The health of refugees and asylum seekers in Europe
All photos in this post by Denis Bosnic (www.denisbosnic.com)
First published 12 February, 2016; Last updated 7 January 2020
In 2015 over one million people arrived in Europe by sea, mostly originating from Syria. In the same year 3,771 people went missing or died attempting to reach safety in Europe. In 2016 people continue to make the hazardous journey across the sea and at the beginning of February 67,072 people made it across, while 357 were reported dead or missing.
Many of those who do reach Europe, across the sea or otherwise, continue to face threats to their health and security. In their attempt to reach countries of asylum, they are forced to endure inadequate shelter and sanitation, and lengthy multi-day walks and waits at borders in adverse weather conditions.
While some of them suffer from chronic medical conditions that go unattended, others are pregnant without access to prenatal care. Many of the refugees and asylum seekers are children, some with respiratory infections. Others suffer from mental trauma related to the conflict and persecution they are fleeing from. The fear of repatriation or detention and bureaucratic hurdles makes them potentially wary of seeking healthcare. The London School of Hygiene and Tropical Medicine published on their website the article titled “On the move: the race to keep forced migrants healthy”, that looks at some of the health consequences for refugees and asylum seekers of being on the move.
Those refugees and asylum seekers who do access some kind of healthcare present medical staff in Europe with several challenges. Whilst some of these challenges are not related to their medical conditions, such as language barriers and cultural differences, others are medical or public health related and, if possible, should be attended to with an evidence-based approach.
The information and collection of evidence within this resource aims to provide those addressing the health of refugees and asylum seekers with some guidance. The collection of evidence is divided between the sources mentioned on this page and a Cochrane Library Special Collection, housed in the Cochrane Library. Both collections of evidence focus on some of the most relevant medical conditions as perceived by experts who have been involved either in guideline development or on the frontline, directly addressing the needs of refugees and asylum seekers. In the first instance, the collaboration (see below) decided on the following priority conditions to address in the Special Collection:
- Common Mental Health Disorders (including PTSD and depression)
- Vaccine Preventable Diseases
- Skin conditions (including Impetigo, Scabies and Cellulitis)
- Sexual and Physical Violence
Latterly, in 2018, Oral Health was added to this list as a priority area.
This Evidence Aid resource will link to each Special Collection, but also identify non-Cochrane systematic reviews. The Cochrane Evidence Aid Special Collection – Health of refugees and asylum seekers in Europe includes only Cochrane Reviews, although these are also listed below. (The Cochrane Evidence Aid Special Collection is also available in Spanish: La salud de los refugiados y solicitantes de asilo en Europa, hosted by Cochrane Iberoamérica.)
This initiative is a collaboration between Cochrane, Wiley, Kevin Pottie, Leo Ho and Evidence Aid and incorporates the suggestions and contributions of many others. The pictures were provided by Denis Bosnic and were all taken in Italy (contact details or link to site).
Please contact us with suggestions and comments, so we can improve this page. We will add to this page whenever we find other relevant materials, so please return to this page if you are interested.
*All of the summaries of the reviews and guidelines have also been translated into Spanish [ES] and French [FR]. We are very grateful to volunteers at Translators Without Borders who help us with this important work.
If you would like to use an appraisal framework when considering the relevance and quality of the full reviews that Evidence Aid links to, a few useful tools are: AMSTAR, CASP and ROBIS. Guidance is also available on reporting reviews: PRISMA.
1 http://data.unhcr.org/mediterranean/regional.php (last accessed on 2 February 2016).
[toggle title_open=”Common mental health disorders” title_closed=”Common mental health disorders”]
Amos T., Stein D.J., Ipser J.C. Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD006239. DOI: 10.1002/14651858.CD006239.pub2. [ES] [FR]
Bisson J.I., Roberts N.P., Andrew M., et al. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub4. [ES] [FR]
Cipriani A., La Ferla T., Furukawa T.A., et al. Sertraline versus other antidepressive agents for depression. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD006117. DOI: 10.1002/14651858.CD006117.pub4 [ES] [FR]
Cipriani A., Purgato M., Furukawa T.A., et al C. Citalopram versus other anti‐depressive agents for depression. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD006534. DOI: 10.1002/14651858.CD006534.pub2. [ES] [FR]
Fazel M., Reed R., Panter-Brick C., et al. Mental health of displaced and refugee children resettled in high income countries: Risk and protective factors. Lancet 2011;379(9812):266-82. [ES] [FR]
Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. Lancet 2005;365(9467):1309-14. [ES] [FR]
Gadeberg A.K., Montgomery E., Frederiksen H.W., et al. Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools. European Journal of Public Health. 2017;27(3):439-46. [ES] [FR]
Gillies D., Taylor F., Gray C., et al. Psychological therapies for the treatment of post‐traumatic stress disorder in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD006726. DOI: 10.1002/14651858.CD006726.pub2. [ES] [FR]
Hazell P., Mirzaie M. Tricyclic drugs for depression in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD002317. DOI: 10.1002/14651858.CD002317.pub2. [ES] [FR]
Hetrick S.E., McKenzie J.E., Cox G.R., et al. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD004851. DOI: 10.1002/14651858.CD004851.pub3. [ES] [FR]
Horyniak D., Melo J.S., Farrell R.M., et al. Epidemiology of substance use among forced migrants: a global systematic review. PLoS one 11.7 (2016): e0159134. [ES] [FR]
Leucht C., Huhn M., Leucht S. Amitriptyline versus placebo for major depressive disorder. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD009138. DOI: 10.1002/14651858.CD009138.pub2. [ES] [FR]
Magni L.R., Purgato M., Gastaldon C., et al. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004185. DOI: 0.1002/14651858.CD004185.pub3 [ES] [FR]
Nakeyar C., & Frewen P.A. (2016). Evidence-based care for Iraqi, Kurdish, and Syrian asylum seekers and refugees of the Syrian civil war: A systematic review. Canadian Psychology/Psychologie canadienne, 57(4), 233-245. [ES] [FR]
Nosè M., Ballette F., Bighelli I., et al. Psychosocial interventions for post traumatic stress disorder in refugees and asylum seekers resettled in high income countries: Systematic review and meta-analysis. PloS One. 2017;12(2):e0171030. [ES] [FR]
Omori I.M., Watanabe N., Nakagawa A., et al. Fluvoxamine versus other anti‐depressive agents for depression. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006114. DOI: 10.1002/14651858.CD006114.pub2 [ES] [FR]
Pooley J.A., Sims K. Post-traumatic growth amongst refugee populations: A systematic review. Chapter 19 of The Routledge International Handbook of Psychosocial Resilience. 2016. [Note: The link to the article shows random samples of the book, and does not guarantee access to the whole publication.] [ES] [FR]
Purgato M., Papola D., Gastaldon C. et al Paroxetine versus other anti‐depressive agents for depression. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD006531. DOI: 10.1002/14651858.CD006531.pub2. [ES] [FR]
Sangalang C.C., Vang C. Intergenerational trauma in refugee families: A systematic review. Journal of Immigrant and Minority Health. 2017;19(3):745-54. [ES] [FR]
Sullivan A.L., and Simonson G.R. A systematic review of school based social-emotional interventions for refugee and war-traumatized youth. Review of Educational Research. 2016;86(2):503-30. [ES] [FR]
Tribe R.H., Sendt K.V., Tracy D.K. A systematic review of psychosocial interventions for adult refugees and asylum seekers. Journal of Mental Health. 2017;8:1-5. [ES] [FR]
Watanabe N., Omori I.M., Nakagaw A., et al. Mirtazapine versus other anti-depressive agents for depression. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD006528. DOI: 10.1002/14651858.CD006528.pub2 [ES] [FR]
[toggle title_open=”Maternal and reproductive health” title_closed=”Maternal and reproductive health”]
In the future, we will to launch a Maternal/Reproductive Health priority area for our collection. If anyone is interested in assisting in this upcoming initiative, please contact Abi Kirubarajan at email@example.com. Meantime, we will collect and publish reviews relating to this topic area as they are identified. If you know of any relevant reviews, please do get in touch.
Gagnon A.J., Merry L.. Robinson C. A systematic review of refugee women’s reproductive health. Refugee (Canada’s Journal on Refugees) 2002;21(1):6-17. [ES] [FR]
[toggle title_open=”Oral health” title_closed=”Oral health”]
Abuhaloob L., Carson S., Richards D., & Freeman R. Community-based nutrition intervention to promote oral health and restore healthy body weight in refugee children: a scoping review. Community Dental Health, 2018;35(2):81-8. [ES] [FR]
Keboa M.T., Hiles N., Macdonald M.E. The oral health of refugees and asylum seekers: a scoping review. Globalization and Health. 2016;12:59. [ES] [FR]
Reza M., Amin M.S., Sgro A., et al. Oral health status of immigrant and refugee children in North America: a scoping review. Journal of the Canadian Dental Association. 2016;82(g3):1488-2159. [ES] [FR]
[toggle title_open=”Sexual and physical violence” title_closed=”Sexual and physical violence”]
Khan O., Ferriter M., Huband N., et al. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database of Systematic Reviews 2015, Issue 2.Art.No.:CD007989.DOI:10.1002/14651858.pub2. [ES] [FR]
Kalt A., Hossain M., Kiss L., et al. Asylum seekers, violence and health: A systematic review of research in high income host countries. American Journal of Public Health 2013;103(3):e30-42 (not open access, request a copy of the publication here). [ES] [FR]
Macdonald G., Higgins J.P.T., Ramchandani P., et al. Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. NO.:CD001930. DOI:10.1002/14651858.CD001930.pub3. [ES] [FR]
O’Doherty L., Hegarty K., Ramsay J., Davidson, L.L., Feder, G., Taft, A. Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.:CD007007.DOI:10.1002/14651858.CD007007.pub3. [ES] [FR]
Parker B., Turner W. Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually and abused. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.:CD008162. DOI: 10.1002/14651858.CD008162.pub2. [ES] [FR]
Rivas C., Ramsay J., Sadowski L., et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane Database of Systematic Reviews 2015, Issue 12. Art No.:CD005043. DOI:10.1002/14651858.CD005043.pub3. [ES] [FR]
Timshel I., Montgomery E., Dalgaard N.T. A systematic review of risk and protective factors associated with family related violence in refugee families. Child Abuse & Neglect. 2017;70:315-30. [ES] [FR]
[toggle title_open=”Skin conditions” title_closed=”Skin conditions”]
Fitzgerald D., Grainger R.J., Reid A. Interventions for preventing the spread of infestation in close contacts of people with scabies. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.:CD009943. [ES] [FR]
[toggle title_open=”Social determinants of health and systemic barriers” title_closed=”Social determinants of health and systemic barriers”]
Filges T., Montgomery E., Kastrup M., et al. The impact of detention on the health of asylum seekers. Campbell Collaboration Library 2015-09-01 Volume 11, number 13. [ES] [FR]
Graham H.R., Minhas R.S., Paxton G. Learning problems in children of refugee background: a systematic review. Pediatrics. 2016 Jun 1;137(6):e20153994. [ES] [FR]
Hadgkiss E.J., Renzaho A.M.N. The physical health status, service utilisation and barriers to accessing care for asylum seekers residing in the community: a systematic review of the literature. Australian Health Review 2014 May;38(2):142-159. [ES] [FR]
Hannigan A., O’Donnell P., O’Keeffe M., et al. How do variations in definitions of ‘migrant’ and their application influence the access of migrants to health care services? Copenhagen: WHO Regional Office for Europe; 2016 (Health Evidence Network (HEN) synthesis report 46). [ES] [FR]
Ott E., Montgomery P. Interventions to improve the economic self-sufficiency and well-being of resettled refugees: A systematic review. Campbell Collaboration Library 2015-01-02 Volume 11, number 4. [ES] [FR]
Robertshaw L., Dhesi S., Jones L.L. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ open. 2017 Aug 1;7(8):e015981. [ES] [FR]
Tyrer R.A., Fazel M. School and community-based interventions for refugee and asylum seeking children: A systematic review. Published February 24, 2014. Plos One 9(2), e89359. [ES] [FR]
[toggle title_open=”Tuberculosis” title_closed=”Tuberculosis”]
Akolo C., Adetifa I., Shepperd S., et al. Treatment of latent Tuberculosis infection in HIV infected persons. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD00171. DOI: 10.1002/14651858.CD00171.pub3. [ES] [FR]
Bozorgmehr K., Razum O., Saure D., et al. Yield of active screening for tuberculosis among asylum seekers in Germany: a systematic review and meta-analysis. Eurosurveillance. 2017;23(22):12. [ES] [FR]
Clark R.C., Mytton J. Estimating infectious disease in UK asylum seekers and refugees: a systematic review of prevalence studies. Journal of Public Health 2007;29(4):420-8. [ES] [FR]
Critchley J.A., Orton L.C., Pearson F. Adjunctive steroid therapy for managing pulmonary tuberculosis. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD011370. DOI: 10.1002/14651858.CD011370. [ES] [FR]
Fox G.J., Dobler C.C., Marks G.B. Active case finding in contacts of people with tuberculosis. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD008477. DOI: 10.1002/14651858.CD008477.pub2. [ES] [FR]
Karumbi J., Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD003343. DOI: 10.1002/14651858.CD003343.pub4. [ES] [FR]
Ziganshina L.E., Titarenko A.F., Davies G.R. Fluoroquinolones for treating tuberculosis (presumed drug-sensitive). Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD004795. DOI: 10.1002/14651858.CD004795.pub4. [ES] [FR]
[toggle title_open=”Vaccine preventable diseases” title_closed=”Vaccine preventable diseases”]
Demicheli V., Barale A., Rivetti A. Vaccines for women for preventing neonatal tetanus. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD002959. DOI: 10.1002/14651858.CD002959.pub4. [ES] [FR]
Demicheli V., Rivetti A., Debalini M.G., et al. Vaccines for measles, mumps and rubella in children. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.:CD004407. DOI:10.1002/14651858.CD004407.pub3. [ES] [FR]
Macartney K., Heywood A., McIntyre P. Vaccines for post-exposure prophylaxis against varicella (chickenpox) in children and adults. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD001833. DOI: 10.1002/14651858.CD001833.pub3. [ES] [FR]
Mipatrini D., Stefanelli P., Severoni S., et al. Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence. Pathogens and Global Health. 2017;111(2):59-68. [ES] [FR]
Poorolajal J., Hooshmand E. Booster dose vaccination for preventing hepatitis B. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD008256. DOI: 10.1002/14651858.CD008256.pub3. [ES] [FR]
Young M.K., Cripps A.W., Nimmo G.R., et al. Post-exposure passive immunisation for preventing rubella dn congenital rubella syndrome. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.:CD010586. DOI: 10.1002/14651858.CD010586.pub2. [ES] [FR]
Young M.K., Nimmo G.R., Cripps A.W., et al. Post-exposure passive immunisation for preventing measles. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010056. DOI: 10.1002/14651858.CD010056.pub2. [ES] [FR]
Zhang L., Prietsch S.O.M., Axelsson I., et al. Acellular vaccines for preventing whooping cough in children. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD001478. DOI: 10.1002/14651858.CD001478.pub6. [ES] [FR]
[toggle title_open=”Guidelines” title_closed=”Guidelines”]
The Canadian Guidelines (2011) below are by far the most comprehensive evidence based guidelines for migrants- the appendices on the article show all the reviews which are all open access on CMAJ and total 500 pages.
We are working hard to develop a shared foundation for evidence based migrant health and so it is important to recognize Australia, US, Ireland and UK; although it should be noted that the UK guidelines are the least evidence based.
With the new EU guidelines coming, this will provide an evidence based foundation for Europe and an update to the other guidelines.
Evidence-based clinical guidelines for immigrants and refugees (Canada – 2011) [ES] [FR]
Evidence-based preventative care checklist for new immigrants and refugees (Canadian Collaboration for Immigrant and Refugee Health) [ES] [FR]
Recommendations for comprehensive post-arrival health assessment for people from refugee like backgrounds (Australasian Society for Infectious Diseases 2016) [ES] [FR]
Guidelines for pre-departure and post-arrival medical screening and treatment of US-bound refugees (Centers for Disease Control and Prevention 2013) [ES] [FR]
Non-communicable health concerns: Migrant health guide (Public Health England 2017) [ES] [FR]
[toggle title_open=”Other information” title_closed=”Other information”]
Kevin Pottie’s blog on the Cochrane Canada website – Cochrane Canada focuses on Evidence-Based Migrant Health
PLOS Collection – Migration & Health
European Centre for Disease Prevention and Control (ECDC) – Migrant health
Cochrane – Migrant health flyer
Cochrane Methods Equity – Migrant Health Subgroup of the Campbell and Cochrane Equity Methods Group
Canadian Medical Association Journal – Refugee Health (collection)
Swinkels H., Pottie K., Tugwell P., et al,, for the Canadian Collaboration for Immigrant and Refugee Health (CCIRH), Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions, CMAJ September 6, 2011 183:E928-E932; published ahead of print June 14, 2010, doi:10.1503/cmaj.090290