Health and Healthcare Access and Utilization Among Syrian Refugees Migrating to Norway : A Longitudinal Study

Background: An unprecedented number of people are on the move today and the health of refugees has become a vital global public health concern. During the migration process, refugees move from one environment to another and can face multiple healthcare challenges along their journey. Yet, how the migration process and the changing risk and protective factors influence refugee health and their use of healthcare services remains poorly understood. Objective: The overarching objective of this thesis is to explore, describe and analyse (a) the changes in health, Quality of Life and use of healthcare services among Syrian refugees migrating to Norway and (b) the association between these changes and sociodemographic and migration-related factors. Methods: This thesis is part of the Changing Health and healthcare needs Along the Syrian Refugees’ Trajectories to Norway (CHART) project. Both quantitative and qualitative methods were used to answer the objective of this thesis. In the quantitative part of the study (papers I and II), a prospective longitudinal design was used. Data were collected among adult Syrian refugees accepted for resettlement to Norway through a self-administered questionnaire repeated at two-time points. The first assessment was conducted pre-arrival in Lebanon in 2017–2018 and the second assessment after one year of resettlement in Norway. Primary outcomes were Selfrated Health (SRH), Quality of Life (QoL) and use of healthcare services (general practitioner [GP], emergency care [EC], outpatient/specialist care and hospitalization). In the qualitative part of the study (paper III), 15 individual interviews were conducted with adult Syrian refugees to capture their experiences in terms of changes in their own health and use of healthcare services after arriving in Norway.  Results: In the quantitative part of the study, 506 Syrians participated in Lebanon and 353 in the follow-up one year later in Norway. In paper I, we found that the percentage of participants reporting good SRH showed a non-significant increase from 58% to 63% from Lebanon to Norway, while mean values of QoL increased significantly. Positive effect modifiers for improvement in SRH and QoL over time included male gender, younger age, low level of social support and lack of residence permit in Lebanon. In paper II, we found that the use of GP and EC increased after resettlement while outpatient/specialist care dropped markedly, and hospitalization rates remained the same. Lack of residence permit and poor SRH prior to resettlement were identified as predictors for the use of healthcare after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and QoL were significantly associated with the use of healthcare services. In paper III, we found that the perceived causes of change in health status seem to be related to the resettlement phase with clear gender differences in the resettlement experience and its impact on health. Participants’ perceptions of the caregiver, communication and consultation/interaction time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver. A model was developed - The Migrant Sensitive Access Model - to address some of the challenges that came to light from our participants’ experiences. Conclusion: Stability and improvement in health and QoL are the most prominent findings of this thesis, indicating strong resourcefulness and adaptability among the studied group, a prerequisite for successful integration. Likewise, this study confirms that both pre- and post-migration factors have an impact on the health and health service use of refugees and underscore that a combination of migration and a social determinant of health approach is necessary for addressing inequities in health and healthcare access. Awareness should be raised of the most disadvantaged refugees with low social support, low education and poor health literacy who may be more susceptible to health disparities by poorer access to healthcare. Despite universal health coverage after resettlement, access barriers and unmet health needs were revealed. To enhance healthcare access, efforts should be made to increase trust in the healthcare system and its caregivers. Further, this thesis substantiates that a responsive resettlement process may have important positive health implications and calls for resettlement countries to provide adequate supportive resources upon arrival for all subcategories of forced migrants.Bakgrunn: Mange mennesker er i dag drevet på flukt, og flyktningers helse har blitt et viktig globalt folkehelseproblem. Under migrasjonsprosessen opplever flyktningene endringer i omgivelser og i livssituasjon. Helsen deres kan under flukt påvirkes av en rekke ulike eksponeringer. Likevel foreligger det i dag lite kunnskap om hvordan migrasjonsprosessen påvirker flyktningers helse, og hvordan de gjennom denne prosessen benytter og opplever bruk av helsetjenester. Mål: Det overordnede målet med denne avhandlingen er å utforske, beskrive og analysere (a) endringer i helse, livskvalitet og bruk av helsetjenester blant syriske flyktninger som migrerer til Norge og (b) sammenhengen mellom disse endringene og sosiodemografiske og migrasjonsrelaterte faktorer. Metoder: Avhandlingen er en del av prosjektet Changing Health and Healthcare Needs Along the Syrian Refugees’ Trajectories to Norway (CHART). Både kvantitative og kvalitative metoder ble brukt for å besvare avhandlingens forskningsspørsmål. Den kvantitative delen av studien (artikkel I og II) benytter et langsgående design med bruk av spørreskjema. Data ble samlet inn fra voksne syriske kvoteflyktninger som hadde fått innvilget bosetting i Norge. Spørsmålene var primært knyttet til egenvurdert helse (SRH), livskvalitet (QoL) og bruk av helsetjenester (fastlege, akuttmottak, poliklinisk/spesialistbehandling og sykehusinnleggelse). Spørreundersøkelsen ble gjennomført to ganger: Første gang før ankomst til Norge, i Libanon fra 2017 til 2018, og deretter etter ett års bosetting i Norge. I den kvalitative delen av studien (artikkel III) ble det utført 15 individuelle intervjuer med voksne syriske flyktninger for å få mer dybdekunnskap om deres erfaringer med endringer i egen helse og bruk av helsetjenester etter ankomst til Norge. Resultater: I den kvantitative delen av studien deltok 506 syrere i Libanon og 353 i oppfølgingen ett år senere i Norge. Funn fra artikkel I viser at andelen deltakere som rapporterte om god SRH viste en ikke-signifikant økning fra 58% til 63% fra de var i Libanon til de kom til Norge. Gjennomsnittsverdiene for egenvurdert livskvalitet (QoL) økte betydelig mellom de to undersøkelsestidspunktene. Å være mann, ha yngre alder, lav sosial støtte, eller mangel på oppholdstillatelse i Libanon var alle positive effektmodifikatorer for forbedring av SRH og QoL over tid. Funn fra artikkel II viser at bruk av fastlege og legevakt økte etter ankomst til Norge, mens poliklinisk/spesialistbehandling falt markert. Sykehusinnleggelse var den samme. Mangel på oppholdstillatelse og dårlig SRH før ankomst ble identifisert som prediktorer for bruk av helsetjenester etter ankomst. Dertil var høy helsekompetanse, høy utdanning, høy sosial støtte og dårlig SRH og QoL signifikant forbundet med bruk av helsetjenester etter ankomst. Funn fra artikkel III indikerer at flyktningene opplevde at årsakene til endring i helsestatus var relatert til bosetningsfasen med forskjellige utfordringer avhengig av tid etter ankomst. Beskrivelser av hva som påvirker egen helse under og etter migrasjon viste også en tydelig kjønnsforskjell. Deltakernes oppfatning av helsearbeideren, kommunikasjon og tid under konsultasjon ble identifisert som sentrale faktorer for å oppnå tillit til eller forårsake mistillit overfor helsearbeideren. En modell kalt The Migrant Sensitive Access Model ble utviklet for å beskrive noen av utfordringene som kom fram fra deltakernes erfaringer. Konklusjon: Stabilitet og forbedring av helse og QoL er de mest fremtredende funnene i denne avhandling. Dette indikerer en sterk motstandsdyktighet og tilpasningsevne blant deltakerne, noe som er en forutsetning for vellykket integrering. I tillegg viser avhandlingen at både faktorer før og etter migrasjon påvirker flyktningers helse og bruk av helsetjenester. Funnene indikerer at en tilnærming som belyser sammenhengen mellom migrasjon og sosiale helseforskjeller er nødvendig for å få bedre kunnskap om ulikheter innen helse og tilgang til helsetjenester. Det er behov for økt bevissthet om helsesituasjonen til de mest vanskeligstilte flyktningene som har lav sosial støtte, lav utdanning og dårlig helsekompetanse ettersom disse kan ha større risiko for å få eller ha helseutfordringer, og ha dårligere tilgang til helsetjenester. Til tross for at flyktningene får universell helsedekning etter bosetting i Norge, viser avhandlingen at de møter hindringer for å kunne ta i bruk helsetjenester og at de har umøtte helsebehov. For å forbedre tilgangen til helsehjelp for denne målgruppen bør det gjøres satsinger på å øke tilliten deres til helsevesen og helsepersonell. Videre får funnene fra avhandlingen fram at en støttende og rask bosettingsprosess kan ha viktige positive implikasjoner på helse. Dette fremhever viktigheten av at mottaksland gir tilstrekkelige støttende ressurser ved ankomst for alle kategorier av flyktninger.Doktorgradsavhandlin

The road to equitable healthcare: A conceptual model developed from a qualitative study of Syrian refugees in Norway

Background Refugees in high-income countries face barriers to healthcare access even when they have the same rights and entitlements as the host population. Disadvantages in healthcare access contribute to differences in health outcomes and impact acculturation. This study explores perceived changes in health status and experiences with the Norwegian healthcare system of Syrian refugees living in Norway, using a trajectory perspective. Methods We conducted 15 semi-structured interviews in April 2020 among purposefully recruited adult refugees from Syria resettled in Norway. Interviews were carried out in Arabic and analysed with Systematic Text Condensation using NVivo software. We used Lévesque's access model and Edberg's migration trajectory perspective as theoretical frameworks. A conceptual model was developed – The Migrant Sensitive Access Model - that highlights the factors contributing to a positive versus negative healthcare journey. Results Findings were summarized under three main themes: changes in health and well-being, expectations, and trust. Perceived changes in health status and attributed causes for change were related to the resettlement phase, gender, and were highly informed by pre-migration and migration experiences. The users’ perception of the caregiver, communication, and time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver. Conclusion Syrian refugees in Norway appreciate the Norwegian healthcare system but are impeded in their access to care. Many of the barriers can be bridged during the doctor-patient interaction with a diversity sensitive caregiver. The model we propose gives a comprehensive overview of key areas determining the healthcare experience of this population. The results of this study can be useful to policymakers and healthcare providers when addressing disparities in healthcare access for forced migrants.publishedVersio

Changes in self-rated health and quality of life among Syrian refugees migrating to Norway: a prospective longitudinal study

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Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study

Background The health of forcibly displaced individuals changes along their migration path and estimates of disease burden are essential to develop health care policies and practices adequately corresponding to their health care needs. This study aims to describe the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. Further, we aim to investigate the associations between migration related exposures and both chronic pain and mental health among Syrian refugees. Methods This is a cross-sectional study based on survey data collected among 827 adult Syrian refugees in Lebanon and Norway during 2017–2018. The survey instrument included items measuring somatic status (including chronic pain), mental health (using the HSCL-10 and HTQ items), use of medication and migration related exposures. We used descriptive statistics to calculate standardised prevalence proportions and regression analyses to study associations between migration related exposures and health outcomes. Results The response rate was 85%. The mean age in the sample was 33 years and 41% were women. Half of the participants reported that they had never had any health problems. The prevalence of non-communicable diseases was 12%. Headache and musculoskeletal complaints were the most prevalent conditions reported, with 30% reporting chronic pain lasting for more than six months. Symptoms indicating anxiety and/or depression were presented by 35%, while 7% revealed symptoms compatible with post-traumatic stress disorder. Among those reporting non-communicable diseases a substantial share did not seem to receive adequate treatment. Trauma experiences were associated with both chronic pain and anxiety/depression symptoms, and the latter were also associated with migrating without family members. Conclusions Migrant-friendly public health policies and practises should acknowledge migration related risks, address discontinuity in care of chronic conditions and target common complaints such as chronic pain and mental health problems among forcibly displaced individuals.publishedVersio

Use of health care services among Syrian refugees migrating to Norway: a prospective longitudinal study

Background Understanding the differential utilization of healthcare services is essential to address the public health challenges. Through the migration process, refugees move from one set of health risk factors to another and can face multiple healthcare challenges along their journey. Yet how these changing risk factors influence refugees’ use of health care services is poorly understood. Methods A longitudinal survey assessing health care utilization of 353 adult Syrian refugees was conducted; first in a transit setting in Lebanon and after one year of resettlement in Norway. The main outcomes are the utilization of general practitioner services, emergency care, outpatient and/or specialist care and hospitalization during the previous 12 months. Associations between use of healthcare services and several sociodemographic, migration-related and health status variables at both time points were found using regression analysis. We also analyzed longitudinal changes in utilization rates using generalized estimating equations. Results The use of general practitioner and emergency care increased after resettlement while outpatient/specialist care markedly dropped, and hospitalization rates remained the same. Undocumented status and poor self-rated health (SRH) prior to resettlement were identified as predictors for use of health care after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and quality of life were significantly associated with use of healthcare services. Conclusions Utilization of health services changes post migration to the destination country and are associated with migration-related and socio-demographic factors. Poor SRH is associated with use of services, both pre-arrival and post-resettlement. Our findings have implications for future resettlements, health care policies and service provision to newly arrived refugees with regard to both health needs as well as delivery of services.publishedVersio

Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study

Objectives This study aims to examine associations, predictors and pharmacological treatment of chronic pain and mental health problems among Syrian refugees in a longitudinal perspective. Design Prospective cohort study. Setting We collected survey data among Syrian refugees in Lebanon granted resettlement to Norway (self-administered questionnaires) and at follow-up 1 year after arrival in Norway (structured telephone interviews). Participants Adult Syrian refugees attending mandatory pretravel courses in Lebanon in 2017–2018 were invited to participate. In total, 353 individuals participated at both time points. Primary and secondary outcomes We examined the cross-sectional associations between pain, mental health and migration-related exposures at baseline and follow-up and assessed whether associations changed significantly with time. Furthermore, we investigated the longitudinal association between mental health at baseline and pain at follow-up. We also evaluated temporal changes in use of analgesics and psychotropic drugs. Results While most refugees reported improved health from the transit phase in Lebanon to the early resettlement phase in Norway, a few had persisting and intertwined health problems. Most migration-related stressors were more closely associated with chronic pain and mental health problems after resettlement as compared with the transit phase. In parallel, poor mental health was associated with chronic pain in the follow-up (adjusted risk ratio (ARR) 1.5 (1.0, 2.2)), but not at baseline (ARR 1.1 (0.8, 1.5)). Poor mental health at baseline was a statistically significant predictor of chronic pain at follow-up among those not reporting chronic pain at baseline. At both timepoints, one in four of those with chronic pain used analgesics regularly. None with mental health problems used antidepressants daily. Conclusions Providers of healthcare services to refugees should be attentive to the adverse effect of postmigration stressors and acknowledge the interrelations between pain and mental health. Possible gaps in pharmacological treatment of pain and mental health problems need further clarification.publishedVersio

Sale, storage and use of legal, illegal and obsolete pesticides in Bolivia ABOUT THE AUTHORS

Abstract: Unregulated selling practices, bad storage habits and the use of illegal pesticides in Bolivia are widespread, with increasing negative consequences on public health and the environment. The present study describes the selling, storage and use of legal, illegal and obsolete pesticides among pesticide retailers and farmers in Bolivia. A cross-sectional study was conducted on 191 pesticide-using farmers and 40 pesticide retailers. Data were gathered in 2009 in La Paz County, Bolivia. A questionnaire was used to evaluate pesticide handling practices and observational data on pesticide stocks and storage was assessed through direct visits on site. Banned, outdated and highly toxic pesticides were found stored on most smallholder farms. A mean of 299 g of pesticides was found on each farm, of which 60% were obsolete. Knowledge on pesticide toxicity and safe handling practices were lacking among both retailers and farmers, and poisonings were frequently reported. Significant figures of obsolete pesticides were found outside of the officially recognized dumping sites. This underlines the necessity of including the small but numerous amounts of pesticides stored at farms, when calculating a country's total amount of obsolete pesticides. Better regulations of imports, sale and storage and an improved use of safety measures when handling pesticides needs to be urgently addressed

Health and Healthcare Access and Utilization Among Syrian Refugees Migrating to Norway : A Longitudinal Study

Background: An unprecedented number of people are on the move today and the health of refugees has become a vital global public health concern. During the migration process, refugees move from one environment to another and can face multiple healthcare challenges along their journey. Yet, how the migration process and the changing risk and protective factors influence refugee health and their use of healthcare services remains poorly understood. Objective: The overarching objective of this thesis is to explore, describe and analyse (a) the changes in health, Quality of Life and use of healthcare services among Syrian refugees migrating to Norway and (b) the association between these changes and sociodemographic and migration-related factors. Methods: This thesis is part of the Changing Health and healthcare needs Along the Syrian Refugees’ Trajectories to Norway (CHART) project. Both quantitative and qualitative methods were used to answer the objective of this thesis. In the quantitative part of the study (papers I and II), a prospective longitudinal design was used. Data were collected among adult Syrian refugees accepted for resettlement to Norway through a self-administered questionnaire repeated at two-time points. The first assessment was conducted pre-arrival in Lebanon in 2017–2018 and the second assessment after one year of resettlement in Norway. Primary outcomes were Selfrated Health (SRH), Quality of Life (QoL) and use of healthcare services (general practitioner [GP], emergency care [EC], outpatient/specialist care and hospitalization). In the qualitative part of the study (paper III), 15 individual interviews were conducted with adult Syrian refugees to capture their experiences in terms of changes in their own health and use of healthcare services after arriving in Norway.  Results: In the quantitative part of the study, 506 Syrians participated in Lebanon and 353 in the follow-up one year later in Norway. In paper I, we found that the percentage of participants reporting good SRH showed a non-significant increase from 58% to 63% from Lebanon to Norway, while mean values of QoL increased significantly. Positive effect modifiers for improvement in SRH and QoL over time included male gender, younger age, low level of social support and lack of residence permit in Lebanon. In paper II, we found that the use of GP and EC increased after resettlement while outpatient/specialist care dropped markedly, and hospitalization rates remained the same. Lack of residence permit and poor SRH prior to resettlement were identified as predictors for the use of healthcare after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and QoL were significantly associated with the use of healthcare services. In paper III, we found that the perceived causes of change in health status seem to be related to the resettlement phase with clear gender differences in the resettlement experience and its impact on health. Participants’ perceptions of the caregiver, communication and consultation/interaction time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver. A model was developed - The Migrant Sensitive Access Model - to address some of the challenges that came to light from our participants’ experiences. Conclusion: Stability and improvement in health and QoL are the most prominent findings of this thesis, indicating strong resourcefulness and adaptability among the studied group, a prerequisite for successful integration. Likewise, this study confirms that both pre- and post-migration factors have an impact on the health and health service use of refugees and underscore that a combination of migration and a social determinant of health approach is necessary for addressing inequities in health and healthcare access. Awareness should be raised of the most disadvantaged refugees with low social support, low education and poor health literacy who may be more susceptible to health disparities by poorer access to healthcare. Despite universal health coverage after resettlement, access barriers and unmet health needs were revealed. To enhance healthcare access, efforts should be made to increase trust in the healthcare system and its caregivers. Further, this thesis substantiates that a responsive resettlement process may have important positive health implications and calls for resettlement countries to provide adequate supportive resources upon arrival for all subcategories of forced migrants

Sale, storage and use of legal, illegal and obsolete pesticides in Bolivia

Unregulated selling practices, bad storage habits and the use of illegal pesticides in Bolivia are widespread, with increasing negative consequences on public health and the environment. The present study describes the selling, storage and use of legal, illegal and obsolete pesticides among pesticide retailers and farmers in Bolivia. A cross-sectional study was conducted on 191 pesticide-using farmers and 40 pesticide retailers. Data were gathered in 2009 in La Paz County, Bolivia. A questionnaire was used to evaluate pesticide handling practices and observational data on pesticide stocks and storage was assessed through direct visits on site. Banned, outdated and highly toxic pesticides were found stored on most smallholder farms. A mean of 299 g of pesticides was found on each farm, of which 60% were obsolete. Knowledge on pesticide toxicity and safe handling practices were lacking among both retailers and farmers, and poisonings were frequently reported. Significant figures of obsolete pesticides were found outside of the officially recognized dumping sites. This underlines the necessity of including the small but numerous amounts of pesticides stored at farms, when calculating a country’s total amount of obsolete pesticides. Better regulations of imports, sale and storage and an improved use of safety measures when handling pesticides needs to be urgently addressed