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MARCH 2021 FEDERAL HEALTH REPORTING
ISSUE
1 JOINT SERVICE BY RKI AND DESTATIS
Journal of Health Monitoring
Monitoring refugee health
1Journal of Health Monitoring Index
Monitoring refugee health
3 Editorial Monitoring refugee health: Integrative
approaches using surveys and routine data
7 Focus Monitoring the health and healthcare
provision for refugees in collective accommodation
centres: Results of the population-based survey
RESPOND
30 Focus Health monitoring of refugees in reception
centres for asylum seekers: Decentralized surveil-
lance network for the analysis of routine medical
data
Journal of Health Monitoring 2021 6(1) 2Journal of Health Monitoring Monitoring refugee health: Integrative approaches using surveys and routine data EDITORIAL
Journal of Health Monitoring · 2021 6(1)
DOI 10.25646/7861
Monitoring refugee health: Integrative approaches using surveys
Robert Koch Institute, Berlin
and routine data
Kayvan Bozorgmehr 1,2, Claudia Hövener 3
The Federal Health Reporting of the future will face the extremely diverse with respect to their country of origin,
1
Department of Population Medicine and challenge of considering not only social developments such languages spoken, reasons for fleeing and route taken, as
Health Services Research, School of Public as demographic ageing but also the increasing diversity of well as residency prospects and socioeconomic background.
Health, Bielefeld University, Bielefeld, society, for example with respect to migration. Since the It is therefore impossible to conduct surveys without a lin-
Germany first focus report on ‘Migration and Health’ has been pub- guistic, cultural and contextual adaptation of survey instru-
2
Section for Health Equity Studies and lished by the Federal Health Reporting in 2008 [1], major ments. In addition, due to the high level of migration dynam-
Migration, Department of General Practice
advances have been made in the underlying data sources. ics and spatial displacement, there is no overview of the
and Health Services Research, University
Hospital Heidelberg, Heidelberg, Germany Health monitoring at the Robert Koch Institute, amongst entire refugee population (denominator population), which
3
Robert Koch Institute, Berlin other efforts, has been further advanced to increase its is an essential parameter for health monitoring among ref-
Department of Epidemiology and sensitivity to migration [2]. However, the inclusion of cer- ugees [3]. There are also substantial limitations when using
Health Monitoring tain migrant groups has remained a challenge. Represent- routine healthcare data. During their initial stay at central,
ative health studies currently do not systematically take state-run reception facilities, refugees usually receive pri-
Submitted: 09.10.2020
Accepted: 12.10.2020
into account migrant workers in precarious employment, mary medical care in the facilities’ own outpatient clinics.
Published: 31.03.2021 people without an official residence permit and refugees. However, routine data is not collected and collated uni-
Particularly in the case of refugees, there are obvious struc- formly in these. Those who use regular, external healthcare
tural weaknesses that have resulted in an incomplete infor- services, while staying at a reception facility or after transfer
mation base. Germany has been a destination for people to the districts, are only identifiable as refugees in health
seeking international protection to varying degrees since insurance provider data in regions which provide refugees
the 1990s. Despite this, nationwide data that are compa- with an electronic health card (eGK). At the same time, ref-
rable over time and space on the health and care of this ugees are generally only issued an eGK after leaving the
migrant population are virtually non-existent. reception facilities. This can be up to 18 months after their
There are many reasons for this gap. During the asylum arrival in Germany or when the entire asylum application
procedure, refugees are initially accommodated in central, process has been completed.
state-run reception facilities before being transferred to col- Due to these factors, data on refugee health and provi-
lective accommodation run by each district. During this sion of care remains incomplete and is based almost exclu-
process, they are not registered in official population regis- sively on local individual studies and surveys of limited
tries and are hence practically not accessible by conven- duration that are generally incompatible with the principles
tional sampling approaches. This group of people is of health reporting. An important exception is the survey
Journal of Health Monitoring 2021 6(1) 3Journal of Health Monitoring Monitoring refugee health: Integrative approaches using surveys and routine data EDITORIAL
of refugees established in 2016 by the Institute for Employ- of this information into health reporting at municipal, state
ment Research (IAB), the Federal Office for Migration and and federal levels? This question, which is highly relevant
Refugees (BAMF) and the Socio-Economic Panel (SOEP), internationally, is addressed by the two articles in this issue
which uses a sample from the Central Register of Foreign- from different, yet complementary, perspectives by present-
ers to supplement the established SOEP surveys. While ing experiences from two projects supported by national
this data source provides information on the living situa- funding programmes [5].
tion of refugees, the number of indicators on health and Biddle et al. describe an approach based on a targeted,
healthcare provision is limited. group-specific sampling and recruitment which enables
The situation is similar in many other European coun- health monitoring among refugees living in collective accom-
tries. A review analysing the integration of migrants into modation by integrating them into health surveys. Jahn et
health information systems and the availability of corre- al. describe an innovative approach to using routine medi-
sponding data in the European Region of the World Health cal data in reception facilities, which is based on the princi-
Organization (WHO) revealed that only 23 of the 53 WHO ple of distributed computing. Both approaches create new
member states have systematic and routine approaches to information resources that enable the integration of the tar-
collecting health data on migrants [4]. Countries with get group in terms of the visibility of relevant health aspects
nation-wide standardised registers were able to examine in settings that have not yet been systematically considered.
key aspects of health such as mortality, life expectancy and However, sustained use of this information in health report-
morbidity as well as collect data relating to pregnancy and ing will require a structural consolidation of these approaches
childbirth for refugees, and compare these to other groups at national, federal state and municipal levels.
such as people with a migrant background or those with-
out a migrant background. Nevertheless, there was a lack Corresponding author
of feasible approaches to a systematic inclusion of migrants Prof Dr Kayvan Bozorgmehr
Department of Population Medicine and Health Services Research,
and particularly refugees in existing health surveys that
School of Public Health, Bielefeld University, Bielefeld, Germany
would allow the collection of self-reported and more com- P.O. Box 10 01 31
plex aspects of health. In many cases, systems for record- 33501 Bielefeld, Germany
ing notifiable infectious diseases were the only sources of E-mail: kayvan.bozorgmehr@uni-bielefeld.de
routinely available data with which to assess the health of
Please cite this publication as
refugees. Routine medical data from individual clinics were
Bozorgmehr K, Hövener C (2021)
also frequently used, yet such data allowed only limited
Monitoring refugee health:
comparisons with other settings. Integrative approaches using surveys and routine data.
How can we ultimately improve the availability of infor- Journal of Health Monitoring 6(1): 3–6.
mation on the health of refugees as well as the integration DOI 10.25646/7861
Journal of Health Monitoring 2021 6(1) 4Journal of Health Monitoring Monitoring refugee health: Integrative approaches using surveys and routine data EDITORIAL
The German version of the article is available at:
www.rki.de/journalhealthmonitoring
Conflicts of interest
The authors declared no conflicts of interest.
References
1. Razum O, Zeeb H, Meesmann U et al. (2008) Migration und
Gesundheit. Schwerpunktbericht der Gesundheitsberichterstat-
tung. Robert Koch-Institut, Berlin.
https://edoc.rki.de/handle/176904/3194 (As at 04.02.2021)
2. Kurth BM, Razum O (2019) Editorial: Health monitoring should
reflect population diversity. Journal of Health Monitoring 4(3):3–6.
https://edoc.rki.de/handle/176904/6107 (As at 04.02.2021)
3. Bozorgmehr K, Stock C, Joggerst B et al. (2018) Tuberculosis
screening in asylum seekers in Germany: a need for better data.
Lancet Public Health 3(8):Pe359–e361
4. Bozorgmehr K, Biddle L, Rohleder S et al. (2019) What is the
evidence on availability and integration of refugee and migrant
health data in health information systems in the WHO European
Region? Health Evidence Network (HEN) Synthesis Report,
Copenhagen
5. WHO (2020) Collection and integration of data on refugee and-
migrant health in the WHO European Region. WHO, Copenhagen
Journal of Health Monitoring 2021 6(1) 5Journal of Health Monitoring Monitoring refugee health: Integrative approaches using surveys and routine data EDITORIAL
Imprint
Journal of Health Monitoring
Publisher
Robert Koch Institute
Nordufer 20
13353 Berlin, Germany
Editors
Johanna Gutsche, Dr Birte Hintzpeter, Dr Franziska Prütz,
Dr Martina Rabenberg, Dr Alexander Rommel, Dr Livia Ryl,
Dr Anke-Christine Saß, Stefanie Seeling, Dr Thomas Ziese
Robert Koch Institute
Department of Epidemiology and Health Monitoring
Unit: Health Reporting
General-Pape-Str. 62–66
12101 Berlin, Germany
Phone: +49 (0)30-18 754-3400
E-mail: healthmonitoring@rki.de
www.rki.de/journalhealthmonitoring-en
Typesetting
Kerstin Möllerke, Alexander Krönke
Translation
Simon Phillips/Tim Jack
ISSN 2511-2708
Note
External contributions do not necessarily reflect the opinions of the
Robert Koch Institute.
This work is licensed under a
Creative Commons Attribution 4.0 The Robert Koch Institute is a Federal Institute within
International License. the portfolio of the German Federal Ministry of Health
Journal of Health Monitoring 2021 6(1) 6Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
Journal of Health Monitoring · 2021 6(1)
DOI 10.25646/7863
Monitoring the health and healthcare provision for refugees in
Robert Koch Institute, Berlin
collective accommodation centres: Results of the population-
Louise Biddle 1,2, Maren Hintermeier 1,
Amir Mohsenpour 2, Matthias Sand 3,
based survey RESPOND
Kayvan Bozorgmehr 1,2 Abstract
To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional
1
ection Health Equity Studies and Migration,
S
health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee
Department of General Practice and Health
Services Research,
health status and healthcare provision. The core elements of the survey consisted of a population-based sampling
University Hospital Heidelberg procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data
2
AG Population Medicine and Health Services collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical
Research, School of Public Health, locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health
Bielefeld University burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet
3
GESIS Leibniz Institute for the Social
needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of
Sciences, Mannheim
primary care services, frequent ambulatory care sensitive hospitalisations, i.e. hospitalisations that could potentially
have been avoided through primary care (25.3%), as well as subjective deficits in the quality of care, suggest barriers to
accessing healthcare services. Almost half of all refugees (45.3%) live in accommodation facilities of poor structural
Submitted: 12.10.2020 quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling,
Accepted: 11.01.2021 multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could
Published: 31.03.2021
complement established procedures for conducting health surveys and be extended to other federal states.
HEALTH MONITORING · REFUGEES · SURVEY · ACCESS BARRIERS · QUALITY OF CARE
1. Introduction Ensuring that refugees in Germany receive adequate
healthcare is challenging. The legal norms of the Asylum
Due to experiences before, during and after flight, refugees Seekers Benefits Act (‘Asylbewerberleistungsgesetz’,
(Info box 1) face specific health risks, which makes an effi- AsylbLG) limit care to the ‘treatment of acute illnesses and
cient healthcare response after arrival in Germany crucial. pain conditions’ (§4 AsylbLG). Children and pregnant asy-
International studies show that providing care for mental lum seekers are exempt from this regulation and further
health issues, chronic diseases, serious infectious diseases services can be accessed on a case-by-case basis (Section
as well as for pregnant women is particularly important [1]. 6 AsylbLG). Nevertheless, this regulation has been shown
Journal of Health Monitoring 2021 6(1) 7Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
to prevent asylum seekers from receiving needs-based care collective accommodation centres are under-represented
Info box 1 [2, 3]. In addition, language, financial, geographical or struc- in population registers. Furthermore, people with a migrant
In this article, the term ‘refugees’ refers to all peo-
tural factors can also act as barriers to accessing adequate background are regularly excluded from studies if the sur-
ple who have applied for asylum at the German
Federal Office for Migration and Refugees (BAMF) healthcare for refugees [4]. Moreover, it is not only access veys are exclusively in German.
– regardless of the outcome of their asylum appli- to healthcare but also the circumstances in the host coun- In Germany, the task of collecting and evaluating infor-
cation – as well as people admitted to Germany
for resettlement in accordance with the Geneva
try after migration which are of great relevance to the health mation on the health of the population lies with the Robert
Refugee Convention of the United Nations High of refugees. Factors such as an insecure residency status, Koch Institute (RKI), amongst other actors. National data
Commissioner for Refugees (UNHCR). satisfaction with the living situation and opportunities for on the health status, access to care services, but also on
social and economic participation can influence health and other relevant indicators such as the health behaviour of
well-being [5]. children, adolescents and adults living in Germany are reg-
Against this backdrop, population-based data are par- ularly collected through several interview and examination
ticularly important in determining healthcare needs. In surveys within the context of health monitoring at the RKI.
addition to routine clinical data, data from surveys and Over the past two decades, increased efforts have been
interviews at national or regional levels form an essential made to integrate individuals with a migrant background
part of national data systems. Only they can provide relia- in the German Health Interview and Examination Survey
ble information on the frequency of certain diseases as well for Children and Adolescents (KiGGS) and the German
as potential access barriers. Furthermore, data on residen- Health Interview and Examination Survey for Adults
tial locations which are used in household surveys can also (DEGS1). Such efforts have included oversampling of par-
be used, for example to assess geographical barriers to ticipants without German nationality, providing multilin-
accessing healthcare. However, a recent analysis of health gual questionnaires and targeted public outreach to recruit
data available for people with a migrant background (Info people with a migrant background [8]. Since 2016, the RKI
box 2) in Europe found that the current utilisation of sur- has been working more intensively on migration-sensitive
vey data is insufficient [6]. This is partly due to the fact that recruitment and data collection procedures as part of the
this population group – which is considered “hard-to-reach” Improving Health Monitoring in Migrant Populations
Info box 2 for research purposes – is often under-represented in pop- (IMIRA) project [8]. However, the samples for these surveys
The publication by Bozorgmehr et al. [6] defined ulation-based studies. In Germany, further problems arise are recruited based on data from the population registra-
‘people with a migrant background’ according to when recruiting refugees for health monitoring surveys. On tion office, which do not adequately represent refugees and
the definition of the International Organisation for
Migration (IOM) as ‘a person who moves away the one hand, refugees cannot be identified in population asylum seekers in initial reception and collective accom-
from his or her place of usual residence, whether registers, as these only record data on nationality and do modation centres in Germany [9].
within a country or across an international border,
not provide information on legal status. On the other hand, The German Institute for Economic Research’s (DIW)
temporarily or permanently, and for a variety of
reasons’ [7]. reporting can be delayed, which is why refugees who have ‘IAB-SOEP-BAMF Panel’, a survey specifically designed to
recently arrived and who often live in initial reception or collect information from refugees, is sampled based on
Journal of Health Monitoring 2021 6(1) 8Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
the Central Register of Foreign Nationals (AZR). The AZR project. The target population was defined as adult refu-
is kept by the Federal Office for Migration and Refugees gees living in initial reception centres (EA) and collective
(BAMF) as a police register and contains detailed informa- accommodation centres (GU) in the state of Baden-Würt-
tion on the legal status and place of residence of refugees temberg at the time of the survey.
arriving in Germany. Using this as its basis, the IAB-SOEP-
BAMF Panel is able to draw a representative sample of ref- 2.1 Questionnaire development
ugees in Germany [10]. However, this survey is primarily
concerned with socioeconomic aspects such as educational Drawing on previous feasibility studies [11–13] and using
status and the integration of refugees in the labour market. established instruments, a questionnaire was developed
The survey includes questions on general and mental health that covers essential dimensions of health status, health-
status [5], but little attention is given to other health-related care utilisation, quality of care as well as sociodemograph-
matters. Questions on utilisation of services are not ic information and adequately takes into account the spe-
included, except for a few variables on the uptake of out- cific context and living conditions of refugees. A description
patient and inpatient care. of the questionnaire development, including a detailed
In order to close these gaps in the availability of survey overview of instruments used, has been published previ-
data, a data collection approach was developed as part of ously [14]. Only a selection of the most important indica-
the project ‘Improving regional health system responses to tors will therefore be presented below.
the challenges of forced migration’ (RESPOND) in 2016. Health status was assessed using instruments from the
Funded by the Federal Ministry of Education and Research European Health Interview Survey (EHIS; general health, pain,
(BMBF), this project set out to conduct a population-based chronic diseases) [15] as well as scales for depressive symp-
health survey among refugees in initial reception and col- toms (PHQ-2; depression) [16] and symptoms of general
lective accommodation centres. This paper presents the anxiety disorders (GAD-2) [17]. Both PHQ-2 and GAD-2 scores
project’s methodological approach as well as selected above a cut-off of three were considered as indicating a
results regarding health status, utilisation of healthcare ser- depressive or anxiety disorder respectively [16]. Utilisation of
vices and quality of care. Furthermore, data on the accom- healthcare services was assessed based on EHIS instruments
modation situation, the quality of accommodation and the (use of specialist and general medical services), the EU Sta-
geographical accessibility of primary healthcare are reported. tistics on Income and Living Conditions (EU-SILC; unmet
needs) [18] and the German Health Interview and Examina-
2. Methodology tion Survey for Adults (DEGS; advice on health behaviour)
[19]. Variables of health status, utilisation of healthcare ser-
The present survey was designed as a population-based, vices, quality of care and perceived distance from health ser-
cross-sectional study and conducted as part of the RESPOND vices were dichotomised for the analysis (Annex Table 1).
Journal of Health Monitoring 2021 6(1) 9Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
Basic DEGS and EHIS sociodemographic items were excluded. The questionnaire also included a question on
supplemented with an adapted version of the MacArthur the abuse of medicines from the Structured Clinical Inter-
Scale (subjective social status) [20], as well as questions view for DSM-5 (SCID; medication abuse) [24]. Possible
related to legal status, health insurance status and length geographical barriers to accessing care were captured using
of stay in Germany (Annex Table 1). With regard to ‘nation- a subjective evaluation of the distance to different care ser-
ality’ and ‘mother tongue’ variables, only categories that vices (pharmacies, primary and specialist care providers,
described at least 2% of the participants were considered hospitals), taken from the European Patient’s Forum (EPF)
in the evaluation, remaining answers were categorised as study [25].
‘other’. Levels of education were recorded based on the The questionnaire was developed in English and Ger-
questions of EHIS on school education and vocational man and then translated into Albanian, Arabic, Persian,
qualification and combined in a separate classification into French, Russian, Serbian and Turkish using a TRAPD (Trans-
three educational levels. An adapted MacArthur Scale of lation, Review, Adjudication, Pretesting and Documenta-
subjective social status (SSS) in Germany was divided into tion) approach. Two independent professional translations
low SSS (levels 1–4), medium SSS (levels 5–6) and high were brought into a joint discussion, and an interdiscipli-
SSS (levels 7–10) [20, 21]. nary translation and research team was then tasked with
A number of aspects related to quality of care were exam- the synthesis of both texts [26]. A cognitive pre-test was
ined. On the one hand, ambulatory care sensitive hospi- conducted for several questionnaire items to ensure com-
talisations (ASH) were assessed using questions on spe- prehensibility [27]. The final version of the questionnaire
cific clinical diagnoses and hospitalisations due to these comprised 68 questions.
conditions [22]. These are hospitalisations for diseases that An instrument was developed to quantify the quality of
are considered potentially avoidable given effective primary housing in terms of its structural condition (small-area
care and can therefore be considered as an indicator of the housing environment deterioration, SHED) and validated
quality of primary care. These are also referred to as ‘avoid- in a separate study [28]. Drawing on the Broken Windows
able hospitalisations’. In addition, the World Health Organ- Index [29], this instrument measures the condition of (1)
ization (WHO) Responsiveness Scale was used to assess window panes and glass, (2) walls and roof, (3) litter, (4)
non-technical aspects of quality of care in the dimensions graffiti inside and outside the building, and (5) external
of cleanliness, respectful treatment, confidentiality, auton- spaces on the basis of five observer-based assessments.
omy in decision-making, communication, choice of pro- The instrument has been shown to be highly reliable when
vider and waiting time during the last appointment [23]. As conducted in the form of independent individual ratings
the WHO Responsiveness Scale specifically focuses on [28]. In the context of this study, however, it was used as a
assessing a patient’s most recent appointment, responses rating by a team, as the joint work on site did not create
from individuals who had not been to see a doctor were an independent, but a combined impression of the resi-
Journal of Health Monitoring 2021 6(1) 10Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
dential environment. A sixth question assessed the general twelve centres. In the first stage, six of the twelve centres
living environment as a global rating. Following Z-stand- were selected with a probability proportional to accommo-
ardisation and 0–1 normalisation of the individual results dation occupancy and responsible authority. In the second
for the purpose of comparability, the variables collected on stage, a random selection was made at room level so that
the quality of accommodation were converted into an over- 25% of the residents were included in the sample. This
all score. Facilities were divided into quintiles based on the self-weighting approach results in an equal selection prob-
overall score in order to examine accommodation quality ability for each person within the sampled population.
based on the distribution of people living in the centres. The sampling procedure for collective accommodation
centres has been described in detail previously [14]. All lower-
2.2 Sampling level reception authorities were contacted in order to obtain
a list of all collective accommodation centres (N = 1,933),
This study had no access to the AZR data so a separate as well as the corresponding occupancy figures, of the 44
sampling frame was constructed. Sampling was carried districts of Baden-Württemberg. This was done in cooper-
out at the level of accommodation centres. After arrival ation with the Ministry of Social Affairs and with the con-
and registration by the BAMF, refugees are accommodat- sent of the County Association (Landkreistag) of
ed in initial reception centres of the federal states. At the Baden-Württemberg. At the time of the survey, a total of
point of data collection, refugees were allowed to stay in 70,634 refugees were living in collective accommodation
these centres for a maximum of six months, with the excep- centres. A random sample proportional to the population
tion of persons from so-called ‘safe countries of origin’ was drawn at the level of accommodation centres, balanc-
(Section 47 Asylum Act, AsylG). Refugees with good pros- ing on the number of refugees in the district as well as
pects of being allowed to stay in the country may then be accommodation size. A total of 65 centres were drawn to
transferred to collective accommodation centres at region- include a net sample of 1% of all refugees at district level.
al level. In the initial reception centres, the reception author- An additional benefit of manually collating the sampling
ities at the federal state level are responsible for accommo- frame at the level of collective accommodation centres was
dation; the responsibility for refugees in collective the possibility of identifying geographical locations. The
accommodation centres and follow-up accommodation geo-coordinates of 1,786 centres were determined. As some
lies with the regional and district authorities. authorities did not provide geo-information, 7.6% (n = 147)
A list of all initial reception centres in the state as well of centres from five urban and rural districts were excluded
as anonymised occupancy lists at the room level was estab- from geographical analysis because their addresses could
lished in co-operation with the Ministry of the Interior of not be determined.
Baden-Württemberg and the responsible regional councils.
A two-stage random sample was drawn from a total of
Journal of Health Monitoring 2021 6(1) 11Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
2.3 Study implementation 2.4 Weighting
Specifically trained, multilingual research staff collected The RESPOND data was weighted to improve the accuracy
the data between February and June 2018. Refugees living of the sample when making estimates regarding the total
in the centres were contacted at least one week in advance refugee population. The weights were calculated using data
by the staff or responsible social workers at the centre to on gender, age group and region of origin from Baden-Würt-
inform about the purpose and time of the visit. In order temberg’s asylum statistics [31]. For country of origin, data
to reach a large proportion of the residents, each centre on asylum applications from 2016 to 2018 (quarters 1 to 4)
was visited on two consecutive days. In the course of field were available. For gender and age group, statistics were
visits, the research staff completed questionnaires on only available for one quarter each of 2016 (Q2), 2017 (Q4)
accommodation quality for each accommodation centre and 2018 (Q3). These asylum application statistics can only
in the sample. approximate the true composition of the refugee popula-
All people living in sampled facilities were personally tion, as first-time applicants before 2016 as well as appli-
informed about the study by multilingual field teams on site cants that apply for asylum more than once are generally
and invited to participate (‘door-to-door recruitment’ [30]). not recorded. To enable weighting with a complete data
Standardised, multilingual audio messages were also used. matrix, missing values were imputed using the ‘mice’ pack-
Criteria for inclusion in the study were being at least 18 years age in R [32]. The complete data matrix was then used to
old and proficiency in at least one of the nine study lan- calculate calibration weights. Data on gender, age and
guages. Illiterate people were included in the study if they region of origin were adjusted to the distribution of these
confirmed that someone could help them fill out the ques- variables in the asylum statistics, taking into account the
tionnaire. Potential participants received a questionnaire sample design and using ‘iterative proportional fitting’ (rak-
and a leaflet with study information in one of the nine lan- ing technique) [33].
guages, as well as non-monetary, unconditional incentives
(notebooks, pens and colouring pads/crayons for children). 2.5 Data evaluation
Respondents could choose between returning the com-
pleted questionnaire in person to the research team or, alter- Descriptive statistics of the weighted data are used to
natively, returning it by post in a pre-paid envelope. In addi- determine physical and mental health status, utilisation
tion, an online version of the questionnaire (using a of health services, unmet needs, quality of care as well
personalised QR code) was also made available. If people as the perceived geographical distance to healthcare
were approached who could not participate in the study or services. For this purpose, prevalence of each indicator,
did not meet the inclusion criteria, the reason for non-par- including 95% confidence intervals, are presented by
ticipation, their gender and language were documented. gender (health status and utilisation) or by type of
Journal of Health Monitoring 2021 6(1) 12Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
accommodation (responsiveness and perceived geo- for several data points. Travel time and date were randomly
graphical distance). These analyses were carried out with selected for a working day.
STATA version 15.1.
To calculate the distance to primary care services, geo- 3. Results
data on general medical practices from the publicly avail-
able database of the Association of Statutory Health Insur- A total of 560 adult refugees (response rate 39.2%; Annex
ance Physicians (Kassenärztliche Vereinigung) of Baden- Figure 1) took part in the study, of which 411 (73.4%) of
Württemberg were used. Geo-information software (QGIS) which lived in collective accommodation centres, with the
was used to determine the nearest practice, which was then remaining 149 (26.6%) living in initial reception centres.
assigned for each centre based on linear distance and using The response rate was calculated according to the recom-
the ‘nearest neighbour analysis’. As refugees usually do mendations of the American Association for Public Opin-
To date, the integration of not have their own car, calculating travel time by public ion Research (AAPOR) [35]. Almost one third (n = 158;
transport or on foot is particularly important. The travel 31.3%) of the sample were women, more than half (n = 253;
refugees in German health
times (walking, driving and public transport) were calcu- 51.4%) were under 31 years of age. The primary regions of
surveys is insufficient. lated using the Google Maps Distance Matrix API (last cal- origin were West Asia (n = 134; 26.7%), South Asia (n = 128;
culation: 19 June 2020, 07:00) [34]. Google Maps’ Distance 25.5%) and West Africa (n = 120; 23.9%). Educational sta-
Matrix API offers the advantage of simultaneous requests tus was mixed, but the subjective social status in Germany
Total proportion
(95% confidence interval)
Bad general health 82.4%
(78.0%–86.0%)
Chronic disease 39.3%
(32.5%–46.5%)
Limitations due to a 16.9%
health problem (12.0%–23.2%)
20.9%
Pain
(16.8%–25.7%)
Depressive symptoms 44.3%
(PHQ) (39.2%–49.6%)
Figure 1 Anxiety symptoms 43.0%
Self-reported, weighted prevalence of health (GAD) (35.2%–51.2%)
issues and symptoms by gender 0 20 40 60 80 100
(with 95% confidence intervals) Proportion (%)
Women Men
Source: RESPOND Study 2018 PHQ = Patient Health Questionnaire, GAD = Generalized Anxiety Disorder
Journal of Health Monitoring 2021 6(1) 13Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
was predominantly (n = 277; 70.7%) assessed as being low. 3.1 Health status
More than half of participants had already been in Germa-
ny for more than one year (n = 253; 55.8%), but the major- After weighting the data, 82.5% of refugees reported either
ity (n = 281; 62.2%) still had asylum seeker status. In initial a moderate, poor or very poor general health status. In
reception centres, there was a tendency toward shorter addition, 39.3% of respondents reported a chronic illness,
length of stay in Germany and a more uncertain asylum 16.9% a limitation due to a health problem and 20.9% suf-
status. Half of the participants (n = 240; 52.2%) held an fered from severe to very severe pain. There was a tenden-
electronic health card (Annex Table 2). cy towards a higher prevalence of health limitations as well
as pain among female refugees (Figure 1). The prevalence
of depressive symptoms was 44.3%, and 43.0% for symp-
toms of anxiety (Figure 1).
The results of the
RESPOND study indicate Total proportion
(95% confidence interval)
a high health burden, while General practitioner visit 51.2%
at the same time showing (during the last 12 months) (44.7%–57.6%)
high unmet needs. Specialist visit
(during the last 12 months)
37.4%
(30.5%–44.8%)
General practitioner unmet need 30.5%
(during the last 12 months) (24.8%–37.0%)
Specialist unmet need 30.9%
(during the last 12 months) (25.8%–36.6%)
Prescription medication 44.7%
(in the past four months) (36.9%–52.7%)
Emergency room visit 29.5%
(during the last 12 months) (24.3%–35.3%)
Advice on health behaviour 32.0%
(during the last 12 months) (27.0%–37.6%)
Avoidable hospitalisation 25.3%
(during the last 12 months) (20.4%–31.0%)
Figure 2
Self-reported, weighted utilisation and quality Medication abuse (ever) 14.4%
of health services by gender (10.2%–19.9%)
(with 95% confidence intervals) 0 20 40 60 80 100
Proportion (%)
Source: RESPOND Study 2018 Women Men
Journal of Health Monitoring 2021 6(1) 14Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
3.2 Utilisation of healthcare services 3.3 Quality of care
In the twelve months prior to the survey, 51.2% of refugees One quarter of refugees stated having been in inpatient
had visited primary and 37.4% specialist care services. treatment in the twelve months prior to the survey due to
Almost one third of refugees reported unmet needs (fore- medical conditions which, with adequate primary care,
gone health services), both in primary and specialist care. should not have required hospitalisation (avoidable hospi-
29.5% of refugees had made use of emergency care in the talisations). In addition, 14.4% of respondents reported
past twelve months, whereas just under half had received having been addicted to prescription drugs or having taken
prescription medication during the four weeks prior to the more of a drug than they had been prescribed at least once
study. For both emergency care and prescription medica- in their life. Reported responsiveness of care varied by type
tion, there was a clear trend towards a greater utilisation of healthcare service and accommodation type (collective
Primary care services are by female refugees. One third of respondents had received accommodation/initial reception centre; Figure 3). The best
advice from their doctor regarding their health behaviour ratings were given for respectful treatment and cleanliness,
accessible geographically,
in the twelve months prior to the study (Figure 2). while choice of provider and waiting time received the worst
but quality indicators
suggest other
Total proportion
access barriers. (95% confidence interval)
85.3%
Respectful treatment
(78.6%–90.2%)
Cleanliness 84.6%
(78.5%–80.2%)
Confidentiality 73.6%
(65.9%–80.2%)
Autonomy in 64.7%
decision-making (56.2%–72.4%)
63.3%
Communication (54.8%–71.1%)
Choice of provider 59.2%
(50.6%–67.2%)
Figure 3 Waiting time 52.5%
(45.6%–59.3%)
Quality of care perceived as good or very good
(responsiveness) by type of accommodation 0 20 40 60 80 100
Proportion (%)
(weighted, with 95% confidence intervals) Regional accommodation centre
Source: RESPOND Study 2018 Federal reception centre
Journal of Health Monitoring 2021 6(1) 15Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
Table 1 Quality of accommo- GU (n = 56) EA (n = 5) Total (n = 61) Residents (n = 5,092)
Number of regional accommodation centres dation in quintiles Number % Number % Number % Number %
(GU) and federal reception facilities (EA) Q1 (very high) 40 71.4 1 20 41 67.2 1,423 27.9
according to accommodation quality in quintiles Q2 (high) 12 21.4 2 40 14 23.0 1,297 25.5
as well as their respective number of residents Q3 (average) 2 3.6 0 0 2 3.3 26 0.5
Source: RESPOND Study 2018 Q4 (low) 1 1.8 0 0 1 1.6 41 0.8
Q5 (very low) 1 1.8 2 40 3 4.9 2,305 45.3
Total 56 100.0 5 100.0 61 100.0 5,092 100.0
Q = quintile, GU = regional accommodation centre, EA = federal reception centre
ratings. When compared to the initial reception centre set- reception centres and 56 collective accommodation cen-
ting, there was a tendency towards a subjectively better tres. With a possible spectrum from very high (value = 0)
Almost half of all assessment of care services for respondents in collective to very low (value = 6) accommodation quality, collective
accommodation across all responsiveness domains; this accommodation received a better average rating of 1.0
refugees (45.3%) live
tendency was particularly clear for cleanliness (Figure 3). (median = 0.5; min. 0.0; max. 4.8) than initial reception
in accommodation facilities centres with an average of 2.7 (median = 1.7; min. 0.5; max.
of poor structural quality. 3.4 Quality of accommodation 5.2). However, when the accommodation size is taken into
account, 45.3% of refugees lived in three accommodation
In total, the 560 respondents were accommodated in 63 centres that all received very low ratings for accommoda-
different centres. The quality of accommodation of 61 of tion quality (lowest quintile) (one initial reception centre,
them was assessed and calculated, and covered five initial two collective accommodation centres) (Table 1).
Total proportion
(95% confidence interval)
Distance to pharmacy 85.8%
(79.9%–90.1%)
Distance 75.2%
to general practitioner (67.6%–81.4%)
Distance to specialist 45.8%
Figure 4 (35.4%–56.6%)
Distance to pharmacies, general practitioners, Distance to hospital 52.7%
specialists and hospitals perceived as ‘close (42.4%–62.8%)
enough’ by type of accommodation 0 20 40 60 80 100
Proportion (%)
(weighted, with 95% confidence intervals) Regional accommodation centre
Source: RESPOND Study 2018 Federal reception centre
Journal of Health Monitoring 2021 6(1) 16Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
Figure 5
Travel time (in minutes) to the nearest primary
care practice per accommodation and mean
travel time per district by car, on foot and by
by car on foot
local public transport
Source: RESPOND Study 2018
Legend
Average travel time per district
Time in minutes
0–5
6–10
by public
11–15
transport
16–20
21 and over
No available data
Travel time from accommodation
Time in minutes
1–9
10–19
20–30
31–45
46–60
61–120
No public transport available
Cities
Journal of Health Monitoring 2021 6(1) 17Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
3.5 Geographical distance to healthcare services 40 accommodation centres had more than 45 minutes
travel time from the respective nearest practice, both on
85.8% of refugees stated that a pharmacy was close enough foot and by public transport.
to their accommodation. 75.2% said that primary medical
services were close enough, while the same was true of only 4. Discussion
45.8% for a specialist practice and 52.7% for a hospital. Phar-
macies tended to be judged as being ‘close enough’ more The RESPOND study is characterised by its population-
frequently by refugees in collective accommodation centres, based sampling procedure, multilingual questionnaires
while hospitals were judged as ‘close enough’ more fre- based on established instruments and personal contact
quently by refugees in reception centres (Figure 4). with respondents, relevant authorities and institutions. This
Figure 5 shows the actual distances from all collective made it possible to obtain reliable epidemiological data on
The collection of valid accommodation centres in Baden-Württemberg to the near- the health status, access to and quality of healthcare as
est primary care practice. The mean travel time by car was well as important aspects of the living and housing envi-
data on the health of
2.7 minutes (standard deviation 2.1; min. 0; max. 18.7). All ronments of refugees. In general, refugees have a high
refugees should be collective accommodation centres were within 30 minutes overall health burden. For example, 44.3% report depres-
continued and extended of the nearest practice by car (Figure 5); only about 90% sive symptoms, a very high figure compared to the gener-
to other federal states. of the centres had a practice within 30 minutes walking al population in Germany (10.1%) [36], which points to a
distance (Figure 5). The mean walking time was 13.2 min- high need for health and psychosocial services. In other
utes (standard deviation 15.5; min. 0; max. 119.3). areas, such as limitations in everyday life due to a health
91% of accommodation centres had a practice within a problem, the figures for refugees (16.9%) are also higher
30-minute journey by public transport (Figure 5). The aver- than for the general German population (6.6%) [37]. Direct
age travel time by public transport was 11 minutes (stand- comparisons are difficult because of the differences in age
ard deviation 11.03; min. 0; max. 97.08), yet 41 accommo- and gender composition between the two populations.
dation centres were not connected to the public transport Important insights can nonetheless be gained from such
network. For these 41 accommodation centres, the travel comparisons, which should be improved through the use
time on foot was at least 60 minutes, and the walking dis- of population standardisation in future studies.
tances were between 4.5 and 10 kilometres each way. The The high mental health burden of refugees in Germany
travel time by car from these accommodations to the near- has been shown previously by analyses based on the IAB-
est primary care practices was nine minutes on average SOEP-BAMF panel [5, 38]. However, when considering the
(standard deviation 2.8 min. 4.2; max. 18.7), with locations burden of physical illnesses, the two studies come to dif-
ranging from five to just under 16 kilometres away. In addi- ferent conclusions: compared to the population living in
tion to the 41 accommodation centres mentioned, another Germany, the IAB-SOEP-BAMF panel [38] records a lower
Journal of Health Monitoring 2021 6(1) 18Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
burden, while the RESPOND study shows a higher burden. condition. Findings from existing research in Germany
To a certain extent, this can be explained by the fact that shows that structurally poor housing conditions can neg-
the RESPOND study mainly captures recently arrived ref- atively impact refugee’s mental health [40]. In addition, the
ugees (since 2016), whereas the IAB-SOEP-BAMF panel international literature points to links between the quality
analyses were based on a sample of refugees which arrived of accommodation, occupancy density and physical health,
in Germany between 2013 and 2016. In addition, RESPOND particularly in relation to the worsening of chronic diseases
is the first study which facilitated population-based insights such as asthma and the spread of infectious diseases [41].
on utilisation, accessibility and quality of care for refugees The COVID-19 pandemic has made explicit the impor-
– topics not covered by the IAB-SOEP-BAMF panel. tance of the link between the housing conditions of refu-
The majority of refugees had used healthcare services gees and their health: in centres with better conditions and
in the twelve months prior to the survey. However, a high lower occupancy levels, authorities had better opportuni-
number of respondents reported foregone care. The com- ties to comply with physical distancing, isolation and quar-
paratively high prevalence of avoidable hospitalisations antine requirements, thereby being more effective in con-
also points to an insufficient coverage of primary care ser- trolling the pandemic [42]. The implementation of existing
vices. With regard to the quality of care experienced (respon- standards for the accommodation of refugees should be
siveness), the overall assessment of cleanliness and re-examined with respect to the structural quality of build-
respectful treatment were good, but assessments of choice ings, occupancy density, geographic location and cleanli-
of provider and waiting time showed room for improve- ness. In addition, further research on the impact of differ-
ment. Compared to a study of patients with chronic ent housing and living conditions on the health of refugees,
illnesses in outpatient care in Germany [39], refugees in including accommodation quality, is needed to support the
the RESPOND study rated every domain of responsiveness planning of accommodation processes from a health per-
as worse. A close analysis of the responsiveness of the spective. In this context, qualitative research is also of great
healthcare system for refugees, including a qualitative anal- importance in providing insights to the significance of the
ysis of the possible reasons for differences between the ‘living environment’ from the perspective of refugees and
different domains from the perspective of those affected, in shedding light on the connections between the living
is urgently needed to comprehensively assess how refu- environment and health in the unique context of collective
gees experience the quality of care. accommodation facilities.
Important insights were also gained with regard to the Primary care services are easily accessible from collec-
quality of accommodation facilities. While the majority of tive accommodation facilities by car, on foot or by public
centres visited were in good or acceptable structural con- transport for most refugees. The average distance travelled
dition, a disproportionately large number of refugees were by car was less than the ten minutes generally reported
living in large accommodation centres which were in poor for the German population [43] for all included districts.
Journal of Health Monitoring 2021 6(1) 19Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
However, access to selected centres proved difficult, espe- Corresponding author
cially in rural areas. The question therefore arises as to Louise Biddle
Section Health Equity Studies and Migration
whether it makes sense to accommodate refugees, who Department of General Practice and Health Services Research
often do not have a car, in structurally underdeveloped University Hospital Heidelberg
regions. This study benefited from the Google Maps Dis- Im Neuenheimer Feld 130.3
tance Matrix API, which enabled the analysis of travel times 69120 Heidelberg, Germany
E-mail: louise.biddle@med.uni-heidelberg.de
by public transport. However, the analysis was limited to
one practice and a single time of travel. Further analyses Please cite this publication as
should aim to extend this to multiple primary care prac- Biddle L, Hintermeier M, Mohsenpour A, Sand M, Bozorgmehr K (2021)
tices, other healthcare services and travel times at differ- Monitoring the health and healthcare provision for refugees in
collective accommodation centres: Results of the population-based
ent points of the day. survey RESPOND.
This is the first population-based study in Germany that Journal of Health Monitoring 6(1): 7–29.
goes beyond individual diseases to map the health situation DOI 10.25646/7863
of refugees in collective accommodation facilities in a Ger-
man federal state. In comparison to other population-based The German version of the article is available at:
surveys of the general population, a high response rate was www.rki.de/journalhealthmonitoring
achieved. The approach shows that migration-sensitive
health monitoring for refugees in initial reception and col- Data protection and ethics
lective accommodation centres is possible in principle and The study received ethical clearance from the Ethics Com-
can complement existing approaches to recruiting refugees mittee of the Medical Faculty of Heidelberg, Heidelberg
via population registers. Refugees are not per se difficult to University (S-516/2017). The study complied with the data
reach within the context of empirical surveys, although other protection regulations of the EU General Data Protection
approaches are necessary in addition to those usually used Regulation (GDPR) and the German Federal Data Protec-
in Germany to date. The study was limited by the fact that tion Act (BDSG). Participants were informed verbally and
it was restricted to one federal state and worked with a rel- in writing about the aims and contents of the study as well
atively small sample size. However, the instruments and the as about data protection.
sampling method applied by the RESPOND survey have
already been successfully repeated in Berlin [44]. Expanding Funding
the approach to other federal states and giving continuity to This study received funding from the Federal Ministry of
the described approaches can improve the empirical foun- Education and Research (BMBF) in the context of the
dation of healthcare provision for refugees and close exist- RESPOND project (reference: 01GY1611).
ing gaps in health monitoring.
Journal of Health Monitoring 2021 6(1) 20Journal of Health Monitoring Monitoring the health and healthcare provision for refugees in collective accommodation centres FOCUS
Conflicts of interest 6. Bozorgmehr K, Biddle L, Rohleder S et al. (2019) What is the
evidence on availability and integration of refugee and migrant
The authors declared no conflicts of interest. health data in health information systems in the WHO European
Region? WHO HEN synthesis report 66. WHO Regional Office
for Europe, Denmark
Acknowledgement
We would like to thank the County Association (Land- 7. International Organization for Migration (IOM) (2019) Glossary
on migration. International Organisation for Migration, Geneva
kreistag) of Baden-Württemberg, the regional level social
8. Santos-Hövener C, Schumann M, Schmich P et al. (2019)
affairs reception authorities of all 44 districts, the Ministry Improving the information base regarding the health of people
of Social Affairs Baden-Württemberg, the Ministry of the with a migration background. Project description and initial
findings from IMIRA. Journal of Health Monitoring 4(1):46–57.
Interior, Digitisation and Migration Baden-Württemberg, https://edoc.rki.de/handle/176904/5915 (As at 14.01.2021)
as well as the responsible regional councils of Baden-Würt- 9. Frank L, Yesil-Jürgens R, Razum O et al. (2017) Health and
temberg for their support of the study. Additional thanks healthcare provision to asylum seekers and refugees in Germany.
Journal of Health Monitoring 2(1):22–42.
go to all social workers and especially the participating ref- https://edoc.rki.de/handle/176904/2601 (As at 14.01.2021)
ugees and asylum seekers for their time and trust. Many
10. Brücker H, Rother N, Schupp J et al. (2018) IAB-BAMF-SOEP-
thanks to Harry Biddle for his support in using the Google Befragung von Geflüchteten 2016: Studiendesign, Feldergebnisse
Maps Distance Matrix API. sowie Analysen zu schulischer wie beruflicher Qualifikation,
Sprachkenntnissen sowie kognitiven Potenzialen. Forschungs
bericht 30. Bundesamt für Migration und Flüchtlinge, Nürnberg
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