WONCA SIG on Migrant Care, International Health & Travel Medicine meet in Vienna.

The WONCA SIG on Migrant Care, International Health and Travel Medicine held several events recently at the WONCA Europe Vienna conference. In keeping with the conference theme a symposium was held on the Art and Science of Migrant Care and International Health and a workshop was held on Migrant Care : Ramadan and health. The organisers were: Marius Besson (Switzerland), Guus Busser (the Netherlands), Pinar Döner (Turkey), Daniel Gelzer (Switzerland), Prof Christos Lionis (Greece) Eldine Oosterberg (The Netherlands) , Wolfgang Spiegel (Austria) Maria van den Muijsenbergh (The Netherlands)

Symposium: Art and Science of Migrant Care and International Health

The Symposium was attended by approximately seventy participants. There were five oral presentations.

Migrant care, international health and travel medicine – an introduction

Presented by Maria van den Muijsenbergh (The Netherlands)
Brief overview of migration patterns and different groups of migrants, influence of migration on health and access to healthcare, the relation between poverty and health, and barriers and levers to deliver good primary care with limited means in Europe and in Africa, hereby introducing the rest of the program of the afternoon and clarifying the role of the SIG.

Searching for a model primary care system for Sub-Saharan Africa

Presented by Wolfgang Spiegel, (Austria) and Gurdeep Parhar (Canada)

Introduction: In its constitution the Republic of South Sudan (RSS), which has been established as a new country on July 9, 2011, stipulates that ".. All levels of government shall promote public health, establish, rehabilitate and develop basic medical and diagnostic institutions and provide free primary health care and emergency services for all citizens.". After the long-lasting, terrible civil war quite a few of the Primary Health Care (PHC)-Centres are out of function or understaffed. But if they function there is where the necessary professional care needs to be delivered when hospitals are not in reach. Austrian Doctors for Disabled explores the PHC delivery process in RSS and their interfaces to secondary care to make suggestions for upgrading them.

Methods: Based on the results of a successful fact-finding mission to South Sudan in December 2011 the researchers, in a first step, we will observe the kind and frequencies of medical problems (incidence, prevalence) and the clinical tasks which Clinical Officers (non-physician health workers) and other staff have to perform. Based on these structured observations we will hold focus groups with stakeholders of PHC using Participatory Learning and Action (PLA) which will aim at elaborating current shortcomings in service delivery and possible solutions to advance the system. In a second step, the results of the structured (in-depth) observations and the results of the focus groups with stakeholders will be discussed with health-policy makers (government) and secondary care providers (hospital-based doctors) so that a consensus can be reached to make a informed suggestion for an upgraded PHC model region. Austrian Doctors for Disabled will then apply for an international grant (together with the Medical University of Vienna) to equip and staff a pilot PHC-Centre in one region of a South Sudan. Service delivery, training of staff, and equipment of the facility will be done in accordance with the results of stage one and two of the pilot project.

Results: First results are expected to be presentable by July 2012.

Ecology of Care – health seeking behaviour of migrants in Austria

Presented by Otto Pichlhöfer, (Austria). Data were presented on the use of primary care of migrants in Austria.

Mental health problems of undocumented migrants in the Netherlands presented by Erik Teunissen, (The Netherlands)

In the Netherlands an estimated 150,000 migrants do not have a regular staying permit (van der Heyden 2005). Although most of them are living within hardship conditions, and report many mental health problems such as anxiety and depression (Schoevers 2009, Yosofi 2009), previous small-scale primary care research showed a rather low prevalence of these mental health problems, as registered by general practitioners in their medical files (Wolswinkel 2009).

It is unclear why these registered prevalence rates are low. Is this the result of a methodological flaw of this small-scale study? Do undocumented migrants report their mental problems when they contact their GP? Are there language and cultural barriers between GPs and migrants that lead to under-recognition of mental health problems? Or do GPs don’t register mental health problems due to other reasons?

By applying quantitative and qualitative research methods we will try to clarify the following research questions:

1. What is the registered prevalence of mental problems of undocumented migrants in general practice files, compared to the registered prevalence of mental problems of a matched control group of patients within the same practices? 
2. How do GPs diagnose and register mental problems of undocumented migrants and what barriers or obstacles do they encounter in their mental health care for these patients? 

We will present the results of an analysis of anonymised data of medical files of undocumented migrants and a matched control group gathered in general practices with at least 15 undocumented migrants on their practice list. We will also present results of semi-structured in depth interviews with these doctors.

The effect of the financial crisis on migrant care and internal migration in Greece: the role of General Practice

By Joanna Tsiligianni, on behalf of Prof Christos Lionis (Greece)

In Greece between 2007 and 2010 the debt grew from 105.4% to 142.8% of gross domestic product (GDP; €239•4 billion to €328•6 billion) (Eurostat 2011) resulting in massive cuts to the health care system. This crisis has affected the daily life of the citizens of Greece in resulting in a 40% increase in the annual suicide rate (Anon 2011). The impact on low growth and current global economic crisis on migration and on health care services is still in questioning. In general, the employment situation of migrant workers, especially of national non- EU countries have deteriorated more rapidly than that of natives during the economic crisis, as the International Organization for Migration (IOM) reported (Koehler et al 2010). The impact of this on welfare and health care of immigrants in Greece is expected more since an integrated primary care system is not established yet (Lionis et al 2009). Thus, the role of general practice and primary care has not received the proper attention. It invites the policy-makers to take part in measures and actions relevant to migrant worker mobility that should be fostered (Koehler et al 2010), and focus on health and welfare issues.

Workshop: "Migrant Care" : Ramadan and Health

The workshop was attended by 53 participants from Austria, Belgium, Canada, Denmark, Estonia, Finland , Greece, Ireland, the Netherlands, Spain, Switzerland, South America, Turkey and the UK. The aim of the workshop was to provide participants with knowledge and skills to deliver good care to migrants, in particular to Muslim migrants during Ramadan (that starts this year around July 20th) We focussed on the care for migrants with chronic disease and medication during Ramadan. 

First scientific information on guidelines and research was provided in an oral presentation by Mrs Eldine Oosterberg of the Dutch college of General Practitioners. Research among Muslim migrants in the UK and the Netherlands revealed that most migrants with chronic disease (such as diabetes) and medication do participate in the fasting, despite the fact that they can be exempted from this. Many of them changed their medication schedule, often without consulting their doctor. 

There is evidence among migrants in the UK that children whose mother was pregnant during Ramadan have slightly less favourable school results. This finding was disputed by the Turkish participants, who declared that, if this would be true, the whole population of Turkey would be less intelligent than they apparently are. This brought us to the very interesting discussion about differences between countries in which the majority of society (and also the doctors) participate in the fasting such as Turkey, and countries in which Muslims are a minority group and doctors don’t know the fasting out of own experience. It seems that in the latter the positive effects of participating in Ramadan are less prominent and dominated by the negative effects of patients not telling their doctors, or not accepting the advices of non-Muslim doctors about the fasting. 

This was illustrated in the interaction between Guus Busser (the Netherlands) and Pinar Döner (Turkey) who presented their view on a case of a woman with diabetes who needed antibiotic treatment but wanted to fast. The Dutch doctor had a problem as he did not know how to convince his patient to take the medication (and thus stop the fasting) where as the Turkish colleague had the experience her patients would follow her advice about medication and fasting.

After this we discussed in small groups our experiences with fasting patients during Ramadan and the advices we give these patients. Especially interesting in this discussion again was the contribution of the Turkish colleagues who not only had a huge experience with fasting patients, but also knew themselves the effects of fasting during Ramadan.

The most interesting results of this discussion were:

• Pregnant women don’t have to fast, but can try.
• Kids practice fasting by joining partly.
• In countries such as Finland were the sun in July never sets, Muslims may follow the time of sunset and rise of Mecca.
• Ramadan is a well-being of the soul, a motivation for change to a healthier lifestyle.
• Very often diabetes is not regulated properly, compliance is always a problem, not just only during Ramadan. Is it necessary to bother?
• Patients are not aware they could be exempted for Ramadan, as a doctor you can involve the Imam, or give information in a mosque together with the Imam.
• Patients will appreciate if you share with them that you know something about Ramadan.
• Communication and the relation with the patient is, as always, central in dealing with patients during Ramadan.
• In contrast to what research suggests, most Turkish doctors don’t experience many problems during Ramadan; there could be an interesting difference between patients and doctors in Turkey, where Ramadan is a celebrated by nearly all society, and patients and doctors in other countries where Ramadan is not so common, and not joined by doctors.
• An international study to the effects of Ramadan on health in which participate countries with a Muslim majority and other countries would be very interesting.

The exchange of information and experience with colleagues with different religious views, living in different societies was seen as extremely fruitful, leading to the proposal to have again such a workshop next WONCA (in Prague) and to choose Spiritual Health as subject of this workshop. As a result of the workshop, colleagues from Turkey immediately after the conference have taken the initiative to start such an international study.

Dr Maria van den Muijsenbergh, convenor

[email protected]