Abstract
Migration is a longstanding, growing global phenomenon. As a social determinant of health, migration can lead to health inequities between people on the move and host populations. Thus, it is imperative that there is a coordinated effort to advance migration‐ and health‐related goals. WHO has a specific remit to support evidence‐based decision‐making in its Member States. As part of that remit, WHO Europe presents this Framework for Refugee and Migrant Health Research in the WHO European Region. It is designed as a starting point for debating and analysing a broad range of options and approaches to help inform a WHO global research agenda on health and migration. This is important because refugee and migrant health research is a complex interdisciplinary field that is expanding in a fast‐changing socio‐political environment. The Framework is intended for all stakeholders involved: academic, civil society organisations, refugees, migrants, policy‐makers, healthcare providers, educators and funders. It is developed by academics in consultation with these stakeholder groups. It reflects on three specific interrelated dynamics in research practice. These are (i) research prioritisation; (ii) study samples and (iii) research design. The Framework offers recommendations to consider for each one of these. It elucidates the value of involving refugees and migrants in research and research agendas and the need to develop an ecosystem that will support and sustain participatory, interdisciplinary, transdisciplinary and inter‐sectoral projects.
Keywords: health equity, migrant research, participatory research, refugee
INTRODUCTION
Migration is a longstanding global phenomenon. While there is no universally accepted definition of ‘migrant’, because it varies from context to context, one of the most widely used definitions is provided by the International Organisation for Migration, that is, ‘a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently and for a variety of reasons’ [1]. ‘Refugee’ is clearly defined by the United Nations High Commissioner for Refugees as ‘persons outside their countries of origin who are in need of international protection because of feared persecution, or a serious threat to their life, physical integrity or freedom in their country of origin as a result of persecution, armed conflict, violence or serious public disorder’ [2].
People move for a variety of reasons and, from an intersectionality perspective, have a diversity of socio‐cultural experiences and identities apart from being a ‘refugee’ or ‘migrant’. Thus, it is necessary to acknowledge the heterogeneity of these populations and to pay attention to their resilience and contributions to host societies. For public health and health equity goals, it is also necessary to be attentive to the ways in which forced and voluntary migration, as social determinants of health, can create specific challenges and vulnerabilities for some refugees and migrants, leading to health inequities [3, 4].
Providing evidence‐based recommendations to promote health equity is a fundamental goal of WHO. In 2019, over 96 million refugees and migrants were estimated to be in the WHO European Region, corresponding to about 35% of the world's population of refugees and migrants and about 10% of the total population of the region [5]. The Migration and Health Programme at the WHO Regional Office for Europe was established in 2011 to facilitate cross‐country policy dialogue and encourage homogeneous health interventions along the migration routes to promote the health of refugees and migrants and to protect public health in the host community. The Programme published a Strategy and Action Plan in 2016, commissioned a series of Health Evidence Network reports and published the first‐ever report of refugee and migrant health in the Region in 2018 [6, 7, 8]. The report found that while there is a mortality advantage for refugees and migrants for the majority of the International Classification of Diseases (ICD‐10), when compared with the host population, they face several barriers in accessing and utilising healthcare services, resulting in poorer health outcomes. The Programme has also established an academic network of WHO Collaborating Centres (CCs) for refugee and migrant health, which has a remit to support the generation of evidence‐based recommendations.
In Europe, research on refugee and migrant health is largely based on only a subset of countries, it often lacks diverse methodology, and projects have been short‐term because of lack of sustainable funding [9]. There are a number of important recent initiatives to provide leadership and coordination of efforts in the field. As part of that, and in line with its remit to support evidence‐based decision‐making for its Member States, WHO Europe presents this Framework for Refugee and Migrant Health Research in the WHO European Region. The rationale for the Framework arose during a WHO CC network meeting (September 2019) where the distinction was made between the need in the region for a research agenda from WHO with priority topics for research and higher‐level principles to shape research practice. The former was progressed internally through the Migration and Health programme, and the latter was progressed through the WHO CC network. The first step for the CC network was to identify key issues that need consideration to support the implementation of the planned research agenda. The process is described in Appendix A. As a summary, the first author distilled the deliberations from the 2019 WHO CC meeting into three dynamics in the field; the first, second, third and last authors identified relevant regional and global evidence around each of these [8, 10, 11, 12]; all co‐authors (academics and policy actors) critiqued the content and supported a consultation with NGOs and health professional stakeholders; the wider network of academics in the WHO CCs received updates on the process and invitations to contribute to drafts.
The outcome is this Framework, which provides a starting point for debating and analysing a broad range of options and approaches to inform research about about refugee and migrant health. It is relevant to all stakeholders involved in the field: academic, civil society organisations, refugees, migrants, policy makers, healthcare providers, educators and funders. As the Framework is written as per the mandate from the WHO European Region and a consortium of WHO CCs in the region, its focus is on the WHO European Region. However, migration is a global phenomenon and, while there are regional differences, many of the issues covered are not unique to the region. Thus the Framework has the potential to be used in other contexts and will help inform a WHO Global Research Agenda.
The Framework describes three interrelated dynamics in the field that shape research practice: (i) research prioritisation; (ii) study samples and (iii) research design. The Framework provides recommendations to consider how to navigate these dynamics in an ethical and sustainable way to build a comprehensive and robust evidence base to inform policy and practice (Table 1).
TABLE 1.
A framework for refugee and migrant health research in the WHO European region: Summary
| Dynamics | Recommendations for consideration |
|---|---|
| What is researched? |
|
| Who is research focused on? |
|
| How is research designed? |
|
RESEARCH PRIORITISATION
This is about what is researched—how are priorities for research set? Several influential top‐down international and national policies stimulate projects to advance migration and health goals [13]. Priority topics will, however, often change as policies are updated or replaced, for example, the 2016 Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region is time‐limited [6]. Further, Member States will have specific and changing interests due to their geographical and socio‐political contexts, for example, ‘hotspot’ countries; countries with longer/shorter experience of immigration and/or emigration; changes in government and immigration policies. Also, unpredicted events such as the COVID‐19 pandemic and the war in Ukraine occur and require immediate attention. Thus, perhaps a research agenda with priority topics is not possible or meaningful? Yet available evidence can be synthesised to identify research gaps and/or service delivery needs. This can form the basis of a research agenda and can galvanise activities toward a common goal in the region within a particular time period.
Topics specified in funding calls from, for example, the European Union can act as top‐down drivers that significantly shape the resources available for research in the WHO European Region. Many countries of origin of migrants are low‐ and low–middle‐income countries where research funding is scarce [10], so there is scope for more research to be undertaken in those countries. Current funding streams for refugee and migrant health research are often focused on comparing refugees and migrants with host populations in individual host countries and there is a need for funding bodies to resource longitudinal, multicountry studies and across migration routes to better understand the role of context and migration [14].
Although there can be specific challenges sourcing funding for locally identified needs, there is a proliferation of research activity driven by academics and health sector personnel. Civil society organisations, in addition to their other critical roles of delivering healthcare and collecting data on these populations, are also engaged in research. This can reflect more bottom‐up style priority setting, which is influenced by a range of factors such as gaps in published literature, local/national experiences of providing statutory and non‐statutory services and advocacy initiatives, or evidence requirements for obtaining and maintaining funding for services.
The combined effect is that a vast, diverse and expanding range of topics is being researched, which often does not meet the need for evidence for comprehensive policy making. There may or may not be clear and comprehensive connections between top‐down policy goals and ‘bottom‐up’ research activity. There can be disproportionate attention to some topics, such as communicable diseases, as well as gaps in knowledge about the health of certain groups, for example, migrant workers, and about specific topics, for example, preventing non‐communicable diseases [9, 10, 15, 16]. Even for domains with a high volume of research, for example, mental health, there is more focus on some disorders such as post‐traumatic stress and gaps for common disorders such as depression and anxiety [17]. The opportunities for researchers to explicate and leverage synergy with policy goals may be missed and the policy goals themselves may not comprehensively reflect evidence or local needs in the region.
Interestingly, despite the rising imperative for public involvement in health research in many international jurisdictions, refugees and migrants are rarely involved in top‐down or bottom‐up decision‐making about health research priorities [12, 18]. This means that the lived experience of being a refugee or migrant in a specific context in the region or for a specific health issue is usually not incorporated into decisions regarding the research agenda. Further, where strong evidence is available about how to improve refugee and migrant health, implementation studies should be prioritised. This would reduce research duplication, support research–policy–practice translation and address research fatigue among refugees and migrants, who need to see concrete changes arising from research [3].
Recommendations to consider
Refer to both top‐down and bottom‐up imperatives for research, encouraging alignment between the two.
Involve refugees and migrants in research prioritisation.
Conduct implementation research to avoid research duplication and to support research–policy–practice translation.
STUDY SAMPLES
This is about who research is focused on. The lack of a universally accepted definition of migrant at the international level poses significant public health challenges. In the research literature, definitions of the specific migrant population of interest are often not provided. Where definitions are provided, several of them are in use, which can refer to a wide range of variables including country of origin, length of stay, legal status, citizenship, residency, reason for migration, first language, parental country of birth and ethnicity [19]. Many studies use project‐specific definitions. It is important for researchers to provide a clear definition of the population for their study. Further, more harmonised or standardised definitions are crucial to ensure comparability of data across studies and build a high‐quality evidence base [19].
The wide range of definitions used reflects the heterogeneity of migration. People who migrate from the same country of origin can differ by language, ethnicity and reason for migration. In the technical guidance for the WHO European Region on the collection and integration of data on refugee and migrant health, a set of core variables for data collection was identified: this included country of birth, country of citizenship, year and month of arrival and country of birth of both parents [5]. A set of expanded variables was recommended that included reasons for migration, knowledge of the official language(s) of the host country, whether refugees and migrants have ever resided abroad and legal status [5]. The importance of an intersectionality approach in research has also been highlighted, reflecting the relationships and interaction between diverse factors and social structures such as gender, country of birth and ethnicity, as well as social position and conditions at different stages of the migration journey and settlement [20].
There are shared and differential needs and experiences within refugee and migrant populations. Some research takes a primary focus on health issues that matter only for specific populations (e.g., trafficking) while other research takes a primary focus on cross‐cutting issues (e.g., language and cultural barriers) [21, 22]. Of course, there can be intersections between these types of studies too, so categorising them as one or the other becomes difficult. There are shared and differential needs and experiences between refugees and migrants and host country populations, for example, non‐communicable diseases, multimorbidity, disability and ageing. General population studies that include refugees and migrants in samples can provide important comparative data to identify health inequities [23].
There are two implications here. First, it is important that there is a clear rationale for who is included in a sample for a specific health topic. Second, there is a need to encourage inclusive samples to generate a comprehensive evidence base and avoid the pitfalls of structural biases in research, such as the recently acknowledged structural gender bias in cardiovascular research [24]. Adequately capturing refugees and migrants in population health surveys can be challenging without considering the representativeness of the sampling frame used, particularly for transient groups in shared and temporary accommodation. The need to translate study materials into multiple languages and over‐sample to generate sufficient sample sizes for multivariable analysis has also been recognised [25]. The value of community‐oriented sampling strategies in epidemiological studies has been highlighted [26]. These strategies led to better acceptance and a more heterogeneous group of migrants recruited but were resource‐intensive. Thus specific funding for these resources may be required in general population studies to ensure that refugees and migrants are included.
Finally, the field of refugee and migrant health also requires research with, and about, other stakeholders who shape the health of this population. This includes research with health care providers and educators (including the experiences of refugees and migrants who are healthcare providers or educators), policy makers and NGOs. Research that brings refugees and migrants and other diverse stakeholders together is important so that different perspectives on problems and solutions can be examined. This facilitates learning and action‐oriented outcomes, for example to inform adaptation of health services [22, 27].
Recommendations to consider
Be cognizant of the heterogeneity of refugee and migrant populations and samples that can inform the field.
Provide a clear definition of the study population, setting and migratory phase in each study.
Support national and international initiatives toward the development of standardised definitions of and data collection for, refugee and migrant health.
Articulate a clear rationale for the selected population and health issues.
Advocate for inclusive samples in general population studies so that refugees and migrants are represented.
Involve refugees and migrants in collaborative, inter‐sectoral, action‐oriented research projects.
RESEARCH DESIGN
This issue is about how research is designed. It is important to exploit existing evidence where possible. Policy makers and researchers can benefit from synthesis of high‐quality evaluation studies across settings to show what works and to provide them with evidence‐based policy actions [28]. Systematic reviews of literature by selected migrant categories, by health focus and by geographical region are also needed [10]. Reviews need to be regular to monitor trends and developments and need to be translated effectively into policy and practice recommendations. The grey literature may be particularly relevant in refugee and migrant health, and conventional searches of the literature may need to be combined with additional strategies to identify all relevant research [29].
It is also important to maximise the use of existing, routinely collected data. Guidance on the collection and integration of data on refugee and migrant health in the WHO European Region concluded that integration of migration health data within national health information systems is the logical and more sustainable approach to support availability and utilisation of health data for refugees and migrants along with those for the host population [5]. The guidance recommends that the focus should be on collecting core variables (see Section 2) because variables that describe migratory status are often not collected or are incomplete, limiting opportunities for data linkage and sharing.
Where there is a need for primary data collection, all study types are required for accumulating a comprehensive evidence base. Refugee and migrant health research, however, can be characterised by observational research and local, regional and national projects, with fewer examples of large, international comparative studies or mixed methods research [30, 31]. These designs are important, for example, to better capture the intersectionality of the migration experience and the often dynamic migration journey. Economic evaluations are also rare, as are studies with comparative data from across the region. Silos of research exist, and the importance of transdisciplinary and interdisciplinary research has been highlighted [9, 32].
Studies with primary data collection in the field of refugee and migrant health could make more use of theory to support the accumulation of a robust evidence base across countries [22, 33, 34]. The use of theory could, for example, enhance conceptualization of migrant health itself [33]; support interpretation of confounders and biases in cross‐sectional studies to understand migrant health status [35];and inform intervention design, implementation and evaluation [34].
Finally, all research in the field of refugee and migrant health can benefit from greater use of a Participatory Research approach. This is defined as the co‐construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study [27]—see Nguyen et al. [36] for a rich description of the heritage and terminologies in this field. In participatory health research, ‘participation is the defining principle throughout the research process’, [37] moving research from ‘research on’ to ‘research with’.
Participatory approaches can be employed for all study types and methods—qualitative, quantitative, mixed methods, trials and literature reviews [27] and to support development and implementation of interventions [22, 38]. It can help combat research fatigue because of the importance it places on involving refugees and migrants in the identification of research priorities (Section 1) and the value of inter‐stakeholder, action‐oriented research (Section 2). As a process, participatory research challenges the deficit model of migration that can dominate racialized political and public discourse and emphasises the resilience and resourcefulness of local communities [3, 39]. Participatory approaches offer inherently culturally sensitive methods and tools that support the cultural preparedness of research for a given community [3], such as Participatory Learning and Action research [22] and arts‐based methods [40].
Participatory health research emphasises the importance of feedback loops and community ownership of research so that research outcomes are clear and transparent for all involved [39]. This can support implementation and uptake of research findings by community and policy actors [22, 39]. Further, participatory approaches are valuable for considering ethical obligations to use research findings in a way that mitigates risk of further stigmatising migrant populations. This is important given the ways in which myths about refugees and migrants can dominate public and political discourse [41].
There are examples of good participatory research practice but, overall, this is not a normalised way of researching in the field [12, 18]. Often, meaningful partnerships for participatory research with migrants are impeded by lack of sustainable funding [9, 10, 12]. Thus inter‐sectoral action is needed so that appropriate funding streams are incorporated into the research ecosystem to support meaningful partnered research beyond the lifetime of individual projects.
Recommendations to consider
Maximise the use of existing data from research and routinely collected data in health information systems.
Conduct interdisciplinary and transdisciplinary primary research using a diverse range of research methods, including mixed methods.
Increase the use of theory in primary research about refugee and migrant health.
Increase the use of participatory health research in refugee and migrant health.
Work across sectors to lobby for longer‐term funding programmes to promote and sustain participatory research projects.
CONCLUSION
Migration is an important public health issue and this Framework for Refugee and Migrant Health in the WHO European Region can be used to stimulate debate and support analysis of three particular dynamics that need attention to strengthen research practice in the field. This is not an exhaustive description of dynamics as it was developed based on the collective expertise of a specific, inter‐sectoral network and has a primary focus on this one region. At the same time, this Framework provides a starting point for generating much‐needed higher level guidance for refugee and migrant health research. It can complement other international, co‐ordinated initiatives and the research work and formation of the global research agenda of the WHO global programme for health and migration, established in 2020.
The common thread throughout the three components of the Framework is that refugees and migrants need to be meaningfully involved in research about their health. This means that their lived experience and expertise are brought to bear on decisions about what is researched, who is in the sample and how the research is designed and conducted. Such participatory research can support the translation of evidence into policy and practice. Participatory research is not, however, a panacea and has its own challenges and barriers to good practice [3]. Further, the research ecosystem needs to be such that participatory research is the norm, so that refugees and migrants are working in partnership with other stakeholders in a sustained way [9].
A commitment to participatory research would signify a transformative moment in the field. Taking this journey together would be an ethical way forward that would have positive public health impacts. It would promote equity and efficiency in research and support co‐design and implementation of interventions to optimise refugee and migrant health [22, 34]. This will help create a more comprehensive evidence base to overcome the challenges of the research–policy nexus in the WHO European Region and promote health equity among refugees and migrants.
ACKNOWLEDGEMENTS
We thank the Editor, peer reviewers and Dr. Miriam Orcutt for comments on a previous draft.
APPENDIX A.
Steps involved in developing the framework for refugee and migrant health research in the WHO European Region
The WHO has over 800 WHO Collaborating Centres (CCs) in more than 80 Member States. These institutions are designated by the WHO Director‐General to assist the organisation's programmes through carrying out activities in countries. The designated institutions are part of an international collaborative network that supports technical programmes through strengthening country resources, providing trusted and timely information, providing services and conducting or reviewing research and trainings.
The process for developing the WHO Research Framework was initiated during the 1st annual Collaborating Centre (CC) meeting for institutions working on migration and health issues, held in 2019, hosted by the Migration and Health (MIG) programme at the WHO Regional Office for Europe. This meeting convened five established WCCs and five key partner institutions. The first author, along with the last author, undertook the task of developing the initial draft for a research framework. During the second CC meeting held during early 2020, the initial structure for a proposed research framework was presented. The MIG programme, CCs and key academic institutions that attended the meeting provided feedback on the structure. During the next CC meeting, held during autumn 2020, the first draft of the research framework document was presented and feedback was sought from the WCCs, key academic institutions and the MIG programme. Based on the interest expressed, a working group of authors consisting of WCCs and key partners from Ireland, Italy, Sweden, Turkey and the MIG programme was created. The working group held several meetings to discuss and take the work forward.
In line with WHO policies for participatory approaches and community involvement [42], the working group considered it important to receive feedback on the research framework from refugees and migrants, and other stakeholders such as healthcare providers and policy‐makers working closely with refugees and migrants. The first, second and last authors designed a consultation process and prepared guidance for the authors to complete consultations in their own countries. The guidance included suggestions on how to organise the workshops and questions that are of interest to discuss during the workshops to ensure procedural similarity for consultations across the countries. This guidance was finalised by all members of the working group.
In line with good practice for participation in healthcare [43], the authors' priority was to invite stakeholders with whom they had established relationships. This meant that the consultation was embedded in existing longstanding partnerships rather than being a ‘one‐off’ encounter. Table A1 shows a breakdown of the stakeholder groups involved in the consultation in each country. Stakeholders in the consultations included refugees and migrants belonging to groups such as unaccompanied minors, asylum seekers, labour migrants and international students, healthcare professionals and civil society organisations working with refugees and migrants, and representatives of government ministries.
TABLE A1.
Summary of stakeholders in the consultation process by country setting
| Setting | Migration context | Stakeholders |
|---|---|---|
| Ireland | Predominantly a ‘new’ destination country to economic migrants, refugees and asylum seekers | Refugees and asylum seekers, 1st‐generation migrants, economic migrants, undocumented migrants, representatives from civil society organisations |
| Sweden | Predominantly a destination country to economic migrants, refugees and asylum seekers and students | Economic migrants, students, ‘settled’ (relatively long‐term) migrants, healthcare providers including cultural mediators |
| Turkey | A destination and transit country | Refugees and asylum seekers, migrants, healthcare providers, representatives from civil society organisations |
| Italy | A destination and transit country | Policy‐makers, academics, healthcare providers, including medical anthropologists and cultural mediators, field experts |
A summary of the research framework was presented and discussed by these stakeholders. They were also asked how far the proposed research framework ‘made sense’ to them and whether there was anything missing from the proposed content based on their views and experiences of refugee and migrant health research. Authors from the respective countries summarised the feedback received and edited the draft research framework document accordingly. The first and last authors reviewed the feedback from each country and prepared a revised draft for sign‐off by all authors. This was shared with the remaining members of the CC network and the MIG programme.
MacFarlane A, Puthoopparambil SJ, Waagensen E, Sisti LG, Costanzo G, Kayi I, et al. Framework for refugee and migrant health research in the WHO European Region. Trop Med Int Health. 2023;28(2):90–97. 10.1111/tmi.13845
Sustainable Development Goals: Good Health and Well‐being, Reduced Inequalities, Partnerships for the Goals
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