EUropean Refugees-HUman Movement and Advisory Network – 717319On behalf of the EUR-HUMAN Consortium

Clinic of Social and Family Medicine, School of Medicine, University of Crete

EGPRN Conference 12-16 October, Leipzig Germany

“This presentation is part of the project ‘717319 / EUR-HUMAN’ which has received funding from the European Union’s Health Programme (2014-2020).”

“The content of this presentations the views of the author only and is his/her sole responsibility; it can not be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.”

Dr Enkeleint Aggelos Mechili in close collaboration with Prof. Christos Lionis and Dr Elena Petelos

EUR-HUMAN Contributors

University of Crete• Christos Lionis• Agapi Angelaki• Enkeleint Aggelos Mechili• Valeria Chatzea• Dimitra Sifaki Pistolla• Elena Petelos

Universiteit Nijmegen• Maria van den Muijsenbergh• Tessa van Loenen

University of Liverpool• Chris Dowrick• Nadja van Ginneken

Arq• Corné Versluis

University of Zagreb• Dean Ajdukovic,• Helena Bakic

Medizinische Universität Wien • Kathryn Hoffman• Elena Jarovsky• Elisabeth Sophie Mayrhuber

Univerza V Ljubljani• Danica Rotar Pavlic

European Forum for Primary Care• Pim de Graaf, • Diederik Aarendonk

Local Health Authority of Tuscany Centre• Piero Salvadori• Giulia Borgioli• Nicole Mascia

University of Debrecen• Imre Rurik, • Laszlo Kolozvari

NIVEL• Michel Duckers

Introduction – I Third Programme for the Union's action in

the field of health (2014-2020) Specific Call HP-HA-2015

Call for proposal entitled: “Support Member States under particular migratory pressure in their response to health”

Project Proposal number: 717319

Duration: 12 months

Grant Amount: 1,320,113 EUR

Co-ordination by the University of Crete (UoC)

Eight participating countries:

Austria, Croatia, Greece, Italy, Hungary, the Netherlands, Slovenia, United Kingdom

Introduction – II The current political crisis, conflicts and riots in Middle

Eastern and African countries massive migration waves towards Europe;

Several challenges given the sheer volume of people arriving in European countries;

Difficult and long journeys to reach Europe adversely impact the health of even young and healthy people refugee crisis representing the biggest displacement crisis of a generation.

UNHCR: Syria conflict at 5 years: the biggest refugee and displacement crisis of our time demands a huge surge in solidarity. Available at: http://www.unhcr.org/en-us/news/press/2016/3/56e6e3249/syria-conflict-5-years-biggest-refugee-displacement-crisis-time-demands.html

Introduction – III

• The growing number of migrants and refugees in European countries represent enormous public health challenge.

• The EUR-HUMAN project focuses on strengthening primary health care as the first point of contact for refugees and migrants.

• Person-centred care, taking into account the multi-cultural setting and the needs, wishes, expectations and preferences of the refugees and migrants.

Aim of the project

The overall aim of the EUR-HUMAN project is to: Enhance the capacity, knowledge and expertise of

European member states who accept refugees and migrants to better address their health needs (CAPACITY BUILDING project)

Safeguard them from risks, while at the same time minimize cross-border health risks

The project will focus on addressing both the early arrival period and transit settlement of refugees in European host countries.

Research Questions (RQ)

1. Which are the needs, wishes, problems and expectations of refugees reaching European countries? (RQ-1)

2. Which are the tools and interventions that could be utilized in the refugees healthcare needs assessment? (RQ-2)

3. What are the main problems and barriers in providing primary healthcare services to refugees? (RQ-3)

4. How we can rapidly assess mental health and psychosocial needs of refugees? (RQ-4)

5. To what extent will training material contribute in the design and provision of acceptable and feasible healthcare services to refugees. (RQ-5)

Objectives Primary objective: to identify, design and assess interventions to improve primary

healthcare delivery for refugees and migrants with a focus on vulnerable groups. Specific objectives

1. to facilitate sense of coherence and community engagement (RQ 1)

2. to conduct an international expert consensus panel meeting of the approval of tools and evidence based practice guidelines (RQ 2)

3. to undertake a systematic review to identify suitable tools for needs assessment and effective interventions (RQ 3)

4. to develop the model and protocol for rapid assessment of mental health and psychosocial needs of refugees and psychosocial care (RQ 4)

5. to enhance capacity building for staff in Community Oriented Primary Care Centres (COPCCs) as well as other existing primary care settings (in 6 countries) (RQ 5)

6. to test the feasibility and acceptability of best practice interventions (RQ 5)

Methods: Theoretical reasoning – I 1. The program utilises theoretical inputs from the current research

evidence base to underpin the selection of interventions to blend, including documentation retrieved from Chronic Care Model (patient-centred services, integrated health services, cultural competency, well-informed patient etc.)

2. Evidence-based methodological approaches are utilised by the program including:

Participatory and Learning Action (PLA) – (RQ-1) and Normalization Process Theory (NPT) Evaluation process (RQ-5)

3. Systematically review of the existing literature in combination with A survey Interviews with experts (RQ-2, RQ-3, RQ-5)

O’ Reilly-de Brun M, de Brún T. The use of Participatory Learning & Action (PLA) Research in Intercultural Health: Some Examples and Some Questions. Translocations: Migration and Social Change. Special Issue on Migration and Health. 2010. http://www.translocations.ie/docs/v06i01/Centre%20for%20Participatory%20Strategies.pdfMay CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, Rapley T, Ballini L, Ong BN, Rogers A, Murray E, Elwyn G, Légaré F, Gunn J, Montori V. Building an interdisciplinary theory of implementation, embedding and integration: The Development of Normalisation Process Theory. Implementation Science. 2009;4:29.

Methods – II

4. Protocol for the rapid assessment (RA) of mental health and psychosocial needs (RQ-4) of refugees on the basis of the Model of Continuity of Psychosocial Refugee Care (MCPRC);

5. Expert Consensus Panel put together (30 experts 14 EU countries) to engage in a two-day decision-making process, with the aim to reach consensus agreement on best practice guidelines, tools and services (RQ-2, RQ-3, RQ-5);

6. Questionnaires for ex ante and ex poste evaluation of the knowledge earned (RQ-5);

7. The NPT method and NOMad, Dispositional Positive Emotions Scale (DPES) and Compassion Subscale and Patient Compassionate Assessment Respecting Expectations (CARE) Survey tool would be tested in order to evaluate the intervention process (RQ-5).

Finch TL, Rapley T, Giriling M et. al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci. 2013;8:43.

• Disabilities and injuries

Violence related wounds, burns, frostbites, broken bones, sprained ankles, pain in back and legs, blisters, hypothermia,

• Mental health problems

Trauma related distress, depression, insomnia, fatigue, anxiety, uncertainty, disorientation

• Pregnancy related issues

Dehydration; no medical examinations, privacy, facilities or healthy food • Infectious diseases

Common cold, flu, respiratory, urogenital, eye, scabies• Gastrointestinal problems and dehydration

Diarrhoea, viral gastroenteritis, vomiting and dehydration• Dental problems • Chronic diseases (not enquired about frequently)

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Results: Common Health problems identified (RQ-1)

Results: Healthcare needs and preferencses (RQ-1)

• Compassionate attitude of health care workers respect, smile, kind word, feeling of

being accepted

Note: many refugees mention good experiences on how they were approached!

• Bridging linguistic and cultural barriers Cultural mediators/interpreters Involve refugees / migrants as

mediators “I'm a paediatrician and speak good English.

Let me help, because these people trust me. .. I'm able to translate and know the taboos. I think I can solve a lot of problems, but I'm just not allowed.” (Male, Syria, Long-term, the Netherlands)

Information needs on healthcare facilities and

organisation on procedures and support

Psychological support in most cases (hotspot and transit)

enough to just talk about situation expert mental health care (long-term

Continuity of care: provide information about medical history about care services in the present

country or the following countries

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Organisational – institutional level• Time pressure

-> instruments rapid assessment• Primary healthcare not always present

-> target also volunteers• Discrimination others than Syrians

-> attention for human rights access to healthcare

• Linguistic and cultural barriers-> facilitate involvement migrants as mediators

• Information needs: provide info about:• Procedures and what to expect at

the site• Health care System

Healthcare provision level• Continuity of care problem

-> personal medical passport• Specific attention main health

problems • Mental health• Injuries • Pregnancy related problems

• Training of health care workers and volunteers:

• how to bridge linguistic and cultural barriers

• working with interpreters• involvement migrant

mediators• specific conditions

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Results: Refugees expectations (RQ-1)

Results: Tools and interventions (RQ-2)

Field Issue Title Author and year

Cultural competence in health care Measuring compassionate care Compassionate Care Assessment Tool (CCAT)

Burnell, Lori, Agan, Donna, 2013

Continuity of care Personal health record IOM personal health record and handbook

IOM, 2015

Needed information and health promotion

Health care system information Migration Integration Policy Index: MIPEX

MIPEX project, 2015

Triage First health assessment Initial assessment and treatment with the ABCDE approach

Troels, Niels, Krarup, et al 2012

Mental Health Refugees health screening Refugee health screener-15 Holliefield, Toolson, Verbillis-Jorp, et al. 2016

Mother and reproductive care Manual on reproductive health Inter-agency Field Manual onReproductive Healthin Humanitarian Settings

WHO, 2010

Child health Trauma risk in children Refugee Service Toolkit (RST) National child traumatic stress network, 2010

Communicable, non-communicable diseases and vaccination

Infectious diseases / Vaccination status Infectious diseases of specific relevanceto newly-arrived migrants in the EU/EEA

ECDC, 2015

Results: Systematic review, survey and interviews (RQ-3)

Preliminary findings on different thematic areas. Patient factors were identified as major barriers (language

communication limitations); Absence of continuity of care; Lack of knowledges, professionals training and skills of PHC

personnel; Lack of comprehensive monitoring system; Social and cultural norms in the community can result in a low

uptake of services; Lack of adherence to medication; Fear of prosecution; Forced lifestyle changes; Passive attitude towards treatment.

Results: Problems identified in different settings (RQ-3)

Lack of staff and resources (particularly the lack of multidisciplinary teams) extremely problematic and challenging in terms of adequate healthcare provision;

No standardized initial health assessment i.e., Greece (no) vs Austria (yes);

Lack of specific guidelines for vulnerable groups, such as pregnant women, unaccompanied minors, refugees and migrants subjected to torture and violence, was also identified as challenging for healthcare provision;

No information on healthcare skills of refugees who at their country of origin were PHC providers;

Results: Mental health (MH) (RQ-4) MH triage (3 steps)1. Recognition of behavioural signs that indicate severe distress;

2. Rapid assessment and immediate assistance;

3. Referral to a specialist, if needed.

MH screening

1. Recognition of behavioural signs that indicate severe distress;

2. Applying the MH screening tool (i.e. RHS-13);

3. Referral to a specialist, if needed.

Physiological first aid 9 step procedure in order mainly to:

1. Reduce initial distress;

2. Meet current needs;

3. Promote flexible coping and building people's capacity to recover and adjust

MH Triage MH Screening

Triage for refugees and immigrants –EUR-HUMAN schematics

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Important contextual factors following Expert Consensus Meeting (RQ-2, RQ-3, RQ-4)

General principle

Primary Healthcare for refugees and other migrants should be person-centred, comprehensive, goal-oriented, minimally disruptive, compassionate, outreaching, integrated within the existing system and other services, and provided by a multidisciplinary team.

Main achievements

Important contextual factors

There are different migrant groups with different entitlements to care, undocumented migrants and unaccompanied minors are in need of special attention;

There is a lack of resources and manpower, especially in crowded first reception centres. This challenges the provision of good quality integrated PHC;

Local circumstances will determine to a high degree the extent to which ideal PHC can be implemented. The ATOMIC model, developed by NIVEL, may play an important role in local decisions on the implementation of interventions.

Concluding remarks based on the findingsThe organisation of outreaching, integrated primary health care should include: Enabling the composition of multidisciplinary PHC teams and task shifting;

Enabling the organisation of person-centred and culturally competent care: Providing quality interpretation service (cultural mediators) avoiding informal

interpreters wherever possible Providing culturally appropriate health promotion in refugees languages and

according their literacy level Providing necessary (on-line) training on cultural competences and compassionate

care

Continuity of care should be guaranteed locally and throughout the migrant

journey by an “INTEROPERABLE” coding-friendly system (electronic ICPC/ICS/ATC coded system, and using English language and universal names/codes for diseases/medication/vaccination).

General impact of the project

Innovative project that is expected to contribute significantly to the development and enhancement of the capacity building for policy makers, stakeholders, PHC providers at local, national and European level;

Advance the knowledge, technical capacities and resources devoted to the care of refugees, along with the provision of physical, psychological and mental health care, within the context of multifaceted, integrated, person-centred and multidisciplinary social services

Impact of the project and relevance to EGPRNGPs and PHC providers Educational tools, and e-training modules significant impact on the training and continuous

professional development; Useful toolbox for the initial healthcare needs assessment and rapid mental health assessment of

needs of the arriving refugees and migrants groups; The establishment of interdisciplinary team along with the NPT and PLA will enable to better

understand, theoretically and practically, the dynamics and pragmatics of refugees health needs;

Primary healthcare services Will promote comprehensive health needs assessment and the services provided will be focused

on different sectors; Will be grounded in a holistic model of health and wellness;

Health policies Will review all migrant related policies and produce a final report introducing the development of

an Early Care and Rehabilitation Centre that could be implemented in other similar European settings;

Enables stakeholders to address immigration issues of joint concern.

PLA data collection in Moria by the Greek team (WP2)

For further information please see:http://eur-human.uoc.gr/category/news

Contact

Website: www.eur-human.uoc.grTwitter: https://twitter.com/eur_human

Thank you

“This presentation is part of the project ‘717319 / EUR-HUMAN’ which has received funding from the European Union’s Health Programme (2014-2020).”

“The content of this presentations the views of the author only and is his/her sole responsibility; it can not be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.”