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Objectives: COVID-19 containment and mitigation measures have been criticised for amplifying pre-existing individual and structural vulnerabilities among asylum seekers. We qualitatively explored their experiences with and attitudes towards pandemic measures to inform people-centred responses in future health emergencies.Methods: We interviewed eleven asylum seekers in a German reception centre (July-December 2020). The semi-structured interviews were recorded, transcribed, and analysed thematically with an inductive-deductive approach.Results: Quarantine was experienced as burdensome by participants. Shortcomings in social support, everyday necessities, information, hygiene, and daily activities exacerbated the strains of quarantine. Interviewees held different opinions about the usefulness and appropriateness of the various containment and mitigation measures. These opinions differed by individual risk perception and the measures’ comprehensibility and compatibility with personal needs. Power asymmetries related to the asylum system furthermore impacted on preventive behaviour.Conclusion: Quarantine can amplify mental health burdens and power asymmetries and can therefore constitute a considerable stressor for asylum seekers. Provision of diversity-sensitive information, daily necessities, and accessible psychosocial support is required to counteract adverse psychosocial impacts of pandemic measures and safeguard wellbeing in this population.

BACKGROUND: Refugees in collective accommodation facilities are at increased risk of COVID-19-infections due to high occupancy density and shared spaces. It is unclear which (organisational) actors the reception authorities were working with in their crisis response and how. The aim of this paper is to examine the working arrangements between reception authorities and other actors involved in accommodation and (health) care during the first wave of the COVID-19 pandemic and to derive recommendations for future crisis responses.; METHODS: The analysis was based on qualitative interviews with representatives responsible for the reception and accommodation of refugees (N =46) conducted from May to July 2020. Cross-actor networks were visualised, and aqualitative analysis of the data material was carried out using the framework method.; RESULTS: The reception authorities worked with amultitude of other (organisational) actors. Health authorities, social workers and security personnel were mentioned most frequently. The crisis response was found to be highly heterogeneous due to its dependence on the commitment, knowledge and attitude of the individuals and organisations involved. In the absence of acoordinating actor, there may also be delays due to a"wait-and-see" attitude of the actors involved.; CONCLUSION: Crisis response in collective accommodation facilities for refugees would benefit from aclear allocation of the coordinating role to an appropriate actor. Instead of improvised ad hoc solutions, sustainable improvements in terms of transformative resilience are needed to reduce structural vulnerabilities. © 2023. The Author(s)., Hintergrund Geflüchtete Menschen in Sammelunterkünften (SU) sind durch hohe Belegungsdichte und gemeinschaftlich genutzte Räume einem erhöhten SARS-CoV-2-Infektionsrisiko ausgesetzt. Unklar ist, mit welchen (organisationalen) Akteuren und in welcher Form die Aufnahmebehörden im Rahmen ihrer Krisenreaktion zur Eindämmung der COVID-19-Pandemie zusammenarbeiteten. Ziel des Beitrags ist es, die Zusammenarbeit zwischen Aufnahmebehörden und weiteren an der Unterbringung und Versorgung beteiligten Akteuren während der ersten Welle der COVID-19-Pandemie darzustellen und Empfehlungen für eine zukünftig verbesserte Krisenreaktion abzuleiten. Methoden Datengrundlage bilden qualitative Interviews die im Zeitraum Mai–Juli 2020 mit Ansprechpersonen in Aufnahmebehörden, die für die Unterbringung von Geflüchteten zuständig sind (N = 46). Es erfolgen eine Visualisierung von Akteursnetzwerken und eine qualitative Analyse des Datenmaterials mittels Framework-Methode. Ergebnisse Die Aufnahmebehörden arbeiteten mit einer Vielzahl weiterer (organisationaler) Akteure zusammen. Am häufigsten wurden Gesundheitsämter, Sozialarbeiter*innen und Sicherheitsdienste genannt. Die Krisenreaktion fiel sehr unterschiedlich aus, häufig in Abhängigkeit von Engagement, Wissen und Einstellungen einzelner Personen und beteiligten Organisationen. Bei Abwesenheit einer koordinierenden Stelle konnte es zu Verzögerungen durch eine „Wartehaltung“ der beteiligten Akteure kommen. Fazit Die Krisenreaktion in SU für Geflüchtete würde von einer klaren Zuordnung der koordinierenden Funktion an einen geeigneten Akteur profitieren. Anstelle von Ad-hoc-Lösungen bedarf es nachhaltiger Verbesserungen im Sinne einer transformativen Resilienz, um strukturelle Vulnerabilitäten zu reduzieren. Abstract

Since the “summer of migration” in 2015, there has been renewed interest in how best to integrate asylum seekers and refugees (ASR) in social and welfare systems across Europe, including health systems. The German health system has been slow to learn from previous periods of high in-migration of ASR, such as the early 1990s. In the light of continued migration, it is important to understand factors that can equip health systems for an adequate response. The aim of this thesis is to analyse the German health system response to ASR migration since 2015 using the concepts of health system resilience and responsiveness; assessing its capacity to collect and integrate different forms of knowledge, handle uncertainties and multiple cross-scale dynamics and create trusted and legitimate institutions, and to derive practical policy solutions to improve the resilience of future responses. This thesis derives an analytical approach for assessing health system resilience from a literature review on empirical studies on the concept (paper I). It then follows a structured assessment of resilience following Blanchet et al.’s (2017) four resilience capacities, presenting research from a literature review of ASR and migrant data collection and integration practices across Europe, including Germany (paper II), the results of a state-wide, population-based, cross-sectional health monitoring survey among ASR in collective accommodation centres (papers III and IV) as well as two qualitative studies with health and integration authorities: the first assessing models of care implemented in ASR reception centres (paper V) and the second mapping public health measures taken in response to the Covid-19 pandemic (paper VI). Overall, the analysis shows room for improvement in all four resilience capacities. Substantial health information gaps, inadequate anticipation of potential future challenges, a lack of evidence-based best practices and lack of a dedicated coordination function for ASR health has hampered a resilient response. Locally, several initiatives have demonstrated how resilience capacities may be strengthened through the increased involvement of public health offices in ASR health. Improved guidance and coordination from national institutions could further strengthen the resilience of the system. The responsiveness of services is generally high, but trust could be further strengthened through the institution of accountability mechanisms at patient and community levels. Going beyond health system accessibility, the resilience and responsiveness lens allowed for an analysis of the “system software” of the German health system for ASR. Applying this lens more rigorously in research on ASR health could contribute to a deeper understanding of health system responses, not just in Germany but internationally.

Background The mental health condition and healthcare needs of asylum seeking and refugee (ASR) children may go unrecognized if barriers to healthcare access exist accompanied by exclusive focus on somatic illness. We analysed the relationship between psychosocial functioning, health status and healthcare access of ASR children. Methods During 2018, 560 ASR adults in 58 collective accommodations in Germany’s 3rd largest federal state were randomly sampled and assessed. The parent-reported Strengths and Difficulties Questionnaire (SDQ) was used to assess child psychosocial functioning. SDQ dimensions (Emotional, Conduct, Peer, Hyperactivity, Prosocial, Total) were compared by demographics (sex, age, region of origin, time since arrival, subjective social status), health status (long-lasting illness, physical limitation, pain) and healthcare access (utilization: paediatrician, specialist, dentist, psychologist, hospital/emergency department, prescribed medicines; and unmet needs: for paediatrician/specialist, reduced spending to cover healthcare cost). Age and sex-adjusted odds ratios (AOR, 95%CI-Confidence Intervals) for scoring in borderline/abnormal ranges in SDQ dimensions were estimated through logistic regression depending on children’ health status and healthcare access. Results We analysed parents’ answers pertaining to 90 children aged 1–17 years old, 57% of which were girls and 58% with (Eastern or Western) Asian nationality. Scoring in the borderline/abnormal range of the SDQ Total Difficulties score was associated with feeling bodily pain (compared to no pain, AOR, 95%CI = 3.14, 1.21–8.10) and with an unmet need for a specialist during the previous year (4.57, 1.09–19.16). Borderline/abnormal SDQ Emotional scores were positively associated with a long-lasting illness (5.25, 1.57–17.55), physical limitation (4.28, 1.49–12.27) and bodily pain (3.00, 1.10–8.22), and negatively associated with visiting a paediatrician (0.23, 0.07–0.78), specialist (0.16, 0.04–0.69), and the emergency department (0.27, 0.08–0.96). Conclusion Poor psychosocial functioning among ASR children is associated with somatic problems, unmet medical needs, and lower healthcare utilisation. Somatic clinical encounters with ASR should include children’ mental health symptomatology assessment, especially in those with worst physical health conditions. Supplementary Information The online version contains supplementary material available at 10.1186/s13034-021-00411-4.

Background Characteristics of the place of residence have been proposed as a key determinant of physical and mental health, but so far, little experimental evidence exists. The quasi-random dispersal of refugees in Germany serves as a natural experiment to study the causal relationship between socio-economic deprivation and health as well as the impact of the social context on this relationship. Methods Refugees subject to dispersal policy (n = 1723) were selected from the nation-wide German IAB-SOEP-BAMF Panel from 2016 to 2018. The effect of German Index of Socioeconomic Deprivation quintiles (Q1-Q5) on change between baseline (t0) and follow-up (t1) in mental (mcs) and physical (pcs) health component scales of SF-12 were analysed using multi-level linear regression. Social context variables were included in a mediation analysis. Results Across quintiles, mental health improves (Δmcs=0.5) and physical health declines (Δpcs=-0.8) between t0 and t1. Fully adjusted models show a negative, dose-responsive relationship between deprivation and physical health, which is statistically significant for Q4 (coef. Q4vsQ1: -1.84, 95%CI: -3.50;-0.17). Models for mental health show an improvement in Q5 (coef. Q5vsQ1: 6.00, 95%CI: 1.70;10.31). Social context variables have no effect on physical health but slightly diminish the effect on mental health (coef. Q5vsQ1: 4.78, 95%CI: 0.65;8.90). Conclusions The quasi-random dispersal of refugees in Germany acts as a natural experiment to disentangle selection effects from the relationship between deprivation and health. Results suggest a negative effect of deprivation on physical health and a potential positive effect on mental health which can be partially explained by the social context. Limitations are the small sample sizes in deprived quintiles and short follow-up periods. This analysis can act as a magnifying glass for similar effects among other population groups, but causal paths need to be investigated further. Key messages

Background Many studies on contextual health effects suffer from compositional bias and selective migration into neighbourhoods. Longitudinal natural experiments have the potential to overcome these limitations, and there are several opportunities for this research design in the migration context. We aimed to synthesize evidence from natural experiments among migrants studying the effect of contextual factors on health and healthcare. Methods Peer-reviewed literature in English or German was systematically searched in four major databases in December 2021. Following systematic abstract- and fulltext-screening, 32 studies were included for analysis. Evidence on contextual impacts on physical and mental health, mortality, and healthcare was narratively synthesized and quality appraisal conducted. Results We found four types of contextual health effects: factors of the place of residence in receiving countries (n = 6), migration-context interactions (n = 10), policy environments (n = 15) and cultural factors (n = 1). Results show the negative impacts of post-migratory contexts on physical health and mortality and the favourable impacts on child health. Impacts on mental health are mixed. Analyses of policy contexts indicate the negative impacts of restrictive migration and social policies on healthcare utilization, mental health and mortality as well as the positive effects when restrictions are lifted. Conclusions Natural experiments can serve as powerful tools in disentangling the effect of context on health and reducing bias through self-selection. Results demonstrate the negative impacts for health which lie at the nexus of migration and neighbourhood disadvantage. At the same time, studies uncover the potential of health, welfare and visa programs to counteract such disadvantages and create healthy post-migratory contexts. With careful consideration of causal pathways, results from migration contexts can serve as a magnifying glass for effects of context in other population groups. Key messages • Natural experiments can serve as powerful tools in disentangling the effect of context on health and reduce bias through self-selection. • Results show the negative impacts for health that lie at the nexus of migration and neighborhood disadvantage, as well as the potential of inclusionary policies to counteract them.

BackgroundAsylum seekers and refugees (ASR) in Germany are dispersed quasi-randomly to state-provided, collective accommodation centres. We aimed to analyse contextual effects of post-migration housing environment on their mental health.MethodsWe drew a balanced random sample of 54 from 1 938 accommodation centres with 70 634 ASR in Germany’s 3rd largest federal state. Individual-level data on depression (PHQ2) and anxiety (GAD2) symptoms as well as sociodemographic- and asylum-related covariates, was collected and linked to contextual geo-referenced data on housing environment (‘Small-area Housing Environment Deterioration’ index, number of residents, remoteness, urbanity and German Index of Multiple Deprivation). We fitted two-level random-intercept models to exploratively estimate adjusted contextual effects.ResultsOf 411 surveyed participants, 45.53% and 44.83%, respectively, reported symptoms of depression or anxiety. 52.8% lived in centres with highest deterioration, 46.2% in centres with >=50 residents, 76.9% in urban, and 56% in deprived districts. 7.4% of centres were remote. The accommodation-level median odds ratio for GAD2 was 2.10 with contextual-level variance of 16%.For odds of reporting GAD2 / PHQ2, the highest degree of deterioration (OR 2.22; 95% CI 0.52-9.59 / 1.99;0.55-7.18), large accommodation size (1.34;0.59-3.06. / 1.12;0.56-2.26), remoteness (2.16;0.32-14.79 / 3.79;0.62-23.18) and district urbanity (3.05;0.98-9.49 / 1.14;0.46-2.79) showed higher, but statistically not significant, point-estimates. District deprivation demonstrated higher odds for GAD2 (1.21;0.51-2.88) and, inversely, lower odds for PHQ2 (0.88;0.41-1.89).ConclusionWe found tendencies for, but no significant, contextual effects of housing environment on ASR mental health in accommodation centres. Confirmatory analyses with prior power calculations are needed to complement these exploratory estimates.Research in contextWhat is already known on this subjectResearch on mental health of asylum seekers and refugees (ASR) has focused on pre- and peri-migratory factors, and increasingly recognizes post-migratory factors and their importance in restoring, sustaining, and protecting health to enable societal integration and participation. Research on the small-area housing environment, and its potential health effects is still scarce, and often limited by high-levels of aggregation of contextual factors, crude or not-standardised measurements on housing characteristics, and risk of compositional bias due to selective migration into housing environments.What this study addsWe make use of the quasi-random allocation of ASR to state-provided, collective accommodation centres, and link individual-level data on health and socio-demographic variables with small-area measures of contextual housing environment at accommodation-level to explore potential effects while minimising the risk of compositional bias. Accommodation-level factors contribute considerably to mental health variance. A tendency towards higher odds of reporting symptoms of generalized anxiety could be observed for housing deterioration, higher numbers of residents, remoteness as well as district urbanity and deprivation. Similar tendencies were estimated for reporting symptoms of depression except for deprivation potentially functioning protectively. Confirmatory research with appropriate sample size calculations as well as mediation and structural equation analysis are needed. Results may guide policy makers in design and planning of needs-based health services and housing infrastructure.

Background Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers’ access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01607-y.

Hintergrund: Die geografische Erreichbarkeit medizinischer Versorgungsangebote für die Regelbevölkerung in Deutschland ist bereits Gegenstand verschiedener Studien. Im Projekt RESPOND wurde bereits die geografische Erreichbarkeit allgemeinmedizinischer Versorgungsangebote für Geflüchtete, die in Gemeinschaftsunterkünften (GU) in Baden-Württemberg leben, untersucht. Die Entfernung zu spezialisierten Versorgungsangeboten z.B. der psychosozialen Versorgung wurde bisher noch nicht analysiert. Ziel dieses Working Papers ist die Berechnung der geografischen Erreichbarkeit der PSZ Standorte für geflüchtete Menschen in Gemeinschaftsunterkünften in Baden-Württemberg. Methode: Es wurden Adressdaten der zwölf Psychosozialen Zentren (PSZ) in Baden-Württemberg ermittelt. Für die Berechnung der Entfernungen zwischen GU für Geflüchtete und den Behandlungsorten der PSZ wurden deren Adressdaten in Geodaten konvertiert. Dasselbe wurde mit den Adressen der Unterkünfte in Baden-Württemberg gemacht, die im Rahmen des RESPOND Projekts Ende 2017 zusammengetragen wurden. Mit der Geoinformations-Software QGIS wurde jeder Unterkunft das jeweils nächstgelegene PSZ mittels der „Nächster-Nachbar-Analyse“ auf Grundlage der Luftlinienentfernung zugeordnet. Daraufhin wurde die Reisezeit von 1788 Unterkünften zu den zwölf PSZ-Standorten berechnet. Die Reisezeit wurde jeweils einfach (nur Hinweg) für die Verkehrsmittel ÖPNV, Auto und Fahrrad über die Google Maps Distance Matrix API berechnet. Ergebnisse: Die Ergebnisse zeigen, dass die Anbindung der Unterkünfte an den ÖPNV bzgl. der Erreichbarkeit der PSZ für mindestens ein Drittel der Unterkünfte sehr schlecht oder nicht gegeben ist. Jedoch liegen die großen Unterkünfte (>50 Bewohner*innen) tendenziell näher an den Standorten der PSZ, sodass das Versorgungsangebot sich insgesamt näher an der Mehrzahl der in GUs lebenden Geflüchteten befindet. Schlussfolgerung: Die gewonnenen Erkenntnisse können u.a. die zukünftige Planung neuer Standorte der PSZ in Baden-Württemberg informieren, damit ihr spezialisiertes Versorgungsangebot von möglichst vielen Personen der Zielgruppe erreicht und flächendeckend angeboten werden kann.

Dieses Working Paper berichtet zentrale Erkenntnisse einer Erhebung unter Sozialarbeiter*innen zur gesundheitlichen Versorgung von geflüchteten Menschen in Baden-Württemberg. Zentrale Erkenntnisse sind: - Insgesamt bewerten die befragten Sozialarbeiter*innen die gesundheitliche Versorgung von geflüchteten Menschen als gewährleistet, weisen jedoch auf Versorgungslücken für bestimmte Subgruppen hin. Insbesondere hervorzuheben ist die Versorgung bei psychischer Erkrankung, die den Befragten zufolge im Median zu nur 30% gewährleistet ist. - Angaben zur Zufriedenheit bei der Kooperation mit Akteur*innen aus dem gesundheitlichen Versorgungskontext und zur Zugänglichkeit medizinischer Versorgungsangebote variieren stark und weisen auf eine hohe Heterogenität der lokalen Versorgungssettings hin. - In Bezug auf die Patientenzentriertheit der Versorgung zeigen sich Verbesserungsbedarfe insbesondere hinsichtlich der ärztlichen Aufklärungs- und Beratungsgespräche, hier bleiben nach Angabe der Sozialarbeiter*innen häufig noch Fragen bei Geflüchteten offen. - Prioritäre Verbesserungsansätze aus sozialarbeiterischer Sicht sind die Einführung der elektronischen Gesundheitskarte für Asylsuchende, die Einführung von Videodolmetschdiensten bei Gesundheitsdienstleistern und die Verbesserung der psychosozialen Versorgung. Aus den Forschungserkenntnissen können u.a. folgende Empfehlungen für eine bedarfsgerechte Weiterentwicklung der Versorgungsstrukturen abgeleitet werden: 1. Abbau von Hürden bei der Inanspruchnahme gesundheitlicher Leistungen durch die Einführung der elektronischen Gesundheitskarte für Asylsuchende ohne Wartezeit. 2. Schaffung adäquater Strukturen zur qualifizierten Sprachmittlung und deren Finanzierung. 3. Verbesserung der Versorgung bei psychischen Erkrankungen, z.B. durch geeignete bedarfsorientierte Stepped Care-Modelle. 4. Berücksichtigung der gesundheitlichen Bedarfslagen geflüchteter Menschen in der regionalen gesundheitlichen Versorgungsplanung, insbesondere hinsichtlich der fachärztlichen Versorgungsstrukturen. 5. Auf- und Ausbau niedrigschwelliger gesundheitlicher Versorgungsstrukturen, die bei der Orientierung und Navigation innerhalb des Gesundheitssystems unterstützen und Versorgungsprozesse steuern können.

Background Research on health and healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness, as non-medical quality of care, in the narratives of ASR patients recently arrived in Germany. Methods 31 ASR with existing medical conditions were recruited in six refugee reception centres and three psychosocial centres. Semi-structured, qualitative interviews were conducted which reconstructed their patient journey after arrival in Germany. Interviews were recorded, transcribed verbatim and evaluated using thematic analysis. Results The experiences of participants throughout the patient journey provided a rich and varied description of the responsiveness of health services. Some dimensions of responsiveness, including respectful treatment, clear communication and trust, resurfaced throughout the narratives. These factors were prominent reasons for positive evaluations of the health system, and negative experiences were reported in their absence. Other dimensions, including cleanliness of facilities, autonomy of decision-making and choice of provider were raised seldomly. Positive experiences in Germany were often set in contrast to negative experiences in the participants’ countries of origin or during transit. Furthermore, many participants evaluated their experience with healthcare services in terms of the perceived technical quality of medical care rather than with reference to responsiveness. Conclusion This qualitative study among ASR analysed patient experiences to better understand responsiveness of care for this population. While our results show high overall satisfaction with health services in Germany, using the lens of responsiveness allowed us to identify particular policy areas where care can be strengthened further. These include in particular the expansion of high-quality interpreting services, provision of professional training to increase the competency of healthcare staff in caring for a diverse patient population, as well as an alignment between healthcare and asylum processes to promote continuity of care.

To date, the integration of refugees in German health surveys is insufficient. The survey RESPOND (Improving regional health system responses to the challenges of forced migration) aimed to collect valid epidemiological data on refugee health status and healthcare provision. The core elements of the survey consisted of a population-based sampling procedure in Baden-Württemberg, multilingual questionnaires and a face-to-face approach of recruitment and data collection in collective accommodation centres with multilingual field teams. In addition, data on the geographical locations of accommodation centres and their structural quality were obtained. The results indicate a high overall health burden. The prevalence of depression (44.3%) and anxiety symptoms (43.0%) was high. At the same time, high unmet needs were reported for primary (30.5%) and specialist (30.9%) care. Despite sufficient geographical accessibility of 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 quality. Collecting valid data on the health situation of refugees is possible through a combination of targeted sampling, multilingual recruitment and survey instruments as well as personal recruitment. The presented approach could complement established procedures for conducting health surveys and be extended to other federal states.

Background Housing is a key social determinant of health. Newly arriving asylum seekers and refugees (ASR) in Germany are assigned to reception centres (RC), comprising large, shared facilities in remote locations. Our aim was to explore how housing affects health from the perspective of ASR in order to develop an empirical framework for further research. Methods We conducted a secondary analysis of 47 qualitative interviews with ASR living in German RC and developed a multidimensional framework containing the effects of housing characteristics on health in this setting. An initial coding scheme with five dimensions was developed from the literature: material aspects, meaningful aspects, housing as an expression of socioeconomic status, community, and immediate environment. Using thematic analysis, sub-codes were generated inductively, resulting in the final framework. Results Important material aspects included building structure, basic amenities, sharing of living space and food provision. Among these, room sharing and food provision were particularly relevant for participants. Meaningful dimensions important for health included autonomy, privacy, safety and stability, which were limited in RC due to missing door locks, room sharing, restrictions of movement and frequent transfers between centres. Based on participants' statements, the community was divided into “outside” and “inside” the RC, which, unlike the “outside” community, have collective and organisational characteristics. We subsumed statements about distances to services and amenities into immediate environment. However, participants reported that short distances did not always guarantee access. Conclusions We identified important interdependent dimensions of housing which affect health and well-being among ASR and consolidated them into an empirical framework which can serve as a basis for further research, including the future development of measurement instruments to assess effects of housing on ASR health. Key messages ASR narratives show that housing dimensions with importance for health in reception centres have specific characteristics and are interdependent. We developed a framework which can be used for further research on the effects of housing on ASR health in this setting, including the construction of quantitative measurement instruments.

Background Research on healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness - the non-medical quality of care - as perceived by recently arrived ASR in Germany. Methods 31 ASR with existing medical conditions were recruited in six refugee clinics and three psychosocial counselling centres. Semi-structured, qualitative interviews were conducted, reconstructing the patient journeys after arrival. Interviews were recorded, transcribed and analysed thematically. Results Responsive care is important in evaluations of the German health system. Trust in providers and their expertise as well as accounts of a “caring” attitude, respectful treatment - e.g. taking afflictions and the situation of ASR seriously - and clear communication resurfaced frequently in ASR narratives. Their evaluation of care was affected by related expectations being exceeded or disappointed. Other responsiveness dimensions, like cleanliness of facilities, autonomy of decision-making and choice of provider were mentioned seldom. Participants voiced a high overall satisfaction with German healthcare. We observed that positive experiences were often set in contrast to negative experiences in countries of origin or during transit and many participants evaluated their healthcare experience initially in terms of the perceived technical quality and outcome of care rather than referring to responsiveness. Conclusions Aspects of respectful treatment, clear communication and trust are important to ASR. To further strengthen the provision of high quality and responsive care to a diverse patient population, policy action is needed: expansion of professional interpreting services, provision of professional training to increase the reflective and structural competence of healthcare staff and alignment between the healthcare and asylum processes to promote continuity of care.

Screening asylum-seekers for active pulmonary tuberculosis is common practice among many European countries with low incidence of tuberculosis. The reported yields vary substantially, partly due to the heterogeneous and dynamic nature of asylum-seeking populations. Rather than screening all new arrivals (indiscriminate screening), a few countries apply targeted screening based on incidence of tuberculosis in asylum-seekers' country of origin. However, evaluations of its cost-effectiveness have been scarce. The aim of this modelling study was to assess whether the introduction of a screening threshold based on the tuberculosis incidence in the country of origin is sensible from an economic perspective. To this end, we compare the current, indiscriminate screening policy for pulmonary tuberculosis in Germany with a hypothetical targeted screening programme using several potential screening thresholds based on WHO-reported incidence of tuberculosis in countries of origin. Screening data is taken from a large German federal state over 14 years (2002-2015). Incremental cost-effectiveness is measured as cost per case found and cost per case prevented. Our analysis shows that incremental cost-effectiveness ratios (ICERs) of screening asylum-seekers from countries with an incidence of 50 to 250/100,000 range between 15,000€ and 17,000€ per additional case found when compared to lower thresholds. The ICER for screening asylum-seekers from countries with an incidence

This subsection discusses the applicability and limitations of instituting financing mechanisms to fund healthcare provision for asylum seekers at the level of the European Union. To illustrate the need for such arrangements, we outline the current dilemma addressing health needs of refugees in Europe, where the financial burden lies disproportionately on countries in the periphery of the region. Taking an economic perspective, we discuss the lack of incentives for countries of the European Union to honour health as a human right and provide universal health coverage for forcibly displaced persons. We propose three financing scenarios, building upon existing financial mechanisms at the EU level, to increase financial solidarity among member states and provide a responsive financing mechanism, catering to the changing size and composition of the asylum-seeking population. We discuss these financing options both in terms of their ability to meet the requirements of “good” financing systems and in light of dominant political discourses of security, austerity, and eligibility. We argue that financial reform is sorely needed in order to address the health needs of an increasingly mobile population but that financing options must be accompanied by political discourses and citizen engagement in order to succeed.

Geflüchtete in Deutschland haben aufgrund ihrer Erfahrungen vor, während und nach der Flucht teilweise spezifische gesundheitliche und medizinische Bedarfe. Wichtige Krankheitsbilder bei Geflüchteten sind, unter anderem, psychische Krankheiten wie Depression und post-traumatische Belastungsstörung, aber auch Infektionskrankheiten, Ernährungsstörungen, Probleme in der reproduktiven Gesundheit und chronische Krankheiten. Praktische Erfahrungswerte zeigen, dass der Bedarf an psychischer und physischer Versorgung für Geflüchtete in Deutschland nicht adäquat gedeckt wird. Außerdem ist bekannt, dass Geflüchtete bei Aufsuchen von Versorgungsangeboten einer Reihe struktureller, sprachlicher, kultureller und geografischer Barrieren begegnen. Jedoch mangelt es in Deutschland an validen Daten, die den Versorgungsbedarf von Geflüchteten ihrem Zugang zu Versorgungsangeboten gegenüberstellen. Aus diesem Grund hat die Abteilung Allgemeinmedizin und Versorgungsforschung des Universitätsklinikums Heidelberg, gemeinsam mit der Bundesweiten Arbeitsgemeinschaft der Psychosozialen Zentren für Flüchtlinge und Folteropfer (BAfF), eine bundesweite Befragung von Geflüchteten in Psychosozialen Zentren durchgeführt. Die Studie fand im Rahmen des vom Bundesministerium für Bildung und Forschung geförderten Projekts RESPOND (www.respond-study.org) statt. Ziel der Befragung war es, verlässliche überregionale Evidenz zum körperlichen und seelischen Gesundheitszustand von Geflüchteten zu generieren und ihre Erfahrungen mit der gesundheitlichen Versorgung mit Blick auf Zugang und Zugangsbarrieren abzubilden. In diesem Zwischenbericht sollen erste deskriptive Ergebnisse der Studie präsentiert, und ein Ausblick auf weitere geplante Analysen gegeben werden.

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Mit den zunehmenden Flüchtlingszahlen seit 2015 wurden in den Aufnahmeeinrichtungen der Länder medizinische Ambulanzen für Geflüchtete eingerichtet. Diese sind notwendig, da verschiedene Barrieren den Zugang zu Angeboten der Regelversorgung für diese Bevölkerungsgruppe einschränken. Die „ad hoc“ entstandenen Strukturen der Ambulanzen sind mangels bundesweiter Standards jedoch sehr unterschiedlich, und oft nicht an die gesundheitlichen Bedarfe der untergebrachten Geflüchteten angepasst. Um den rechtlichen Anforderungen auf nationaler und internationaler Ebene gerecht zu werden und die Nachhaltigkeit der gesundheitlichen Versorgung sicherzustellen, ist es erforderlich in den medizinischen Ambulanzen klare Informations-, Finanz-, Logistik- und Personalstrukturen zu schaffen, welche sich proaktiv an die Bedarfe der sich ständig ändernden Population Geflüchteter anpassen können. Um dies zu ermöglichen ist es erforderlich, regelmäßig und auf einer soliden Datengrundlage die Bedarfe der Geflüchteten in Aufnahmeeinrichtungen zu ermitteln, zum Beispiel durch Gesundheitsmonitoring oder Statistiken aus elektronischen Dokumentationssystemen. Hierdurch können das Versorgungsangebot vor Ort, inklusive des Ärztespektrums, Einsatz von nicht-ärztlichem Personal, sowie Öffnungszeiten an die Bedarfe angepasst werden. Gleichzeitig werden auf Ebene der zuständigen Behörden klar strukturierte Abläufe benötigt, die für eine nachhaltige Verbesserung der Versorgungseffizienz sorgen. Dazu gehören ein regelmäßiger Austausch zwischen allen Akteuren, ein Finanzierungsmechanismus, der die die Gesundheitskosten gerecht verteilt, ein elektronisches Abrechnungssystem sowie klar definierte Arznei- und Hilfsmittellisten. Im Jahr 2019 befinden sich die Akteure der Gesundheitsversorgung von Geflüchteten in Deutschland in einer besonderen Situation: die Anzahl neu registrierter Asylsuchenden geht zurück, und es kann nun aus den vergangenen vier Jahren Bilanz gezogen werden. Dabei sollte die Verstetigung von guter Praxis und erfolgreichen Strukturen im Zentrum stehen, damit die gesundheitliche Versorgung auch bei wieder zunehmenden Flüchtlingszahlen bedarfsgerecht, effizient und qualitativ hochwertig durchgeführt wird.

Background Despite large numbers of asylum seekers, there is a lack of evidence on pregnancy outcomes and obstetric care of asylum seeking women in Germany. Methods Cross-sectional study (2010–2016) using administrative data of the main referral hospital for pregnant asylum seekers of the reception center of a large federal state in South Germany. Inclusion criteria: women aged 12–50 years, admitted in relation to pregnancy, childbirth or post-partum complications. Outcomes: differences between asylum seekers and residents in the prevalence of high-risk pregnancy conditions, abortive outcomes/stillbirths, peri- and postnatal maternal complications, neonatal complications, and caesarean sections. Analysis: odds ratios (OR) and 95% confidence intervals (CI) obtained by single and multiple logistic regression analysis. Attributable fractions among the exposed (Afe) and among the total population (Afp) were calculated for selected outcomes. Results Of 19,864 women admitted in relation to pregnancy, childbirth or post-partum complications, 2.9% (n = 569) were asylum seekers. Adjusted odds for high-risk pregnancy conditions (OR = 0.76, 95%CI: 0.63–0.91, p