flush toilets compared with those of finding internationally comparable,
in the urban areas. In Indonesia, for example, representative and validated data about the
86% of urban-dwelling international migrants health of refugees and migrants. However,
had access to flush toilets compared with equally important, the chapter also illustrates
only 79% of those in rural locations. the great potential that the DHS, MICS and
other surveys have if certain modifications
Access to improved toilet facilities is influenced and adaptations can be introduced to
by determinants such as employment and these internationally supported surveys.
277
Table 5.11. Percentage of respondents by type of toilet facility and migratory status
% of respondents and type of toilet
Flush toilet Pit toilet latrine No facility/bush/field
Country or area Survey Year(s) International Host International Host International Host
migrants population migrants population migrants population
Armenia DHS-VII 2015–2016 77.5 73.0 22.5 27.0 15.9 0.0
Benin DHS-VII 2017–2018 10.7 6.1 37.2 37.7 8.2 54.6
Burundi DHS-VII 2016–2017 3.4 6.7 94.6 91.3 29.6 1.7
Cameroon DHS-VII 2018 20.9 14.2 69.8 80.0 30.2 3.6
Central African MICS6 2018–2019 3.9 1.5 79.1 65.5 53.5 22.6
Republic
Chad MICS6 2019 9.3 4.0 39.3 21.7 16.9 65.5

Ethiopia DHS-VII 2016 14.9 7.6 67.7 58.1 33.8 32.9
Gambia MICS6 2018 27.9 28.1 70.1 70.7 41.5 1.1
Ghana MICS6 2017–2018 19.9 22.7 43.9 48.2 13.5 24.5
Guinea DHS-VII 2018 18.7 12.6 65.3 72.2 20.1 12.6
Guinea-Bissau MICS6 2018–2019 18.5 15.6 73.5 71.6 65.5 12.4
Guyana MICS6 2019–2020 64.9 65.5 31.6 33.2 3.5 1.0
Indonesia DHS-VII 2017 81.9 87.5 7.6 3.1 0.0 9.3
Jordan DHS-VII 2017–2018 88.0 95.4 11.9 4.6 0.3 0.0
Lesotho MICS6 2018 6.9 3.5 77.0 74.0 3.4 22.0
Liberia DHS-VII 2019–2020 36.5 26.9 29.9 26.2 14.2 42.2
Malawi DHS-VII 2015–2016 4.1 4.1 87.7 90.6 10.8 4.9
Mali DHS-VII 2018 9.5 4.9 81.3 81.0 26.9 12.5
Montenegro MICS6 2018 98.4 99.3 0.6 0.6 0.0 0.1
Nepal MICS6 2019 85.4 89.8 5.7 4.1 0.0 4.3
Sao Tome MICS6 2019 51.5 25.7 30.3 28.3 0.0 45.2
and Principe
Sierra Leone DHS-VII 2019 10.1 9.1 73.4 70.4 27.4 17.5
Suriname MICS6 2018 89.5 88.4 6.4 8.9 3.5 1.7
Thailand MICS6 2019 99.2 99.6 0.4 0.0 0.0 0.2
Togo MICS6 2017 21.4 24.8 30.5 30.0 9.4 42.5
Tonga MICS6 2019 96.3 88.9 2.4 9.9 1.2 0.0
Zimbabwe MICS6 2019 49.4 41.5 35.0 38.0 4.4 20.3
This chapter did not consider the majority of of health, such as migratory status, are not
data sources that originate from routine HIS. registered. Even where such information is
It is generally more challenging to use such registered, ensuring the confidentiality of such
data sets for global and regional, or even data is extremely important. These challenges
national, especially in the case of refugees and are not insurmountable, and it is urgent to
migrants, because data on the determinants comprehensively review all data sources,
278
including administrative records. Only then • A dapt sampling designs and approaches in
will it be possible to assess where resources surveys to ensure good representation of
can be best invested, including to strengthen refugees and migrants by using strategies
national capacities, enhance national HIS and such as oversampling.
introduce innovative approaches to modernize • Collect qualitative data to gain deeper
national information and statistical systems. insights into the health status of and health
determinants for refugees and migrants.
The following approaches should be • Strengthen the capacity in countries for
considered to address the main issues collecting, analysing and reporting on
discussed in this chapter. health outcomes and burden of disease by
key characteristics including sex, age and
• D
evelop a consensus on definitions and on disability, as well as the ability for further
a set of essential variables that can be used disaggregation by subgroups of refugees
to determine migratory status in all data and migrants, such as labour migrants,
collection systems to ensure comparability irregular migrants, asylum seekers and IDPs.
and clarity, including in household surveys, • Ensure that data collected to safeguard
specialized quantitative assessments and health are not used for non-health-
routine HIS. related purposes by guaranteeing the
confidentiality of the data and preventing
unauthorized access.
• Explore various sources of information
on migration to cover countries of origin,
transit and destination. Sources include
civil registration vital statistics systems,
administrative data from government HIS
and, potentially, the untapped data sets
collected by major commercial enterprises.
• Investigate approaches that address the
interoperability of data sets (22) – that is,
Refugees and migrants are largely the linking of different data sets to generate
comprehensive data about a given group
invisible in official data relating of individuals. This would help to ensure
to the health SDGs because of the interoperability of databases at national and
global levels to permit the exchange of data
lack of disaggregated data. It is, and generation of comprehensive data sets.
therefore, hard to understand and
address the needs of refugees
and migrants, develop inclusive
public health approaches and
track progress towards national
and global goals.
279
References 8. Contreras-González IM, Markhof Y, Gonzales Morales L,

Wollburg PR, Zezza A. Dealing with disruption: national
statistical offices are adjusting to continued challenges as
COVID-19 keeps affecting their operations. In: World Bank
Blogs [website]. Washington (DC): World Bank; 2020 (https://
1. Wolf L. What gets measured gets done: key performance blogs.worldbank.org/opendata/dealing-disruption-national-
indicators. In: California Digital Library [website]. Oakland statistical-offices-are-adjusting-continued-challenges-covid,
(CA): Regents of the University of California; 2010 (https:// accessed 11 February 2022).
cdlib.org/cdlinfo/2010/09/15/what-gets-measured-gets-done-
9. Resolution WHA61.17. Health of migrants. In: Sixty-first World
key-performance-indicators/, accessed 11 February 2022).
Health Assembly, Geneva, 19–24 May 2008. Resolutions and
2. Sustainable Development Goals: background on the goals. In: decisions. Annexes. Geneva: World Health Organization;
United Nations Development Programme, Oslo Governance 2008:23–5 (WHA61/2008/REC/1; https://apps.who.int/gb/
Centre [website]. Oslo: United Nations Development ebwha/pdf_files/WHA61-REC1/A61_REC1-en.pdf, accessed
Programme; 2022 (https://www.undp.org/sdg-accelerator/ 23 June 2022).
background-goals, accessed 11 February 2022).
10. Resolution A/71/L.1. New York declaration for refugees and
3. Resolution 55/2. United Nations Millennium Declaration. In: migrants. In: Seventy-first session, United Nations General
Fifty-fifth session, United Nations General Assembly, Assembly, New York, 13 September 2016. New York: United
6–8 September 2000. New York: United Nations; 2000 (A/ Nations; 2016 (https://digitallibrary.un.org/record/840982,
RES/55/2; https://digitallibrary.un.org/record/422015?ln=en, accessed 17 November 2021).
11. The global compact on refugees. New York: United Nations;
4. Resolution A/RES71/313 (Annex). Global Indicator Framework 2021 (https://www.unhcr.org/the-global-compact-on-
for the Sustainable Development Goals and Targets of the refugees.html, accessed 4 October 2021).
2030 Agenda for Sustainable Development. In: Seventy-first
12. Resolution A/RES/73/195. Global compact for safe, orderly
session of the United Nations General Assembly, July 2017.
and regular migration. In: Seventy-third session, United
New York: United Nations; 2017 (https://unstats.un.org/sdgs/
Nations General Assembly, New York, 11 January 2019.
indicators/Global%20Indicator%20Framework%20after%20
New York: United Nations; 2019 (https://www.un.org/en/
2022%20refinement_Eng.pdf, accessed 19 January 2022).
development/desa/population/migration/generalassembly/
5. Resolution A/RES/70/1. Transforming our world: the 2030 docs/globalcompact/A_RES_73_195.pdf, accessed
Agenda for Sustainable Development. In: Seventieth session, 6 August 2021).
United Nations General Assembly, 25 September 2015. New
13. Practical guidebook on data disaggregation for the
York: United Nations; 2015 (https://www.un.org/ga/search/
Sustainable Development Goals. Manila: Asian Development
view_doc.asp?symbol=A/RES/70/1&Lang=E, accessed
Bank; 2021 (https://www.adb.org/sites/default/files/
19 January 2022).
publication/698116/guidebook-data-disaggregation-sdgs.pdf,
6. Roser M, Ortiz-Ospina E, Ritchie H, Mispy J. Sustainable accessed 4 October 2021).
Development Goal 17: revitalize the global partnership for
14. Interlinkages of the 2030 Agenda Sustainable Development
sustainable development. In: SDG tracker [website]. Oxford:
Goals. In: 8th Meeting of the Inter-Agency and Expert Group
Global Change Data Lab; 2021 (https://sdg-tracker.org/global-
on Sustainable Development Goal Indicators, 5–8 November
partnerships, accessed 19 January 2022).
2018, Stockholm, Sweden. New York: United Nations
7. United Nations Statistical Commission. Implementing the Statistical Commission Interlinkages Working Group of the
2020 World Programme on Population and Housing Censuses Inter-Agency and Expert Group on Sustainable Development
during the COVID-19 pandemic. In: United Nations Statistics Goal Indicators; 2018 (https://unstats.un.org/sdgs/files/
Division [website]. New York: United Nations Statistics meetings/iaeg-sdgs-meeting-08/5a_Cara%20Williams_
Division; 2021 (https://unstats.un.org/unsd/statcom/52nd- Canada_Interlinkages_Report_SlideDoc.pdf, accessed
session/side-events/20210225-population-and-housing- 21 June 2022).
censuses-during-the-covid-19-pandemic/, accessed
15. How immigrants contribute to South Africa's economy. Paris:
11 February 2022).
Organisation for Economic Co-operation and Development,
International Labour Organization; 2018 (https://www.oecd-
ilibrary.org/development/how-immigrants-contribute-to-
south-africa-s-economy_9789264085398-en, accessed
1 December 2021).
280
16. Castles S. Development and migration or migration 26. Sampling and household listing manual: demographic and
and development: what comes first? Asian Pac Migr J. health surveys methodology. Calverton (MD): Measure DHS,
2009;18(4):441–71. doi:10.1177/011719680901800401. ICF International; 2012 (https://dhsprogram.com/pubs/pdf/
DHSM4/DHS6_Sampling_Manual_Sept2012_DHSM4.pdf,
17. IOM institutional strategy on migration and sustainable
development. Geneva: International Organization for
Migration; 2020 (https://publications.iom.int/system/files/ 27. Bonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant
pdf/iom-institutional-strategy.pdf, accessed 19 January 2022). J et al. Reaching the hard-to-reach: a systematic review of
strategies for improving health and medical research with
18. Mosler Vidal E. Leave no migrant behind: the 2030 Agenda
socially disadvantaged groups. BMC Med Res Methodol.
and data disaggregation. Geneva: International Organization
2014;14:42. doi:10.1186/1471-2288-14-42.
pdf/Migrants-in-the-SDGs_5.pdf, accessed 4 October 2021). 28. Marpsat M, Razafindratsima N. Survey methods for hard-to-
reach populations: introduction to the special issue. Methodol
19. UN Statistical Commission adopts 36 changes to SDG
Innov. 2010;5(2):3–16. doi:10.4256/mio.2010.0014.
indicators. In: International Institute for Sustainable
Development SDG Knowledge Hub [website]. Winnipeg: 29. Edwards A. "Refugee" or "migrant" – which is right? Geneva:
International Institute for Sustainable Development; 2020 Office of the United Nations High Commissioner for Refugees;
(https://sdg.iisd.org:443/news/un-statistical-commission- 2015 (https://www.unhcr.org/news/latest/2016/7/55df0e556/
adopts-36-changes-to-sdg-indicators/, accessed unhcr-viewpoint-refugee-migrant-right.html, accessed
17 November 2021). 2021). 18 November 2021).
20. IOM migration data strategy in brief: informing policy and 30. Glossary on migration. Geneva: International Organization
action on migration, mobility and displacement (2020–2025). for Migration; 2019 (https://publications.iom.int/system/files/
Geneva: International Organization for Migration; 2021 pdf/iml_34_glossary.pdf, accessed 19 January 2022).
(https://publications.iom.int/system/files/pdf/IOM-Migration-
31. Recommendations on statistics of international migration,
Data-Strategy-Overview.pdf, accessed 2 January 2022).
revision 1. New York: United Nations Department of Economic
21. A pilot study on disaggregating SDG indicators by migratory and Social Affairs; 1998 (https://unstats.un.org/unsd/
status. Geneva: International Organization for Migration; 2018 publication/seriesm/seriesm_58rev1e.pdf, accessed
(https://publications.iom.int/system/files/pdf/a_pilot_study_ 9 January 2022)
on_disaggregating_sdg_indicators.pdf, accessed
32. Krieger J, Higgins DL. Housing and health: time again for
16 January 2022).
public health action. Am J Public Health. 2002;92(5):758–68.
22. Collection and integration of data on refugee and migrant doi:10.2105/ajph.92.5.758.
health in the WHO European Region: technical guidance.
33. Howden-Chapman P, Roebbel N, Chisholm E. Setting housing
standards to improve global health. Int J Environ Res Public
Health. 2017;14(12):1542. doi:10.3390/ijerph14121542.
12 November 2021).
34. Soeiro RE, Rocha L, Surita FG, Bahamondes L, Costa ML.
23. Stroetmann KA. Health system efficiency and eHealth
Period poverty: menstrual health hygiene issues among
interoperability: how much interoperability do we need?
adolescent and young Venezuelan migrant women at the
In: Rocha A, Correia AM, Tan FB, Stroetmann KA, editors.
northwestern border of Brazil. Reprod Health. 2021;18(1):238.
New perspectives in information systems and technologies,
doi:10.1186/s12978-021-01285-7.
volume 2. Cham: Springer; 2014:395–406.
35. Evans GW. The built environment and mental health. J Urban
24. International migrant stock 2019. New York: United Nations
Health. 2003;80(4):536–55. doi:10.1093/jurban/jtg063.
Department of Economic and Social Affairs; 2020 (POP/DB/
MIG/Stock/Rev.2020; https://www.un.org/development/desa/ 36. WHO housing and health guidelines. Geneva: World
pd/sites/www.un.org.development.desa.pd/files/undesa_ Health Organization; 2018 (https://apps.who.int/iris/
pd_2020_international_migrant_stock_documentation.pdf, handle/10665/276001, accessed 20 November 2021).
37. Chepo M, Astorga-Pinto S, Cabieses B. Atención inicial de
25. Designing household survey samples: practical guidelines. migrantes en Chile: iniciativa en atención primaria de salud
New York: United Nations Department of Economic a un año de su implementación [Initial care for migrants in
and Social Affairs; 2005 (https://unstats.un.org/unsd/ Chile: status of a primary health care initiative after one year
demographic/sources/surveys/handbook23june05.pdf, of implementation]. Rev Panam Salud Publica. 2019;43:e71
accessed 19 January 2022). (in Spanish). doi:10.26633/RPSP.2019.71.
281
38. Hanley J, Ives N, Lenet J, Hordyk S-R, Walsh C, Ben Soltane 48. Comparison of health care coverage for workers in the GCC:
S et al. Migrant women's health and housing insecurity: draft. Gulf Cooperation Council countries. Migrant-rights.
an intersectional analysis. Int J Migr Health Soc Care. org; 2020 (https://www.migrant-rights.org/wp-content/
2019;15(1):90–106. doi:10.1108/IJMHSC-05-2018-0027. uploads/2020/03/Comparison-Of-Health-Care-Coverage-For-
Migrant-Workers-In-The-GCC-.pdf, accessed 24 January 2022).
39. Hernández-Vásquez A, Vargas-Fernández R, Rojas-Roque
C, Bendezu-Quispe G. Factors associated with the non- 49. Medical insurance requirements for migrant worker. In:
utilization of healthcare services among Venezuelan migrants Ministry of Manpower, Singapore [website]. Singapore:
in Peru. Rev Peru Med Exp Salud Publica. 2019;36(4):583–91. Ministry of Manpower; 2021 (https://www.mom.gov.sg/
doi:10.17843/rpmesp.2019.360.4654. passes-and-permits/work-permit-for-foreign-worker/sector-
specific-rules/medical-insurance, accessed 24 January 2022).
40. Villalobos NVF, Montoya MPA. Factores relacionados con
los casos de tuberculosis en Costa Rica, 2012–2015 [Factors 50. Kunpeuk W, Teekasap P, Kosiyaporn H, Julchoo S, Phaiyarom
related to tuberculosis cases in Cost Rica, 2012–2015]. Rev M, Sinam P. Understanding the problem of access to public
Cuba Salud Publica. 2020;46(3) (in Spanish; http://www. health insurance schemes among cross-border migrants
revsaludpublica.sld.cu/index.php/spu/article/view/1455, in Thailand through systems thinking. Int J Env Res Public
accessed 23 June 2022). Health. 2020;17(14):5113. doi:10.3390/ijerph17145113.
41. Tan EDD, Davis WA, Davis TME. Changes in characteristics and 51. Suphanchaimat R, Putthasri W, Prakongsai P,
management of Asian and Anglo-Celts with type 2 diabetes Tangcharoensathien V. Evolution and complexity of
over a 15-year period in an urban Australian community: government policies to protect the health of undocumented/
the Fremantle Diabetes Study. J Diabetes. 2016 8(1):139–47. illegal migrants in Thailand: the unsolved challenges. Risk
doi:10.1111/1753-0407.12267. Manag Healthc Policy. 2017;10:49–62. doi:10.2147/
RMHP.S130442.
42. Alkhamis MA, Youha SA, Khajah MM, Haider NB, Alhardan
S, Nabeel A. Spatiotemporal dynamics of the COVID-19 52. Legido-Quigley H, Chuah FLH, Howard N. Southeast Asian
pandemic in the State of Kuwait. Int J Infect Dis. 2020;98: health system challenges and responses to the "Andaman
153–60. doi:10.1016/j.ijid.2020.06.078. Sea refugee crisis": a qualitative study of health-sector
perspectives from Indonesia, Malaysia, Myanmar, and
43. Öztürk MK. Skin diseases in rural Nyala, Sudan (in a rural
Thailand. PLOS Med. 2020;17(11):e1003143. doi:10.1371/
hospital, in 12 orphanages, and in two refugee camps). Int J
journal.pmed.1003143.
Dermatol. 2019;58(11):1341–9. doi:10.1111/ijd.14619.
53. Nepal R, Bhattarai B. The grim reality of health system
44. Quandt SA, Brooke C, Fagan K, Howe A, Thornburg TK,
uncovered with COVID-19 pandemic in Nepal. J Nepal Health
McCurdy SA. Farmworker housing in the United States
Res Counc. 2020;18(3):569–71. doi:10.33314/jnhrc.v18i3.2755.
and its impact on health. New Solut. 2015;25(3):263–86.
doi:10.1177/1048291115601053. 54. Status of Nepali migrant workers in relation to COVID-19.
45. BADEHOG. In: Onceavo taller regional metodologías para
(https://publications.iom.int/system/files/pdf/rapid-phone-
la integración de bases de datos de encuestas de hogares
survey.pdf, accessed 22 January 2022).
[Eleventh regional workshop on methodologies for the
integration of household survey databases], Lima, Perú, 16–18 55. Shadmi E, Chen Y, Dourado I, Faran-Perach I, Furler J,
July 2003. Santiago: United Nations Economic Commission Hangoma P et al. Health equity and COVID-19: global
for Latin America and the Caribbean; 2021:295–300 (https:// perspectives. Int J Equity Health. 2020;19(1):104. doi:10.1186/
repositorio.cepal.org/handle/11362/31828, accessed s12939-020-01218-z.
17 November 2021).
56. Bojorquez-Chapela I, Flórez-García V, Calderón-Villarreal A,
46. Tangcharoensathien V, Thwin AA, Patcharanarumol W. Fernández-Niño JA. Health policies for international migrants:
Implementing health insurance for migrants, Thailand. a comparison between Mexico and Colombia. Health Policy
Bull World Health Organ. 2017;95(2):146–51. doi:10.2471/ OPEN. 2020;1:100003. doi:10.1016/j.hpopen.2020.100003.
BLT.16.179606.
57. Concha NPL, Mansilla MA. Pacientes ilegítimos: acceso
47. C143: migrant workers (supplementary provisions) a la salud de los inmigrantes indocumentados en Chile
convention, 1975 (No. 143). Geneva: International Labour [Illegitimate patients: undocumented migrants' access to
Organization; 1975 (https://www.un.org/en/development/ health care in Chile]. Salud Colect. 2017;13(3):507–20 (in
desa/population/migration/generalassembly/docs/ Spanish). doi:10.18294/sc.2017.1110.
globalcompact/ILO_C_143.pdf, accessed 3 January 2022).
282
58. Santacruz JSR, Georg RR, Cubillos AF, Valverde JR, Wiesner 67. Roberton T, Weiss W, Doocy S, Jordan Health Access Study
MLR, Rodriguez AYR. Realidades migratorias actuales: una Team, Lebanon Health Access Study Team. Challenges
mirada frente a la recepción de la población de venezolanos in estimating vaccine coverage in refugee and displaced
en el contexto colombiano y sus efectos en la salud [Current populations: results from household surveys in Jordan
migratory realities: a look at the reception of the Venezuelan and Lebanon. Vaccines. 2017;5(3):22. doi:10.3390/
population in the Colombian context and its health effects]. vaccines5030022.
In: Pardo F, editor. América Latina en las dinámicas de
68. Harvey B, Dalal W, Amin F, McIntyre E, Ward S, Merrill RD et
la migración internacional: perspectivas críticas [Latin
al. Planning and implementing a targeted polio vaccination
America in the dynamics of international migration: critical
campaign for Somali mobile populations in northeastern
perspectives]. Santiago: Universidad del Externado; 2019:273–
Kenya based on migration and settlement patterns. Ethn
300 (in Spanish).
Health. 2020;2020:1–16. doi:10.1080/13557858.2020.1838455.
59. Ortega CF, Valderrama CG, Melis RP. Políticas públicas y salud
en materia de inmigración: puntos críticos en la accesibilidad
Charatrueangrongkun R et al. Immunization coverage in
del sistema público chileno [Public policies and health in
migrant school children along the Thailand–Myanmar border.
terms of immigration: critical points in the accessibility of
J Immigr Minor Health. 2016;18(5):1038–45. doi:10.1007/
the Chilean public health system]. Acciones Investig Soc.
s10903-015-0294-x.
2017;(37):61–93 (in Spanish; https://dialnet.unirioja.es/
servlet/articulo?codigo=6135546, accessed 23 June 2022). 70. González Morales F. One and a half years after: the impact
of COVID-19 on the human rights of migrants. New York:
60. Rodríguez Vargas JM, López Jaramillo AM. La afiliación
United Nations; 2021 (A/76/257; https://documents-dds-
al sistema de salud de personas migrantes venezolanas
ny.un.org/doc/UNDOC/GEN/N21/212/04/PDF/N2121204.
en Colombia [The integration of Venezuelan migrants
pdf?OpenElement, accessed 19 January 2022).
in Colombia to the health-care system]. Poblac Salud
Mesoam. 2021;18(2):181–214 (in Spanish). doi:10.15517/psm. 71. Ellawela Y, Nilaweera I, Holton S, Rowe H, Kirkman M, Jordan
v18i2.42795. L et al. Contraceptive use and contraceptive health care needs
among Sri Lankan migrants living in Australia: findings from
61. Cabieses B, Oyarte M. Health access to immigrants: identifying
the Understanding fertility management in contemporary
gaps for social protection in health. Rev Saude Publica.
Australia survey. Sex Reprod Healthc. 2017;12:70–5.
2020;54:20. doi:10.11606/S1518-8787.2020054001501.
doi:10.1016/j.srhc.2017.03.003.
62. Voorend K, Bedi AS, Sura-Fonseca R. Migrants and access
72. Ganle JK, Amoako D, Baatiema L, Ibrahim M. Risky sexual
to health care in Costa Rica. World Dev. 2021;144:105481.
behaviour and contraceptive use in contexts of displacement:
doi:10.1016/j.worlddev.2021.105481.
insights from a cross-sectional survey of female adolescent
63. Brownwright TK, Dodson ZM, van Panhuis WG. Spatial refugees in Ghana. Int J Equity Health. 2019;18(1):127.
clustering of measles vaccination coverage among children doi:10.1186/s12939-019-1031-1.
in sub-Saharan Africa. BMC Public Health. 2017;17(1):957.
73. Tapales A, Douglas-Hall A, Whitehead H. The sexual and
doi:10.1186/s12889-017-4961-9.
reproductive health of foreign-born women in the United
64. Aragón E, El-Assar A. Migration governance in the Caribbean: States. Contraception. 2018;98(1):47–51. doi:10.1016/j.
report on the island states of the Commonwealth Caribbean. contraception.2018.02.003.
San José: International Organization for Migration Regional
74. Bahamondes L, Laporte M, Margatho D, de Amorim HSF,
Office for Central America, North America and the Caribbean;
Brasil C, Charles CM et al. Maternal health among Venezuelan
2018 (https://caribbeanmigration.org/sites/default/files/
women migrants at the border of Brazil. BMC Public Health.
repository/regional_report_on_migration_governance_in_
2020;20(1):1771. doi:10.1186/s12889-020-09912-x.
the_island_states_of_the_commonwealth_caribbean.pdf,
accessed 19 January 2022). 75. Davidson AS, Fabiyi C, Demissie S, Getachew H, Gilliam ML.
Is LARC for everyone? A qualitative study of sociocultural
65. Charania NA, Paynter J, Lee AC, Watson DG, Turner NM.
perceptions of family planning and contraception among
Exploring immunisation inequities among migrant and
refugees in Ethiopia. Matern Child Health J. 2017;21(9):1699–
refugee children in New Zealand. Hum Vaccin Immunother.
705. doi:10.1007/s10995-016-2018-9.
2018;14(12):3026–33. doi:10.1080/21645515.2018.1496769.
76. Salisbury P, Hall L, Kulkus S, Paw MK, Tun NW, Min AM et al.
66. De Vito E, Parente P, De Waure C, Poscia A, Ricciardi W.
Family planning knowledge, attitudes and practices in refugee
WA review of evidence on equitable delivery, access and
and migrant pregnant and post-partum women on the
utilization of immunization services for migrants and
Thailand–Myanmar border: a mixed methods study. Reprod
refugees in the WHO European Region. Copenhagen: WHO
Health. 2016;13(1):94. doi:10.1186/s12978-016-0212-2.
283
77. Shah R, Kiriya J, Shibanuma A, Jimba M. Use of modern 88. Alradie-Mohamed A, Kabir R, Arafat SMY. Decision-making
contraceptive methods and its association with QOL among process in female genital mutilation: a systematic review. Int
Nepalese female migrants living in Japan. PLOS One. J Environ Res Public Health. 2020;17(10):3362. doi:10.3390/
2018;13(5):e0197243. doi:10.1371/journal.pone.0197243. ijerph17103362.
78. Tran TDH, Tuan DK, Anh ND, Le TKA, Bui TTH. Premarital sex, 89. Rouzi AA, Berg RC, Alamoudi R, Alzaban F, Sehlo M.
contraceptive use among unmarried women migrant workers Survey on female genital mutilation/cutting in Jeddah,
in industrial parks in Vietnam, 2015. Health Care Women Int. Saudi Arabia. BMJ Open. 2019;9(5):e024684. doi:10.1136/
2018;39(4):377–88. doi:10.1080/07399332.2017.1412439. bmjopen-2018-024684.
79. Inoue K, Kelly M, Bateson D, Rutherford A, Stewart M, Richters 90. Wahlberg A, Johnsdotter S, Selling KE, Källestål C, Essén B.
J. Contraceptive choices and sexual health of Japanese Baseline data from a planned RCT on attitudes to female
women living in Australia: a brief report from a qualitative genital cutting after migration: when are interventions
study. Aust Fam Physician. 2016;45(7):523–7. PMID:27610438. justified? BMJ Open. 2017;7(8):e017506. doi:10.1136/
bmjopen-2017-017506.
80. Dolan H, Li M, Bateson D, Thompson R, Tam CWM, Bonner C
et al. "Every medicine is part poison": a qualitative inquiry into 91. Johansen REB. Virility, pleasure and female genital
the perceptions and experiences of choosing contraceptive mutilation/cutting. A qualitative study of perceptions and
methods of migrant Chinese women living in Australia. BMC experiences of medicalized defibulation among Somali and
Womens Health. 2021;21(1):100. doi:10.1186/s12905-021- Sudanese migrants in Norway. Reprod Health. 2017;14(1):25.
01226-3. doi:10.1186/s12978-017-0287-4.
81. Inci MG, Kutschke N, Nasser S, Alavi S, Abels I, Kurmeyer C. 92. De Schrijver L, Van Baelen L, Van Eekert N, Leye E. Towards a
Unmet family planning needs among female refugees and better estimation of prevalence of female genital mutilation
asylum seekers in Germany: is free access to family planning in the European Union: a situation analysis. Reprod Health.
services enough? Results of a cross-sectional study. Reprod 2020;17:105. doi:10.1186/s12978-020-00947-2.
Health. 2020;17(1):115. doi:10.1186/s12978-020-00962-3.
93. Progress on the Sustainable Development Goals: the gender
82. Mamuk R, Şahin NH. Reproductive health issues of snapshot 2021. New York: UN Women; 2021 (https://www.
undocumented migrant women living in Istanbul. Eur J unwomen.org/sites/default/files/Headquarters/Attachments/
Contracept Reprod Health Care. 2021;26(3):202–8. doi:10.1080 Sections/Library/Publications/2021/Progress-on-the-
/13625187.2020.1843618. Sustainable-Development-Goals-The-gender-snapshot-2021-
en.pdf, accessed 26 December 2021).
83. Schmidt NC, Fargnoli V, Epiney M, Irion O. Barriers to
reproductive health care for migrant women in Geneva: a 94. Fetters T, Rubayet S, Sultana S, Nahar S, Tofigh S, Jones L et
qualitative study. Reprod Health. 2018;15(1):43. doi:10.1186/ al. Navigating the crisis landscape: engaging the Ministry of
s12978-018-0478-7. Health and United Nations agencies to make abortion care
available to Rohingya refugees. Confl Health. 2020;14(1):50.
84. Children in the state of Palestine: child development data
doi:10.1186/s13031-020-00298-6.
from the 2019/2020 multiple indicator cluster survey (MICS).
New York: United Nations Children's Fund; 2021 (https://www. 95. Reques L, Aranda-Fernandez E, Rolland C, Grippon A, Fallet
unicef.org/sop/media/1681/file/Children%20in%20the%20 N, Reboul C. Episodes of violence suffered by migrants
State%20of%20Palestine.pdf, accessed 4 February 2022). transiting through Libya: a cross-sectional study in “Médecins
du Monde's” reception and healthcare centre in Seine-Saint-
85. Steinbrook E, Min MC, Kajeechiwa L, Wiladphaingern J, Paw
Denis, France. Confl Health. 2020;14:12. doi:10.1186/s13031-
MK, Pimanpanarak MPJ et al. Distance matters: barriers to
020-0256-3.
antenatal care and safe childbirth in a migrant population
on the Thailand–Myanmar border from 2007 to 2015, 96. Parrado EA, Flippen CA, McQuiston C. Migration and
a pregnancy cohort study. BMC Pregnancy Childbirth. relationship power among Mexican women. Demography.
2021;21:802. doi:10.1186/s12884-021-04276-5. 2005;42(2):347–72. doi:10.1353/dem.2005.0016.
86. Khosla R, Banerjee J, Chou D, Say L, Fried ST. Gender equality 97. Quang LT. Asia-Pacific generation equality dialogue: gender-
and human rights approaches to female genital mutilation: based violence. In: UN Women, generation equality forum
a review of international human rights norms and standards. [website]. New York: UN Women; 2021 (https://asiapacific.
Reprod Health. 2017;14(1):59. doi:10.1186/s12978-017-0322-5. unwomen.org/en/get-involved/beijing-plus-25/generation-
equality-forum-ap-regional-journey, accessed
87. Agu J, Lobo R, Crawford G, Chigwada B. Migrant sexual
19 January 2022).
health help-seeking and experiences of stigmatization and
discrimination in Perth, Western Australia: exploring barriers 98. Al-Modallal H. Effect of intimate partner violence on health of
and enablers. Int J Environ Res Public Health. 2016;13(5):485. women of Palestinian origin. Int Nurs Rev. 2016;63(2):259–66.
doi:10.3390/ijerph13050485. doi:10.1111/inr.12239.
284
99. Delkhosh M, Merghati Khoei E, Ardalan A, Rahimi Foroushani 110. Habib Rima R, El-Harakeh A, Ziadee M, Abi Younes E, El
A, Gharavi MB. Prevalence of intimate partner violence and Asmar K. Social capital, social cohesion, and health of
reproductive health outcomes among Afghan refugee women Syrian refugee working children living in informal tented
in Iran. Health Care Women Int. 2019;40(2):213–37. doi:10. settlements in Lebanon: a cross-sectional study. PLOS Med.
1080/07399332.2018.1529766. 2020;17(9):e1003283. doi:10.1371/journal.pmed.1003283.
100. Hirsch JS, Muñoz-Laboy M, Nyhus CM, Yount KM, 111. Alemi Q, Stempel C. Discrimination and distress among
Bauermeister JA. They "miss more than anything their normal Afghan refugees in northern California: the moderating
life back home": masculinity and extramarital sex among role of pre- and post-migration factors. PLOS One.
Mexican migrants in Atlanta. Perspect Sex Reprod Health. 2018;13(5):e0196822. doi:10.1371/journal.pone.0196822.
2009;41(1):23–32. doi:10.1111/j.1931-2393.2009.4112309.x.
112. Kim B, Son K-B. Factors affecting the self-rated health of
101. Croft TN, Marshall AMJ, Allen CK. Guide to DHS statistics. immigrant women married to native men and raising children
Rockville (MD): ICF; 2018 (https://www.dhsprogram.com/ in South Korea: a cross-sectional study. BMC Womens Health.
pubs/pdf/DHSG1/Guide_to_DHS_Statistics_DHS-7.pdf, 2020;20(1):210. doi:10.1186/s12905-020-01073-8.
113. Cavazzoni F, Fiorini A, Shoman H, Diab M, Veronese G. The role
102. Henkelmann J-R, de Best S, Deckers C, Jensen K, Shahab M, of gender and living context in shaping Palestinian children's
Elzinga B et al. Anxiety, depression and post-traumatic stress agency and well-being. Gend Place Cult. 2021;29(2):222–47.
disorder in refugees resettling in high-income countries: doi:10.1080/0966369X.2021.1882954.
systematic review and meta-analysis. BJPsych Open.
114. Alduraidi H, Saleh Z, Hamdan-Mansour A. Socio-demographic
2020;6(4):e68. doi:10.1192/bjo.2020.54.
predictors of perceived health among Syrian refugees in
103. Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet Jordan. Med Leg Update. 2021;21(1):287–91. doi:10.37506/
EJ, Cardoso G et al. Trauma and PTSD in the WHO World mlu.v21i1.2322.
Mental Health Surveys. Eur J Psychotraumatol. 2017;8(suppl
115. Ng E, Zhang H. The mental health of immigrants and refugees:
5):1353383. doi:10.1080/20008198.2017.1353383.
Canadian evidence from a nationally linked database. Health
104. Tarricone I, D'Andrea G, Jongsma HE, Tosato S, Gayer- Rep. 2020;31(8):3–12. doi:10.25318/82-003-
Anderson C, Stilo SA et al. Migration history and risk x202000800001-eng.
of psychosis: results from the multinational EU–GEI
116. Hoell A, Kourmpeli E, Salize HJ, Heinz A, Padberg F, Habel U
study. Psychol Med. 2021;2021:1–13. doi:10.1017/
et al. Prevalence of depressive symptoms and symptoms of
S003329172000495X.
post-traumatic stress disorder among newly arrived refugees
105. Malmusi D. Immigrants' health and health inequality by type and asylum seekers in Germany: systematic review and
of integration policies in European countries. Eur J Public meta-analysis. BJPsych Open. 2021;7(3):e93. doi:10.1192/
Health. 2015;25(2):293–9. doi:10.1093/eurpub/cku156. bjo.2021.54.
106. Ikram UZ, Malmusi D, Juel K, Rey G, Kunst AE. Association 117. Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM,
between integration policies and immigrants' mortality: an Fitzgerald G et al. The prevalence of mental illness in refugees
explorative study across three European countries. PLOS One. and asylum seekers: a systematic review and meta-analysis.
2015;10(6):e0129916. doi:10.1371/journal.pone.0129916. PLOS Med. 2020;17(9):e1003337. doi:10.1371/journal.
pmed.1003337.
107. Malmusi D, Palència L, Ikram UZ, Kunst AE, Borrell C.
Inequalities by immigrant status in depressive symptoms in 118. Priebe S, Giacco D, El-Nagib R. Public health aspects of mental
Europe: the role of integration policy regimes. Soc Psychiatry health among migrants and refugees: a review of the evidence
Psychiatr Epidemiol. 2017;52(4):391–8. doi:10.1007/s00127- on mental health care for refugees, asylum seekers, and
017-1348-2. irregular migrants in the WHO European Region. Copenhagen:
WHO Regional Office for Europe; 2016 (https://apps.who.int/
108. Juárez SP, Honkaniemi H, Dunlavy AC, Aldridge RW, Barreto
iris/handle/10665/326308, accessed 19 January 2022).
ML, Katikireddi SV et al. Effects of non-health-targeted policies
on migrant health: a systematic review and meta-analysis. 119. Heeke C, O'Donald A, Stammel N, Böttche M. Same same
Lancet Glob Health. 2019;7(4):e420–35. doi:10.1016/S2214- but different? DSM-5 versus ICD-11 PTSD among traumatized
109X(18)30560-6. refugees in Germany. J Psychosom Res. 2020;134:110129.
doi:10.1016/j.jpsychores.2020.110129.
109. Borrell C, Palència L, Bartoll X, Ikram U, Malmusi D. Perceived
discrimination and health among immigrants in Europe 120. Sacchetti E, Garozzo A, Mussoni C, Liotta D, Novelli G, Tamussi
according to national integration policies. Int J Env Res Public E et al. Post‐traumatic stress disorder and subthreshold post‐
Health. 2015;12(9):10687–99. doi:10.3390/ijerph120910687. traumatic stress disorder in recent male asylum seekers: an
expected but overlooked "European" epidemic. Stress Health.
2020;36(1):37–50. doi:10.1002/smi.2910.
285
121. Barbieri A, Visco-Comandini F, Alunni Fegatelli D, Schepisi 132. MICS surveys [online database]. New York: United Nations
C, Russo V, Calò F et al. Complex trauma, PTSD and Children's Fund; 2022 (https://mics.unicef.org/surveys,
complex PTSD in African refugees. Eur J Psychotraumatol. accessed 18 May 2022).
2019;10(1):1700621. doi:10.1080/20008198.2019.1700621.
133. Michalopoulos LM, Ncube N, Simona SJ, Kansankala B,
122. Makowski AC, von dem Knesebeck O. Depression stigma and Sinkala E, Raidoo J. A qualitative study of migrant-related
migration: results of a survey from Germany. BMC Psychiatry. stressors, psychosocial outcomes and HIV risk behaviour
2017;17(1):381. doi:10.1186/s12888-017-1549-y. among truck drivers in Zambia. Afr J AIDS Res. 2016;15(3):219–
26. doi:10.2989/16085906.2016.1179653.
123. Bilal PI, Chan CKY, Somerset SM. Depression mediates
association between perceived ethnic discrimination and 134. Thuita W, Conn C, Wilson K. The role of marginalised women
elevated blood glucose levels among sub-Saharan African in sanitation initiatives: Somali women in northern Kenya.
migrants in Australia. J Immigr Minor Health. 2021;23(2):199– Dev Pract. 2017;27(1):16–25. doi:10.1080/09614524.
206. doi:10.1007/s10903-020-01131-1. 2017.1256951.
124. Mougenot B, Amaya E, Mezones-Holguin E, Rodriguez-Morales
AJ, Cabieses B. Immigration, perceived discrimination and
mental health: evidence from Venezuelan population living
in Peru. Glob Health. 2021;17(1):8. doi:10.1186/s12992-020-
00655-3.
125. Carey RN, El-Zaemey S, Daly A, Fritschi L, Glass DC, Reid A.
Are there ethnic disparities in exposure to workplace hazards
among New Zealand migrants to Australia? Asia Pac J Public
Health. 2021;33(8):870–9. doi:10.1177/10105395211007648.
126. Gosselin A, Daly A, El Zaemey S, Fritschi L, Glass D, Perez
ER et al. Does exposure to workplace hazards cluster by
occupational or sociodemographic characteristics? An
analysis of foreign‐born workers in Australia. Am J Ind Med.
2020;63(9):803–16. doi:10.1002/ajim.23146.
127. Thela L, Tomita A, Maharaj V, Mhlongo M, Burns JK.
Counting the cost of Afrophobia: post-migration adaptation
and mental health challenges of African refugees in
South Africa. Transcult Psychiatry. 2017;54(5–6):715–32.
doi:10.1177/1363461517745472.
128. Di Napoli A, Rossi A, Baralla F, Ventura M, Gatta R, Perez M et
al. Self-perceived workplace discrimination and mental health
among immigrant workers in Italy: a cross-sectional study.
BMC Psychiatry. 2021;21(1):85. doi:10.1186/s12888-021-
03077-6.
129. Chiumento A, Rutayisire T, Sarabwe E, Hasan MT, Kasujja
R, Nabirinde R et al. Exploring the mental health and
psychosocial problems of Congolese refugees living in
refugee settings in Rwanda and Uganda: a rapid qualitative
study. Confl Health. 2020;14(1):77. doi:org/10.1186/s13031-
020-00323-8.
130. Rivenbark JG, Ichou M. Discrimination in healthcare as
a barrier to care: experiences of socially disadvantaged
populations in France from a nationally representative survey.
8124-z.
131. Radi S. Hospital interactions in Morocco: access to health
care policies from a patient perspective. Mondes Dev.
2019;187(3):71–84. doi:10.3917/med.187.0071.
© Mark Pringle
I have had the opportunity to be – to a certain extent – in the shoes

of the millions of displaced people globally, and have the challenge
and privilege to voice their experiences.
The physical, economic and psychological challenges posed by

migration and displacement, and integration in host communities,
are often misheard, overlooked or misperceived.
I welcome how this report assembles available global evidence

on the health of people on the move – international migrants and
those forcibly displaced – in a single authoritative document. I am
grateful for how it shines a light on the health risks, challenges,
barriers and needs these populations face every day in every corner
of the world. I urge planners, policy-makers and donors alike to use
the wealth of information found in this report to inform decision-
making. I would also like to invite them to consider the action
points for governments and other stakeholders around the world
to step up efforts and make good health and well-being a reality for
all members of society, of which refugees and migrants are – and
should be considered by everyone, everywhere at any time – an
integral part. Concrete steps towards protecting and promoting the
health of refugees and migrants are steps closer to
our health.
Abdulrazak Gurnah
Novelist and Professor, Nobel Prize in Literature (2021) for his uncompromising
and compassionate penetration of the effects of colonialism and the fates of
the refugee in the gulf between cultures and continents
CHAPTER 6
Health and
migration: the
way forward
288
A mother and her baby waiting to receive her two bags of cattle feed. Following a major drought in 2017 in Mauritania, people in the
Hodh El Chargui region are receiving humanitarian assistance. © IOM / Sibylle Desjardins
Health and migration: the way forward
289
6.1 The current state of affairs

This report brings together evidence that is as comprehensive as possible
concerning a multitude of health challenges faced by hundreds of millions
of refugees and migrants. It highlights key global gaps in data quality and
knowledge and the need for development of robust evidence-informed policies,
programmes and plans for implementation. The report also presents good
practices and case studies on current and possible collective responses that can
be taken by governments and other global stakeholders, together with refugees
and migrants, to ensure effective, multisectoral research, policy and action.
By presenting the current global data and evidence on health and migration,
this report outlines both current and future opportunities and challenges.
Every effort was made to collect together all the evidence to show trends
and good practices, as well as to derive an evidence-informed way forward.
However, comparable data and evidence across countries and over time have
been challenging to collect, and this has made it difficult to produce clear and
concise health messages as seen in the preceding chapters. Having said this,
the evidence does show that improving the access of refugees and migrants
to preventive and curative health care, health promotion services and health
A Syrian refugee at a health facility in Türkiye. Syrian health professionals have been trained so that they can be integrated into the
Turkish health system to help meet the needs of refugee communities in the country. © WHO / Burak Ercan
290
in order to reach these objectives, policy and

practice must be rooted in the principles of
This report highlights key global health equity and the right to health, and must
gaps in data quality and knowledge ensure UHC.
and the need for the development It is, therefore, necessary to ensure that
of robust evidence-informed refugees and migrants are included in and
empowered by participatory governance;
policies, programmes and plans identifiable in the data; prioritized in research;
for implementation. and included in health and social protection
schemes and health systems worldwide.
The report also emphasizes the need to centre
health within migration policies as much as
centring migration within health policies.
systems is essential to addressing global 6.1.1 Population movement

inequalities in health and achieving, among and health: an overview
other global health goals, the health-related The number of migrants worldwide has been
SDGs by 2030. Equitable access to health steadily increasing, from 153 million in 1990, to
care for refugees and migrants is also 173 million in 2000 and to 281 million in 2020.
key to addressing broader structural and The growth rate rose from 2.3% over 5 years
social determinants of health, which in turn (2010–2015) to 2.5% over the following 5 years
strengthens the health of communities more (2015–2020). In 2022 UNHCR reported a
broadly. Furthermore, the report shows that, staggering milestone: for the first time on
A Ukrainian refugee covers her son with a blanket at a reception centre in Poland. © WHO / Kasia Strek
291
record, as a result of the war in Ukraine and history can make refugees and migrants
other conflicts, the number of people forcibly more vulnerable or marginalized, or both,
displaced globally rose above a staggering and affects all aspects of their health.
100 million (1). This number continues to
increase. Across the WHO regions, the WHO Only through understanding and addressing
European Region hosts the highest number of the underlying determinants of health for
migrants: approximately 101 million people, refugees and migrants can their health be
while the WHO Eastern Mediterranean Region ensured. For example, the core health care
hosts the highest number of refugees and needs of a migrant woman seeking ANC to
asylum seekers, with approximately 9.6 million. ensure that she and her fetus are healthy might
be similar to those of a woman from the host
As well as affecting the health of refugees population who is also seeking ANC. However,
and migrants themselves, displacement and the migrant woman may have faced different
migration also affect populations in countries experiences and be less comfortable with
along the migratory pathway. Increased and knowledgeable about accessing health
population movement has profound impacts care in the host country: not just in terms of
on health systems in all countries affected language and culture but also other aspects,
by migration, for both migrant and host such as health insurance and social care.
populations. Addressing the health needs
related to moving populations is also integral Another example is the higher levels of
to public health principles, including occupational health hazards faced by low-
the right to health for all. skilled migrant workers compared with their
counterparts from the host population.
6.1.2 Determinants of refugee This higher risk may be attributed to a lack
and migrant health of occupational insurance coverage for
Health outcomes cannot be understood, much migrant workers who are in the so-called 3D
less improved, without knowledge of the jobs (dirty, dangerous and demanding, and
underlying contexts, conditions and enabling sometimes degrading or demeaning) such
factors that shape them. Addressing these as construction and mining. Migrant workers
determinants will often be more effective and may also be more vulnerable to exploitation
less expensive than providing treatment and by employers due to factors such as their
health services when people are already ill. visa status or other rules and regulations.
This report demonstrates the importance of
examining the determinants that affect health
outcomes of refugees and migrants at each stage
of their displacement and migration, as well as
considering the health of host populations.
Only through understanding
Refugees and migrants are affected by the and addressing the underlying
same determinants of health as everyone else.
However, a key finding in Chapter 2 is that
determinants of health for
migratory status adds a layer of complexity refugees and migrants can their
and intensity to the interactions between other
determinants of health and this is relevant
health be ensured.
across all the WHO regions. Their migratory
292
Migratory status is, therefore, both an population if the conditions they live and
important determinant of health and a work in are not conducive to good health.
determinant of access to health services and Without sufficient comparable evidence, this
to the social protections that contribute to report cannot draw global or even regional
health outcomes. This strongly supports the conclusions about health care access or the
conclusion that greater inclusivity – that is, health status of refugees and migrants or for
ensuring equitable and appropriate health any specific subgroups. This reflects the highly
services for all refugees and migrants, rather heterogeneous nature of refugee and migrant
than only for those of a certain category – pays populations. Threats, risks and vulnerabilities
dividends in health outcomes for all. While often differ between regions and among
addressing health outcomes is vital, it is even groups. This report emphasizes that diseases
more important to address the underlying must be dealt with through a migration
determinants that create or exacerbate poor perspective – at points of origin, transit and
health outcomes. The fact that many of arrival and throughout the migratory cycle –
these determinants are not within the direct and be tailored to the specific target group. For
influence of the health sector suggests a example, although common barriers such as
practical course of action: health ministries language might exist among irregular migrants
must take the lead in promoting whole-of- and labour migrants, access to health care and
government and whole-of-society approaches social protection differs between these groups.
to ensure the health of refugees and migrants If addressed in a timely manner, diseases can
both nationally and across borders. be prevented or treated so they do not become
a burden for refugees and migrants or for their
6.1.3 Health status of refugees host population, thus strengthening the
and migrants capacity of refugees and migrants to make
It is clear that, around the world, refugees active contributions to their countries of origin
and certain groups of migrants (such as and destination.
international low-skilled migrant workers)
face poorer health outcomes than the host Refugees and migrants also tend to experience
poorer access to MCH services than women in
their host country; this includes ANC coverage.
Access is hampered by barriers such as out-of-
pocket costs, poor awareness of health services,
Refugees and migrants often a low level of education and cultural beliefs.
This indicates the need for interventions that
experience poor living and working target the various determinants rather than
conditions during departure, transit interventions that target the provision of health
or on arrival in host countries and, services alone. Across regions, the SRH needs
of some refugee and migrant groups are not
therefore, face additional barriers to being met, such as the need for contraception
receiving timely diagnosis, treatment and other family planning care, due to a lack
of awareness of such services and culturally
and care, which might increase the competent provision of services.
prevalence of diseases among them.
Refugees and migrants are at particularly high
risk for NCDs, such as diabetes, CVDs and
293
hypertension, some of which are significant of family or social support, discrimination,

causes of premature mortality, particularly age, ethnicity and length of time spent in
where barriers exist to accessing health care. the host country. There is clear evidence
Cancer, for example, is often diagnosed at a that some specific populations who have
late stage for many refugees and migrants, experienced conflict and war, such as younger
and diabetes and hypertension often go migrants and adolescents, are affected by
undiagnosed and uncontrolled until they poor mental health more than others. Groups
reach a critical stage. However, poorer health such as refugees and UASC tend to show a
outcomes for refugees and migrants are not higher prevalence of depression; however,
universal; research has revealed deviations its occurrence is strongly dependent on their
from this rule in some regions and for some living conditions and the trauma experienced
conditions. For example, while migrant during their displacement. While health care
schoolchildren in some countries were at services to address poor mental health should
lower risk for overweight/obesity than children be put in place, the determinants that affect
from the host population, the opposite was the living and working conditions of refugees
true in other countries. There also were and migrants also need to be considered when
variations among migrant groups. One such developing interventions to ensure that these
example was the higher prevalence of CVD challenges are addressed holistically.
risk factors among migrants who arrived
as children compared with migrants who No evidence suggests that being a refugee
arrived during adulthood. Another example or migrant is more strongly associated with
is the higher prevalence of diabetes among common infectious diseases. However, refugees
refugees and migrants in the WHO European and migrants often experience living and
Region compared with host populations, with working conditions during departure, transit or
refugees and migrants from South-East Asia on arrival in host countries and, therefore, face
having the highest risk, and women having a additional barriers to receiving timely diagnosis,
higher prevalence than men or women in their treatment and care, which might increase
country of origin. the prevalence of diseases among them. For
example, while there is evidence that refugees
One of the main factors associated with and migrants represent a large proportion of
the higher prevalence of NCDs and their people living with HIV/AIDS in some countries
risk factors is the limited awareness among with a low prevalence among the host
refugees and migrants of prevention and population, studies show that a significant
control mechanisms for these conditions. proportion acquired their infection after arriving
In addition to making health care services in the host country. This highlights a missed
available for refugees and migrants, it is opportunity for the health system to prevent
important to improve their awareness of further spread of the disease.
diseases, availability of prevention and
treatment services, and their entitlements in Stigma and discrimination experienced by
accessing health services. refugees and migrants during interactions
with the health care system may hamper
Although refugees and migrants may their access to health services, including
experience a wide range of mental health diagnostic services related to TB, HIV or
conditions, these vary depending on social and hepatitis and SRH services. TB provides an
environmental factors, such as the absence example: in high-income settings where TB
294
prevalence is low, refugees and migrants pandemic, which increased their burden of
account for a higher proportion of TB cases. disease, reduced their income, affected their
Poor living conditions and poverty are linked social and mental well-being and reduced
to increases in TB cases in general, and many their mobility through travel restrictions.
refugee and migrant communities often live Some of the major reasons for the increased
in overcrowded and poorly ventilated living burden were crowded living conditions, jobs
quarters, which increases their vulnerability to that required direct contact with others and a
TB. Additionally, the process of migration can lack of inclusion of refugees and migrants in
make access and adherence to TB treatment public health interventions such as testing and
more difficult, and can contribute to the vaccination, particularly during the initial stage
development of drug-resistant TB. In some of the pandemic.
high-income contexts, drug-resistant TB is an
emerging concern among refugee and migrant While the direct impact was the increased
populations. This points to the need for burden of disease, the indirect impacts included
continuity of care throughout the migratory loss of jobs and income, and inability to travel
pathway and after refugees and migrants due to border closures. Women and girls were
reach their destination. Poor living and severely impacted and were more vulnerable
working conditions also need to be addressed to child marriage and human trafficking due to
to prevent new infections and to facilitate school closures, job and income losses, and
access to treatment if needed. It is worthwhile increased livelihood insecurity. In some countries
to note that the report found no evidence of many girls are not expected to return to schools
TB spreading from refugees and migrants to after they reopen.
host populations.
Several countries introduced policies such
Low-skilled migrant workers are highlighted as ensuring free access to COVID-19 testing
as a priority population as they suffer greater and vaccination regardless of legal status for
occupational health risks, including injury refugees and migrants, or releasing migrants
and death, than workers in their host country. from immigration detention centres, which
Low-skilled migrant workers are less likely helped to ease the burden of the pandemic
to use health care services for a variety of on refugee and migrant communities. The
reasons. Male migrant workers tend to be COVID-19 pandemic has once again shown
in sectors with a high risk of physical injury that the health of refugees and migrants and
and, as a result, tend to have higher rates their host communities cannot be protected
of workplace injury. In some contexts, the and promoted if refugees and migrants are not
prevalence of having at least one occupational included in national public health strategies,
injury was almost 50% among migrants including preparedness and response.
from low- and middle-income countries (see
Chapter 3). Policy-makers and those who 6.1.4 Gaps and good practices in
implement policies must urgently consider health systems
creating or expanding occupational health and The evidence indicates that particular groups
safety standards and providing work-related of refugees and migrants are being left behind.
insurance that covers all working men and Some are left behind intentionally, for example
women, including low-wage migrant workers. when their access to health care is restricted as
Finally, refugees and migrants have been a result of their migratory status. Others are left
disproportionately affected by the COVID-19 behind inadvertently, for example when health
295
Migrant workers learn about COVID-19 prevention measures at a workshop held by the NGO Migrant Workers’ Centre at a dormitory in
Singapore. © WHO / Juliana Tan
care staff or other service providers are not and migrants. Despite a lack of incentives
adequately trained to ensure the equal and to include refugees and migrants in health
equitable provision of health care to refugees programmes in many governments, evidence
and migrants. Regardless of the reason, shows that the cost of excluding them may
access to health systems and equitable health ultimately be higher than the cost of ensuring
care is often compromised for refugees and their inclusion. At the same time, some
migrants, with additional barriers including subgroups of refugees and migrants require
legal obstacles, discrimination, administrative small, targeted interventions in sectors such as
and financial hurdles, lack of information MCH, and these could yield significant results.
about health entitlements, low health literacy,
language and cultural barriers, and fear of This report shows that refugees and migrants
detention and deportation. face barriers in accessing health services
similar to those of the host population,
Using WHO's six building blocks of health but migratory status adds barriers through
systems as a frame, the evidence indicates factors such as language and discrimination
that ensuring health systems and health care by health care providers. In addition, the
workers are sensitive to and knowledgeable health workforce in host countries often lacks
about the health needs of refugees and support and training to provide health care
migrants is feasible and cost-effective. It is also that is people centred and responsive to
a key element in strengthening health systems, the needs of refugees and migrants. There
benefiting host populations as well as refugees are, however, good examples of training
296
programmes and instances where refugees refugees and migrants from accessing the care
and migrants are integrated into the health they need. A lack of awareness about subsidized
workforce not only as doctors and nurses but care, including free vaccination for children,
also as cultural mediators, thus contributing was also reported in refugee contexts where
to bridging the gap between refugees and health care utilization by refugees was low.
migrants and the health care system. In
many high-income contexts, migrants are a One such measure is the implementation of
significant proportion of the host country's UHC in some countries, which facilitates easier
health workforce, highlighting the importance inclusion of refugees and migrants. However,
of the contributions that they make. as shown in this report, certain groups of
migrants, including irregular migrants, are still
Evidence indicates that not providing often excluded from accessing health care,
information in a language that is understood resulting in financial hardship and suboptimal
by refugees and migrants inhibits their access care. A positive example is legislation in
to vaccines, medicines and wider health care some countries that requires employers to
services. In certain migratory contexts, larger provide health insurance for employees,
challenges exist; for example, evidence has including migrant workers. An example of
shown that the supply of medicines is often inclusion occurred when restrictions on
limited in camps and informal settlements. accessing health systems were removed so
In addition to ensuring adequate supplies, that refugees and migrants could be tested
priority must be given to providing information for and vaccinated against COVID-19.
and access to services such as vaccination that
are tailored to the health-seeking behaviour UHC has been an integral part of WHO's and
and living context of refugees and migrants. others' policy frameworks for several years.
The COVID-19 pandemic brought about
Developing a refugee- and migrant-sensitive the most unprecedented public health and
health system starts with the leadership and socioeconomic crisis of our lifetime. This affects
governance building block. When policies are us all, particularly vulnerable populations,
inclusive and when support structures exist which often include refugees and migrants. The
for implementation and monitoring, initiatives pandemic provides the backdrop for increasing
to reduce health inequalities among refugees advocacy for the right to the enjoyment of the
and migrants yield better and faster results. For highest attainable standards of physical and
example, the evidence clearly indicates that mental health for all, including for refugees and
large out-of-pocket payments often prohibit migrants. Assessing the public health and social
impacts of addressing COVID-19 preparedness,
prevention and control showed us that our
systems are only as strong as our weakest link.
Therefore, protecting the health of refugees
Developing a refugee- and migrant- and migrants through the implementation of
sensitive health system starts with informed policies and interventions is critically
important to public health protection for
the leadership and governance all citizens.
building block.
WHO's vision is to enable integrated
approaches to health systems resilience to
297
move towards UHC and health security based modifying and adapting these surveys and
on a foundation of PHC, including essential other national and international data collection
public health functions and a focus on equity. systems to overcome these problems.
This will not be achieved without the inclusion
of refugees and migrants. The world is currently not on track to meet
most of the health and health-related SDG
6.1.5 Refugees and migrants are not targets and the progress made has been
visible in global data sets: uneven. The majority of low- and middle-
Sustainable Development income countries in Africa, Asia, Latin America
Goal targets will be missed and the Small Island Developing States have a
This report made a unique attempt in high likelihood of excluding marginalized, poor
Chapter 5 to extensively explore major global and vulnerable population groups such as
data sets from household and other topical refugees and migrants. Displacement arising
surveys in an attempt to gauge progress from conflicts and climate crises is also on the
towards the SDGs relevant to migration rise and is becoming protracted. This includes
and health, particularly those aimed at but is not limited to crises in the African Sahel
reducing inequalities in access to health and Tigray regions, as well as in Afghanistan,
care services and in ensuring health for all. the Democratic Republic of the Congo,
However, this exploration highlighted the Myanmar, Nigeria, Somalia, the Syrian Arab
inadequacies of the data. Although the world Republic, Ukraine, the Bolivarian Republic of
has well-established international survey Venezuela, Yemen and several other countries
instruments that are constantly improving, and areas. These crises stall the already slow
the largest data sets currently yield relatively or modest progress made towards achieving
little robust, comparable information about the SDGs, and in some cases, even reverse it.
the health of refugees and migrants, and
these data are from only a small number The COVID-19 pandemic created deep
of countries and for only a small number economic turmoil around the world and near
of indicators. The main challenge in HIS financial meltdown in many low- and middle-
arises from the lack of actionable data and income countries, many of which host labour
effective indicators that would allow for the migrants. The pandemic also halted or reversed
disaggregation of data by migratory status. progress in health and, in turn, resulted in
major threats beyond disease or health itself.
This report's findings of unrepresentative About 90% of countries are still reporting one
samples and unclear definitions of migratory or more disruptions to essential health services,
status – among other data inadequacies – and data from a few countries show that the
highlight the main challenge: calls made pandemic has shortened life expectancy.
5 years ago by all Member States for data to be
disaggregated by migratory status (and other Not surprisingly, the COVID-19 pandemic has
factors) by 2020 (SDG Target 17.18) have yet to disproportionately affected disadvantaged
be answered in any comprehensive or useful groups, including irregular refugees, migrants
way. Data do not currently permit accurate and asylum seekers. The pandemic has
measurement of the progress made by and for demonstrated the importance of UHC
refugees and migrants towards achieving the and multisectoral coordination for health
SDG targets. However, Chapter 5 suggests that emergency preparedness. Moreover,
some quick wins could be possible by to design effective pandemic policy
298
interventions, governments will need to measurable impact on improving the health of

improve and strengthen the collection of refugees and migrants. Additionally, refugees
basic demographical and epidemiological and migrants must be active participants
data, with disaggregation for various not only in policy-making but also in
variables including for migratory status. implementation.
Before the world was able to recover from Fundamentally, collective action will require
the pandemic, unprecedented numbers greater political dedication and the necessary
of refugees and IDPs were observed at resources to ensure that policies for health
the highest levels since the Second World systems and services include refugees and
War. The war in Ukraine is triggering global migrants, regardless of their legal status. In
ripple effects through multiple channels, the long run, the "othering" of refugees and
including commodity markets, trade, migrants needs to be reduced and eventually
financial flows, market confidence and removed to avoid "us versus them" discussion
displaced people. If protracted, it can further in policy-making and society at large.
dampen global growth, peace and security
around the world, which are fundamental As seen in Chapter 1, there have been several
enablers and determinants for promoting successful policy initiatives at global and
health of refugees and migrants (2). regional levels during recent years. These have
resulted in some national measures, such
These situations seriously put at risk the as including refugees and migrants in health
achievability of the health and health- policies, as highlighted in Chapters 2 to 4.
related SDG targets, including addressing the However, as Chapters 2 and 3 show, there still
health needs of refugees and migrants (3). exist relatively large health inequalities among
refugees and migrants. This illustrates the gap
between policy and practice and highlights
6.2 The way forward: the need to both translate policy into practice
health for a world in motion and to follow up the implementation of
policies with monitoring for health outcomes.
6.2.1 Health and migration: Chapter 5 shows that this follow-up is almost
a global health priority impossibly difficult with the routine data
This report shows there is growing recognition collection systems currently in place.
that the health needs of refugees and migrants
are a global health priority. These needs Interesting patterns emerge from the evidence.
require concerted action beyond the health The majority of the evidence reviewed for
sector, requiring coordination between health Chapters 2 to 4 comes mainly from only three
and other ministries to bring about whole-of- of the six WHO Regions, covering mainly
government and whole-of-society approaches high-income destination countries, while
to address health and migration issues at the remaining regions also host a significant
the national level. WHO seeks to integrate proportion of refugees and migrants. This
health and migration into its coordination and demonstrates the urgent need to support regions
consolidation efforts with Member States, key to develop capacity for research and evidence-
UN agencies and non-state actors, including generation activities so that the data reflect the
NGOs and civil society organizations, to drive magnitude and characteristics of the refugee and
an international health agenda that will have a migrant populations across all regions.
299
Although refugees and asylum seekers Ultimately, national governments already have
account for only 12% of individuals who several tools that can improve the health of
cross an international border, according to refugees and migrants. Clear plans of action
estimates from UNDESA (4), they account for and for implementation are needed at the
34% of those studied in the literature that was subnational and national levels in order to
reviewed. Almost one third of the literature have a real impact locally while contributing
had no indication of which migrant group to global actions and accelerating progress
was studied. The most commonly studied towards global goals and targets, including
health issues were communicable diseases those related to the SDGs. However, such plans
and mental health. While these studies have must be truly agreed upon by a range of sectors
produced key evidence in these areas, other and stakeholders at country level first and then
health issues such as NCDs and SRH need to at the regional and global levels if real progress
have similar attention. This will allow for a is to be achieved, in line with the whole-of-
more comprehensive analysis of the health government, whole-of-society and Health in
burden on refugees and migrants. It is crucial All Policies approaches. WHO's Health and
that the data used for evidence-informed Migration Programme, the United Nations and
policy-making are representative of the target other international organizations will support
population. Therefore, efforts to address Member States and national authorities in
the unrepresentative nature of the literature these efforts.
that is available need to be put in place.
With the overall aim of supporting the
This report shows that refugee- and highest attainment of health for refugees
migrant-inclusive policies exist. The report and migrants, the following action points
also shows that, while it is important to are provided to focus the thinking of
review and revise existing policies and governments and other stakeholders around
develop new evidence-informed policies, the world to help them to work together to
it is not the lack of policies, but the lack of strengthen policies and translate these into
implementation and effective monitoring interventions to bring about real progress in
necessary for creating an accountability the field of health and migration.
framework that lead to health inequalities.
6.2.3 Effectively integrating
6.2.2 Towards concerted efforts: refugees and migrants into
a paradigm shift universal health coverage
It is time for governments, United Nations and and primary health care
non-United Nations organizations, NGOs and If integration of refugees and migrants
civil society organizations and other non- into UHC and PHC is to be achieved, it is
state actors, including refugee and migrant essential to support WHO's drive towards
advocacy groups and other stakeholders, to a radical reorientation of health systems
work together to "walk the talk" and to assist towards PHC as the foundation of UHC.
Member States, national and international This must be coupled with a shift towards
policy-makers and actors on the ground to health promotion and disease prevention
translate policies and guidelines into practice. by addressing health determinants and
These efforts must be coupled with an effective risks; strengthening systems and tools for
monitoring framework to ensure accountability, epidemic and pandemic preparedness and
to track progress and to take corrective actions. response, supported by governance and
300
financing reforms; and harnessing the power issue of human resources, it emphasizes
of science, research innovation, data and investing in a health workforce with the
digital technologies. These are foundational training, skills, tools, working environments
elements for the WHO Health and Migration and fair pay to deliver safe, effective and
Programme. WHO further affirmed this during high-quality care.
the Seventy-fifth World Health Assembly (2022)
and reiterated its commitment to work with With the demonstrated health implications
partners to help Member States to achieve of a world in motion for refugees and
their SDG aspirations of meeting health and migrants in particular, WHO has undertaken
health-related targets and to leave no one a strategic approach aimed at reorienting
behind, including any refugee and migrant. and strengthening health systems, not only
to take the needs of refugees and migrants
Restoring, expanding and sustaining access into account but also to actively include these
to essential health services will be needed, populations in all aspects of programming
particularly those focusing on health and service provision. The strategy aims
promotion and disease prevention, as well as to build strong health systems that benefit
reducing out-of-pocket spending. This also host populations and are responsive
means focusing on the least-served, most- also to the health needs of refugees and
vulnerable populations, particularly women, migrants, focused on PHC as a foundation
children and adolescents, and refugees and for UHC and on health security rooted in
migrants. It emphasizes ensuring access to the principle of Health in All Policies (5).
vaccines, medicines, diagnostics, devices and
other health products. Finally, on the essential
A health worker attends a Burundian refugee after she delivered her baby girl at Natukobenyo health clinic in Kalobeyei settlement.
© UNHCR / Samuel Otieno
301
6.2.4 Global action plan Policies should deal specifically with the needs
The SDGs and WHO's GPW13 provide the of subpopulations of refugees and migrants
global context for WHO's Global Action Plan on that are particularly vulnerable. These include
promoting the health of refugees and migrants those with poor access to preventive and
(the GAP) (6). The goal of the GAP is to assert curative health care; women and children;
health as an essential component of protection those affected by sex- and gender-based
and assistance for refugees and migrants and of disadvantages, exclusionary processes, stigma
good migration governance. More specifically, and discrimination and other intersecting
the GAP aims to improve global health by discriminations, such as age and ethnicity;
addressing the health and well-being of refugees and the special needs of UASC. Policies should
and migrants inclusively and comprehensively provide for regular assessments to analyse
as part of holistic efforts to respond to health whether the health system is meeting the
needs in any setting. It recognizes that, to prevent needs of refugees and migrants.
inequities, the public health opportunities and
the challenges offered by refugees and migrants 6.3.2 Strengthen the capacity and
cannot be separated from those of the host increase the sensitivity of
population. This approach is justified not only health systems to meet the
by humanitarian motivations but also because specific health needs of
it reflects rational public health practice. It also refugees and migrants
reflects the urgent need for the health sector to Policies related to refugees and migrants
deal more effectively with the impacts on health are often siloed, and policy coherence may
of displacement and migration. be absent if the health sector is excluded
from or has a limited voice in policy-making
(7). The same is true if the health sector
6.3 Policy and practice does not include other sectors in planning,
implementation and follow-up of policies.
6.3.1 Develop short- and long-term
public health action plans that Health systems should be strengthened
include refugees and migrants, so they have the capacities needed to
and support their implementation respond to the health needs of the whole
Policies relating to health and migration should population, including refugees and migrants,
be built on documented health needs and thus enhancing the continuity and quality
evidence-based standards and practices. This of care as well as workforce competencies
requires ensuring policy coherence among the and achieving UHC. In many countries,
ministries responsible for the range of sectors significant impact would be achieved by
and ministries that affect the health status of extending and improving occupational
refugees and migrants; health and also finance, health services in industries with high levels
social welfare, labour, immigration, housing of migrant workers and by placing a strong
and education. Such policies should address emphasis on preventive interventions.
the immediate health risks resulting from
inadequate migration policies – such as working Based on experiences gained during the
conditions, accommodation, conditions in COVID-19 pandemic, WHO has identified three
camps and access to health care, preventive components necessary for implementing an
and SRH services – and the impacts of the social integrated approach to policies addressing
determinants of health. migration and public health (8):
302
• p rotection-sensitive access to territory – and capabilities of health personnel and the

enabling access to territories and health sector can affect health by ensuring
asylum procedures for people who need the availability and affordability of health
international protection; promotion and disease prevention services
• migratory status flexibility – facilitating and treatments. A critical element is to
regularization of the status of irregular effectively include refugees and migrants as
(undocumented) migrants to ensure they part of the health workforce and professionalize
have safe and lawful access to health their contributions (10). Wherever possible,
services; and diaspora health workers should be included
• non-discriminatory access to health care – in designing, implementing and evaluating
providing equal access to health care for all, refugee- and migrant-sensitive health services
regardless of status, nationality, gender, and educational programmes. In addition,
age or ethnicity. health and migration should be included in
the graduate, postgraduate and continuing
6.3.3 Enhance understanding of professional training of all health personnel.
the health promotion and
health needs of refugees 6.3.4 Actively include refugees and
and migrants migrants within financial
Advocacy and public health education efforts and social protection systems
should be implemented to build support for The health of refugees and migrants is an
safeguarding and promoting the health of increasingly prominent and urgent issue of
refugees and migrants, as well as ensuring wide our time. Investing in their health is important
participation in these efforts by refugees and not only because it is a sound public health
migrants, the public, government and other strategy, which can bring increasingly positive
stakeholders. Refugees and migrants must be impacts from migration when addressed
actively present as integral partners in these appropriately, but also because it is a
efforts, and solutions must be co-created with human rights issue: excluding refugees and
all relevant stakeholders, most importantly migrants – who account for a significant
refugees and migrants themselves (9). proportion of the global population – from
and restricting their access to health services,
The backbone to a refugee- and migrant- knowingly or inadvertently, leads to health
sensitive health system is health professionals inequalities and compromised health security.
that have the resources and capacity to Furthermore such restrictions contravene the
deliver appropriate services. The capacities principle of the 2030 Agenda for Sustainable
Development of leaving no one behind,
WHO's transformation mantra of serving
the vulnerable and the goals of many other
international covenants and treaties (11–14).
Refugees and migrants should be
integrated within social protection Refugees and migrants often face significant
social, financial and environmental
arrangements, including social disadvantages, as discussed in Chapter 2
security programmes. regarding the determinants of health.
For example, migratory status is often
a major barrier for irregular migrants
303
to securing employment and workplace

protections (15,16), while access to safe and
stable housing and standards-based working
It is not the lack of policies, but
conditions vary according to the inclusiveness the lack of implementation and
of national policies and programmes.
effective monitoring necessary
Refugees and migrants should be integrated for creating an accountability
within social protection arrangements,
including social security programmes. The
framework that lead to health
WHO Health and Migration Programme is inequalities.
working across the United Nations system
and with other actors and stakeholders to
ensure that refugees and migrants have the
protections necessary to attain the highest
levels of mental and physical health (12,13). Beyond the national level, regional and
Active inclusion measures are required. international organizations concerned with
the health and well-being of refugees and
6.3.5 Strengthen accountability migrants need to work urgently to improve
and indicators framework the availability and quality of data about their
Policies that are not informed by evidence will health. To this effect, WHO is actively engaged
likely be ineffective, and gathering evidence with and across the United Nations in efforts
and data without a policy framework is to ensure health data and indicators are fit
misguided. Therefore, the strategic direction for purpose to guarantee there is effective
for health and migration policy must monitoring of SDG goals and targets.
be founded on a results framework and
supported by strengthened HIS. Introducing core variables into data collection
tools is a relatively straightforward first step
The responsibility to guarantee privacy and that can be taken to facilitate disaggregation.
confidentiality and avoid using data to limit National surveys should ensure that refugees
access to services should be respected and and migrants are appropriately represented
underpinned by a governance framework. in their samples: for this to happen, trust and
It should be underpinned by legislation and legal safeguards to prevent the misuse of data
firewalls that prevent unauthorized access to, should exist between the people who provide
or the abusive use of, such information. data (the refugees and migrants) and those
In addition, data privacy must be guaranteed, who collect and use it (the authorities and
particularly as information becomes easier other stakeholders). For trust and safeguards
to exchange among databases (17). Refugees to be co-created, whole-of-government and
and migrants should be offered a thorough whole-of-society approaches need to be
explanation so they understand why non- adopted, as highlighted in Chapters 2 and 4.
discriminatory health-related data are being Dismantling the silos and collaborating across
collected and how providing these data can sectors and institutional boundaries present
benefit them. At a minimum, information both challenges and opportunities for all
should be available in languages that refugees aspects of refugee and migrant health.
and migrants can understand to allow them to Based on the effective and collaborative
make informed decisions and give consent. approaches used in preparing this report,
304
WHO, through its Global Data Initiative on efforts on a variety of issues: capacity-building
Health and Migration, will use a multipronged for institutions in the global south; making
approach to strengthen data and evidence health and migration a global research and
about health and migration. This involves evidence-gathering priority for donors;
working directly with Member States, with supporting the development of regional
facilitation by regional and country offices, research networks; and engaging refugee and
as well as through regional bodies of United migrant populations in both the process of
Nations agencies. However, it should also research as well as in operational research. In
involve working across WHO programmes and addition, translating research and evidence
with regional and country offices through the into policy and practice often remains a
Data Hub and Spoke Collaborative to make challenge, with substantive gaps between the
various health data collection efforts fit for evidence base and policy and implementation.
purpose for health and migration monitoring.
Similarly, such efforts will be needed to work This prioritization of global research
with United Nations agencies, international also reflects the focus of the SDGs and
organizations and non-state actors to embed the Global compact for safe, orderly and
health and migration data and monitoring in regular migration on ensuring access to
their data efforts. In addition to strengthening health services for refugees and migrants,
existing approaches to data collection and both globally and at the country level (18).
evidence generation, emphasis should be Consequently, the Health and Migration
placed on innovation and the use of digital Programme will collaborate with key
technologies, such as big data, machine stakeholders – national authorities, United
learning and artificial intelligence. Nations agencies and non-state actors –
to conduct operational research in the
6.3.6 Promote global research, priority areas identified, with the objective
strengthen knowledge of building research capacity on health
production and build research and migration at the country, regional and
capacity in health and migration global levels and ensuring that the evidence
Health and migration research is a priority drives policies and implementation. By
for WHO's Health and Migration Programme strengthening health and migration research
and across all public health impact activities globally, the Programme will support the
for WHO, ensuring policy impact through effective development of evidence-informed
supporting evidence-informed decision- normative products and knowledge
making. The prioritization of research about production based on the needs and gaps
health and migration being developed by identified at the country level.
WHO's Health and Migration Programme is
a vital part of filling global evidence gaps
and it outlines priority research themes as
they relate to health and migration under
the Triple Billion Targets. The aim of this
prioritization is to overcome not only the
challenges of limited research about health
and migration in low- and middle-income
countries but also the limited focus on only
certain groups or diseases. This requires
305
References 10. Health of refugees and migrants: regional situation analysis,

practices, experiences, lessons learned and ways forward.
New Delhi: WHO Regional Office for South-East Asia; 2018
(https://www.who.int/docs/default-source/documents/
publications/health-of-refugees-and-migrants-searo-2018.
1. Global trends report 2021. Geneva: United Nations High pdf?sfvrsn=b7c1ad1f_1, accessed 3 June 2022).
Commissioner for Refugees; 2022 (https://www.unhcr.
11. Resolution A/RES/70/1. Transforming our world: the 2030
org/62a9d1494/global-trends-report-2021, accessed
Agenda for Sustainable Development. In: Seventieth session,
21 June 2022).
United Nations General Assembly, 25 September 2015. New
2. Guénette JD, Kenworthy P, Wheeler C. Implications of the York: United Nations; 2015 (https://www.un.org/ga/search/
war in Ukraine for the global economy. Washington (DC): view_doc.asp?symbol=A/RES/70/1&Lang=E, accessed
World Bank Group; 2022 (https://thedocs.worldbank.org/ 19 January 2022).
en/doc/5d903e848db1d1b83e0ec8f744e55570-0350012021/
12. General comment No. 14: the right to the highest attainable
related/Implications-of-the-War-in-Ukraine-for-the-Global-
standard of health (article 12 of the International Covenant
Economy.pdf, accessed 3 June 2022).
on Economic, Social and Cultural Rights). In: Committee on
3. Sustainable Development Goals progress chart 2021. New Economic, Social and Cultural Rights, Twenty-second session,
York: United Nations Statistics Division, Department of Geneva, 25 April–12 May 2000. New York: United Nations Economic
Economic and Social Affairs; 2021 (https://unstats.un.org/ and Social Council; 2000 (E/C.12/2000/4; https://digitallibrary.
sdgs/report/2021/progress-chart-2021.pdf, accessed un.org/record/425041?ln=en, accessed 25 April 2022).
3 June 2022).
13. General comment No. 19: the right to social security
4. International migrant stock 2020 [online database]. New York: (article 9 of the International Covenant on Economic,
United Nations Department of Economic and Social Affairs, Social and Cultural Rights). In: Committee on Economic,
Population Division; 2020 (https://www.un.org/development/ Social and Cultural Rights, Thirty-ninth session, 5–23
desa/pd/content/international-migrant-stock, accessed November 2007. New York: United Nations Economic and
28 May 2021). Social Council; 2007 (E/C.12/GC/19; https://www.refworld.
5. Health in all policies: Helsinki statement. Framework for org/docid/47b17b5b39c.html, accessed 3 January 2022).
country action. Geneva: World Health Organization, Finland 14. Leaving no one behind: equality and non-discrimination
Ministry of Social Affairs and Health; 2014 (https://apps.who. at the heart of sustainable development - a shared United
int/iris/handle/10665/112636, accessed 5 May 2022). Nations System framework for action. New York: United
6. Global action plan on promoting the health of refugees Nations System Chief Executives Board for Coordination;
and migrants, 2019–2023. In: Seventy-second World Health 2017 (https://unsceb.org/sites/default/files/imported_files/
Assembly, Geneva, 20–28 May 2019. Resolutions and CEB%20equality%20framework-A4-web-rev3.pdf, accessed
decisions, annexes. Geneva: World Health Organization; 13 January 2022).
2019: Annex 5 (WHA72/2019/REC/1; https://apps.who.int/gb/ 15. Legido-Quigley H, Pocock N, Tan ST, Pajin L, Suphanchaimat
ebwha/pdf_files/WHA72-REC1/A72_2019_REC1-en.pdf). R, Wickramage K et al. Healthcare is not universal if
7. Interrelations between public policies, migration and undocumented migrants are excluded. BMJ. 2019;366:14160.
development. Paris: Organisation for Economic Co-operation doi:10.1136/bmj.14160.
and Development; 2017 (https://www.oecd-ilibrary.org/ 16. Moyce SC, Schenker M. Occupational exposures and health
development/interrelations-between-public-policies- outcomes among immigrants in the USA. Curr Environ Health
migration-and-development_9789264265615-en, accessed Rep. 2017;4(3):349–54. doi:10.1007/s40572-017-0152-1.
25 April 2022).
8. Refugees and migrants in times of COVID-19: mapping trends health in the WHO European Region: technical guidance.
of public health and migration policies and practices. Geneva: Copenhagen: WHO Regional Office for Europe; 2020 (https://
World Health Organization; 2021 (https://apps.who.int/iris/ apps.who.int/iris/handle/10665/337694, accessed
handle/10665/341843, accessed 3 June 2022). 12 November 2021).
9. MacFarlane A, Ogoro M, de Freitas C, Niranjan V, Severoni S, 18. Resolution A/RES/73/195. Global compact for safe, orderly and
Waagensen E. Migrants’ involvement in health policy, service regular migration. In: Seventy-third session, United Nations
development and research in the WHO European Region: a General Assembly, New York, 11 January 2019. New York:
narrative review of policy and practice. Trop Med Int Health. United Nations; 2019 (https://www.un.org/en/development/
2021;26(10):1164–76. doi:10.1111/tmi.13643. desa/population/migration/generalassembly/docs/
globalcompact/A_RES_73_195.pdf, accessed 3 June 2022).
ANNEX
Methodology
Annex. Methodology
307
A.1 Methodology for Chapters 2–4

The evidence base for Chapters 2–4 is a review of recent literature about the
health of refugees and migrants. The review included both peer-reviewed
scientific literature and grey literature in English and in the other major
languages of WHO regions: Arabic, French, German, Italian, Portuguese, Russian
and Spanish. Literature published between January 2015 and June 2021 was
included to cover the most recent work, but key documents published prior to
2015 and after June 2021 were also considered.
A literature review with a relatively wide The evidence review was initially conducted
scope and broad search terms was deemed by regional experts in the six WHO regions.
appropriate, given that this report aims to The regional reviews were then further
establish a baseline of global evidence on the integrated to develop the global synthesis
health of refugees and migrants. This resulted that is presented in Chapters 2–4.
in collecting and reviewing more than 82 000
documents. In addition to collecting a vast Of the more than 82 000 documents collected,
amount of literature, several key experts from the review finally synthesized evidence from
each of the WHO regions were involved in the more than 3250 documents that met the
entire review and analysis processes. This inclusion criteria.
not only enabled literature to be reviewed in
regional languages but also allowed for regional The WHO Region of the Americas, WHO
variations in the search strategy and analysis. European Region and WHO Eastern
To supplement the broad review conducted Mediterranean Region each accounted for
for the report, a more targeted review of approximately one fourth of the total amount
selected topics was conducted and is still being of literature reviewed, with the WHO African
conducted through another flagship publication Region, WHO South-East Asia Region and WHO
series from the WHO Health and Migration Western Pacific Region accounting for the
Programme: the Global Evidence Review on remainder of the literature (Fig. A.1).
Health and Migration. Table A.1 provides a
detailed list of inclusion and exclusion criteria The largest proportion of documents reviewed
for the literature reviewed for this report. (30%) was quantitative studies, followed by
qualitative studies (20%). The grey literature
Several key databases and the websites reviewed included surveys and reports
of key ministries and organizations were from organizations (14%) and observational
also searched (Box A.1). Additional targeted studies (11%).
literature searches were conducted to
address gaps identified during the searches.
308
Approximately one third of the evidence in the provided information about labour migrants
included literature was about refugees, and (17%) and other groups such as asylum
another one third did not specify the refugee seekers, irregular migrants and international
or migrant groups studied. The remaining third students (Fig. A.2).
Table A.1. Inclusion and exclusion criteria for the review of the health of refugees and migrants
Category Criteria
Inclusion Exclusion
Population Refugees and/or international migrants Citizens of the host country and/or ethnic or
racial minorities if there was no indication that
international migrants were present among the
study participants; internal migrants; IDPs
Study focus Health and/or factors affecting health NA

Geographical location of study Studies performed in any of the six WHO regions NA
Study design and type Qualitative, quantitative and mixed methods; Narrative reviews, scoping reviews, systematic
descriptive and analytical studies, experimental reviews, letters to the editor, expert opinions
(randomized clinical trials) or observational
(cohort studies, cross- sectional, case–control,
case studies, case series); meta-analyses
Publication date From January 2015 to June 2021; however, key NA
documents published before 2015 and after
June 2021 were also considered
NA: not applicable.
Fig. A.1. Proportion of documents included in the review, by WHO region
African Region
Region of the Americas
7% 11%
9%
European Region
23%
27%
23%
Annex. Methodology
309
Box A.1.
Databases and sources searched for the review
Source URL
CABI Global Health https://www.cabi.org/publishing-products/global-health/
Cochrane Library https://www.cochranelibrary.com/
DANS EASY https://easy.dans.knaw.nl/ui/home
Eldis https://www.eldis.org/
Embase https://www.embase.com/
Google https://google.com/
Google Scholar https://scholar.google.com/
Health Policy Reference Center https://www.ebsco.com/products/research-databases/
health-policy-reference-center
International Bibliography of the Social Sciences https://about.proquest.com/en/products-services/ibss-set-c/

Lancet Migration https://migrationhealth.org/
Migrant Integration Policy Index https://www.mipex.eu/
OpenGrey https://opengrey.eu/
OpenSIGLE http://www.greynet.org/opensiglerepository.html
PsycInfo https://www.apa.org/pubs/databases/psycinfo
PubMed/MEDLINE https://pubmed.ncbi.nlm.nih.gov/
Sabinet https://sabinet.co.za/
SciELO https://scielo.org/
Scopus https://www.elsevier.com/en-gb/solutions/scopus
Semantic Scholar https://www.semanticscholar.org/
SOPHIE http://www.sophie-project.eu/project.htm
Web of Science https://clarivate.com/webofsciencegroup/solutions/web-
of-science/
WHO documents https://apps.who.int/iris/
Websites of international organizations Various
(e.g. IOM, UNHCR), universities, research
institutes, health departments, research
networks and NGOs
Websites of ministries of health, foreign affairs Various
and immigration; and national public health
agencies
CABI: Centre for Agriculture and Bioscience International; DANS: Data Archiving and Networked Services; OpenSIGLE: System for Information on Grey Literature in Europe; SciELO:
Scientific Electronic Library Online; SOPHIE: Structural Policies for Health Inequalities Evaluation.
310
Health status was the health issue studied Approximately two thirds of the documents
most often (58% of the documents reviewed), about health systems focused on service
followed by health determinants (29%) and delivery (62%). Other building blocks of
health systems (21%). Among the documents health systems, such as the health workforce
that explored health status, approximately one and leadership or governance, were
fourth studied communicable diseases (24%) studied in less than 10% of documents.
or mental health (21%), and the remainder
studied MCH, NCDs, occupational health
and SRH.
Fig. A.2. Proportion of documents included in the review, by migrant group studied
104 | 3%
17 | 1.0%
69 | 2%
Refugees
Not specified
Labour migrants
Multiple migrant groups
164 | 5% Migrant children and adolescents
998 | 31%
Asylum seekers
328 | 10% Irregular (undocumented) migrants
International students
545 | 17%
989 | 31%
Annex. Methodology
311
A.2 Methodology for Chapter 5 offer greater potential for disaggregation

since they provide comparable global
The review for Chapter 5 began by considering data sets with information about health,
which large data sets to explore. Censuses determinants of health and migratory status.
and household surveys have traditionally For this reason, these major international
been reliable sources of global and regional surveys were chosen as the data sets for the
indicators of health. Standards for conducting review (Box A.2). As a result, 2 294 household
them have been established and accepted by surveys were screened based on the inclusion
the international statistics community and, criteria mentioned in the next section.
with technical guidance from United Nations
agencies, many countries have adopted Other data sources were also considered,
questionnaires and data codes for such work (1). including civil registration and vital statistics
systems and the administrative data
Both approaches have their strengths and produced by government HIS. However,
weaknesses, and this is particularly true these data sources are not always accessible
when attempting to disaggregate data on for research purposes. Moreover, they
migratory status (Table A.2). However, global pose problems regarding privacy, and their
surveys such as BADEHOG (3), DHS-VII (4), data are not always comparable (8).
ESS (5), MICS6 (6) and PISA (7) may currently
Table A.2. Censuses versus surveys: strengths and weaknesses for analyses of health and migration
Characteristic Data source
Population census Household survey
Strengths • C overs the whole population • Can collect in-depth information about health
• Collects information about a broad range of and employment (e.g. DHS, MICS, labour-force
topics surveys)
• Can produce subpopulation-level estimates • Usually conducted more frequently than
if the specific group is included in the census censuses, thus providing timelier data
frame • Specialized and targeted surveys may also
• Can be used with other data sources that be useful for collecting data about certain
are not appropriate for disaggregation to subgroups, such as refugees and migrants
model disaggregated estimates for specific • Can be used with other data sources to
subgroups produce estimates for specific groups
• Can produce proxy estimates (i.e. use
substitute measures for original indicators)
• Can provide data for comparative analyses
across countries and over time by applying
harmonized coding schemes
Weaknesses • Census questionnaires cover a limited number • Covers a sample population and may miss
of topics: they are not designed to collect in- populations in irregular settlements, hard-
depth health data or information to-reach groups or those who are not part of
• Information is not timely since most censuses national census coverage
are conducted only every 10 years • Disaggregation by migratory status may not
• Access to complete census data is often be appropriate due to issues arising from the
limited, which reduces full exploitation of the sample size
data and information
Source: Mosler Vidal (2).

312
Box A.2.
International surveys included in this review
Five surveys were selected for analysis and exploration in this review: the Household Survey Databank
(BADEHOG; Banco de Datos de Encuestas de Hogares) (3), Demographic and Health Survey (DHS) (4),
European Social Survey (ESS) (5), Multiple Indicator Cluster Survey (MICS) (6) and the Organisation for
Economic Co-operation and Development's Programme for International Student Assessment (PISA) (7).
BADEHOG. This databank is maintained by the Economic Commission for Latin America and the
Caribbean. It compiles and harmonizes household surveys from 18 countries in the WHO Region of the
Americas.
DHS. This survey has been supported by the United States Agency for International Development since
1985 and has collected and analysed accurate and representative data about populations, health,
HIV prevalence and nutrition through more than 400 nationally representative surveys in more than
90 countries. Originally designed as a follow-up to the World Fertility Survey and the Contraceptive
Prevalence Survey projects, the DHS Program has provided technical assistance for more than 350
surveys, thereby advancing global understanding of trends in health and population in developing
countries. The DHS Program is implemented in overlapping 5-year phases.
ESS. This cross-national survey has been conducted throughout Europe since 2001. Every 2 years, face-
to-face interviews are conducted with people from newly selected, cross-sectional samples. The survey
measures the attitudes, beliefs and behaviour patterns of diverse populations in more than 30 nations.
MICS. This survey has been supported by the United Nations Children's Fund since 1995; it was started
in response to the World Summit for Children in 1990 to measure mid-decade progress. A total of 118
countries have carried out one or more MICS rounds, generating nationally representative data about
key indicators of the well-being of children and women, and helping to shape policies to improve
their lives.
PISA. This survey measures the ability of 15-year-olds to use their reading, mathematics and science
knowledge and skills. It provides comparable data aimed at helping countries to improve education
policies and outcomes. First carried out in 2000, it is repeated every 3 years.
A.2.10Selecting countries for • t he percentage of international migrants

the review in the total sample had to be at least 1% in
The following criteria were used to determine order to conduct a meaningful analysis.
which countries and surveys to include in
this review: The countries selected from each survey are
shown in Table A.3.
• s urvey data and documentation had to be
available in English;
• the survey reference period had to be from
2015 onwards in order to capture the most
recent trends; and
Annex. Methodology
313
Table A.3. Countries considered for this review, by survey and WHO region
Survey and WHO region Country or area
DHS-VII and MICS6
African Region Benin, Burundi, Cameroon, Central African Republic, Chad, Ethiopia, Gambia, Ghana, Guinea,
Guinea-Bissau, Lesotho, Liberia, Malawi, Mali, Sao Tome and Principe, Sierra Leone, Togo, Zimbabwe
Region of the Americas Guyana, Suriname
South-East Asia Region Indonesia, Nepal, Thailand
European Region Armenia, Kosovo,a Montenegro
Eastern Mediterranean Region Jordan
WHO Western Pacific Region Tonga
PISA 2018
African Region NA
Region of the Americas Argentina, Canada, Chile, Costa Rica, Dominican Republic, Mexico, Panama, United States, Uruguay
South-East Asia Region NA
European Region Austria, Azerbaijan (Baku),b Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czechia,
Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel,
Italy, Kazakhstan, Kosovo,a Latvia, Lithuania, Luxembourg, Malta, Montenegro, Netherlands, North
Macedonia, Norway, Portugal, Republic of Moldova, Russian Federation, Serbia, Slovakia, Slovenia,
Spain, Sweden, Switzerland, Ukraine, United Kingdom
Eastern Mediterranean Region Jordan, Lebanon, Qatar, Saudi Arabia, United Arab Emirates
Western Pacific Region Australia, Brunei Darussalam, China (Hong Kong Special Administrative Region and Macao Special
Administrative Region), Malaysia, New Zealand, Philippines, Singapore
ESS 2002–2018
European Region Belgium, Estonia, Finland, France, Germany, Ireland, Netherlands, Norway, Portugal, Slovenia
BADEHOG 2017–2019
Region of the Americas Argentina, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Panama, Paraguay, Uruguay
a
b
In Azerbaijan, PISA 2018 was limited to the city of Baku.
314
A.2.2 Countries excluded • T

able 5.10. Percentages of women
A total of 77 candidate countries had (15–49 years) subjected to physical or sexual
conducted MICS6 and DHS-VII and had their violence by a husband or partner during the
data available online for further analysis previous 12 months, by migratory status.
(Fig. A.3). However, 17 lacked indicators of
migratory status, which reduced the list to 60. Another two countries were excluded because
In only 36 of these countries did international their surveys were carried out among ethnic
migrants represent 1% or more of those communities in specific settlements rather
included in the survey sample. Of these, six than across the entire country.
countries were excluded because their surveys
provided data only from female respondents. Countries with data cell count below 25
However, since these six satisfied all other were excluded following DHS guidelines
criteria, they were included in the tables that on statistics.
discuss gender-specific issues:
Using the SDGs as reporting frameworks,
• T able 5.7. Percentage of women using the items in DHS-VII and MICS6 were reviewed
modern or traditional contraception, by to map indicators of health to the SDGs
migratory status; (Table A.4). These indicators were then
• Table 5.8. Percentage of women attending compared with the SDG indicators related
antenatal care, by number of visits and to health. This mapping can be done for any
migratory status; reporting framework that considers health and
• Table 5.9. Percentage of women migration. See section A.3 for an explanation
(15–49 years) and their daughters of how the indicators were calculated.
(0 months to 14 years) in the WHO African
Region who have experienced FGM, by
migratory status; and
Fig. A.3. Country selection criteria for review of data from the DHS-VII and MICS6 surveys
Criteria for inclusion No. of countries
MICS6 or DHS-VII data sets available for download 77
Have indicators on migratory status 60
≥1% of sample is international migrants 36
Data sets available for both males and females 30
Surveys only in settlements subtracted (2)
Total surveys included in review 28

Table A.4. SDGs and relevant survey indicators
SDG Survey and indicators of health
BADEHOG DHS-VII and MICS6 ESS PISA
1. End poverty in all its forms Materials used to build homes, Wealth index Main source of income for • H as a bank account
everywhere including floors, walls and roof • Has an account in a bank or household of international • Household annual income
financial institution migrants • Family wealth index
• Main material for home's
flooring
• Main material for home's roof
• Main material for home's walls
• Various household possessions
2. End hunger, achieve food NA • N utritional status of children NA NA

security and improved nutrition aged > 5 years
and promote sustainable • BMI and height for age, weight
agriculture for age, weight for height
3. Ensure healthy lives and Health insurance coverage • D eaths due to road accidents • Subjective self-reported general • B MI of students
promote well-being for all at all • Births attended by skilled health health of international migrants • S atisfaction of students with
ages personnel • Opinion of international their health
• Children received first dose of migrants about the state of • A ssessment by students of their
pneumococcal vaccine health services in the country by health
• Children received measles destination country • F requency in past 6 months of
vaccine • International migrants who are various illnesses (e.g. headache,
• Women of reproductive age (15– hampered in their daily activities stomach pains, back pain,
49 years) who have their need in any way by illness, disability, feeling depressed, irritability
for family planning satisfied with infirmity or mental health or bad temper, feeling nervous,
modern methods problem difficulty getting to sleep, feeling
• Currently smoking cigarettes dizzy, feeling anxious)
• Health insurance coverage
• Type of health insurance
• Use of mosquito nets
• Anaemia
• Health impact of salt iodization
• Place of birth of youngest child
(most recently born)
• Tested for HIV as part of
antenatal care or visit
• BCG vaccination of children
• Children received hepatitis B
vaccine at birth
Annex. Methodology
• Children received one dose of

pentavalent vaccine
315
Table A.4 contd
316
4. Ensure inclusive and ighest educational level

H Highest educational level NA Highest level of schooling
equitable quality education completed completed or whether respondent completed by student
and promote lifelong learning is still in school
opportunities for all
5. Achieve gender equality and NA • W omen and girls (15–49 years) NA NA

empower all women and girls who have ever had a partner and
been subjected to physical or
sexual violence by a current or
former intimate partner, or both,
during the previous 12 months,
by type of violence and by age of
respondent
• Women and girls aged 15–49
years who have undergone FGM
• Women aged 15–49 years
who make their own informed
decisions regarding sexual
relations
• Decisions about contraception
use made by women aged 15–49
years
• Decisions about own health care
made by women aged 15–49
years
6. Ensure availability and ccess to improved water sources

A • M ain source of drinking-water NA NA
sustainable management of with improved sanitation • Household has place for
water and sanitation for all handwashing, with observation
of presence of water and soap
• Type of toilet facility
• Time needed to get drinking-
water
• Type of toilet
• Type of disposal for children's
stool
Table A.4 contd
16. Promote peaceful and NA F eeling personally discriminated • O pinion of international • A gree or disagree that immigrant
inclusive societies for against or harassed due to migrants about whether children should have the same
sustainable development, ethnicity or country of origin immigration is bad or good for a opportunities for education as
provide access to justice for all country's economy other children in the country
and build effective, accountable • Opinion of international • Agree or disagree that
and inclusive institutions at migrants about whether immigrants who live in a country
all levels immigrants make a country a for several years should have the
worse or better place to live opportunity to vote in elections
• Opinion of non-migrants about • Student's attitude towards
the migrant population immigration
17. Strengthen the means of NA • N

umber of questionnaire items NA NA
implementation and revitalize with disaggregation by migratory
the Global Partnership for status
Sustainable Development:
Target 17.18. enhance capacity-
building support...to increase NA • I nternet use during the past 3 NA • L ink to internet in student's
significantly the availability of months home
high-quality, timely and reliable • Frequency of using the internet • Length of time student uses
[disaggregated] data during the past month Internet at school
• Length of time student uses
Internet outside of school
NA: not applicable.

Annex. Methodology
317
318
A.3 Computational method used

for indicators
The indicators are computed for each country and for each migratory status using the following:
nij
pij = Nij
where:
pij = percentage of individuals or households in the sample with a charateristic, for migratory status i of country j;
nij = number of individuals or households in the sample with the charateristic, for migration status i of country j;
Nij = total number of sampled individuals or households with migration status i of country j;
i = international migrant, internal migrant, or non-migrant; and
j = country satisfying the inclusion criteria.
Categories of migratory status are derived as prevalence of stunted international migrant

shown in Chapter 5, Table 5.3. For example, children is 22.9%, the result of dividing 287 by
to estimate the prevalence of stunting 1253 and multiplying by 100. In contrast, the
among international migrant children estimated prevalence of stunted children in the
(pij) in Gambia, the counts needed are the host population (internal migrants and non-
number of international migrant children in migrants) of Gambia is the number of stunted
the survey (Nij = 1253) and the number of children in the sample of the host population
international migrant children in the survey (1636) divided by number of children sampled
who are classified as stunted (nij = 287), where from the host population (7974), which is a
i = international migrant and j = Gambia. The prevalence of 20.5%.
Annex. Methodology
319
References 5. About the European Social Survey European Research

Infrastructure (ESS ERIC). In: European Social Survey
[website]. London: European Social Survey; 2021 (https://
www.europeansocialsurvey.org/about/, accessed
17 November 2021).
1. Report of the Intersecretariat Working Group on Household
6. About MICS. In: Multiple Indicator Cluster Survey [website].
Surveys: note by the Secretary-General. In: United Nations
New York: United Nations Children’s Fund; 2022 (https://mics.
Statistical Commission, Fiftieth session, 5–8 March 2019.
unicef.org/about, accessed 30 August 2021).
New York: United Nations Statistical Commission; 2019 (E/
CN.3/2019/25; https://digitallibrary.un.org/record/3897161/ 7. PISA: Programme for International Student Assessment. In:
files/E_CN.3_2021_16-EN.pdf, accessed 17 November 2021). Organisation for Economic Co-operation and Development
[website]. Paris: Organisation for Economic Co-operation
2. Mosler Vidal E. Leave no migrant behind: the 2030 Agenda
and Development; 2022 (https://www.oecd.org/pisa/data/,
and data disaggregation. Geneva: International Organization
pdf/Migrants-in-the-SDGs_5.pdf, accessed 4 October 2021). 8. Collection and integration of data on refugee and migrant
health in the WHO European Region: technical guidance.
3. BADEHOG. In: Digital repository: Economic Commission
for Latin America and the Caribbean [website]. Santiago:
United Nations Economic Commission for Latin America
12 November 2021).
and the Caribbean; 2021 (https://repositorio.cepal.org/
handle/11362/31828, accessed 17 November 2021).
4. Croft TN, Marshall AMJ, Allen CK. Guide to DHS statistics: DHS-
7 (version 2). Rockville (MD): Measure DHS, ICF International;
2018 (https://www.dhsprogram.com/pubs/pdf/DHSG1/
Guide_to_DHS_Statistics_DHS-7_v2.pdf, accessed
3 November 2021).
Health and Migration Programme (PHM)
World Health Organization
20, Avenue Appia
1211 Geneva 27, Switzerland
Web: https://www.who.int/teams/health-and-migration-programme
Email: healthmigration@who.int

World Report On The Health of Refugees and Migrants

Uploaded by

Copyright:

Available Formats

World Report On The Health of Refugees and Migrants

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

World Report On The Health of Refugees and Migrants

Uploaded by

Copyright:

Available Formats

World report on the

ISBN 978-92-4-005446-2 (electronic version)

© World Health Organization 2022

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

1. Population movement and health: an overview 1

2. Determinants of refugee and migrant health 39

3. Health status of refugees and migrants: a global perspective 91

3.7 Communicable diseases 129

4. Refugee- and migrant-sensitive health systems 189

5. Mapping progress towards global health goals: an exploratory review 247

5.4 Review results 261

6. Health and migration: the way forward 287

This report is the first to offer a global

Whether by choice or by force, to be on the move is to be human and is part of

We urge governments, agencies, donors and other partners to think creatively

Dr Tedros Adhanom Ghebreyesus

Climate change and the increased number of conflicts mean increasing

There are solutions. This report offers practical considerations to address

Dr Zsuzsanna Jakab Dr Santino Severoni

Leadership and coordination

WHO contributors and reviewers

WHO regional offices

Regional literature reviews

Synthesis of the evidence reviews

The regional evidence reviews were synthesized by the following teams:

The report was also subject to a comprehensive review by global experts on

WHO gratefully acknowledges the financial contributions to the development

Abbreviations and acronyms

ANC antenatal care

MICS Multiple Indicator Cluster Survey

1.3 Global displacement and number of forcibly displaced globally to be

The number of people who have been forcibly

Region of the Americas European Region

International migrants: 3.5% (22 049 842)

Eastern Mediterranean Region

International migrants: 22.8% (46 916 863)

South-East Asia Region

International migrants: 2.7% (11 768 016)

Western Pacific Region

International migrants: 15.7% (24 618 179)

Source: United Nations Department of Economic and Social Affairs (67).

Region of the Americas European Region

International migrants Refugees and asylum seekers

Côte d’Ivoire: 9.7% (2 564 857) Uganda: 80.3% (1 381 122)

Eastern Mediterranean Region

International migrants Refugees and asylum seekers

South-East Asia Region

International migrants Refugees and asylum seekers

Thailand: 5.2% (3 632 496) Bangladesh: 40.4% (854 820)

Western Pacific Region

Source: United Nations Department of Economic and Social Affairs (67).

1.4 Migratory patterns in and criminal activity. In 2021 the Bolivarian

refugees, about 15% of all people displaced

Refugees and other forcibly displaced

distance to facilities, language The sudden arrival of large numbers of

1.7 Health and the dynamics Understanding the determinants of

especially if seeking international a chronic disease moves from one place

Fig. 1.3. Determinants of health and phases of migration

Social and community networks

• individual characteristics and behaviours – genetics, gender and personal