The rate of immigration has increased over recent decades. While immigration can have many benefits for a host country, it can also pose challenges for the country’s healthcare system, including how to meet the needs of this heterogenous group. Immigrants may face a number of barriers to taking advantage of the full range of healthcare services available, including language or cultural barriers. The Norwegian Directorate of Health together with the Directorate of Integration and Diversity commissioned a systematic review to examine whether system-level healthcare interventions, specifically health equity tools, can improve health equity for immigrants.
We attempted to conduct an overview of systematic reviews on the effect of system-level healthcare interventions on health equity outcomes for immigrants according to the methods outlined in an approved protocol. The systematic search, however, resulted in no moderate or high quality reviews that met inclusion criteria. We thus revised the review question and conducted a systematic review of studies examining the effect of a specific system-level healthcare intervention, namely health equity tools, on health equity outcomes for immigrants.
We identified one small randomized controlled trial which examined the effect of a health equity tool (i.e. a computer-assisted psychosocial risk assessment tool) for refugees. The results showed that it is uncertain whether such a tool can improve integration of medical and social care (as measured by refugees’ intention to seek psychosocial support) (very low certainty evidence). Research is needed to develop an inventory of specific interventions, including the range of health equity tools, to improve health equity outcomes for immigrants in particular.
Immigration has many benefits for a host country, but can also pose new challenges. A rapid and large growth in the immigrant population may place pressure on the infrastructure, the environment, and the human capital within a healthcare system. Although the healthcare system may be well equipped and experienced enough to diagnose and treat diseases that are common among the native population, it may not necessarily be prepared to deal with the specific needs of particular immigrant groups. At last census count (2016), there were almost 700,000 immigrants living in Norway (approximately 13% of the population). Although Norway grants full equality of care and treatment to new arrivals after awarding them immigrant status, research indicates that immigrants use primary and specialty healthcare differently than ethnic Norwegians. The Norwegian Directorates of Health, and Integration and Diversity have recognized this as an area where more research is needed, specifically with respect to identifying which system-level healthcare interventions can improve health equity outcomes for immigrant populations.
We attempted to conduct an overview of systematic reviews on the effect of system-level healthcare interventions on health equity outcomes for immigrants according to the methods outlined in an approved protocol. The systematic search, however, resulted in no reviews that met inclusion criteria. We posited that the review question needed revision before proceeding and thus revisited the review question with the commissioners and, upon agreement, amended the review question to examine a specific system-level healthcare intervention, namely health equity tools, on health equity outcomes for immigrants. Health equity tools refer to any resource that aims to improve health equity and can include resources that assess the degree to which policies and programs promote health equity, or resources that promote the inclusion of health equity in programmes or policies.
To evaluate the effect of health equity tools for immigrants (also referred to as inventories, checklists, assessments), on health equity outcomes.
We conducted a systematic review in accordance with the handbook used by the division for health services in the Norwegian Institute of Public Health. In March 2017, an information specialist developed and conducted a literature search in 11 databases to identify relevant randomized, and non-randomized controlled studies, interrupted time series studies and controlled before-and-after studies as well as systematic reviews of high or moderate quality. Two reviewers independently screened identified references and read in full any publications that met predefined inclusion criteria. Two reviewers critically appraised the included study independently of each other. One reviewer extracted data related to study characteristics, population, intervention and outcome. Data extraction was checked by a second reviewer. We assessed the certainty of the evidence for the primary outcome using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).
We identified 16,765 unique references in our literature search to address the amended review question. We considered nine of these to be potentially relevant and read them in full. One randomized controlled trial met the inclusion criteria. This study assessed the effect of using a computer-assisted psychosocial risk-assessment (CaPRA) tool compared to usual services. The tool was developed with the objective of improving the integration of medical and social services for refugees, and the primary outcome, intention to visit psychosocial counsellor, was chosen as a proxy for measuring this objective given that previous research has indicated that intention is a good indicator of actual action. Secondary outcomes included patient acceptance of the intervention (intervention group only), and patient satisfaction. The study was conducted in a community health centre where 50 patients were randomized to receive either the intervention (n=26; CaPRA tool prior to consultation with service provider) or usual services (n=24; no risk assessment prior to consultation). The outcomes were measured in both groups immediately after the consultation using a paper-format exit-survey. The results showed that it is uncertain whether the CaPRA tool has an effect on integration of medical and social services, as measured by patients’ intention to visit a psychosocial counsellor (very low certainty).
As is evident from the results of this systematic review, there appears to be little research on the effect of health equity tools for improving health equity outcomes for immigrants. We identified one small study that evaluated the effect of a health equity tool for immigrants. The evidence from this study was assessed as being of too low quality to ascertain whether a computer-assisted psychosocial risk-assessment tool has an effect on integrating medical and social services (very low certainty).
We used a comprehensive and systematic approach to searching, screening and reviewing the records found. The search strategy was developed, peer reviewed, and implemented by experienced information specialists. We used a duplicate screening and consensus process, and finally we had no language restrictions.
There are, however, some limitations to this systematic review. As evidenced by the two phase progression, there were a number of challenges in conducting this systematic review. The original review question was very broad and difficult to operationalize in terms of developing a search strategy and inclusion criteria. Specifically, the challenges related to the search strategy were poor indexing in databases, and identifying the correct search terms that would ensure that all relevant studies were identified without being so broad as to come up with an unmanageable number of references to screen.
There is little rigorous evidence available on the effect of health equity tools to improve health equity outcomes for immigrants.
Given that we only identified one eligible randomized controlled study for inclusion in this review (despite two comprehensive literature searches), there is a need for more research on the effect of health equity tools for immigrants. Future research may begin by examining how health equity is defined and measured, and what is the best way by which to measure health equity. It would also be of interest to develop an inventory of system-level healthcare interventions that currently exist to improve health equity outcomes for immigrants.