‘ Leaving No One Behind ’ : The Challenge of Reaching Migrant Populations

The aim of this paper is to discuss the relevance of tailored interventions to ensure that vulnerable groups, such as migrants, are covered by public health programs. Most migrants do not have access to universal health care, including preventive and protective services. Tailored interventions can play an important role in helping to promote better migrant health through improved access to health care, increased awareness, better community-based structures and positive behaviour changes. The paper identifies some of the most effective strategies for the application of tailored public health interventions for migrants. In particular, migrants are especially vulnerable during a health emergency or disease outbreak and tailored approaches can be more effective than mainstream approaches. The paper advocates for the use of tailored interventions alongside the strengthening of universal health care to improve the health of migrants.


Introduction
Globally, many countries are experiencing an unprecedented flow of migrants.More than 65 million people are displaced worldwide and this rate is likely to accelerate.For example, the conflicts in North Africa and the Middle East continue to raise migration trends in Europe with an estimated 172,301 people in 2017 arriving via the Mediterranean, who are mostly of African and Middle Eastern nationalities [1].The internationally agreed definition for a migrant is used in this paper as "any person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (i) the person's legal status; (ii) whether the movement is voluntary or involuntary; (iii) what the causes for the movement are; or (iv) what the length of the stay is" [2].
Migrants may come from countries whose healthcare systems are weak and where poverty has impacted on the quality of services, such as screening and vaccination.Migrants should have equal access to health care, however,the high rates of morbidity and mortality reflects the reality in many countries.This situation can be made worse for migrants who face restricted legal rights, a poor understanding of the local language, different spiritual and cultural beliefs and a low income [3].Migrant women also face challenges with regards to maternal, newborn and child health and sexual and reproductive health.Children are prone to respiratory and gastro-intestinal illnesses and can be vulnerable to trauma and violence.Migrants are affected by vaccine-preventable diseases, such as measles, tuberculosis and hepatitis, and to waterborne infections.Many will become a core part of society and are susceptible to chronic cardio-vascular, cancers and diabetes as well as post-traumatic stress disorder, mood and anxiety with symptoms of sleeplessness and feelings of stress.This may be compounded by the World Health Organization advice not to have obligatory screening of migrants but instead to rely on health checks for diseases for identifying and treating migrant health problems after their arrival in the host country [4].Universal health care provides all people, including migrants, with the health services that they need, which must be of sufficient quality to be effective and ensures that they are not exposed to financial hardship [5].The provision of universal health care to migrants is dependent on the existence of an effective and equitable health system in the host country.However, in some countries, it will still take many years to achieve universal care and the health of migrants will continue to deteriorate unless tailored interventions can be used to address the inequalities in health.In this paper, a 'tailored' intervention is one that has been designed to reach a specific population group, such as migrants, by using a culturally sensitive approach and the most effective strategies and techniques available in the context in which the program is being delivered.A 'tailored' intervention can be a part of a broad multifaceted intervention or it can be a single, targeted intervention with a single purpose.
Disease outbreaks and health emergencies are closely connected.In this paper, an outbreak refers to an increase, which is often sudden, in the number of cases of a disease above the endemic (the usual prevalence of a disease within a geographic area) level in the population.A health emergency especially occurs when the consequences of a disease outbreak have the potential to overwhelm the capabilities of the health system to contain the problem [6].Over the past 20 years, the ease of the transmission of diseases between countries has become a major issue and the response in one country cannot be separated from another because the connections between people and organisations span geographic and cultural borders, which is sometimes exasperated by conflict that can help to spread a disease outbreak [7].A unique aspect of health emergencies is that the situation can change quickly and the speed at which the activities are delivered can be a deciding factor in preventing the transmission of a disease.The existing health system may not be responsive enough and tailored interventions can play a valuable role to reach vulnerable groups, such as migrants.
The aim of this paper is to show the importance of using tailored interventions, such as during health emergencies, to ensure that migrants are covered by public health interventions without having to rely on a deficient health care system.
Next, the experiences of using tailored interventions in public health programs and in health emergencies are discussed to demonstrate the relevance of using tailored interventions.

Using Tailored Public Health Interventions with Migrants
Migration can have a direct effect on people's physical and mental health and it is essential to get the "basics right" in public health programs to ensure that they can deliver interventions which have the greatest impact.Tailoring interventions to the needs of migrants involves a cultural competence that has not yet emerged as an important area of professional training.Migrants do have specific cultural health concerns and the use of tailored interventions can be a more effective option than using mainstream approaches alone [8].
A review of what works to eliminate female genital mutilation, for example, identified that a combination of tailored interventions, including training change agents, community-led approaches and public statements and legal measures [9], were most effective.Tailored communication interventions have also been successful in improving the uptake of immunization programs among migrants, such as using door to-door communication, mass, media campaigns and peer education [10].Hospital discharge data has been used in Italy to help the health authorities to develop tailored interventions to meet migrant needs, such as outreach services and confidential health services [11].The concerns about HIV infection in migrant groups have been addressed using tailored counselling services, which were operated in the presence of peer mediators answering in the languages of the migrants that subsequently led to an uptake in the number of calls [12].Mediators can play an important role and in Belgium, school mediators visit migrant families when teachers feel that stricter supervision of parents is necessary or when a child is missing classes or under-performing.Their aim is to clarify the problem and involve parents in its solution.They help parents to understand their rights, responsibilities and obligations towards their own child's school success.The approach is tailored to address problems with languages and to find ways to motivate parents to develop an interest in their children's education [13].
Integration into the community is another important approach and in Norway, the participation of migrants in cultural activities and traditional events was associated with better health and lower levels of anxiety and depression [14].In Berlin, the Stadtteilmütter (Neighbourhood Mothers) project used migrant mothers in the community as mentors to help to build the trust needed to help others to change.Tailoring a peer education strategy to allow mothers to meet informally to talk about their needs, especially with regards to their children and families, seems to have been a pivotal approach.The use of small groups to discuss personal challenges with regards to health was also an important strategy to help to empower migrant women [15].In Amsterdam, the sexual health of migrants was approached using community-based organisations (CBOs) and a grant scheme to implement sexually transmitted infections/HIV projects within their own communities.CBOs can act as an intermediary between the government services and the needs of migrant communities and can provide tailored interventions, including the cultural awareness training of health professionals, to improve the effectiveness of a program [16].
Tailored interventions that demonstrate the potential to have an impact in improving the health of migrant populations are provided in Table 1.There is evidence for the use of established approaches that can be easily adapted, such as peer education to promote the use of condoms, group work for smoking cessation and directly observed treatment (DOTs) for tuberculosis [17], screening and triage.Tailored interventions that have directly had an impact on migrant health include the use of printed materials, video and social media apps in appropriate languages, which were reinforced through inter-personal communication [18], strengthening community-organisations and culturally sensitive immunization programs.

Tailored Public Health Interventions Demonstrating the Potential for Success With Migrant Populations
Peer education, mentoring and mediation.

Community-based interventions on sexual health.
Screening and triage services.

Vaccination programs.
Awareness raising using print materials, videos and social media apps.
Self-help groups for smoking cessation.
DOTs for adherence to the treatment of tuberculosis.

Tailoring Interventions for Migrants in Health Emergencies
Migrants present an especially vulnerable group during a health emergency because they can be difficult to reach using mainstream approaches and are often disproportionately affected by a disease outbreak.In a health emergency, tailored interventions can be a quick and effective way to raise awareness, to promote positive behaviour change and to help people to empower themselves.The application of using tailored interventions in this context have included the response to an outbreak of cholera among Burundian refugees in Tanzania.The high number of people living in a temporary camp with limited access to drinking water and inadequate sanitation led to the cholera outbreak.It became essential for health workers to quickly identify and track cases in real time by using "RapidPro" technology on mobile phones to notify authorities of new cases and to report on the progress of each hospitalized case.The mobile phone technology assisted in raising awareness and geo-locating specific cholera cases and with the provision of safe drinking water and vaccination helped to contain the spread of the disease [19].Short Message Service (SMS)-based platforms have been used with some success during disease outbreaks to increase awareness about polio in a crisis context in Somalia.Mobile phones were widely used and on average, 10 people shared the benefit of information delivered to one phone even with refugees in remote and rural areas.One interactive SMS campaign on polio prevention was conducted over a six-month period, which included information on hand washing, how to keep water safe from contamination and vaccination.The use of mobile phones was an important aspect of the approach, especially in areas that were inaccessible, and because the infrastructure and technology already existed, this reduced start-up costs [20].
Community radio stations have been used to provide a variety of edutainment activities that were broadcast as part of an initiative to eradicate polio in Chad, including with migrants.In Chad, radio remains one of the main channels of communication that can reach people with immunisation messaging.During the national campaign, 23% of parents were informed about vaccination through the community radio.Almost 40 radio stations disseminated awareness messages and produced edutainment activities in local communities.This was supported by a network of social mobilisers, public announcers and community volunteers.Training workshops were also periodically held to provide better skills in the design and production of public radio programs, to directly engage communities and to educate them on the importance of vaccination [21].Communities have worked with response agencies to empower themselves by gaining more responsibility for and control over local situations, including community led-quarantines.Raising the awareness of communities about the benefits of quarantines and the role that they can play in stopping an outbreak was proven to be an important factor in helping to minimize quarantine violations during the Ebola Virus Disease outbreak in West Africa.Community-led quarantines are not problematic if the timely and reliable delivery of resources, such as food, water, money and information, are received by the person or household being detained.For example, during the Ebola Virus Disease outbreak, quarantines were most effective at the community level in Liberia when coordinated by local people and religious leaders.This was crucial for minimising violations as well as for the tracing of contacts and of new cases in coordination with services to remove bodies safely and to train contact tracers [22].

Conclusions
Ideally, all migrants will have equal access to universal health care, including preventive and protective services.However, in some countries, it will take many years to achieve universal care and in the meantime, we know that the health of migrants will deteriorate upon arrival in a host country.Tailored public health interventions can play an important role to help in promoting better migrant health through improved access to health care, increased awareness, greater community-based action and positive behaviour changes.This paper has identified effective strategies for the application of tailored public health interventions for migrants.In particular, migrants are especially vulnerable during a health emergency and tailored approaches can be more effective than mainstream approaches especially for a population that is often disproportionately affected by a disease outbreak.This paper places great importance on using tailored interventions for migrants alongside the ongoing strengthening of universal health care.

Table 1 .
Tailored interventions for migrant populations.