Journal of Health Monitoring - Monitoring refugee health ISSUE

 
MARCH 2021   FEDERAL HEALTH REPORTING
  ISSUE
        1    JOINT SERVICE BY RKI AND DESTATIS

             Journal of Health Monitoring

             Monitoring refugee health

                                                 1
Journal 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)                                                             2
Journal 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)                                                                                                                                     3
Journal 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)                                                                                                                                        4
Journal 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)                                                                                        5
Journal 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)                                                                                        6
Journal 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

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Journal 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)                                                                                                                                    8
Journal 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)                                                                                                                                 9
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                                              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)                                                                                                                              10
Journal 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

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Journal 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

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                                               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)                                                                                                                                              13
Journal 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

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                                                  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)                                                                                                                                      15
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                                          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)                                                                                                                                         16
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                                           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

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                                             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)                                                                                                                              18
Journal 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)                                                                                                                                 19
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                                         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)                                                                                                                                      20
Journal 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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