Proefschrift A Safe and Healthy Future - Simone Goosen

A safe and healthy future?
Epidemiological studies on the health of asylum

seekers and refugees in the Netherlands
Simone Goosen

Simone Goosen

Epidemiological studies on the health of asylum seekers and refugees in the Netherlands
The studies in this thesis were conducted at the Department of Public Health of the
Academic Medical Centre of the University of Amsterdam and the Netherlands Association for Community Health Services (GGD GHOR Nederland), The Netherlands.
Cover design
Graphic design
Layout and printing
ISBN
Marcela Rados
Angelique Ketelaar
Optima Grafische Communicatie, Rotterdam, The Netherlands
978-94-6169-525-3
2014 ESM Goosen, Utrecht, The Netherlands

Sections 2.1, 2.2, 2.3, 2.4, 3.1, and 3.3 are printed with permission of the publishers of the
respective journals. The use of these sections is subject to the copyright rules of these
journals.

ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. D.C. van den Boom
ten overstaan van een door het college voor promoties
ingestelde commissie,
in het openbaar te verdedigen in de Aula der Universiteit
op vrijdag 13 Juni 2014, te 13:00 uur
door
Elisabeth Simone Maria Goosen
geboren te Bergen op Zoom
Promotiecommissie
Promotor:
Co-promotor:
Prof. dr. K. Stronks

Dr. A.E. Kunst
Overige leden:
Prof. dr. M.W. Borgdorff

Prof. dr. W.L.J.M. de Devill
Prof. dr. ir. G.A. Zielhuis]
Prof. dr. M.C.H. Donker
dr. M.E.T.C. van den Muijsenbergh
Faculteit der Geneeskunde
COnTEnTS
Preface
Chapter 1
Chapter 2
Chapter 3
7
Introduction
11
1.1
13
Background
1.2
The health status of asylum seekers and refugees
16
1.3
Aims of this thesis
19
1.4
Data sources
20
Diseases and conditions
27
2.1
Mortality and causes of death among asylum seekers in the

Netherlands, 2002-2005
29
2.2
Suicide death and hospital-treated suicidal behaviour in

asylum seekers in the Netherlands: a national registry-based
study
47
2.3
High diabetes risk among asylum seekers in the Netherlands
63
2.4
Induced abortions and teenage births among asylum

seekers in the Netherlands: analysis of national surveillance
data
83
2.5
HIV prevalence among pregnant asylum seekers in the

Netherlands; a nationwide study based on antenatal HIV
tests
99
Risk factors for the health of asylum seekers
115
3.1
Frequent relocations between asylum-seeker centres are

associated with mental distress in asylum-seeking children:
a longitudinal medical record study
117
3.2
Increased risk of physical child abuse in asylum-seeking

families in which the mother suffers from mental health
problems
139
3.3
Relationship between post-traumatic stress disorder and

diabetes among 105,180 asylum seekers in the Netherlands
157
Chapter 4
Chapter 5
General discussion
173
4.1
Principal findings
175
4.2
Methodological considerations
178
4.3
Reflections and recommendations
181
4.4
Reflections and recommendations with respect to research
189
4.5
Main conclusions
191
Summary / Samenvatting
Abbreviations
197
219
Appendix
Obstetric outcomes and expressed health needs of pregnant asylum seekers; a literature survey (English abstract.
paper in Dutch)
221
Appendix
Curriculum Vitae
PhD portfolio
Dankwoord (Acknowledgements)
237
Preface
Preface
PREFACE
For various reasons, asylum seekers and refugees are considered to be a vulnerable
group with respect to their health.1-4 However, there is still limited information on the
distribution of health problems and risk factors among asylum seekers and refugees,
in the Netherlands as well as in other countries. Insight into the health status of and
risk factors for a population is a pre-requisite for developing policies and practices that
promote their health.
The studies in this PhD thesis were developed and carried out in light of the epidemiological task of the Community Health Services for Asylum Seekers (MOA). This epidemiological task is comparable to the epidemiological task of municipal and regional
community health services (GGDs) as laid down in the Dutch Public Health Act. As of
2000 the national-level component of this task for asylum seekers has been the responsibility of the Netherlands Association for Community Health Services (GGD Nederland).
To bring the epidemiological studies at an academic level, I have sought collaboration
with the Department of Public Health at the Academic Medical Centre (AMC) of the
University of Amsterdam. This collaboration has been the basis for this thesis.
Whereas the studies in this thesis provide data on asylum seekers only, we have extended the scope of this thesis to refugees. We have done so because the health status
of asylum seekers is the precursor for the health status of refugees and because there is
limited insight into the health of refugees in the Netherlands.
Chapter 1 starts with a short introduction on asylum seekers and refugees in the Netherlands, including their demographic profile and the health care provided to them. At
the end of this chapter we describe the aims of this thesis and give an overview of the
studies that are the main body of this thesis. Chapters 2 through 4 contain the scientific
papers written about the respective studies. Chapter 5 starts with a summary of the
main findings and a discussion of methodological issues. This is followed by overarching reflections, recommendations, and conclusions with respect to the distribution of
diseases and conditions among asylum seekers and refugees in the Netherlands and risk
factors that affect their health.
ChaPtEr 1
IntroductIon
12
Chapter 1
Box 1.1.1 Definition of asylum seeker and refugee5

Asylum seeker
An asylum seeker is a person who has left his or her country of origin, has applied for recognition as
a refugee in another country, and is awaiting a decision on his or her application.
Refugee
The official definition of a refugee is any person who is outside their country of origin and unable or
unwilling to return there or to avail themselves of its protection, on account of a well-founded fear
of persecution for reasons of race, religion, nationality, membership of a particular group, or political
opinion.
In this thesis, the term refugees refers to persons who have been given refugee status in the host
country, independent of whether the person has a permanent or a temporary residence permit.
Introduction
1.1 BACkGROunD
Asylum seekers and refugees in the netherlands
Asylum seekers have fled their country of origin and applied for protection as a refugee
in another country (definitions in Box 1.1.1). During their asylum procedure they must
demonstrate that they have a well-founded fear of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group.
The number of asylum requests lodged in the Netherlands is subject to change. Whereas
the number of requests was 43,900 in the year 2000, it was only 9,730 in 2007, and then
increased again to 17,190 in 2013 (Figure 1.1.1).
50000
Afghanistan
Iraq
Number of asylum requests
40000
Somalia
Other countries
30000
20000
10000
2000
2001
2002
2003
2004
2005
2006 2007
Year
2008
2009
2010
2011
2012
2013
Figure 1.1.1 Number of asylum requests per year in the Netherlands, 2000-2008 (first and subsequent
requests combined)6,7
Beyond the shared hope of being recognized as a refugee, asylum seekers are very
diverse. This diversity becomes visible during any visit to an asylum-seeker centre. It
can also be visualised by thinking about the geographical distribution of the wars and
conflicts that have caused important refugee movements over the last decades, for
example, in Afghanistan, the former Yugoslavia, Iraq, Iran, Rwanda, Somalia, and Syria.
In figure 1.1.1 the number of asylum requests for persons from Afghanistan, Iraq, and
Somalia are shown, as these countries have been on the top five for more than ten
years. The group other countries contains approximately two thirds of the total number
of asylum seekers in the years presented.
13
14
Chapter 1
The asylum-seeking population is very young compared with the population of the
Netherlands. Nearly half of the asylum seekers who arrived between 2000 and 2008 were
younger than 20 years of age at the time of arrival, whereas only less than a quarter of
the population of the Netherlands is younger than 20. The proportion of asylum seekers
aged 40 or over was 11% compared with 52% in the population of the Netherlands.6
Male asylum seekers constituted nearly two thirds of the asylum seekers who arrived
between 2000 and 2008.
Asylum seekers are housed at asylum-seeker centres managed by the Central Agency
for the Reception of Asylum Seekers (COA). These centres include former cloisters or
barracks, and, sometimes, caravans or semi-permanent housing units throughout the
Netherlands. An average asylum-seeker centre houses about 400 occupants from some
40 nationalities. Asylum seekers look after themselves as much as possible. They usually
live in housing units in groups of between five and eight persons. Each housing unit
has a number of bedrooms and a shared living room, kitchen, and sanitary facilities.
The COA gives asylum seekers weekly pocket money for food and clothing. The COA
gives a one-off allowance for household goods and, as necessary, occasional allowances
for purposes such as travelling expenses or buying baby clothes. Asylum seekers are
allowed to work up to 24 weeks per year.a
Asylum seekers stay at an asylum-seeker centre until the Dutch Immigration and Naturalisation Service or if they lodge an appeal, the court reaches a decision on their request for
asylum. When asylum seekers are granted a residence permit, the search starts for a place
there they can live on their own. Municipalities have an obligation to provide housing to
a certain number of refugees per year. The COA allocates a residence permit holder to a
particular municipality, which then sets to work finding suitable accommodation based on
the profile of the asylum seeker. Municipalities do so by allocating social housing owned
by housing associations. Residence permit holders can also find a place to live themselves.b
Due to the use of different definitions, estimates of the total number of refugees living
in the Netherlands vary between data sources. According to CBS Statistics Netherlands,
on 1 January 2010, 69,620 persons had arrived in the Netherlands as asylum seekers
and were living in the Netherlands with a permanent or temporary residence permit.8
According to the Netherlands Institute for Social Research SCP there were around 38,000
people of Afghan origin, 52,000 people originating from Iraq, 31,000 from Iran and
27,000 from Somalia living in the Netherlands in 2010.9 Figure 1.1.2 shows the trend
in the number of first- and second- generation persons from Afghanistan, Iraq, and
Somalia.
Introduction
Number of persons (1st and 2nd generation)
140000
120000
Afghanistan
Iraq
Somalia
100000
80000
60000
40000
20000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
Figure 1.1.2 Number of persons from Afghanistan, Iraq and Somalia in the Netherlands, including firstand second-generation migrants by year6
Health care for asylum seekers and refugees

For asylum seekers in the Netherlands, entitlement to healthcare is similar to that for
residents of the Netherlands. The current organisation of health services for asylum
seekers dates from 1 January 2009. The studies in this thesis are based on data for the
period between 2000 and 2008, and therefore we describe below the organisation of
the health systems during these years.
Starting in 2000, the COA contracted local GGDs and a health care insurer to provide
health services for all asylum seekers in the Netherlands.10 For administrative reasons the
local GGDs set up the MOAs, which are separate foundations. The main responsibility
of the MOA was to provide regular public health services to asylum seekers (such as
health education, preventive child health care (JGZ), infectious diseases control, testing
for tuberculosis (TB), hygiene and safety inspections, and epidemiology).
In addition to the regular tasks of public health services, nurse practitioners from the
MOA were the first point of health care contact for asylum seekers. The nurse practitioners worked in close collaboration with family physicians contracted by the health care
insurer. The health care insurer also contracted other standard health care providers,
such as pharmacists, dentists, midwives, hospitals, mental health care providers and
home care services.
15
16
Chapter 1
As of 2009, the public health services for asylum seekers have been an integral part of
local GGDs and the Asylum Seekers Health Centre (GC A) is responsible for the provision
of primary care.11
As soon as asylum seekers get a residence permit and move to a house in a municipality, they are obliged to get a health insurance, and will have access to health services
accordingly. The GGD of the municipality in which they resettle is responsible for the
public health services.
1.2 THE HEAlTH STATuS OF ASyluM SEEkERS AnD REFuGEES

With television and newspaper images of the situation of refugees in places like Afghanistan, Somalia, and Syria in mind, it is not difficult to imagine that asylum seekers and
refugees are a vulnerable group with respect to their health. Factors that may affect the
health of asylum seekers and refugees are exposure to war and violence, food shortages
and limited access to health care. The health of asylum seekers and refugees will also be
influenced by the context in which asylum seekers live during their asylum procedure
such as the uncertainty of the asylum procedure, the living conditions in asylum-seeker
centres, the limited possibilities for participation (e.g. work, education), and limited
financial means.12 Once a residence permit has been granted, the circumstances will be
better but adversities (such as the consequences of limited language skills, discrimination, and unemployment) may still place the health of refugees at risk.9
The available evidence shows that due to the accumulation of their experiences in the
past and in the host country, asylum seekers and refugees are indeed a vulnerable group
with respect to their health.4,12,13 However, to know whether special policies and interventions are needed, it is essential to have more detailed insight in the health problems
and the risk factors that affect the health of asylum seekers and refugees.4,13
In this chapter, an overview of the epidemiological studies with respect to mental
health, diseases and conditions and sexual and reproductive health in asylum seekers
and refugees in Western host countries published before 2009 is given. More recent
literature will be addressed in the discussion in chapter 4.
Mental health
A relatively large proportion of the literature on asylum seekers and refugees addressed
mental health problems and post-traumatic stress disorder (PTSD) in particular. The
studies among adults show large variations in the prevalence rates of mental health
Introduction
problems. For PTSD, depression, and anxiety, the prevalence rates range from a few
percent to more than 70%.14 A systematic review of large clinical studies reported that
9% of the refugees had been diagnosed with PTSD and 5% had a major depression.
The review observed a wide range of rates for both conditions.15 The systematic review
attributes this variation to differences in the composition of the study population and
measurement instruments used.14
In the Netherlands two medical record studies that covered the years 1982-1988 report
prevalence rates of diagnosed PTSD among Latin American and Middle Eastern refugees
of 6% and 11% respectively.16 A study among Iraqi asylum seekers in the Netherlands
reports prevalence rates of 37% for PTSD, 35% for depressive disorder, and 22% for
anxiety disorder.17 The study Gevlucht-Gezond? reports symptoms of PTSD in 28% of
the asylum seekers and 11% of the refugees from Afghanistan, Iran, and Somalia.18 The
study reports symptoms of anxiety or depression for 68% of the asylum seekers and 39%
of the refugees.18
In 1998-1999, compared with the general population, the suicide mortality among
asylum seekers in the Netherlands was 2.8 times higher (95% confidence interval (CI)
1.5-4.1) for male and 1.5 times higher (95% CI 0.0-3.6) for female asylum seekers.19 A
study in Denmark shows a rate of suicidal behaviour that is 3.8 times higher compared
with the general population.20
For the children of asylum seekers and refugees, studies in different countries also
report a wide range of prevalence rates: from 19% to 54% for PTSD and from 3% to
30% for depression.21 A study based on strengths and difficulties questionnaires filled
out by teachers reports an elevated score for 25% of the young (<11 years) and 20%
of the adolescent asylum-seeking children in the Netherlands.22 The mental health of
unaccompanied minor asylum seekers (UMAs) was analysed in a large study in the Netherlands.23,24 Fifty percent of the UMAs had severe and chronic mental distress.25
Several studies show that the mental health of adults and children is associated with
the exposure to traumatic events in the country of origin and the conditions in the host
country.2,15,16,18,26,27 Several studies report on the effect of lengthy asylum procedures
and relocations on the mental health of asylum seekers; these studies, however, share
the limitations of the use of cross-sectional data.17,28,29 A longitudinal study in Sweden
concludes that for many refugee children, the circumstances in the host country were
of equal or greater importance than previous exposure to organised violence in the
country of origin or experiences during the flight.30
17
18
Chapter 1

With respect to infectious diseases, studies in the Netherlands and other Western host
countries report higher prevalence rates for infectious diseases in subgroups of asylum
seekers and refugees compared with the host population (for TB, hepatitis B, HIV and
intestinal parasites, amongst others).16,31-36 TB prevalence among asylum seekers at entry
to the Netherlands was 222 per 100,000 asylum seekers in the years 1994-1997, while
TB incidence in the general population was lower than 10 per 100,000.31 In 1992, the
percentage of hepatitis B carriers among asylum seekers was reported to be 11% to 16%
compared with 0.2 to 2 % in the general population.37 In a cause-of-death study among
asylum seekers in the Netherlands in 1998-1999, infectious disease mortality was four
times higher among male asylum seekers and eight times higher among female asylum
seekers compared with the general population.19
With respect to noncommunicable diseases, only a few studies among asylum seekers
and refugees were published before 2009. Primary-care-based studies show that low
back pain, other musculoskeletal conditions, dermatological problems and anaemia
are common health problems among asylum seekers and refugees.16,34,38,39 However,
the study populations of the available studies are too small to give insight into the
prevalence of specific health problems such as diabetes and cardiovascular diseases. For
the same reason, few studies provide data that have been disaggregated by country or
region of origin.34,38,39
Only a few studies were found that report on somatic health problems in asylum-seeking
and refugee children. In a study in Denmark the most frequently reported physical
health problems were dental problems, skin problems and enuresis.40 Studies in the
Netherlands and the USA show high rates of growth and nutritional disorders, such as
caries, iron deficiency, stunting, and obesity.41-44
Sexual and reproductive health

Already before 2009, sexual and reproductive health was recognized as an important
aspect of the health of refugees.45,46 War-affected populations are considered to be
disproportionately at risk for sexually transmitted infections including HIV, sexual and
gender-based violence, female genital mutilation, and unmet contraceptive needs.45-48
However, to our knowledge, no epidemiological data on the reproductive health status
of asylum seekers and refugees in Western host countries had been published before
2009.49
Introduction
The need for more information

The epidemiological data available before 2009 show the vulnerability of asylum seekers
and refugees in Western host countries with respect to various health aspects. However,
the available evidence was scarce, and while it was clear that asylum seekers and refugees are not a homogeneous group with respect to their health problems and needs,
there was scarcely any disaggregated data available. To inform policies and practices,
more information was needed with respect to:
Which diseases and conditions are more prevalent among asylum seekers and refugees compared with the general population in the Netherlands?
Which subgroups of asylum seekers and refugees are particularly at risk of certain
diseases or conditions?
What are the specific risk factors for the health of asylum seekers and refugees?
The topics for the studies in this thesis were chosen so as to address each of these three
questions. Moreover, we took into account the information needs expressed by policy
makers as well as research topics suggested by health professionals.
1.3 AIMS OF THIS THESIS

The main aim of this thesis is to describe the distribution of diseases and conditions
among asylum seekers in the Netherlands and to analyse a number of risk factors that
affect their health. Based on this knowledge and the scientific literature, we will explore
the implications for policies and practices aimed at the promotion of the health of asylum seekers and refugees.
The studies in this thesis are presented in two chapters. Chapter 2 contains five studies
that aim to analyse for which diseases and conditions asylum seekers are at increased
risk compared with the general population in the Netherlands and whether risk differences exist within the asylum-seeking population. The first study addresses mortality
and causes of death, the second suicide and suicidal behaviour, and the third, diabetes.
The last two studies in this chapter address two topics with respect to the sexual and
reproductive health of asylum-seeking women: induced abortions and teenage pregnancies, and HIV prevalence among pregnant asylum seekers.
Chapter 3 contains three studies aimed at gaining insight into risk factors for the health
of asylum seekers. The first study in this chapter analyses whether relocations between
asylum-seeker centres are associated with mental distress in asylum-seeking children.
19
20
Chapter 1
The second study analyses whether maternal violence exposure and maternal mental
health problems are associated with the risk of newly diagnosed physical child abuse.
The last study explores the association between PTSD and the prevalence of diabetes.
1.4 DATA SOuRCES

The studies in this thesis are based on two data sources, both of which are based on data
from the MOA.
The first data source consists of the notification forms that were filled out nationwide
by health professionals of the MOA. Under a national protocol, public health doctors
and nurses of the MOA were instructed to complete a standard form for every case of
death (general death notification form) and suicidal behaviour. The health professionals
submitted the forms to their regional managers, who sent the forms to GGD Nederland.
For the study on induced abortions and teenage pregnancies, a temporary notification
form was used. The COA provided the denominator data for these studies.
The second data source is an electronic database that contains medical data from the
MOA and family physicians as well as demographic data from the COA. This database,
which is referred to as the MOA database contains data on all asylum seekers in the
Netherlands between 2000 and 2008.
Nationwide the health professionals of the MOA and the family physicians recorded
health and psychosocial data (based on their findings during preventive and curative
consultations) in paper medical records. They used the problem-oriented records (POR)
method.50 Main and chronic health problems were recorded on the problem list along
with the International Classification of Primary Care (ICPC) code, date of diagnosis, and
a short open field description. Health professionals from the MOA entered the problem
list data into a dedicated medical section of the COAs electronic information system.
After the implementation of changes to the health system in 2009, the electronic
medical data and the relevant demographic and reception data for the years 2000-2008
were transferred into the MOA database with the aim of using them in epidemiological
studies.
The reference data that have been used for comparison with the population of the
Netherlands differ between studies; details are described in Chapters 2 and 3.
Table 1.1.1 shows for each study the data source(s) used, the study population, the
outcome variables, and the risk factors that were studied.
Introduction
Table 1.1.1 Overview of the studies in this thesis

Section Theme and study title
Data source
Population
Outcome
variable
Asylum-specific
variables
Chapter 2. Diseases and conditions

Notifications 222,217
person years,
all ages,
2002-2005
2.1
Mortality and causes of

death among asylum
seekers in the Netherlands
2.2
Suicide death and hospital- Notifications 179,942 person

years,
treated suicidal behaviour
age group >= 15
in asylum seekers in the
years, 2002-2007
Netherlands
2.3
High diabetes risk among

asylum seekers in the
Netherlands
MOA
database*
2.4
Induced abortions and

teenage births among
asylum seekers in The
Netherlands
Notifications 9,218 women,

age group
& MOA
15 49 years,
database
2004-2005
2.5
MOA
HIV prevalence among
pregnant asylum seekers in database
the Netherlands
- Mortality
- Causes of
death
- Suicide
- Suicidal
behaviour
- Stressors
associated with
suicidal behaviour
- Diabetes
- Length of stay
- Induces
abortions
- Teenage
pregnancies
- Length of stay
- HIV
- Length of stay
8,047 children,
age group 4 18
years,
2000-2008
- Mental
distress
- Relocations
- Length of stay
- Childs violence
exposure
- Maternal PTSD
and depression
59,380 persons,
age group
20 79 years,
2000-2008
4,854 women
who delivered in
reception,
2000-2008
Chapter 3. Risk factors for the health of asylum seekers

3.1
MOA
Frequent relocations
database
between asylum-seeker
centres are associated with
mental distress in asylumseeking children
3.2
Increased risk of physical

child abuse in asylumseeking families in which
the mother suffers from
mental health problems
MOA
database
17,780 children,
age group
0 18 years,
2000-2008
- Physical child - Maternal violence

abuse
exposure
- Maternal PTSD
and depression
3.3
Relationship between
PTSD and diabetes among
105,180 asylum seekers in
the Netherlands
MOA
database
105,180 persons,
age group
>= 18 years,
1998-2008
- Diabetes
- PTSD
* Database of the Community Health Services for Asylum Seekers (MOA).
In line with Dutch legislation, the privacy statement of the MOA included a statement
on the anonymous use of data for epidemiological purposes. Because only data collected for health care purposes were used, the medical ethics review committee of the
Academic Medical Center at the University of Amsterdam stated that the approval of the
21
22
Chapter 1
medical ethics review committee was not required for the studies based on the MOA
database (letter W12-276#12.17.0315).
Introduction
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ. 2001;322:544-7.
Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012;379:266-82.
Huber M, Stanciole A, Wahlbeck K, Tamsma N, Torres F, Jelfs E, et al. Quality in and Equality of
Access to Healthcare Services. Bruxelles: European Commission; 2008.
International Organization for Migration. International Migration, Health and Human Rights.
Geneva: International Organisation for Migration; 2013.
http://www.unhcr.org/cgi-bin/texis/vtx/search?page=search&docid=45c06c662&query=definiti
ons
www.cbs.nl
WODC Wetenschappelijk Onderzoek- en Documentatiecentrum. Migratie naar en vanuit Nederland; een eerste proeve van de Migratiekaart (WODC cahier 2009-3). The Hague: Ministerie van
Justitie; 2009.
VluchtelingenWerk Nederland. Vluchtelingen in getallen 2013. 2013.
Netherlands Institute for Social Research (SCP). Refugee groups in the Netherlands; The integration of Afghan, Iraqi, Iranian and Somali immigrants (Vluchtelingengroepen in Nederland). The
Hague: The Netherlands Institute for Social Research (SCP); 2011.
Netherlands Association for Community Health Services. Community Health Services for Asylum
Seekers in the Netherlands. Utrecht; 2005.
http://www.gcasielzoekers.nl
GGD Nederland. Preventieve gezondheidszorg voor asielzoekers; Uitgangspunten voor de zorg
in een dynamisch speelveld. Utrecht: GGD Nederland; 2005.
Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet. 2013;381:1235-45.
Gerritsen AA, Bramsen I, Deville W, van Willigen LH, Hovens JE, van der Ploeg HM. Health and
health care utilisation among asylum seekers and refugees in the Netherlands: design of a study.
BMC Public Health. 2004;4:7.
Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in
western countries: a systematic review. Lancet. 2005;365:1309-14.
Hondius AJ, van Willigen LH, Kleijn WC, van der Ploeg HM. Health problems among LatinAmerican and middle-eastern refugees in The Netherlands: relations with violence exposure and
ongoing sociopsychological strain. J Trauma Stress. 2000;13:619-34.
Laban CJ, Komproe IH, Gernaat HB, de Jong JT. The impact of a long asylum procedure on quality
of life, disability and physical health in Iraqi asylum seekers in the Netherlands. Soc Psychiatry
Psychiatr Epidemiol. 2008;43:507-15.
Gerritsen AA, Bramsen I, Deville W, van Willigen LH, Hovens JE, van der Ploeg HM. Physical and
mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2006;41:18-26.
Koppenaal H, Bos CA, Broer J. [High mortality due to infectious diseases and unnatural causes
of death among asylum seekers in the Netherlands, 1998-1999]. Ned Tijdschr Geneeskd.
2003;147:391-5.
Staehr MA, Munk-Andersen E. [Suicide and suicidal behavior among asylum seekers in Denmark
during the period 2001-2003. A retrospective study]. Ugeskr Laeger. 2006;168:1650-3.
23
24
Chapter 1
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
Bronstein I, Montgomery P. Psychological distress in refugee children: a systematic review. Clin

Child Fam Psychol Rev. 2011;14:44-56.
Wiegersma PA, Stellinga-Boelen AA, Reijneveld SA. Psychosocial problems in asylum seekers children: the parent, child, and teacher perspective using the Strength and Difficulties Questionnaire.
J Nerv Ment Dis. 2011;199:85-90.
Bean T, Derluyn I, Eurelings-Bontekoe E, Broekaert E, Spinhoven P. Comparing psychological
distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with
experiences of adolescents accompanied by parents. J Nerv Ment Dis. 2007;195:288-97.
Bean TM. Assessing the Psychological Distress and Mental Healthcare Needs of Unaccompanied
Refugee Minors in the Netherlands (Thesis). Leiden; 2006.
Bean TM, Eurelings-Bontekoe E, Spinhoven P. Course and predictors of mental health of unaccompanied refugee minors in the Netherlands: one year follow-up. Soc Sci Med. 2007;64:1204-15.
Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van OM. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass
conflict and displacement: a systematic review and meta-analysis. JAMA. 2009;302:537-49.
Hallas P, Hansen AR, Staehr MA, Munk-Andersen E, Jorgensen HL. Length of stay in asylum centres
and mental health in asylum seekers: a retrospective study from Denmark. BMC Public Health.
2007;7:288.
Nielsen SS, Norredam M, Christiansen KL, Obel C, Hilden J, Krasnik A. Mental health among
children seeking asylum in Denmarkthe effect of length of stay and number of relocations: a
cross-sectional study. BMC Public Health. 2008;8:293.
Almqvist K, Broberg AG. Mental health and social adjustment in young refugee children 3 1/2
years after their arrival in Sweden. J Am Acad Child Adolesc Psychiatry. 1999;38:723-30.
Burg JLv, Verver S, Borgdorff MW. The epidemiology of tuberculosis among asylum seekers in The
Netherlands: implications for screening. Int J Tuberc Lung Dis. 2003;7:139-44.
Clark RC, Mytton J. Estimating infectious disease in UK asylum seekers and refugees: a systematic
review of prevalence studies. J Public Health (Oxf). 2007;29:420-8.
Ouimet MJ, Munoz M, Narasiah L, Rambure V, Correa JA. [Current pathologies among asylum
seekers in Montreal: prevalence and associated risk factors]. Can J Public Health. 2008;99:499-504.
Tiong AC, Patel MS, Gardiner J, et al. Health issues in newly arrived African refugees attending
general practice clinics in Melbourne. Med J Aust. 2006;185:602-6.
Tjon ATW, Schulpen TW. [Medical care of underage refugees]. Ned Tijdschr Geneeskd.
1999;143:1569-72.
Westerhuis JB, Mank TG. [Intestinal parasites in African asylum seekers: prevalence and risk factors]. Ned Tijdschr Geneeskd. 2002;146:1497-501.
Richardus JH, Petersen LT, Knoppers WJ, Cobelens FGJ, Dolmans WMV. Preventive medical examination of asylum seekers in the Netherlands. Infectious disease bulletin. 2002;13
Bischoff A, Schneider M, Denhaerynck K, Battegay E. Health and ill health of asylum seekers in
Switzerland: an epidemiological study. Eur J Public Health. 2009;19:59-64.
Yaman H, Kut A, Yaman A, Ungan M. Health problems among UN refugees at a family medical
centre in Ankara, Turkey. Scand J Prim Health Care. 2002;20:85-7.
Abdalla K. [Health status of asylum seeking children]. Ugeskr Laeger. 2002;164:5765-9.
Geltman PL, Radin M, Zhang Z, Cochran J, Meyers AF. Growth status and related medical conditions among refugee children in Massachusetts, 1995-1998. Am J Public Health. 2001;91:1800-5.
Introduction
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
Stellinga-Boelen AA, Storm H, Wiegersma PA, Bijleveld CM, Verkade HJ. Iron deficiency among
children of asylum seekers in the Netherlands. J Pediatr Gastroenterol Nutr. 2007;45:591-5.
Stellinga-Boelen AA, Wiegersma PA, Bijleveld CM, Verkade HJ. Obesity in asylum seekers children
in The Netherlandsthe use of national reference charts. Eur J Public Health. 2007;17:555-9.
Stellinga-Boelen AA, Wiegersma PA, Storm H, Bijleveld CM, Verkade HJ. Vitamin D levels in children of asylum seekers in The Netherlands in relation to season and dietary intake. Eur J Pediatr.
2007;166:201-6.
Bartlett LA, Purdin S, McGinn T. Forced migrantsturning rights into reproductive health. Lancet.
2004;363:76-7.
Hynes M, Sheik M, Wilson HG, Spiegel P. Reproductive health indicators and outcomes among
refugee and internally displaced persons in postemergency phase camps. JAMA. 2002;288:595603.
McGinn. Reproductive health of war-affected populations: what do we know. Int Fam Plan Perspect. 2000;26:174-80.
McGinn T, Purdin S. Editorial: Reproductive health and conflict: looking back and moving ahead.
Disasters. 2004;28:235-8.
Janssens K, Bosman M, Temmerman M. Sexual and reproductive health and rights of refugee
women in Europe; Rights, Policies, Status and Needs. Ghent: Academia Press; 2005.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593-600.
25
ChaPtEr 2
dIseAses And condItIons
Section 2.1
Mortality and causes of death
among asylum seekers in the
netherlands, 2002-2005
This study has been published as:

van Oostrum IEA, Goosen S, Uitenbroek DG, Koppenaal H, Stronks K. Mortality
and causes of death among asylum seekers in the Netherlands, 2002-2005.
J Epidemiol Community Health. 2011;65:376-383.
30
Section 2.1
ABSTRACT
Background
The worlds growing population of asylum seekers faces different health risks from the
populations of their host countries because of risk factors before and after migration.
There is a current lack of insight into their health status.
Methods
A unique notification system was designed to monitor mortality in Dutch asylum seeker
centres (2002 - 2005).
Results
Standardised for age and sex, overall mortality among asylum seekers shows no difference from the Dutch population. However, it differs between subpopulations by
sex, age and region of origin and by cause of death. Mortality among asylum seekers
is higher than among the Dutch reference population at younger ages and lower at
ages above 40. The most common causes of death among asylum seekers are cancer,
cardiovascular diseases and external causes. Increased mortality was found from infectious diseases (males, standardised mortality ratio (SMR) = 5.44 (95% CI 3.22 to 8.59); females, SMR=7.53 (95% CI 4.22 to 12.43)), external causes (males, SMR=1.95 (95% CI 0.52
to 2.46); females SMR=1.60 (95% CI 0.87 to 2.68)) and congenital anomalies in females
(SMR=2.42; 95% CI 1.16 to 4.45). Considerable differences were found between regions
of origin. Maternal mortality was increased (rate ratio 10.08; 95% CI 8.02 to 12.83) as a
result of deaths among African women.
Conclusion
Certain subgroups of asylum seekers (classified by age, sex and region of origin) are at
increased risk of certain causes of death compared with the host population. Policies
and services for asylum seekers should address both causes for which asylum seekers
are at increased risk and causes with large absolute mortality, taking into account differences between subgroups.
InTRODuCTIOn
Of the estimated 11.4 million refugees worldwide in 2007,1 760,000 asylum seekers lived
in Western countries. Presumably, both pre-migration and post-migration factors are
risks to asylum seekers health,2 as are genetic factors3,4 and stress factors before and
during their flight from war-struck countries. Some authors mention limited access to
healthcare as a negative factor.5-7 Asylum seekers are thought to be subjected to specific
health problems,6,7 of which infectious diseases and mental health problems receive the
most attention.
Little information on the health of asylum seekers in Europe is available. There is
not much systematic research, and it is carried out on too small a scale or is limited
to qualitative data. In quantitative studies, such as those based on national mortality
statistics, it is impossible to distinguish asylum seekers from other migrants8; however,
given the specific situation of asylum seekers, overall data on migrants are unlikely to be
applicable to them.
The aim of this study was to (a) determine differences in overall and cause-specific
mortality between asylum seekers and the Dutch population, (b) relate these to available determinants such as age, gender and country of origin, and (c) identify possible
subgroups at risk.
Learning more about the absolute number of deaths and mortality patterns may help
healthcare providers plan adequate health provision, and data on increased mortality
of asylum seekers from specific causes will help health authorities make choices about
establishing specific prevention programmes to reduce health risks and inequalities in
health.
METHODS
Study population
An asylum seeker is a person who has left his or her country of origin, has applied for
recognition as a refugee in another country, and is awaiting a decision on his or her
application.9 The present study population comprised all inhabitants of asylum seeker
centres in the Netherlands (Box 2.1.1). Asylum seekers live in these centres until they
receive a final decision about their asylum procedure. The average duration of residence
in these centres had increased from 23 months on 1 January 2002 to 47 months on 1
January 2005.10 The reference population is the standard Dutch population for 20022005, as published by Statistics Netherlands.11
31
32
Section 2.1
Box 2.1.1 Health services for asylum seekers in the Netherlands in the period 2002-2005.
Asylum seekers in the Netherlands live in asylum seekers centres. They have freedom of movement,
but they may only work a limited number of weeks annually. The Central Agency for the Reception
of Asylum Seekers manages all asylum seeker centres and is responsible for the provision of several
entitlements for asylum seekers, including healthcare. Asylum seekers are entitled to full access
to healthcare with minor exceptions. The Central Agency for the Reception of Asylum Seekers has
contracted the Community Health Services (CHS) for Asylum Seekers to provide preventive health
services in all asylum seeker centres for:
Health education, child healthcare, infectious disease control, hygiene and safety inspections,
and specific nurse practitioner services.
Referral of asylum seekers to mainstream healthcare professionals and institutions and

coordination of care.
Data
The Community Health Services (CHS) for Asylum Seekers have managed a unique
health notification system for asylum seekers since 2002, as mortality data on asylum
seekers cannot be derived from other mortality registers. Medical staff at asylum seeker
centres report all deaths to their regional office. A doctor (HK) verifies and forwards the
data in an anonymous form to epidemiologists at the central office of the CHS for Asylum
Seekers. Statistics Netherlands codes all causes of death according to the International
Classification of Diseases, 10th revision,12 into 17 main primary cause-of-death groups
based on the European shortlist.13
The Central Agency for the Reception of Asylum Seekers provides monthly reference
data on asylum seekers in centres by age and sex, including the numbers of births, stillbirths and deaths. Individual data on inflow and outflow are unavailable, so we used the
annual average of the monthly number of residents (listed by age group, nationality and
sex) who were present on the 1st day of each month. We summed the annual average
occupations in the period 2002-2005 to obtain the denominators for our calculations.
The limited number of cases compelled us to merge countries of origin into regions
(Box 2.1.2). In the absence of a standard classification for health reporting for asylum
seekers, we used the regional classification of the United Nations High Commissioner for
Refugees (UNHCR)14 to group countries of origin. Because of the study population size,
some UNHCR regions were merged on the basis of geographical location and/or cultural
similarities (appendix 1 available online).
Box 2.1.2. Regions of origin of asylum seekers in the Netherlands

Region of origin: Definition
Major contributing countries of origin
WCS Africa
West, central and southern Africa
Democratic Republic of Congo, Angola
NEH Africa
North, east and Horn of Africa
Somalia, Sudan
CES Europe
Central, eastern and southern Europe
Azerbaijan, former Yugoslavia
ME/SW Asia
Middle East and southwest Asia
Afghanistan, Iraq
CES Asia
Central, east and southern Asia
China, Sri Lanka
Other
Stateless persons, South and Middle

America.
Statistical analysis
Mortality of asylum seekers was compared with that of the Dutch resident population
by using data from the national mortality register of Statistics Netherlands for the years
2002-2005. Different mortality measures were applied. Comparisons for all-age overall
and cause-specific mortality were made using indirectly standardised mortality ratios
(SMRs).15 These were estimated by dividing the observed number of deaths among asylum seekers by the expected number of deaths, the latter being calculated by applying
national age-specific and sex-specific mortality to age-specific and sex-specific numbers
of asylum seekers. SMR values above 1 indicate higher mortality among asylum seekers
than among the Dutch population. Perinatal, infant and maternal mortality of asylum
seekers was expressed in terms of number of deaths per 1000 or 100,000 births. These
rates were compared with corresponding rates derived from the national mortality and
birth registers. Mortality by region of origin was compared with that for the Netherlands
by means of age-stratified and sex-stratified rate ratios. We obtained 95% CIs to SMR and
mortality using SISAs t-test procedure (http://www.quantitativeskills.com/sisa/).
For the analysis of three broad cause-of-death groups (infectious diseases, external
causes, chronic diseases) by region of origin, ratios were estimated by means of Poisson regression analyses, with number of deaths as the dependent variable, number of
person-years at risk as the offset variable, and region of origin as the independent variable. The Dutch population was taken as the reference group. The regression model was
controlled for sex and age. In the cause-specific analysis, because of the small number of
deaths, we used two broad age groups, divided in such way that the model showed the
least error (eg, 0-39 vs 40+ years for chronic diseases). Poisson regression was applied
using R software (http://www.r-project.org). CIs were derived from the standard errors
to the regression coefficients.
33
34
Section 2.1
RESulTS
Population characteristics
The CES Europeans and ME/SW Asians were the largest subgroups of asylum seekers
(Table 2.1.1). There were considerably more male than female asylum seekers, but the
sex distribution differed per region (Table 2.1.1). African populations were the youngest, followed by the ME/SW Asian population. The age distribution of the CES European
population was more similar to the Dutch population.
Table 2.1.1 Characteristics of the asylum seeker population in the Netherlands in 20022005
All asylum
seekers
WCS
Africans
NEH
CES
Africans Europeans
ME/SW
Asians
CES
Other
Asians countries
Number of person-years
Male
Female
Total
Percentage of all asylum seekers
134,331
33,362
15,170
32,151
42,499
7,125
4,024
87,886
16,601
9,502
27,303
26,471
4,915
3,094
222,217
49.963
24,672
59,454
68,970
12,040
7,118
100
22.5
11.1
26.8
31.1
5.4
3.2
Number of deaths*
Male
193
44
21
54
59
10
Female
138
36
13
30
36
16
Total
346*#
80
34
84
95
13
41*,#
100
23.1
9.8
24.2
27.4
3,7
11.8
Percentage of total deaths
*Nine persons whose country of origin was unknown were included in the category other countries
#
Fifteen persons whose sex was not known are included
In 2002-2005, 346 asylum seekers died and 28 stillborns (in 4327 deliveries) were reported. The sex of 15 people who died was unknown, and the cause of death was unknown
for 39 cases. The overall crude mortality (156/100,000) of this young population was
lower than that of the Dutch population, which was 859/100,000 inhabitants.
Cause-specific mortality: main primary cause-of-death categories

The standardised overall mortality among asylum seekers was similar to that of the
host population for males and females (Table 2.1.2). The main causes of death of asylum
seekers were cancer, cardiovascular diseases and external (Table 2.1.2). Mortality from
infectious diseases, diseases of the blood, congenital anomalies and external causes was
significantly higher in asylum seekers than in the host population. In contrast, asylum
seekers had lower mortality for cancer, cardiovascular, respiratory, gastroenterological
and neurological diseases.
With 36 cases, perinatal mortality in asylum seekers (8.32/ 1000 births) was similar to that
of the Dutch population (rate ratio 1.16, 95% CI 0.84 to 1.61). Infant mortality (17 cases,
3.95/ 1000 live births) was not significantly different from that of the Dutch population
(rate ratio 0.83, 95% CI 0.51 to 1.33). In 15 cases, it was not reported whether the baby
was alive at birth. The maternal mortality ratio (69.33/100,000 births) was 10.08 times
that of the Dutch population (95% CI 8.02 to 12.83) (results not in tables).
Differences by age, sex and region

Comparison of overall mortality between asylum seekers and the Dutch population
showed differences between subgroups by age, sex and region of origin (figure 2.1.1).
In the age groups < 1, 1-19 and 20-39 years, mortality was higher in females from WCS
Africa than in Dutch females. Increased mortality was also found in the age group 1e19
years for males from WCS Africa and CES Europe, and in the age group 20-39 years for
females from NEH Africa and males from CES Europe. In the age groups 40-64 and 65
years and over, mortality was lower than, or at the same level as, in the Dutch population
for all regions of origin.
Poisson regression analysis, giving standardised rate ratios corrected for age and sex
(figure 2.1.2), shows an increased risk of dying from infectious diseases for NEH and WCS
Africans. WCS Africans and CES Europeans were at increased risk of dying from external
causes, especially the young men (results not in the figures). The risk of dying from
chronic diseases was significantly lower than for the host population for asylum seekers
from all regions of origin, except for WCS Africa.
Mortality for subgroups of main primary cause-of-death categories

AIDS, hepatitis and tuberculosis are the most common causes of death from infectious
diseases among both male and female asylum seekers (Table 2.1.2). Of 33 infectious
disease deaths, 29 were asylum seekers from WCS and NEH Africa. Of the 16 AIDS related
cases, 15 originated from these regions (results not in tables).
Table 2.1.2 shows that roughly half of the non-natural deaths resulted from accidents
and injuries, predominantly of male asylum seekers. Deaths from accident or injury prevailed in male asylum seekers younger than 30 years (34 of 40 cases, results not in table).
For accidents and injuries, there appear to be differences in mortality between regions
of origin, but the numbers are too small to draw firm conclusions. Suicide mortality was
highest in males from NEH Africa (results not in tables). The high SMR for drowning is
noteworthy. Drowning occurred irrespective of season, and 16 of the 20 cases were
younger than 20 years (results not in tables).
35
4
7
Congenital anomalies#
Conditions originating perinatal

period#
36
Diseases of the circulatory system
Diseases of the respiratory system
1.49
4
1
Mental and behavioural disorders
Diseases of the nervous system
Complications of pregnancy,
childbirth, and the puerperium#
2.98
Endocrine, nutritional, metabolic

diseases
26.80
0.74
26
Neoplasms
Blood/blood-forming organs and

immunological diseases
Diseases of the digestive system
19.36
10
- Hepatitis
- AIDS
Diseases of the genitourinary system
7.44
5.21
2.98
1.49
2.98
2.23
0.74
2.23
1.49
13.40
18
Infectious and parasitic diseases
- Tuberculosis
206.80
3.52
3.56
14.04
29.81
86.35
269.09
19.02
22.67
22.67
2.33
268.37
0.86
0.46
0.53
10.52
831.0
Crude death rate

/ 100,000 person
years
Crude death rate

/ 100,000 person
years
193
Number of
deaths
All causes
Primary causes of death categories
NL
Asylum seekers
Male
1.30
0.60
1.23
0.29
0.38
0.75
0.18
1.39
0.59
1.77
0.42
14.04
16.52
13.02
5.44
0.93
SMR*
0.52-2.46
0.16-1.55
0.15-4.43
10
0.04-1.05
31
0.53-1.04
0.10-0.98
0
1
0.78-7.37
0.00-0.98
0.12-1.71
27
0.27-0.61
0.02-9.77
1
6
3.44-48.70
15
3.22-8.59
1.61-48.16
6.75-25.90
138
Number of
deaths
0.75-1.12
95% CI
Asylum / NL
11.38
4.55
3.41
2.28
1.14
25.27
1.14
5.69
3.41
30.72
6.83
1.14
3.41
17.07
121.52
Crude death rate

/ 100,000 person
years
Asylum seekers
NL
3.08
2.52
0.16
19.05
36.37
74.28
273.16
23.33
50.32
32.06
3.51
221.56
10.44
0.19
0.36
11.31
824.15
Crude death rate

/ 100,000 person
years
Female
4.22-12.43
0.86-1.43
95% CI
Asylum / NL
2.42
0.84
15.01
1.32
0.14
1.17
0.26
1.34
6.95
0.61
39.99
18.77
1.16-4.45
0.23-2.13
3.09-43.83
0.16-4.78
0.00-0.70
0.79-1.65
0.00-1.40
0.44-3.13
1.44-20.44
0.40-0.89
14.68-87.06
0.50-111.00
47.65 10.31-146.00
7.53
1.14
SMR*
Table 2.1.2 Mortality of asylum seekers as compared to the total population of the Netherlands: numbers of deaths, crude death rates and standardised mortality
ratios (2002-2005)
36
Section 2.1
8.93
16.38
40
12
22
5
3
- Accidents: drowning
- Suicide
- Homicide
- Other external causes of death
NL
0.98
0.67
1.61
12.98
21.70
37.94
36.80
Crude death rate

/ 100,000 person
years
Male
2.97
2.13
1.63
12.88
2.12
1.95
1.19
SMR*
4
3
6.66-22.54
1.02-2.46
0.37-10.95
0.94-5.55
14
0.52-2.46
22
Number of
deaths
1.52-2.89
0.66-1.95
95% CI
Asylum / NL
1.14
3.41
3.41
4.55
7.96
15.93
25.03
Crude death rate

/ 100,000 person
years
Asylum seekers
NL
0.89
0.44
0.74
6.03
17.48
25.58
37.94
Crude death rate

/ 100,000 person
years
Female
2.36
4.01
0.90
18.74
1.67
1.60
3.78
SMR*
* SMR standardised for age, 95% CI not including 1 in bold $Accidents including drowning. # does not take into account the number of deliveries or births
2.23
3.72
29.78
52.11
70
External causes of injury/ poisoning
- Accidents and injuries$
10.42
Crude death rate

/ 100,000 person
years
15
Number of
deaths
Symptoms, signs, ill-defined

conditions
Primary causes of death categories
Asylum seekers
0.06-12.95
0.83-11.69
0.19-2.63
5.18-48.70
0.77-3.44
0.87-2.68
2.37-5.72
95% CI
Asylum / NL

37
38
Section 2.1
Figure 2.1.1 Rate ratios by age group, sex and region of origin for asylum seekers in comparison with the
Dutch standard population. 95% CIs not including 1 are considered significant. The numbers of deaths
are: 0 years old (26 cases); 1-19 years old (44 cases); 20-39 years old (115 cases); 40-65 years old (83 cases);
65 years and more (64 cases); 15 cases of unknown sex not included in calculations.
(Bestaat uit 5 plaatjes met los legenda plaatje)
Figure 2.1.2 Age and sex standardised rate ratios for disease groups per region of origin in comparison
with the Dutch population. (a) Infectious diseases; (b) external causes; (c) chronic diseases (all primary
death causes other than infectious diseases and external causes of death) (2002-2005). CES Asia and other
countries not presented as no satisfactory regression function could be determined.
DISCuSSIOn
This is the first study reporting overall and cause-specific mortality among asylum seekers as compared with the host population. It shows high numbers of deaths from cancer,
cardiovascular diseases and external causes. Whereas at younger ages mortality among
asylum seekers was higher than among the Dutch population, it was lower above the
age of 40. Mortality from cancer and cardiovascular disease was reduced, whereas
mortality due to infectious diseases, pregnancy and childbirth, and external causes was
increased. Important cause-of-death differences between regions of origin indicate that
preventive health programmes for asylum seekers require a subgroup differentiated
approach.
The advantage of this study is that it provides the first data specific to asylum seekers
and identifies mortality patterns within the asylum seeker population, differentiated by
39
40
Section 2.1
age, sex and region of origin. However, as a consequence of the limited size of the asylum
population, although the study was carried out over 4 years, results for subgroups by
region of origin and for cause-of-death categories need to be interpreted with caution.
Some of the deaths of asylum seekers may be included in the national mortality register.
They are, however, not identifiable and can therefore not be extracted from the reference data. As the number is small in comparison with the reference population, the
effect on the results is assumed to be limited.
Aggregation of data into UNHCR regions is chosen in the absence of a standard classification for asylum seekers and because of UNHCRs involvement with the study population.
As the classification influences the results, validation of regional classification for health
studies among asylum seekers would be welcome and would facilitate international
comparison.
In the multivariate analysis, because of the limited number of cases, data were aggregated into just two age groups. This reduced error, but may have allowed some effect of
age differences to go unnoticed. It is unlikely that the risk differences we did find were
the result of this procedure. The difference between the SMR and the rate ratio in the
multivariate analysis for infectious diseases is notable. The SMR is very high because of
the over-representation of younger age groups in the asylum population and because
of a much higher infectious disease mortality among asylum seekers than among the
Dutch in these age groups. The standardised rate ratio calculated with Poisson regression
though is less influenced by the fact that the asylum seeker age distribution is skewed.
Results in relation to other studies

The way age affects asylum seeker mortality, with lower mortality in older age groups
and higher mortality in younger groups, is similar to that reported in labour migrant
studies.16-20 The cause-specific mortality of all asylum seekers combined matches other
studies that show increased mortality from infectious diseases and external causes in
migrants.16,20,21 Lower mortality from cancer matches other European studies on nonWestern ethnic groups.16-19 More importantly, we should point out that analysis by region of origin showed considerable differences in mortality by cause of death between
subgroups of asylum seekers.
The present study shows that the increased risk of infectious disease mortality among
asylum seekers is primarily a result of AIDS deaths in Africans. AIDS is a leading cause of
mortality world wide and the primary cause of death in sub-Saharan Africa.22 Statistics
Netherlands has identified AIDS as a major cause of death for migrants.20 Tuberculosis
and hepatitis are important causes of excess risk for labour migrants,16 but low numbers
of cases in our study make it difficult to draw conclusions about these diseases in asylum
seekers. Infant mortality for all migrants living in the Netherlands has been reported to
be increased by 35% in comparison with the Dutch population.20
Infant mortality among asylum seekers in this study is similar to that of the general
population. However, it may be underestimated because some of the 15 cases in which
it was not reported whether the baby was alive at birth may also be infant death cases.
Perinatal mortality did not differ from that of the Dutch population, but was also underestimated due to under-reporting of stillbirths and also because possibly some of
the above 15 cases were stillbirths. Maternal mortality among asylum seekers was 10
times that of the general population of the Netherlands and twice that of the ethnic
group with the highest risk (35/100,000 live births from Surinam/Antillean mothers).23 In
this study, the three mothers who died from complications of pregnancy and childbirth
originated from WCS Africa, where maternal mortalities of 905 (453-1480)/100,000 live
births have been estimated.24 Home country risk factors for maternal mortality may still
be present in women from this region. Added to the fact that WCS African asylum seekers also face many teenage pregnancies and induced abortions,25 we believe that WCS
African asylum seeker mothers and babies are at increased risk with respect to issues of
reproductive health and infancy.
The increased risk of accidents and injuries among asylum seekers adds to the evidence
of increased injury risks among migrant groups.21 Moreover, the existence of differences
in injury mortality between subgroups is also seen in ethnic minority groups in the
Netherlands.26
The risk of drowning among asylum seekers is twice that among all non-Western migrants in the Netherlands, for which a 4-8 times increased risk in comparison with the
native Dutch population has been reported.27,28
Suicide has been described as a risk factor for Iranians and Afghans in England,29 and
for men from southern and eastern Europe in the Netherlands.30 This study showed
increased suicide mortality in men from NEH Africa. Further subgroup analysis of suicide cases, especially when data from additional years are included, may show more
differences between subgroups by sex, age and region of origin, and will be studied
separately. Suicide among asylum seekers may be related to traumatic events in the
countries from which they have fled and having to cope with an uncertain future. The
suicide risk factor may also come from the country of origin. Suicide rates among young
men in former Soviet states have risen substantially since the 1990s, and are the major
41
42
Section 2.1
cause of death of young men.31 Homicide was reported to be a risk factor for African and
west Asian immigrants in the Netherlands,16 but was not significantly increased among
the asylum seeker population in our study.
The health advantage for older asylum seekers, particularly with regard to the major
chronic diseases, has also been seen among migrants in general,16-19,32,33 and has been
a topic of debate. The advantage may come from the healthy migrant effect, where
only the strongest and healthiest in a population are able to migrate. Given the young
age of many asylum seekers and the relatively old age at which the advantage is first
observed,34 it seems unlikely that the healthy migrant effect is an important factor in
the relative health of the asylum population as a whole. Mortality differentials between
migrants and the general Dutch population diminished in the period 2002-2006,26
influenced by acculturation among other things. Such a decrease is not to be expected
for asylum seekers because of the continuous influx of new asylum seekers and outflow
of asylum seekers after a decision on their asylum request. Health status at immigration will therefore remain an important health determinant for natural causes of death
among asylum seekers.
Implications for policy and practice

The results of our study highlight important issues for asylum seeker health policies.
It shows that, in addition to the often mentioned mental health and communicable
disease problems among asylum seekers, other health problems are of importance.
The high absolute mortality from chronic diseases and external causes, and the excess
mortality in comparison with the host population from infectious diseases, external
causes and pregnancy and childbirth related causes, reflects the variety of the burden
of ill health among asylum seekers. It also indicates the importance of full access to
healthcare and prevention for the asylum population.2
Preventive interventions should address the increased risk of certain subgroups with
respect to specific causes. The birth-related mortality among WCS African mothers,
combined with unfavourable reproductive health outcomes of this population,25 for example, indicates that targeted interventions addressing reproductive and infancy health
risks are required for this group. Drowning prevention interventions should be aimed
at all parents and children. As many asylum seekers have limited knowledge about
the dangers of open water, good safety education,28 and swimming lessons should be
provided.
Future research
Collection of mortality data on asylum seekers in other host countries is important, as it
is unclear whether the data presented here can be extrapolated to asylum populations in
other countries. Variations between host countries in composition of the asylum population, reception conditions, access to healthcare,2 and other factors may influence asylum
seeker health and, consequently, mortality. If mortality data for asylum seekers in other
host countries become available, analysis of aggregated mortality and cause-of-death
data from several countries may help to explain the risk differences between subgroups
of asylum seekers. For causes of death with high relative risks but low absolute numbers,
such as maternal mortality, aggregation of data from different host countries is essential
to allow in-depth aetiological studies.
In addition to the need for more mortality studies, there is an international need for
more insight into subgroup-specific morbidity. Combination of mortality and morbidity
data may guide the development of screening and prevention policies and practices to
reduce health risks for asylum seekers. Such policies and practices should also be based
on insight into which preventive interventions work for which asylum seekers. There
is a serious need for studies in this domain, as prevention is a further challenge for a
population whose first concern is their asylum procedure.
ACknOwlEDGEMEnTS
We thank our colleagues from the Community Health Services for Asylum Seekers for
reporting mortality data. We thank the Central Agency for the Reception of Asylum
Seekers for providing denominator data, and Statistics Netherlands for coding the
primary causes of death. We also thank A. Kunst and C. Schouten, who commented on
the manuscript, and C. van Steenis and D. van der Schuit, who prepared the tables and
figures. We thank M. Savage and S. van Roosmalen for correcting the English.
43
44
Section 2.1
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
UNHCR Report Division of Operational Services, Field Information and Coordination Support Section. 2007 Global Trends: refugees, asylum seekers, returnees, internally displaced and stateless
persons. June 2008. http://www.unhcr.org/statistics/STATISTICS/4852366f2.pdf
Norredam M, Mygind A, Krasnik A. Access to health care for asylum seekers in the European
Union; a comparative study of country policies. Eur J Public Health 2006;16:285-9.
Bischoff A, Wanner P. The self-reported health of immigrant groups in Switzerland. J Immigr Minor
Health 2008;10:325-35.
Wiking E, Johansson SE, Sundquist J. Ethnicity, acculturation, and self reported health. A
population-based study among immigrants from Poland, Turkey, and Iran in Sweden. J Epidemiol
Community Health 2004;58:574-82.
Norredam ML. Migrants access to health care [thesis]. Copenhagen, University of Copenhagen,
Institute of Public Health, 2008.
Burnett A, Peel M. Asylum seekers and refugees in Britain Health needs of asylum seekers and
refugees. BMJ 2001;322:544-7.
Adams KM, Gardiner L, Assefi N. Health care challenges from the developing world; postimmigration refugee medicine. BMJ 2004;328:1548-52.
Schmeets H, Reep C, Spijkers G. Afbakenen van moeilijk waarneembare bevolkingsgroepen. [Defining problematically identifiable population subgroups.] Voorburg/Heerlen, The Netherlands:
Centraal Bureau voor de Statistiek, Bevolkingstrends 2003;51:62-8.
United Nations High Commissioner for Refugees, UNHCR. http://www.unhcr.org/statistics/
STATISTICS/4852366f2.pdf (accessed 25 Mar 2009).
Dutch Parliament Report 2004-2005. Tweede Kamer, vergaderjaar 2004-2005, 19 637, nr. 962 [In
Dutch].
Statline. Statistics Netherlands. (accessed Feb 2009).
International Classification of Diseases. Tenth Revision [ICD-10]. www.cbs.nl (accessed June
2009).
Eurostat. Eurostat Working Paper on population and social conditions, n8 22, causes of death
1994-1995 statistics. Eurostat, Luxemburg. 1998.
UNHCR. Structure: regions and sub-regions. 2006. http://www.unhcr.org/publ/
Rothman KJ. Modern epidemiology. Boston/Toronto: Little, Brown & Co, 1986:41-50.
Bos V, Kunst AE, Key-Deerenberg IM, et al. Mortality differences between Native Dutch and people
of Turkish, Moroaccan, Surinamese, and Antillean/Aruban origin. Int J Epidemiol 2004;33:1112-19.
Grulich AE, Swerdlow A. Cancer mortality in African and Caribbean migrants in England and
Wales; a follow-up study. Br J Cancer 1992;66:905-11.
Bhopal RS, Rankin J. Cancer in minority ethnic populations; priorities from epidemiological data.
Br J Cancer Suppl 1996;29:S22-32.
Zeeb H, Razum O, Blettner M, et al. Transition in cancer patterns among Turks residing in Germany.
Eur J Cancer 2002;38:705-11.
Garssen J, Bos V, Kunst A, et al. Differential mortality risks and causes of death among non-Western
foreigners in the Netherlands. Paper for the European Population Conference, Warsaw, 2003.
Stirbu I, Kunst AE, Bos V, et al. Injury mortality among ethnic minority groups in the Netherlands.
J Epidemiol Community Health 2006;60:249-55.
UNAIDS 2007 Epidemic update. UNAIDS/07.27E / JC1322E (English original, Dec 2007). http://
data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
Waelput AJM, Achterberg PW. Etniciteit en zorg rondom zwangerschap en geboorte; een verkenning van Nederlands onderzoek. RIVM report 270032004/2007. [in Dutch].
Hill K, Thomas K, AbouZahr C, et al. Estimates of maternal mortality worldwide between 1990 and
2005: an assessment of available data. Lancet 2007;370:1311-19.
Goosen ESM, Uitenbroek DG, Wijsen C, et al. Induced abortions and teenage births among asylum
seekers in the Netherlands: analysis of national surveillance data. J Epidemiol Community Health
2009;63:528-33.
Garssen J. Dalende sterfte bij autochtonen en allochtonen. In: van Hilten O, Mares A, eds. Gezondheid en Zorg in cijfers. Voorburg/Heerlen, the Netherlands: CBS, 2007;59-70 [in Dutch].
Garssen MJ, Hoogenboezem J, Bierens JJLM. Afname van het verdrinkingsrisico bij jonge kinderen, maar verhoogd risico bij kinderen van recent gemmigreerde niet-westerse allochtonen.
Ned Tijdschr Geneesk 2008;52:1216-20.
Oostrum IEA van, Goosen ESM. Afname van het verdrinkingsrisico bij jonge kinderen, maar
verhoogd risico bij kinderen van recent gemmigreerde niet-westerse allochtonen. Ned Tijdschr
Geneesk 2008;152:1896 [in Dutch].
Cohen J. Safe in our hands?: a study of suicide and self-harm in asylum seekers. J Forensic and
Legal Med 2008;15:235-44.
Garssen MJ, Hoogenboezem J, Kerkhof AJ. Zelfdoding onder migrantengroepen en autochtonen
in Nederland. [Suicide among migrant populations and native Dutch in the Netherlands]. Ned
Tijdschr Geneesk 2006;150:2143-9.
Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet
2001;357:917-21.
Razum O, Twardella D. Time travel with Oliver Twist. Towards an explanation for a paradoxically
low mortality among recent immigrants. Trop Med Int Health 2002;7:4-10.
Mackenbach JP, Bos V, Garssen MJ, et al. Sterfte onder niet-westerse allochtonen in Nederland.
Ned Tijdschr Geneesk 2005; 149:917-23 [in Dutch].
Uitenbroek DG, Verhoeff AP. Life expectancy and mortality differences between migrant groups
living in Amsterdam, the Netherlands. Soc Sci Med 2002;54: 1379-88.
45
Section 2.2
suicide death and hospital-treated
suicidal behaviour in asylum
seekers in the netherlands: a
national registry-based study

Goosen S, Kunst AE, Stronks K, van Oostrum IEA, Uitenbroek DG, Kerkhof AJFM.
Suicide death and hospital-treated suicidal behaviour in asylum seekers in the
Netherlands: a national registry-based study. BMC Public Health. 2011;11:484.
48
Section 2.2
ABSTRACT
Background
Several suicide and suicidal behaviour risk factors are highly prevalent in asylum seekers,
but there is little insight into the suicide death rate and the suicidal behaviour incidence
in this population. The main objective of this study is to assess the burden of suicide and
hospital-treated non-fatal suicidal behaviour in asylum seekers in the Netherlands and
to identify factors that could guide prevention.
Methods
We obtained data on cases of suicide and suicidal behaviour from all asylum seeker reception centres in the Netherlands (period 2002-2007, age 15+). The suicide death rates
in this population and in subgroups by sex, age and region of origin were compared
with the rate in the Dutch population; the rates of hospital-treated suicidal behaviour
were compared with that in the population of The Hague using indirect age group
standardization.
Results
The study included 35 suicide deaths and 290 cases of hospital-treated suicidal behaviour. The suicide death rate and the incidence of hospital-treated suicidal behaviour
differed between subgroups by sex and region of origin. For male asylum seekers, the
suicide death rate was higher than that of the Dutch population (N=32; RR=2.0, 95%CI
1.37-2.83). For females, the suicide death rate did not differ from the Dutch population
(N=3; RR=0.73; 95%CI 0.15-2.07). The incidence of hospital-treated suicidal behaviour
was high in comparison with the population of The Hague for males and females from
Europe and the Middle East/South West Asia, and low for males and females from Africa.
Health professionals knew about mental health problems prior to the suicidal behaviour
for 80% of the hospital-treated suicidal behaviour cases in asylum seekers.
Conclusions
In this study the suicide death rate was higher in male asylum seekers than in males
in the reference population. The incidence of hospital-treated suicidal behaviour was
higher in several subgroups of asylum seekers than that in the reference population.
We conclude that measures to prevent suicide and suicidal behaviour among asylum
seekers in the Netherlands are indicated.
Suicide and suicidal behaviour
BACkGROunD
In 2008 an estimated 383,000 asylum applications were recorded in 51 Western
countries, including most European countries, the USA and Canada.1 Asylum seekers
are people who have left their country of origin, applied for protection as a refugee in
another country, and are awaiting a decision on their application.2
Recent reviewsquite clearly identify mental disorders, such as depression, schizophrenia, substance use disorder, personality disorder and comorbid anxiety disorder, as the
most prominent risk factors for suicide.3,4,5 Other risk factors for suicide are traumatic life
events and psychosocial crisis.3 The stress-diathesis model for suicides, however, states
that suicide is never the consequence of one single cause or stressor but also requires
a predisposition for suicidal ideation, with psychiatric illness and psychosocial crises as
proximal stressors.3 This means that most people will not have suicide ideation, even
in very difficult circumstances. Risk factors for non-fatal suicidal behaviour include the
number of stressful life events, family disruption, lack of social support, low income,
unemployment, previous traumatic experiences.5,6,7 In people presenting with first-ever
suicidal behaviours, the prevalence of psychiatric disorders may be rather low,whereas
socio-economic deprivation (low education, low income, unemployment, poverty
and divorce) is much more prevalent.6 A recent general review showed a moderate association between post-traumatic stress disorder (PTSD) and suicidal ideation, but no
evidence for a link between PTSD and completed suicide.8
It is known that several suicide and suicidal behaviour risk factors are highly prevalent in
asylum seekers.9,10,11,12,13 However, data about the suicide death rate and the incidence of
non-fatal suicidal behaviour among asylum seekers are very limited. To our knowledge,
the only study that reports rates for suicide death and suicidal behaviour specifically for
asylum seekers was conducted in Denmark (2001-2003), but it included only three cases
of suicide.14 A UK study into suicide and self-harm among asylum seekers did not publish
any rates, and concluded that the number of asylum seekers who die from suicide or
have suicidal behaviour is still unknown.15 A study into the influence of country of birth
on the risk of suicidal behaviour - conducted in Sweden - shows large differences between sexes and between countries/regions of origin, but does not provide specific data
on asylum seekers.7 On the basis of differences in the suicide death rate and the suicidal
behaviour incidence worldwide,3 we expected that suicide and suicidal behaviour risks
are not evenly distributed between subgroups of asylum seekers.
Insight into the burden of suicide death and suicidal behaviour is necessary in order to
determine whether extra preventive efforts with regard to these issues are required for
49
50
Section 2.2
asylum seekers; such insight could also provide directions for prevention.16,17 The main
objective of the current study was to assess the burden of suicide and hospital-treated
suicidal behaviour in asylum seekers in the Netherlands and to identify factors that
could guide prevention.
The specific steps taken were as follows:
to assess the suicide mortality rate and the incidence of hospital-treated suicidal
behaviour in asylum seekers, and compare it to the Dutch population and the population of The Hague;
to assess the extent to which health staff were aware of the existence of mental
health problems in asylum seekers prior to the date of hospital-treated suicidal
behaviour and the extent to which these cases were under mental health treatment
prior to the date of the hospital-treated suicidal behaviour;
to determine which methods were used by cases of suicide death and of hospitaltreated suicidal behaviour and what stressors were reported in cases of hospitaltreated suicidal behaviour.
METHODS
Context of the study
Asylum seekers in the Netherlands are housed in residential reception centres, managed
by the Central Agency for the Reception of Asylum Seekers (COA). Asylum seekers are
free to leave the centres and are allowed to work for a limited number of weeks per year.
They are entitled to full access to health care. Up until 2008, COA contracted a health
insurance company to arrange curative health care for asylum seekers through access to
mainstream health services, including inpatient and outpatient mental health services.
COA also contracted local public health services (GGDs) to provide preventive health
services and specific nurse practitioner services, collectively called Community Health
Services for Asylum Seekers (MOA). MOA nurse practitioners working at the reception
centres provided a bridge function between the asylum seeker and regular health care.
Asylum seekers with mental health problems could be offered up to five consultations
with a public health doctor specialized in refugee health care to clarify any mental health
and other health problems and needs. Asylum seekers could be referred, with or without
these consultations, to the mental health service and/or offered preventive interventions.
Since January 2009 the health system for asylum seekers in the Netherlands has changed.
Data sources
We collected data on suicide deaths and hospital-treated suicidal behaviour that took
place among asylum seekers living in reception centres in the Netherlands from 20022007. Under a national protocol, public health doctors and nurses at the MOA were
required to complete a standard form for every case of death (general death notification
form) and suicidal behaviour.18 Neither the protocol nor the form gave a definition of
suicidal behaviour. As it is difficult to determine in self-injury cases whether there was an
intent to die,19 this study does not further differentiate self-injury cases. In order to limit
the study to cases with considerable injury, only cases of suicidal behaviour treated at a
hospital were included. This categorisation was made on the basis of a question on the
form on whether and where the asylum seeker was treated after the suicidal behaviour.
Repeated suicidal behaviour cases were included in the database as separate events if
these were reported on different forms. Data about suicide deaths were extracted from
the general asylum seeker mortality database.18 Statistics Netherlands (CBS) coded the
cause of death using the ICD-10. We included all cases allocated ICD-codes X60-X84 or
Y87.0.18
We grouped countries of origin into regions according to the United Nations High Commissioner for Refugees (UNHCR) classification.2 Some regions were combined because
of small numbers; data for regions with very small populations were not presented. The
regions are as follows, in brackets the abbreviations used and the two most frequently
encountered countries: West, Central, Southern Africa (WCS Africa; Angola, Democratic
Republic of Congo), North, East, Horn of Africa (NEH Africa; Somalia, Sudan), Central, East
and Southern Europe (CES Europe; Azerbaijan, former Yugoslavian countries), Middle
East/South West Asia (ME/SW Asia; Afghanistan, Iraq).
The suicidal behaviour notification form included open questions on medical history,
stressors and methods used. Classification of these variables was performed by SG and
AK, who also classified the methods used in suicide deaths. The form also contained
dichotomous questions on whether the health professional knew of any mental health
problems in the asylum seeker prior to the suicidal behaviour (without any further
specification) and whether the asylum was using mental health treatment prior to the
suicidal behaviour. No further specification of mental health problems and treatment
were included as the questions were included with an exploratory objective.
The COA provided data on the number of asylum seekers by sex, age group and country
of origin on every first day of the month in the study period. These were used to calcu-
51
52
Section 2.2
late estimates of the person years spent in reception facilities. These data are considered
good estimates for the denominator.
Comparison of the suicide death rate in asylum seekers with that of the general population of the Netherlands was performed using 2002-2007 data from the CBS national
mortality register.20 Suicidal behaviour data were compared with data from a study in
the Dutch city of The Hague, as no national data were available. The study in The Hague
covered all cases of hospital-treated suicidal behaviour cases in 2002-2004, based on
data from the emergency departments of the citys four general hospitals.21
The rates used the suicide mortality rate and the incidence rate of hospital-treated suicidal behaviour - were calculated for the population aged 15 years and older per 100,000
person-years. The numerators were the reported number of suicide deaths and cases of
hospital-treated suicidal behaviour. Person-years at risk were calculatedon the basis of
the occupancy numbers for asylum seeker centres on the first day of each month during
the study period.
Rate ratios were calculated using indirect standardization.22 The observed numbers
of suicide and hospital-treated suicidal behaviour were compared with the expected
numbers based on the rates for the reference populations, specifically for age and sex.
The expected numbers were obtained by multiplying the person-years at risk in each
category by the age and sex-specific suicide death rates in the Netherlands,20 andhospital-treated suicidal behaviour incidence rates in The Hague respectively.21 Finally, the
observed/expected (O/E) ratios and the 95% confidence intervals (CIs) were calculated
using Byars approximation of the exact interval for the Poisson distributed variables.
This approximation is accurate even with small numbers.23
To make comparisons across subgroups of asylum seekers, with regards to the percentage of people with hospital-treated suicidal behaviour known to have had mental health
problems and the percentage receiving treatment for these problems, we calculated
prevalence rate ratios and 95%CI with SISAs t-test procedure.24
RESulTS
Burden of suicide death and hospital-treated suicidal behaviour
In total 35 cases of death from suicide were recorded (Table 2.2.1), resulting in a suicide
mortality rate of 17.5/100,000/year. Mortality was much higher in males than females
Table 2.2.1 Suicide death rates in asylum seekers by sex, age, region of origin and rate ratios for asylum
seekers in comparison with the general population of the Netherlands
Sex
number of
person years
number of
suicide deaths
Suicide
mortality rate/
100,000/year
Mortality
rate ratio*
39,068,490
6131
15.7
125,026
32
25.6
2.00*
1.37-2.83
15-24
44,171
18.1
2.33
1.164.70
25-34
42,459
13
30.6
2.32
1.34-4.01
>=35
38,396
11
28.6
1.58
0.88-2.86
40,278
17.4
1.28*
0.51-2.63
Subgroup
95% CI
Males
Netherlands
Asylum seekers
Asylum seekers by age group
Asylum seekers by region#

ME/SW Asia
WCS Africa
31,205
25.6
2.36*
1.01-4.63
NEH Africa
14,284
42.0
3.32*
1.21-7.19
CES Europe
28,165
32.0
2.31*
1.06-4.38
40,509,314
2854
7.0
74,916
4.0
0.73*
Females
Netherlands
Asylum seekers
0.15-2.07
# numbers do not add up to total as not all regions are presented No further breakdown because of
small number of cases * rate ratios standardized for age
(risk ratio=7.3, 95% CI=2.2-23.7). Suicide mortality was more common in male asylum
seekers than in males in the general population in the Netherlands. No difference was
found between suicide mortality in female asylum seekers and in the female general
population of the Netherlands (Table 2.2.1). Compared to the Dutch population, we
found increased risk for suicide for males from WCS Africa, NEH Africa and CES Europe.
The number of suicide deaths in females was too small to be able to draw any conclusions. No suicide deaths were recorded in asylum seekers under the age of 15 (data not
shown).
There were 290 cases of suicidal behaviour treated in hospital (Table 2.2.2). Hospitaltreated suicidal behaviour was more common in female asylum seekers than in male
asylum seekers (RR=1.58; 95% CI=1.25-1.99). Compared to the population of The Hague,
male and female asylum seekers from CES Europe and ME/SW Asia were at increased risk
of hospital-treated suicidal behaviour; asylum seekers from NEH and WCS Africa were
at lower risk of hospital-treated suicidal behaviour (Table 2.2.2). In the age group < 15
years we recorded 11 acts of hospital-treated suicidal behaviour in girls but none in boys
(data not shown).
53
54
Section 2.2
Table 2.2.2 Hospital-treated suicidal behaviour rates by sex, age, region of origin and rate ratios for
asylum seekers in comparison with the population of The Hague
95% CI
Subgroup
number of
person years
number of hospitaltreated suicidal

behaviour
cases#
Hospitaltreated suicidal
behaviour rate/
100,000/year
Hospitaltreated
suicidal
behaviour
rate ratio*
The Hague
558,762
489
87.5
Asylum seekers
125,026
149
119.2
1.42*
1.20-1.66
44,171
48
108.7
1.49
1.02-2.17
25-34
42,459
39
91.9
1.02
0.71-1.46
>=35
38,396
58
151.1
1.68
1.27-2.22
ME/SW Asia
40,278
55
136.6
1.60*
1.20-2.08
WCS Africa
31,205
22
70.5
0.88*
0.55-1.32
Sex
Males

15-24
Asylum seekers by region
NEH Africa
14,284
35.0
0.41*
0.13-0.96
CES Europe
28,165
57
202.4
2.37*
1.79-3.07
The Hague
595,215
947
159.1
Asylum seekers
74,916
141
188.2
1.00*
0.84-1.18
15-24
22,655
34
150.1
0.51
0.36-0.73
25-34
24,384
46
188.6
1.18
0.86-1.63
>=35
27,877
56
200.9
1.57
1.19-2.07
ME/SW Asia
21,894
55
251.2
1.40*
1.06-1.82
WCS Africa
13,570
36.8
0.17*
0.05-0.38
Females
Asylum seekers by region
NEH Africa
8,041
37.3
0.19*
0.04-0.55
CES Europe
23 992
61
254.3
1.44*
1.10-1.85
# numbers do not add up to totals as age is not available for all cases and not all regions are presented *
rate ratios standardized for age
Factors that could guide prevention

Mental health problems
In nearly 80% of cases of hospital-treated suicidal behaviour, the notifying health professional was aware of the existence of mental health problems and nearly three quarters
of these asylum seekers were receiving some form of mental health treatment prior to
the hospital-treated suicidal behaviour (Table 2.2.3). The table shows no significant differences between male and female cases with respect to health professionals knowledge
Table 2.2.3 Distribution of mental health problems and mental health treatment among hospital-treated
suicidal behaviour cases
% of suicidal behaviour Prevalence rate % of suicidal behaviour cases
with known mental health
ratio
cases for which health staff
problems that received
(95% CI)
knew of the existence of
mental health treatment
prior to the reported suicidal
prior to the reported suicidal
behaviour (absolute number
behaviour (absolute number
of cases)
of cases)#
Total
78.7 (222)
Treatment rate
ratio (95% CI)
73.0 (162)
Sex
Male
74.5 (108)
66.7 (72)
Female
83.2 (114)
1.12 (0.99-1.26)
78.9 (90)
1.18 (1.01-1.39)
Age group
15-24
64.6 (53)
64.2 (34)
25-34
82.4 (70)
1.27 (1.06-1.54)
72.9 (51)
1.14 (0.98-1.45)
>=35
85.2 (98)
1.32 (1.10-1.57)
77.6 (76)
1.21 (0.96-1.52)
ME/SW Asia
78.0 (85)
72.9 (62)
WCS Africa
63.0 (17)
0.86 (0.58-1.53)
29.4 (5)
0.41 (0.32-2.05)
NEH Africa
75.0 (6)
0.96 (0.37-1.94)
33.3 (2)
0.38 (0.11-2.78)
CES Europe
83.8 (98)
1.06 (0.81-1.21)
80.6 (79)
1.14 (0.79-1.23)
Region of origin
# number of hospital-treated suicidal behaviour cases for which health staff were aware of the existence
of mental health problems;
number of hospital-treated suicidal behaviour cases for which health staff were aware of the existence
of mental health problems and who were receiving mental health treatment
about their mental health problems, but mental health treatment was 20% more common
in females. The prevalence of mental health treatment seems to be lower for asylum seekers originating from Africa compared with people from other regions, while only small
differences were found in the known existence of mental health problems (Table 2.2.3).
Stressors
The most frequently reported stressor for hospital-treated suicidal behaviour was the
asylum procedure (30.4%). The other stressors were: relationship issues (21.2%), loss of
a family member (13.1%), transfer between centres (9.2%), substance abuse (9.2%) and
living conditions (3.9%).
Methods used
The distribution of methods used differed considerably between cases of death from
suicide and hospital-treated suicidal behaviour (Table 2.2.4). In suicide deaths, hanging
was the most common method used and in hospital-treated suicidal behaviour cases,
this was poisoning with drugs.
55
56
Section 2.2
Table 2.2.4 Distribution of methods used in suicide death and hospital-treated suicidal behaviour cases
Method used
Suicide death cases (%)*
Hospital-treated suicidal behaviour

cases (%)*
Hanging
5 (25.0)
8 (2.9)
Poisoning by drugs
3 (15.0)
203 (72.8)
Moving object
3 (15.0)
3 (1.1)
Poisoning by other means
2 (10.0)
12 (4.3)
Drowning
2 (10.0)
2 (0.7)
Jumping
2 (10.0)
6 (2.2)
Cutting
2 (10.0)
39 (14.0)
Burning
1 (5.0)
6 (2.2)
* as a percentage of the cases for which a method was reported
DISCuSSIOn
This study is, to our knowledge, unique in the length of the study period, the number
of cases observed and the combination of suicide death and suicidal behaviour data.
The suicide death rate was high in male asylum seekers compared with the reference
population, whereas no conclusion could be drawn for females due to the small number
of cases. The hospital-treated suicidal behaviour incidence was not homogenously
distributed in the asylum seeker population. In several subgroups the rates were higher
than in the reference population, but lower rates were also found. Among African asylum seekers, male suicide mortality was high, but male and female hospital-treated
suicidal behaviour rates were low. Among Europeans, the suicide mortality rate was
low for males and hospital-treated suicidal behaviour rates were high for both sexes.
For Middle East/South West Asians, only hospital-treated suicidal behaviour rates were
increased. Health professionals were aware of mental health problems existing prior to
the hospital-treated suicidal behaviour in nearly 80% of the cases.
All suicide death notifications contained clear case descriptions, so we do not expect
any overestimation with regard to suicide death. It is possible, as in other studies of
this kind, that some suicide deaths have not been included because they may have
been coded under other external causes of death.18 Cases of death in asylum seekers
for which no cause has been reported can also hide suicides. However, because of the
huge impact of a suicide death in an asylum seeker centre, we assume that virtually all
cases considered suicide deaths were reported. For hospital-treated suicidal behaviour,
on the other hand, we expect that our results are an underestimation as some of this
behaviour may not have come to the attention of MOA staff. Moreover, the reporting
may have been incomplete. But due to the continuous presence of medical staff at the
asylum centres, cases may have come to their knowledge that might have been missed
in the general population.
The results of this study should be interpreted with caution because of the small number of cases, particularly for suicide death. No conclusion could be drawn with respect
to suicide mortality among females because of the small number of cases. Comparison
with data from other studies has to be done cautiously because of differences in data
sources, particularly for the hospital-treated suicidal behaviour rate. The use of suicidal
behaviour reference data for the city of The Hague may have influenced our results. The
incidence rate in The Hague is 10-20% higher than estimates for the Netherlands.21 This
implies that for the subgroups with increased hospital-treated suicidal behaviour rates,
the difference with the general population of the Netherlands would be somewhat
larger. For the African groups, for whom we observed lower rates, the difference would
be somewhat smaller, but would still remain.
Interpretation of results
The current study suggests that suicide death is higher in male asylum seekers than
in the general male population of the Netherlands. The incidence was higher than in
the reference population for several regions of origin, despite supposed underreporting. As in many populations, in asylum seekers suicide was more prevalent in men and
hospital-treated suicidal behaviour more prevalent in women.5 The male to female ratio
for the number of suicide deaths in this study (10:1), however, was higher than generally
found (between 3:1 and 7.5:1).5 Various hypothesises can be formulated for this gender
difference. The higher risk for males could be related to the lower use of mental health
services. Additional explanations are that males are at greater risk if they are forced
to return to their country of origin, the supposed higher pressure to succeed, more
negative consequences of not being allowed to work and a higher prevalence of drug
use.25,26 Protective factors for women could be having children to care for and stronger
social networks.26 The gender differences for hospital-treated suicidal behaviour varies
between regions of origin, reflecting the general fact that the gender difference paradox
in suicidal behaviour is not constant across countries.27
The regional differences found in hospital-treated suicidal behaviour rates are fairly
consistent with data from Sweden, where the rates showed considerable differences between countries and regions of origin, with the lowest risk among Africans.7 In general,
rates in immigrants tend to co-vary with rates in the country of birth.3 It is uncertain
whether the differences found between regions reflect suicide death and hospitaltreated suicidal behaviour rates in countries of origin, as we had to group countries
57
58
Section 2.2
together and because suicide statistics for countries of origin were either unavailable
or outdated.28
The majority of asylum seekers with hospital-treated suicidal behaviour were known
to suffer from mental health problems. A recent review states that evidence on a relationship between PTSD and suicide or suicidal behaviour among refugees is limited.26
In a retrospective case-control study in asylum seekers in the Netherlands, including
40 suicide deaths and 40 matched controls, PTSD was not associated with suicide, and
mental health treatment in the home country was more prevalent in suicide cases than
controls (unpublished study by Koeman M and Kerkhof AJFM, 2004).
The much lower treatment rate of mental health problems in people with hospitaltreated suicidal behaviour from Africa, compared with people from ME/SW Asian and
CES European origin, is a concern. Low mental health treatment rates in African asylum
seekers and refugees have been reported in other studies in the Netherlands and the
UK.30,31
Hanging was the most common method in deaths from suicide in asylum seekers; it is
also the most common method in deaths from suicide in the general population, according to a European study into suicide methods.32 However, the proportion of asylum
seekers that used hanging (25%) was lower than in the European study (50%). This might
be related to the housing situation; asylum seekers share their room with others and
have little privacy. In cases of hospital-treated suicidal behaviour, poisoning by drugs
was the most common method and cutting the second most common. This pattern is
similar to that observed in both migrants and non-migrants in the WHO/EURO multicentre study on suicidal behaviour.33
Relationship issues, loss of family members, and other stressful life events are associated
with suicidal behaviour in the general population,3,5 and are also commonly reported in
asylum seekers.
The asylum procedure, however, is a stressor specific for this population. Asylum procedure recognition rates may well influence suicide death and suicidal behaviour rates.
As recognition rates and other factors, such as composition of the asylum population,
reception conditions and accessibility of health care for asylum seekers vary between
countries and over time,34,35 we expect that suicide death rates and suicidal behaviour
will vary between host countries and may change over time. Comparative research in
various host countries, including qualitative research, is required to assess how national
asylum policies influence the rate of suicide and suicidal behaviour in asylum seekers
and which preventive interventions are effective.
Training physicians to recognize and treat depression and suicidal behaviour has already shown impressive effects in reducing suicide death rates in general populations
and might contribute to reduction in asylum seekers as well.17 In parallel with suicide
prevention in prisons,36 health professionals and reception centre personnel who are
working with asylum seekers should be trained to recognize suicide ideation and to take
appropriate action.
COnCluSIOnS
This study suggests that male asylum seekers are at increased risk of death from suicide
in comparison with the population of the Netherlands. No conclusion could be drawn
for females due to the small number of cases. For males and females the incidence of
hospital-treated suicidal behaviour was higher for asylum seekers from ME/SW Asia
and CES Europe than in the reference population and lower for asylum seekers from
the African sub regions. The majority of people with hospital-treated suicidal behaviour
from ME/SW Asia and CES Europe had received some form of mental health treatment
prior to the hospital-treated suicidal behaviour. For asylum seekers from Africa the rate
of mental health treatment seemed to be lower. On the basis of this study we conclude
that targeted prevention of suicide death and suicidal behaviour in asylum seekers is
indicated.
ACknOwlEDGEMEnTS
We thank the Central Agency for the Reception of Asylum Seekers (COA) for providing
the denominator data and GGD The Hague for the reference data on suicidal behaviour.
We also thank Hennie Nijsingh for proofreading the paper, Wim Busschers for his advice
on statistical methods and Mandy Savage and Julie Box for the language editing.
59
60
Section 2.2
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
United Nations High Commissioner for Refugees: Asylum levels and trends in industrialized countries. Statistical overview of asylum applications lodged in Europe and selected Non-European
countries 2008. http://www.unhcr.org/statistics/STATISTICS/49c796572.pdf
United Nations High Commissioner for Refugees: [http://www.unhcr.org/cgibin/texis/vtx/search
?page=search&docid=45c06c662&query=definitions], (accessed March 25 2009).
Hawton K, van Heeringen K: Suicide. Lancet 2009, 373:1372-81.
Lonnqvist J: Major psychiatric disorders in suicide and suicide attempters. In The Oxford textbook
of suicidology and suicide prevention. Edited by: Wasserman D, Wasserman C. Oxford: Oxford
University Press; 2009:275-286.
Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S: Suicide and suicidal behavior. Epidemiol
Rev 2008, 30:133-54.
Arensman E, Kerkhof AJFM: Deliberate self-harm: epidemiology and risk factors. In New Oxford
Textbook of Psychiatry. 2 edition. Edited by: Gelder MG, Andreasen NC, Lopz-Ibor JJ, Geddes JR.
Oxford: Oxford University Press; 2009:957-963.
Westman J, Hasselstrm J, Johansson SE, Sundquist J: The influence of place of birth and socioeconomic factors on attempted suicide in a defined population of 4,5 million people. Arch Gen
Psychiatry 2003, 60:409-14.
Krysinska K, Lester D: Post-Traumatic Stress Disorder and suicide risk: a systematic review. Arch
Suicide Res 2010, 14:1-23.
Fazel M, Wheeler J, Danesh J: Prevalence of serious mental disorder in 7000 refugees resettled in
western countries: a systematic review. Lancet 2005, 365:1309-14.
Gerritsen AA, Bramsen I, Devill W, van Willigen LH, Hovens JE, van der Ploeg HM: Physical and
mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol 2006, 41:18-26.
Dupont HJBHM, Kaplan CD, Verbraeck HT, Braam RV, van de Wijngaart GF: Killing time: Drug and
alcohol problems among asylum seekers in the Netherlands. Int J Drug Policy 2005, 16:27-36.
Porter M, Haslam N: Predisplacement and postdisplacement factors associated with mental
health of refugees and internally displaced persons. JAMA 2005, 294:602-12.
Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M: Association of torture and other
potentially traumatic events with mental health outcomes among populations exposed to mass
conflicts and displacement: a systematic review and meta-analysis. JAMA 2009, 302:537-549.
Staehr MA, Munk-Andersen E: Suicide and suicidal-behavior among asylum seekers in Denmark
during the period 2001-2003. A retrospective study. Ugeskr Laeger 2006, 168:1650-3.
Cohen J: Safe in our hands?: A study of suicide and self-harm in asylum seekers. J Forensic Leg Med
2007, 15:235-44.
Bhui KS, Mckenzie K: Rates and risk factors by ethnic group for suicides within a year of contact
with mental health services in England and Wales. Psychiatr Serv 2008, 59:414-20.
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K,
Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M,
Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H: Suicide prevention strategies: a systematic
review. JAMA 2005, 294:2064-74.
van Oostrum I, Goosen S, Uitenbroek D, Koppenaal H, Stronks K: Mortality and causes of death
among asylum seekers in the Netherlands. J Epidemiol Community Health 2011;65:376-83.
Nock MK: Self-injury. Annu Rev Clin Psychol 2010, 6:339-63.
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
Statistics Netherlands: Statline Databank.http://statline.cbs.nl/StatWeb/?LA=en], (accessed

March 8 2009).
Burger I, Hemert E van, Schudel WJ, Middelkoop BJC: Suicidal behavior in four ethnic groups in
The Hague, 2002-2004. Crisis 2009, 30:63-7.
Rothman KJ: Modern Epidemiology Boston: Little Brown; 1986.
Breslow NE, Day NE: Statistical methods in cancer research. Vol 2. The analysis of cohort studies
Lyon: International Agency for Research on Cancer; 1980.
Uitenbroek DG: SISA 1997. http://www.quantitativeskills.com/sisa/distributions/binomial.htm],
(accessed Nov 15 2009).
Renner W: Post-Traumatic Stress in Asylum Seekers and Refugees from Chechnya, Afghanistan,
and West Africa: Gender Differences in Symptomatology and Coping. Int J Soc Psychiatry 2009,
55:99-108.
Kposowa AJ, McElvain JP, Breault KD: Immigration and suicide: The role of marital status, duration
of residence, and social integration. Arch Suicide Res 2008, 12:82-92.
Canetto SS: Women and suicidal behavior: a cultural analysis. Am J Orthopsychiatry 2008, 78:259266.
World Health Organization: Mental health country reports and charts. [http://www.who.int/
mental_health/prevention/suicide/country_reports/en/index.html], accessed 28 March 2011.
Panagioti M, Gooding P, Tarrier N: Post-traumatic stress disorder and suicidal behavior: A narrative
review. Clin Psychol Rev 2009, 29:471-82.
Gerritsen AA, Bramsen I, Devill W, van Willigen LH, Hovens JE, van der Ploeg HM: Use of health
care services by Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Eur J Pub Health 2006, 16:394-9.
McCrone P, Bhui K, Craig T, Mohamud S, Warfa N, Stansfeld SA, Thornicroft G, Curtis S: Mental
health needs, service use and costs among Somali refugees in the UK. Acta Psychiatr Scand 2005,
111:351-7.
Vrnik A, Klves K, van der Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, Reisch T, Scheerder
G, Arensman E, Aromaa E, Giupponi G Gusmo R, Maxwell M, Pull C, Szekely A, Sola VP, Hegerl U:
Suicide methods in Europe: a gender-specific analysis of countries participating in the European
Alliance Against Depression. J Epidemiol Community Health 2008, 62:545-51.
Michel K, Ballinari P, Bille-Brahe U, Bjerke T, Crepet P, De Leo D, Haring C, Hawton K, Kerkhof A,
Lnnqvist J, Querejeta I, Salander-Renberg E, Schmidtke A, Temesvary B, Wasserman D: Methods
used for parasuicide: results of the WHO/EURO multicentre study on parasuicide. Soc Psychiatry
Psychiatr Epidemiol 2000, 35:156-63.
Kate MA: The provision of protection to asylum-seekers in destination countries. New issues in
refugee research Working paper 114 Geneva: UNHCR; 2005.
Norredam M, Mygind A, Krasnik A: Access to health care for asylum seekers in the European Union
- a comparative study of country policies. Eur J Pub Health 2006, 16:285-9.
Konrad N, Daigle MS, Daniel AE, Dear GE, Frottier P, Hayes LM, Kerkhof A, Liebling A, Sarchiapone
M, International Association for Suicide Prevention Task Force on Suicide in Prisons: Preventing
suicides in prisons, part 1; Recommendations from the International Association for Suicide
Prevention Task Force on Suicide in Prisons. Crisis 2007, 28:113-21.
61
Section 2.3
High diabetes risk among
asylum seekers in the netherlands
This study has been accepted for publication in Diabetic Medicine as:
Goosen S, Middelkoop BJC, Stronks K, Agyemang Kunst AE. High diabetes risk
among asylum seekers in the Netherlands
64
Section 2.3
ABSTRACT
Aims
Migrants have been reported to be at increased risk for diabetes in comparison with
host populations in Western countries. Data for new migrant groups including asylum
seekers, however, are scarce. This study aimed to map the prevalence and incidence of
recorded diabetes among asylum seekers by demographic factors and length of stay in
the host country.
Methods
We used a nationwide database from the Community Health Services for Asylum Seekers. The study population consisted of all asylum seekers aged 20 to 79 years who arrived
in the Netherlands between 2000 and 2008. Case allocation was based on codes of the
International Classification of Primary Care (ICPC). Data from a general practice registry
were used as reference population. Standardized prevalence (SPR) and incidence ratios
(SIR) were calculated; Cox regression was used to explore association with length of stay.
Results
The study included 59,380 asylum seekers and 1,227 cases of recorded diabetes. The
prevalence of recorded diabetes was higher among asylum seekers compared to the
reference population among men (SPR=1.85; 95%CI 1.71-1.91) and women (SPR=2.26;
95%CI 2.08-2.45). The highest standardised prevalence ratios were found for asylum
seekers from Somalia, Sudan and Sri Lanka. The standardised prevalence ratio was
higher as of 30 years. Incidence rates were higher than in the reference population in all
length-of-stay intervals.
Conclusions
Asylum seekers from the majority of countries of origin were at increased risk of diabetes
compared to the general population in the Netherlands. Asylum seekers from Somalia
were at particularly high risk. This emerging public health issue requires attention from
policy makers and health care providers.
Diabetes prevalence and incidence
InTRODuCTIOn
Migrants from various non-Western countries of origin are reported to be at increased
risk of diabetes in comparison with host populations of industrialized countries.1-7 However, available data mainly report on migrant groups with a relatively long migration
history.1-7 Epidemiological data on diabetes for migrant groups that have arrived more
recently, including asylum seekers, are scarce.
People who have fled their country of origin and are awaiting a decision on their
asylum request are called asylum seekers. The United Nations High Commissioner for
Refugees (UNHCR) estimates that 479,300 asylum applications were registered in the 44
industrialized countries in 2012.8 The top ten countries of origin were Afghanistan, Syria,
Serbia, China, Pakistan, Russian Federation, Iraq, Iran, Somalia and Eritrea.8 The number
of refugees, the persons who have been granted asylum, was estimated at two million in
the 44 industrialized countries in 2011.9
The asylum population may face an accumulation of diabetes risk factors such as increased genetic susceptibility, early life exposures such as low birth weight, exposure
to famine in childhood, a sweeping socio-economic change, acculturation stress, and
lifestyle factors in the host country.2,3,7,10,11 On top of that some risk factors may be
particularly prevalent among asylum seekers such as stress, depression, post-traumatic
stress disorder (PTSD), and sleep disorders.12,13 We have reported earlier that asylum
seekers with PTSD had a nearly one and a half times greater odds of diabetes diagnosis
compared to other asylum seekers.14
In several countries of origin of asylum seekers the diabetes prevalence is higher than
in the Netherlands (e.g. Iran, Iraq, Syria and Sudan). In conjunction with the risk factors
that asylum seekers face this suggests that asylum seekers may be a high-risk group for
diabetes.15 In order to know whether interventions aimed at prevention, early diagnosis
and treatment of diabetes among asylum seekers are required policy makers and health
professionals will need insight into the burden of diabetes among asylum seekers.
However, data on the diabetes prevalence among asylum seekers are scarce. A study in
the United States of America (USA) based on health screenings shortly after arrival in the
US, showed a low rate of diabetes among asylum seekers and refugees.16 Studies in the
USA and Canada, however, found a one and half times higher diabetes risk for refugees
compared to other migrants.6,17 Several studies report on migrants from the regions of
origin of asylum seekers, but do not distinguish by residence status and provide results
for only a few of the countries that asylum seekers originate from.1,5,6,12,13 These studies
65
66
Section 2.3
found larger differences in women than in men for the diabetes risk in comparison with
the host population, a lower age at onset of diabetes and a growing risk difference with
increasing length of stay.1,5,6,12,13
A database with health data on 59,380 asylum seekers in the Netherlands allowed for
analysis of prevalence rates of recorded diabetes for asylum seekers from 17 countries
of origin. Reference data for comparison with the Dutch population were also available.
The database allowed for a unique analysis of the development of the incidence of
recorded diabetes by length of stay. This gives an indication of how the risk difference
between asylum seekers and the reference population developed with length of stay.
The aim of this study was to assess the prevalence and incidence of diabetes among
asylum seekers by country of origin, gender, age, and length of stay.
METHODS
Study population
The study population consists of 59,380 asylum seekers. Inclusion criteria were arrival in
asylum reception between 1 January 2000 and 31 December 2008, at least three months
stay in reception, and age on arrival between 20 and 79 years. Resettlement refugees
were excluded as they were invited by the Dutch government to resettle in the Netherlands because of specific needs, which may include health problems.
Asylum seekers in the Netherlands live in asylum-seeker centres managed by the Central
Agency for the Reception of Asylum Seekers (COA). Health care for asylum seekers in
the Netherlands did not differ much from the health care provided to residents of the
Netherlands.18 Primary curative care was provided by nurse practitioners of the Community Health Services for Asylum Seekers (MOA) and mainstream family physicians,
who worked in close collaboration. Nurses and public health physicians of the Community Health Services for Asylum Seekers offered all asylum seekers a (non-mandatory)
preventive health assessment in the first months after arrival. There was no routine
screening for diabetes or other chronic diseases.
Data
We used data from an electronic database of the Community Health Services for Asylum
Seekers. Staff of the Community Health Services for Asylum Seekers and family physicians recorded health and psychosocial data, based on their findings during preventive
and curative consultations, in paper medical records. They used the problem-oriented
records (POR) method.19 Main and chronic health problems were recorded on the
problem list along with the International Classification of Primary Care code (ICPC), date
of diagnosis, and a short open field description. Problem list information was entered
in the electronic medical record system of the Community Health Services for Asylum
Seekers. This system also contained demographic and reception data from the Central
Agency for the Reception of Asylum Seekers.
The diagnosis of diabetes followed the protocol in use in family practices in the Netherlands. The diagnosis required an elevated glucose level (fasting plasma glucose levels
of 7.0 mmol/l, a fasting capillary glucose level of 6.0 mmol/l, or non-fasting plasma or
capillary glucose level of 11.0 mmol/l) that was confirmed using a fasting glucose test a
few days later. Data with respect to the type of diabetes were insufficiently complete for
distinction between type 1 and type 2 diabetes.
For case status allocation a computerized search was done to select all asylum seekers
with the ICPC code for diabetes (T90) or an open field description containing diabe,
DM, D.M, or suikerziekte (Dutch for diabetes). SG manually checked all records.
Fifty-nine asylum seekers with ICPC code T90 were not allocated case status because the
open field descriptions did not contain any information indicating diagnosis of diabetes
or only contained description of gestational diabetes. Seventy-four cases were allocated
case status on the basis of open field descriptions.
Country of origin is the country that was documented by the Immigration Department;
in general this was the nationality of the asylum seeker. Grouping into regions follows
the World Bank classification (http://data.worldbank.org/about/country-classifications/
country-and-lending-groups).
The Netherlands Information Network of General Practice (LINH) provided the reference
data on diabetes in the general population.20 The database of the Netherlands Information Network of General Practice includes continuous family practice data on morbidity
among more than 350,000 listed patients. Participating general practices are considered
representative for all general practices in the Netherlands.20 Patients of the Netherlands
Information Network of General Practice general practices are comparable to the general
population of the Netherlands with respect to age, gender and health insurance type.20
LINH does not contain data on socioeconomic status or ethnicity of the patients, but
there are no indications that LINH would not be representative in this respect (I. Stirbu,
20-2-2014, personal communication). Non-Western migrants constituted approximately
10% of the population in the Netherlands in 2005 and main countries of origin were
Turkey, Morocco and Surinam.21
67
68
Section 2.3
Analysis of the prevalence of recorded diabetes

We calculated the prevalence of recorded diabetes as the number of recorded cases of
diabetes per 100 asylum seekers. As diabetes is a chronic condition this can be considered as point prevalence of diagnosed cases of diabetes at the end of reception period.
Comparison of the prevalence of recorded diabetes between asylum seekers and the
population of the Netherlands Information Network of General Practice was done with
standardized prevalence ratios (SPR) using the indirect method of standardization.22
Standardised prevalence ratios are ratios of the observed and the expected number
of cases. The former represents the number of cases observed for the asylum seeker
group. The latter represents the number of cases expected in the hypothetical case that
this group would have the age-sex-specific diabetes prevalence rates of the patients of
the Netherlands Information Network of General Practice. In these calculations asylum
seekers were classified according to age at arrival in the Netherlands. Country-specific
analysis of the reception-time prevalence was done for countries with more than 1,000
asylum seekers in the study population. We calculated 95 percent confidence intervals
(95% CI) for the standardised prevalence ratio using the exact method proposed by
Ulm.23
Analysis of the association with length of stay

Cases of diabetes recorded in the first months after arrival in the host country were a
combination of new diabetes diagnoses as well as cases that already had developed
diabetes before arrival. Because of this catching-up process, it is not useful to compare
incidence rates observed in the first months after arrival with incidence rates in the
reference population. As it seemed likely that this catching-up process concentrated in
the first months after arrival, we have calculated point prevalence rates at six months
length of stay and incidence rates for the intervals as from six months length of stay. Like
in any health care based study the incidence is not a diabetes-onset incidence but an
incidence of diagnosed diabetes.
The incidence of recorded diabetes was calculated as the number of newly recorded
cases divided by the cumulative number of years spent in reception, multiplied by 1,000
to get the rate per 1,000 person years. For cases only the time spent in reception up to the
date of diagnosis of diabetes was included in the denominator. Standardised incidence
ratios (SIR) and 95% confidence intervals were calculated using the same methodology
as for the standardised prevalence ratio.
For studying the association with length of stay, we divided the data for each asylum
seeker into records per length-of-stay interval (0-5, 6-11, 12-23, 24-35, 36-47, 48-59 and
60-108 months). Details on the methodology that is based on multivariate Cox regres-
sion has been described in detail for another study on the same database.24 With this
methodology we calculated relative risks (RR) controlled for country of origin, sex, age
in years and calendar year. Country-specific analyses of the prevalence at six months
after arrival, the incidence as from six months after arrival and multivariate models were
for reasons of statistical power only done for countries with more than 5,000 asylum
seekers.
Standardised prevalence and incidence ratios with 95% CI were calculated with Excel.
Multivariate analyses were performed with Statistical Software SPSS (SPSS Inc., Version
20.0, Chicago, IL).
RESulTS
Socio-demographic characteristics of the 59,380 asylum seekers in the study are
presented in Tables 2.3.1 and 2.3.2. Nearly two-thirds of the asylum seekers were men.
Countries with the largest number of asylum seekers were Iraq (15.9%), Somalia (10.5%)
and Afghanistan (9.1%). The study population was young, with an average age at arrival
of 28.4 years for men and 30.5 for women. The average length of stay in reception during
the study period was 2.5 years for men and 4.4 years for women. The average age at
arrival and the average length of stay differed between countries of origin (Table 2.3.1
and 2.3.2).
The total number of diabetes cases recorded during the study period was 1,227 and
the crude prevalence of recorded diabetes was 2.1%. The prevalence was higher for
women (2.7%) than for men (1.7%) for almost all countries of origin. Crude countryspecific prevalence rates ranged from and from 0.3% for women from Guinea to 11.7%
for women from Sri Lanka (Table 2.3.2).
The standardised prevalence ratio indicated a two times higher prevalence for asylum
seekers than for the reference population (SPR= 2.10; 95% CI 1.91-2.13). The standardised
prevalence ratio in comparison with the reference population was higher for women
(SPR=2.26; 95% CI 2.08-2.45) than for men (1.85; 95% CI 1.71-1.99). For most countries
of origin the age-standardised prevalence ratios of recorded diabetes were higher than
one for men and women (Table 2.3.1 and 2.3.2). For men and women from China and
men from Turkey the diabetes prevalence was at comparable level as in the reference
population (Table 2.3.1 and 2.3.2). Countries with the highest standardised prevalence
ratios for men and women were Sudan, Sri Lanka and Somalia (Table 2.3.1 and 2.3.2).
69
6,680
762
Syria
1,413
Sudan
39,043
All countries
28.4
28.7
27.2
28.1
29.8
34.7
34.7
29.7
30.5
26.0
28.0
22.6
20.7
28.6
26.7
24.5
31.6
30.4
30.6
Mean age at
arrival
in years
30.2
31.8
34.5
31.1
38.2
54.4
43.6
27.0
37.8
34.7
15.3
33.1
45.5
34.7
22.4
38.3
44.2
16.6
38.4
Average length of
stay
in months*
670
128
20
29
22
28
66
22
82
18
10
13
12
12
18
144
31
1.7
1.5
0.9
0.7
1.5
4.7
4.4
4.9
1.9
1.6
2.2
0.7
0.8
1.5
1.2
0.7
2.4
2.2
1.5
Recorded cases Crude prevalence of

of diabetes recorded diabetes (%)
* At departure from reception or 31st of December 2008 when still in reception ** Other than the countries presented individually in table
8,746
Other countries**
China
571
1,215
Turkey
East Asia and Pacific
1,365
611
Former Yugoslavia
498
Azerbaijan
570
Armenia
Europe and Central Asia
Sri Lanka
Afghanistan
3,457
3,695
Somalia
South Asia
2,612
Sierra Leone
888
DR Congo
1,205
972
Burundi
Guinea
1,721
Angola
Sub Sahara Africa
2,077
Iraq
number of
persons in study
Iran
Middle East and North Africa
Region / country of origin
1.85
1.71-1.99
0.37-2.49
1.38-1.96
1.13
0.40-1.58
1.65
0.87
0.82-2.04
1.36-2.87
2.03
1.35
1.15-2.73
1.83
2.69-5.76
1.79-4.26
2.86
1.10-1.80
2.28-3.54
2.86
4.05
1.11-2.89
1.87
1.43
1.00-3.12
1.13-4.16
1.88
2.35
0.68-2.24
1.25-4.11
1.32
0.91-2.38
2.43
1.54
0.90-1.85
1.75-2.43
1.32
95% CI
2.07
Standardised
prevalence ratio
Comparison with
reference population
Table 2.3.1 Characteristics of the study population, number of recorded diabetes cases, prevalence, and standardized prevalence ratio compared to the reference
population (MEN)
70
Section 2.3
st
Turkey
20,337
All countries
30.5
30.2
26.4
31.1
30.3
35.4
35.0
38.1
33.5
26.5
29.0
22.8
53.2
35.0
35.6
34.3
45.8
60.5
49.7
31.7
36.9
37.3
16.6
33.1
40.9
32.9
18.7
39.7
49.0
22.9
43.1
Average length
of stay
in months*
557
81
10
15
33
27
27
81
12
85
11
16
19
101
19
Recorded cases
of diabetes
2.7
1.7
0.8
2.9
1.7
5.3
5.6
11.7
4.1
2.8
3.4
1.0
0.3
1.8
1.2
1.5
4.7
3.7
1.7
Crude prevalence of
recorded diabetes
(%)
* At departure from reception or 31 of December 2008 when still in reception ** Other than the countries presented individually in table
4,863
Other countries**
China
392
879
343
Former Yugoslavia
480
619
Armenia
231
Azerbaijan
Sri Lanka
Afghanistan
1,967
426
South Asia
2,525
302
686
Guinea
Sierra Leone
Sudan
20.8
614
DR Congo
Somalia
28.4
735
Burundi
26.6
1,048
Angola
25.7
33.6
407
Sub Sahara Africa
Syria
34.5
1,094
2,756
31.5
Mean age at
arrival
in years
Iran
number of
persons in study
Iraq
Region / country of origin
2.26
2.08-2.45
0.24-3.05
1.27-1.98
1.14
1.60
0.93-2.67
1.31-4.86
1.66
2.74
1.60-3.48
1.62-3.26
2.43
2.47-5.37
2.35
1.76-2.73
5.19
3.75
2.96-4.56
2.68-8.78
3.71
2.21
0.03-5.86
1.12-5.49
1.25
1.28-5.09
1.23-4.26
2.46
2.80
1.64-4.54
2.86
1.50-3.82
2.50
2.79
0.91-2.31
1.77-2.63
1.51
95% CI
2.18
Standardised
prevalence ratio
Comparison with
reference population
Table 2.3.2 Characteristics of the study population, number of recorded diabetes cases, prevalence, and standardized prevalence ratio compared to the reference
population (WOMEN)

71
72
Section 2.3
a. Standardised prevalence ratio - Men
b. Standardised incidence ratio - Men
2
1
1
0
Afghanistan
Iraq
Somalia
Other countries
All countries
Afghanistan
c. Standardised prevalence ratio - Women

6
1
0
Afghanistan
Iraq
Somalia
Other countries
Somalia
Other countries
All countries
d. Standardised incidence ratio - Women
Iraq
All countries
Afghanistan
Iraq
Somalia
Other countries
All countries
Figure 2.3.1 Standardized prevalence ratio of recorded diabetes at six months after arrival and
standardized incidence ratio of recorded diabetes as from 6 months after arrival in comparison with the
reference population by country of origin for men (a, b) and women (c, d)
For Somali men and women the prevalence of recorded diabetes was higher than in the
reference population as from the age group 20-29 (Table 2.3.3). For all other countries
the standardised prevalence ratio was higher than one as from the age group 30-39
years, although the difference with the reference population was not for all subgroups
statistically significant. Among asylum seekers aged 60-79 years the diabetes prevalence
was 21% and the standardised prevalence ratio was nearly twice as high as in the reference population (men SPR=1.81; 95% CI 1.53-2.14 and women SPR=1.83; 95% CI 1.582.11; data not presented).
Figure 2.3.1 shows that the prevalence of recorded diabetes among asylum seekers was
already higher than in the reference population within six months after arrival in men
(all countries: SPR=1.35; 95% CI 1.24-1.48) and women (SPR=2.26; 95% CI 2.08-2.45)
(data in online appendix). For men from Iraq, Somalia and the other countries group the
standardised prevalence ratio six after arrival was higher than in the reference population (Figure 2.3.1a).The standardised incidence ratios as from six months after arrival for
men were for all subgroups higher than one, but the difference with the reference population was only statistically significant in the other-countries group (Figure 2.3.1b). For
women the standardised prevalence ratio six months after arrival and the standardised
incidence ratio as from six months after arrival were significantly higher than one for all
subgroups (Figure 2.3.1a and 2.3.1b). The highest ratios for these indicators were found
76
114
97
59
30-39
40-49
50-59
60-79
36
60-79
countries
31
50-59
31
51
40-49
20-29
18
25
60-79
30-39
15
50-59
20-29
17
40-49
19
60-79
13
50-59
30-39
15
40-49
18
20-29
17
30-39
Recorded
cases of
diabetes
20-29
Age group
Other
Iraq
Afghanistan
Somalia
Country of
origin
325
796
2,723
7,607
13,775
162
240
763
2,088
3,427
112
199
571
1,077
1,498
60
77
269
874
2,415
number of
persons in
study
18.2
12.2
4.2
1.0
0.2
22.2
12.9
6.7
0.9
0.2
22.3
7.5
3.0
0.7
0.1
31.7
16.9
5.6
2.1
0.7
Crude
prevalence
of recorded
diabetes (%)
Men
2.10-5.47
1.61-4.63
1.71-5.33
1.79-4.55
3.54
2.88
3.21
2.97
1.36-2.14
1.79-2.60
1.84-2.76
1.28-2.15
2.18
2.27
1.68
1.38-2.70
1.97
1.72
1.59-3.29
2.35
0.51-1.06
2.59-4.54
3.48
0.76
0.89-2.31
1.49
0.32-1.42
1.33-2.98
2.05
0.75
0.76-2.17
0.90-2.41
0.55-2.40
1.35
1.54
1.27
0.01-1.02
1.32-3.55
2.27
0.22
95% CI
Standardised
prevalence
ratio
80
88
64
43
15
50
31
11
30
23
15
11
23
14
11
25
12
401
640
1,773
4,107
6,198
195
223
452
918
968
180
142
296
651
698
96
86
163
634
1,546
number of
Recorded
cases of persons in study
diabetes
20.0
13.8
3.6
1.0
0.2
25.6
13.9
2.4
0.8
0.2
16.7
16.2
5.1
1.7
0.3
24.0
16.3
6.7
3.9
0.8
1.78
3.29
2.25
1.91
1.15
2.32
3.18
1.47
1.39
1.01
2.05
1.35
1.54
1.27
0.22
2.33
4.00
4.30
7.57
3.64
Crude
Standardised
prevalence
of recorded prevalence ratio
diabetes (%)
women
1.41-2.21
2.64-4.04
1.73-2.85
1.39-2.55
0.65-1.85
1.72-3.03
2.16-4.46
0.74-2.55
0.56-2.72
0.12-3.24
1.33-2.26
0.76-5.64
0.90-5.14
0.55-5.23
0.01-4.51
1.48-3.44
2.19-6.53
2.15-7.45
4.90-10.99
1.88-6.17
95% CI
Table 2.3.3 Prevalence rate of recorded diabetes and age standardized prevalence ratio (SPR) compared to the reference population by gender, country of origin, and
age group

73
74
Section 2.3
for men and women from Somalia (Figure 2.3.1). Multivariate analyses showed that the
increased risks for asylum seekers from Somalia cannot be explained by demographic
and reception variables (online appendix 1).
Table 2.3.4 shows that an increased incidence of recorded diabetes in asylum seekers
compared to the reference population was observed in all length-of-stay intervals,
although it did not always reach statistical significance. In women an increase in the
incidence was observed as from four years length of stay; in men this increase was not
observed. The pattern of the relative risks by length-of-stay interval, calculated with the
Cox regression analysis, is similar to the pattern of the standardised incidence ratios
over the length-of-stay intervals (Table 2.3.4). This shows that the incidence patterns
cannot be explained by changes over time in the composition of the asylum population
by country of origin, age and calendar year.
Table 2.3.4 Number of cases and incidence of recorded diabetes as of 6 months after arrival, standardised
incidence ratios compared to the reference population and relative risk (RR) compared to the 6-11 month
interval by gender and length of stay*
length of stay at
start interval
Men
Comparison with
Incidence Comparison with reference
Recorded number
population
6-11 months interval*
per 1,000
cases of of person
years person years Standardised
diabetes
95% CI Relative
95% CI
incidence ratio
risk
6-11 months (ref.)
44
13,222
3.33
2.11
1.53-2.80
12-23 months
34
18,752
1.81
1.12
0.77-1.54
0.58
0.36-0.93
24-35 months
29
12,720
2.28
1.29
0.87-1.83
0.59
0.34-1.02
36-47 months
25
8,812
1.50
1.50
0.97-2.18
0.66
0.38-1.16
48-59 months
20
5,754
3.48
1.73
1.05-2.61
0.66
0.35-1.25
60-108 months
26
8,132
3.20
1.39
0.91-2.01
0.46
0.22-0.96
women 6-11 months (ref.)
30
7,062
4.25
2.34
1.58-3.29
12-23 months
45
10,274
4.38
2.35
1.72-3.12
1.13
0.70-1.85
24-35 months
22
7,403
2.97
1.52
0.96-2.27
0.64
0.35-1.19
36-47 months
18
5,505
3.27
1.61
0.96-2.50
0.64
0.34-1.23
48-59 months
19
3,695
5.14
2.39
1.44-3.66
0.84
0.43-1.66
60-108 months
31
5,773
5.37
2.39
1.63-3.35
1.00
0.51-1.99
* Cox regression model included country of origin, age (as continuous variable) and calendar year at start
interval
DISCuSSIOn
The risk of recorded diabetes in asylum-seeking men and women was approximately
twice as high as in men and women in the reference population. Increased prevalence
rates were observed for most countries of origin and as of 30 years. The highest prevalence ratios were observed for asylum seekers from Somalia, Sudan and Sri Lanka. The
prevalence was already higher among asylum seekers than in the reference population
at six months after arrival. The incidence as from six months after arrival was higher than
the incidence in the reference population. For men and women from Somalia particularly
high prevalence and incidence ratios were observed. The incidence of recorded diabetes
among asylum seekers was higher than in the reference population in all length-of-stay
intervals.
Strengths and limitations

Unique features of this study are the size of the population, the availability of longitudinal data as from shortly after arrival in the host country and the nationwide coverage.
The study also has some limitations. The study has underestimated the actual prevalence of diabetes as it only includes diagnosed cases of diabetes, which is the case in all
studies based on health care registries.25 The comparisons with the reference population
could have been influenced by observation bias as the ratio of diagnosed and undiagnosed diabetes cases may have been different in asylum seekers and in the reference
population. The medical intake shortly after arrival might have increased the chance
of diagnosis of diabetes among asylum seekers. However, a relative overestimation of
diabetes cases among asylum seekers is not to be expected. It is unlikely that physicians have ordered diabetes tests at high rates because the majority of asylum seekers
was young and because most of physicians attention was in all probability drawn to
predominant health problems such as PTSD, depression, anxiety and stress related somatic complaints.26-29 On the contrary, the rates among asylum seekers may have been
underestimated as the diagnosis of diabetes among asylum seekers may have been
hampered by communication difficulties, limited health literacy, different interpretations of symptoms, and the predominance of issues related to the asylum procedure.
Another limitation is that variations in the mean length of stay between countries of
origin and between men and women may have influenced the prevalence ratios. As a
consequence, standardised prevalence ratios may have been underestimated for the
groups with relatively low average length of stay (e.g. men from Iraq with on average <
1.5 years length of stay) compared to groups with longer lengths of stay (e.g. men from
Azerbaijan > 4 years). The multivariate analyses provide estimates for risk differences
that have been corrected for length of stay, but this could for reasons of power only be
done for the larger countries of origin.
75
76
Section 2.3
Interpretation
The high diabetes prevalence and incidence ratios found for asylum seekers compared
to the reference population may have been caused by the accumulation of risk factors
such as genetic susceptibility, sweeping economic change, lifestyle factors and stress
related to migration and the asylum context. Whereas among asylum seekers the diabetes prevalence was higher among men than among women, the diabetes prevalence
is similar for men and women in the reference population. The finding that the risk
differences with the reference population are larger for women than for men is in line
with general migrant studies in Canada and Sweden.1,5 The increased risk as from the
30-39 year age group in comparison with the reference population adds to evidence
from other studies with respect to a lower age at diabetes onset in migrants.2,3,6
With respect to country of origin our study is the first to provide data for migrants in
Western host countries for most countries of origin. The increased risks found for most
countries of origin compared to the reference population can partly be explained by the
prevalence rates in the countries of origin. The most recent estimates of the International
Diabetes Federation (IDF) are only lower than the estimate for the Netherlands (5.9%)
for the African countries of origin. Sudan is an exception among the African countries
with an estimated rate of 9.1%.15 Other countries with an estimated prevalence more
than 1.5 times higher than for the Netherlands are Iran (10.6%), Iraq (9.7%), Syria (9.6%)
and China (8.8%). The high risks found for asylum seekers from Somalia in our study are
striking as the IDF estimates for Somalia is only 3.9%.15 It has to be noted, though, that
the IDF estimates have a considerable level of uncertainty due to limited availability of
primary data, particularly in countries at war.15,30
Other explanations for the high diabetes risk for asylum seekers from the majority of
countries of origin may be sought in the factors associated with the diabetes prevalence
such as exposure to famine in childhood, a sweeping economic change, life style factors
and stress may differ between countries of origin.
The particularly high diabetes risk for asylum seekers from Somalia is noteworthy. For
Somali men and women the standardised prevalence ratios of recorded diabetes within
six months after arrival were higher than for the other countries. For Somali women the
incidence as from six months after arrival was nearly twice as high as for women from
other countries. The age as from which an increased diabetes risk was observed, was
lower for asylum seekers from Somalia than for asylum seekers from other countries of
origin. Several qualitative studies among Somali immigrants in Western host countries
suggest that the increased diabetes risk in this population has already been noticed in
practice.31,32
Although the number of asylum seekers from Sudan was too small for the detailed
analyses, the standardised prevalence ratios suggest that their diabetes risk may be at
the same level as asylum seekers from Somalia. The results for the other African countries of origin suggest that the diabetes risk for asylum seekers from these countries
is high, but not as high as for asylum seekers from Somalia and Sudan. The rather low
prevalence for asylum seekers from Iran may be an example of selection mechanisms
that may be associated with diabetes risk. Iranian asylum seekers have a relatively high
educational level, which in general is associated with lower diabetes risk.33 The high
diabetes prevalence for Sri Lankan men and women is in line with findings for Sri Lankan
migrants in other Western host countries.34-36
The analysis of the incidence of recorded diabetes over the length-of-stay intervals
showed that incidence rates were persistently higher than in the reference population.
This implies that, with increasing length of stay, the difference in prevalence between
asylum seekers and the reference population increased. The pattern observed in female
asylum seekers of a decrease in the incidence ratio compared to the reference population after two years, followed by an increase as from four years after arrival that has been,
is striking. This pattern may be related to a combination of factors such as catching-up
of diabetes diagnosis in the first years after arrival, the possibility of varying stress levels
over time, and effects of changes in lifestyle and overweight. A longitudinal study in the
Netherlands showed that the diabetes risk may continue to increase after the granting
of asylum status.37 The difference in prevalence with the host population may, in line
with studies in general migrant groups, continue to increase long after arrival in the host
country.6,17
Asylum populations in other Western host countries are also likely to be at high risk of
diabetes as they largely originate from the same countries of origin as asylum seekers
in the Netherlands and are likely to share diabetes risk factors. Nevertheless it has to
be taken into account that the diabetes risk may be influenced by the demographic
composition of the asylum population, conditions in the host country and distribution
of length of stay.3 Furthermore, the ratio between diagnosed and undiagnosed diabetes
cases may vary between host countries as this may be influenced by differences in the
accessibility and quality of health care for asylum seekers.18
The high diabetes prevalence among asylum seekers shortly after arrival and the likelihood of further increase in risk over time suggest that diabetes among asylum seekers
and refugees is a problem of considerable public health importance in Western host
countries. The public health actions needed can be build upon the actions formulated for
migrants in general.36 The essentials of these actions include raising diabetes awareness,
77
78
Section 2.3
reducing stress and helping asylum seekers to develop a physically active lifestyle and
healthy dietary habits in their new environment.36,38 Interventions aimed at increasing
physical activity may have large effects as it will contribute to stress reduction, a risk factor for diabetes that is highly prevalent among asylum seekers. Policy makers may play
an important role in the prevention of diabetes by creating the conditions that stimulate
asylum seekers, adults and children, to be physically active as from shortly after arrival.
More research is needed to provide insight into the possibilities for intervention and
into the diabetes risk in refugee populations with longer lengths of stay.
In order to ensure early identification of diabetes cases health professionals should be
aware of the high diabetes risks among asylum seekers. Evidence suggests that diabetes
screening for recently arrived asylum seekers and refugees as from 35 years may be
indicated.4
ACknOwlEDGEMEnTS
We would like to thank Hennie Nijsingh for reading and commenting on draft versions
of the manuscript. The Netherlands Association for Community Health Services funded
the creation of the database of the Community Health Services for Asylum Seekers.
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
Abouzeid M, Philpot B, Janus ED, Coates MJ, Dunbar JA. Type 2 diabetes prevalence varies by
socio-economic status within and between migrant groups: analysis and implications for Australia. BMC Public Health. 2013;13:252.
Agyemang C, Addo J, Bhopal R, Aikins AG, Stronks K. Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature
review. Global Health. 2009;5:7.
Agyemang C, Kunst AE, Bhopal R, et al. Diabetes prevalence in populations of South Asian Indian
and African origins: a comparison of England and the Netherlands. Epidemiology. 2011;22:563-7.
Arunmozhi D, Harris SB. Guidelines for immigrant health; Appendix 14: Type 2 diabetes mellitus:
evidence review for newly arriving immigrants and refugees. CMAJ. 2011 (appendix).
Carlsson AC, Wandell PE, Hedlund E, et al. Country of birth-specific and gender differences in
prevalence of diabetes in Sweden. Diabetes Res Clin Pract. 2013
Creatore MI, Moineddin R, Booth G, et al. Age- and sex-related prevalence of diabetes mellitus
among immigrants to Ontario, Canada. CMAJ. 2010;182:781-9.
Oza-Frank R, Narayan KM. Overweight and diabetes prevalence among US immigrants. Am J
Public Health. 2010;100:661-8.
UNHCR. UNHCR Asylum trends 2012; Levels and trends in industrialized countries. Geneva; 2013.
United Nations High Commisioner for Refugees. UNHCR Statistical Yearbook 2011; Trends in
Displacement, Protection and Solutions. Geneva: UNHCR; 2012.
Misra A, Ganda OP. Migration and its impact on adiposity and type 2 diabetes. Nutrition.
2007;23:696-708.
Vandenheede H, Deboosere P, Stirbu I, et al. Migrant mortality from diabetes mellitus across
Europe: the importance of socio-economic change. Eur J Epidemiol. 2012;27:109-17.
Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental
health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294:602-12.
Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z. Anxiety, depression and PTSD in asylumseekers: assocations with pre-migration trauma and post-migration stressors. Br J Psychiatry.
1997;170:351-7.
Agyemang C, Goosen S, Anujuo K, Ogedegbe G. Relationship between post-traumatic stress
disorder and diabetes among 105,180 asylum seekers in the Netherlands. Eur J Public Health.
2012;22:658-62.
International Diabetes Federation. IDF Diabetes Atlas; Fifth edition. 2013.
Geltman PL, Dookeran NM, Battaglia T, Cochran J. Chronic disease and its risk factors among
refugees and asylees in Massachusetts, 2001-2005. Prev Chronic Dis. 2010;7:A51.
Oza-Frank R, Stephenson R, Narayan KM. Diabetes prevalence by length of residence among US
immigrants. J Immigr Minor Health. 2011;13:1-8.
Stirbu-Wagner I, Ursum J, Davids R, Gravestein JV, Van Althuis T, Jansen B, et al. Landelijk Informatienetwerk Huisartsenzorg. Feiten en cijfers over huisartsenzorg in Nederland. Utrecht /
Nijmegen; 2011.
CBS Statistics Netherlands. Demography of migrants in the Netherlands [in Dutch]. Bevolkingstrends. 2005;53:96-117.
79
80
Section 2.3
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
Rothman K.J. Modern Epidemiology. Boston/Toronto: Little, Brown & Co; 1986.
Ulm K. A simple method to calculate the confidence interval of a standardized mortality ratio
(SMR). Am J Epidemiol. 1990;131:373-5.
Goosen S, Stronks K, Kunst AE. Frequent relocations between asylum-seeker centres are associated with mental distress in asylum-seeking children: a longitudinal medical record study. Int J
Epidemiol. 2013;
Thygesen LC, Ersboll AK. When the entire population is the sample: strengths and limitations in
register-based epidemiology. Eur J Epidemiol. 2014;
Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ. 2001;322:544-7.
Uniona comparative study of country policies. Eur J Public Health. 2006;16:286-90.
Mbanya JC, Motala AA, Sobngwi E, Assah FK, Enoru ST. Diabetes in sub-Saharan Africa. Lancet.
2010;375:2254-66.
Guerin PB, Elmi FH, Corrigan C. Body composition and cardiorespiratory fitness among refugee
Somali women living in New Zealand. J Immigr Minor Health. 2007;9:191-6.
Wieland ML, Morrison TB, Cha SS, Rahman AS, Chaudhry R. Diabetes care among Somali immigrants and refugees. J Community Health. 2012;37:680-4.
Dourleijn E, Dagevos J (ed). Refugee groups in the Netherlands; The integration of Afghan, Iraqi,
Iranian and Somali migrants (in Dutch). The Hague: Netherlands Institute for social research;
2011.
Holmboe-Ottesen G, Wandel M. Changes in dietary habits after migration and consequences for
health: a focus on South Asians in Europe. Food Nutr Res. 2012;56
Jenum AK, Diep LM, Holmboe-Ottesen G, Holme IM, Kumar BN, Birkeland KI. Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with
Norwegians - the association with adiposity is strongest for ethnic minority women. BMC Public
Health. 2012;12:150.
Misra A, Khurana L. The metabolic syndrome in South Asians: epidemiology, determinants, and
prevention. Metab Syndr Relat Disord. 2009;7:497-514.
Lamkaddem M, Essink-Bot M.L., Devill WD, Gerritsen AA, Stronks K. Health changes of refugees
from Afghanistan, Iran and Somalia: the role of residence status and experienced living difficulties in the resettlement process. Submitted. 2013;
Bhopal RS. A four-stage model explaining the higher risk of Type 2 diabetes mellitus in South
Asians compared with European populations. Diabet Med. 2013;30:35-42.
Section 2.4
Induced abortions and teenage
births among asylum seekers
in the netherlands: analysis of
national surveillance data

Goosen S, Uitenbroek D, Wijsen C, Stronks K. Induced abortions and teenage
births among asylum seekers in The Netherlands: analysis of national
surveillance data. J Epidemiol Community Health. 2009;63:528-533
84
Section 2.4
ABSTRACT
Background
Asylum seekers are assumed to be a vulnerable group with respect to sexual and
reproductive health. The objective of this study was to quantify induced abortion and
teenage birth indicators for this group.
Methods
The population comprised all female asylum seekers aged 15-49 in the Netherlands
between September 2004 and August 2005. Information was collected about induced
abortions from notification forms and electronic patient files. The central agency for the
reception of asylum seekers provided population and birth data.
Results
Among asylum seekers the abortion rate (14.4/ 1000 women) and teenage birth rate
(49.1/1000) were higher than average in the Netherlands (8.6/1000 and 5.8/1000). Great
differences were found between subgroups. High abortion rates were seen among
women who were pregnant on arrival or got pregnant in the first months after arrival at
the reception facilities. Abortion and teenage birth rates were particularly high among
asylum seekers aged 15-19 from specific parts of Africa and Asia. Abortion ratios were
high among asylum seekers aged 30-49 from parts of Europe and Asia. Decreases in the
abortion rate and teenage birth rate were observed as the length of stay increased.
Conclusion
Abortions and teenage births were more common among asylum seekers than among
the overall population of the Netherlands. Increased rates were a consequence of
subgroups being at high risk. Abortion and teenage birth rates were very high among
women who were pregnant on arrival or got pregnant in the first few months after arrival, but decreased as the length of stay increased.
Induced abortions and teenage pregnancies
InTRODuCTIOn
Insight into sexual and reproductive health indicators is considered to be crucial for
policy and programmatic decisions concerning reproductive health services.1-4 Asylum
seekers are assumed to be a vulnerable group with respect to sexual and reproductive
health.5-9 By the end of 2004 European countries were host to more than 2,000,000
refugees and 270,000 asylum seekers.10 About a quarter of the refugees and internally
displaced persons worldwide are women of reproductive age.11 Studies on fertility and
contraceptive use in emergency phase camps revealed a mixed response to childbearing among those affected by war.12 Quantitative data about the sexual and reproductive
health status of asylum seekers in industrialised countries are, however, very scarce.9
The asylum population is diverse in many factors that are known to be associated with
abortions and teenage birth rates, for example age, country of origin, socioeconomic
status and level of education.13,14 The sexual and reproductive health of asylum seekers
may in addition be influenced by factors such as experiences in the country of origin and
during their flight, the uncertainty of the asylum procedure, frequent transfers, absence
of social structure, language and limited knowledge of the health system.7,9 A distinction can be made between asylum seekers becoming pregnant before or after arrival
at the reception facilities. Conception after arrival could have been influenced by the
reproductive health services available in the host country. So, indicators for this group
give a particularly good indication of the groups that need to be targeted with policy
and action aimed at preventing unwanted and teenage pregnancies in the host country.
The aim of the present study was to estimate the incidence of induced abortions and
teenage births in asylum seekers in the Netherlands in 2004-2005. Abortion and teenage birth indicators were compared among asylum seekers and with indicators for the
general population in the Netherlands. In addition, an attempt was made to find out
whether the incidence of abortions and teenage births varies between subgroups by
age, region of origin, and length of stay in the reception facilities.
METHODS
Data sources
Data were assembled on abortions and live births that took place between 1 September
2004 and 31 August 2005. Nurses from the community health services for asylum seekers (MOA, see box 2.4.1) were requested to report every abortion that came to their
knowledge. They did this on a form similar to the Dutch national abortion registry form.
85
86
Section 2.4
In addition, data were extracted from the MOA electronic database for records that
contained the International Classification of Primary Care (ICPC) code W83 (induced
abortion).
Data were obtained on live births in the reception facilities from the central agency for
the reception of asylum seekers (COA). COA also provided data on the total population
in the reception facilities on 1 April 2005 (mid-study), and these were used to estimate
the total person years spent in reception facilities during the study period. For comparison with the population of the Netherlands, data were used from the Dutch abortion
registry16 and Statistics Netherlands for 2005.17
Box 2.4.1 Health services for asylum seekers in the Netherlands
Health services for asylum seekers are very similar to services available to other residents of
the Netherlands. A health insurance company, through a special health insurance scheme, has
contracted mainstream health care providers to provide these services. Public health services,
including sexual and reproductive health promotion, are provided by regional associations of
community health services (MOA) in all asylum seekers centres. MOA offers every newly arrived
asylum seeker an initial consultation with a practice nurse and, if indicated, a public health doctor.
The nurse will in most cases address sexual and reproductive health issues at that occasion as
advocated for by Adams and colleagues.15
MOA nurses are also the first point of contact for asylum seekers for health issues and are responsible
for referral to mainstream health care. This includes referring pregnant women to a midwife and
helping women to get access to abortion services if they want to terminate an unwanted pregnancy.
Abortion and other sexual and reproductive health services are available free of charge, but asylum
seekers aged 21 years and over have to pay for contraceptives themselves. Condoms, though, are
available free of charge.
Indicators and demographic variables

The common reproductive health indicators were used: abortion rate, abortion ratio and
teenage birth rate (Box 2.4.2).3 Age at abortion or delivery was calculated using the date
of abortion or birth and the womans own date of birth. Length of stay in the reception
facilities at the time of abortion or childbirth was calculated using the date of abortion
or delivery and the date of registration at the reception facilities. For the denominator
population age and length of stay were used at 1 April 2005. The countries of origin
were first grouped according to the regions used by UNHCR.18 As the numbers were
small, these were merged into five regions (see footnote Table 2.4.3), taking into account
geographical location and differences in abortion indicators. Data about the few women
from other regions and stateless women are included in all analyses except those by
region.
Box 2.4.2 Indicators3

Induced abortion rate: number of abortions per 1000 women aged 15-49 - or per specific
subgroup - per year.
Induced abortion ratio (to live births): number of abortions per 1000 live births.
Teenage birth rate: number of live births per 1000 women aged 15-19 at delivery per year.
Research report
Three length-of-stay groups were distinguished. The first group had a length of stay of
less than three months. Three months was chosen as the cut-off point as the pregnancy
duration at the time of abortion was less than 13 weeks for more than 95% of the notified abortions. Women in this group who gave birth or had an abortion were pregnant
on arrival. The second group had a length of stay of between three and eight months.
Women in this group who gave birth were pregnant on arrival, and women who had an
abortion got pregnant after arrival in the reception facilities. The third group included
women with a length of stay of nine months or longer. All women in this group who
gave birth or had an abortion got pregnant after arrival in the reception facilities. Reproductive health choices of this group could have been influenced by services provided in
the Netherlands. Women who had an abortion after a length of stay of between three
and eight months could also have been influenced in their reproductive health choices
by services provided in the Netherlands. These abortions were analysed separately to
ensure clarity and consistency in abortion ratio calculations. Because of the limited
numbers in the shorter length of stay groups, analysis by age and region of origin was
only done for the group with length of stay nine months or longer.
Analyses were performed using the Statistical Package R (http://www.r-project.org)
and the online statistical calculator SISA (http://www.quantitativeskills.com/sisa). For
the tables, the Gamma measure was used as an indicator for ordinal association, chisquare for differences in distribution. The abortion rate is a proportional measure and
the proportions were univariately compared using the risk ratio and multivariately using
Poisson regression. The abortion ratio is in fact a rate ratio. In comparing the different
abortion ratios, a measure was used which can be interpreted similar to the risk ratio,
but the standard error was calculated on the basis of the odds ratio, using the odds of
having an abortion against not having an abortion. The standard errors for the ratios
were calculated according to the usual methods.19,20 For multivariate analysis, Poisson
regression was used. If the value 1 was not in the confidence interval, the comparison
was considered statistically significant. Significant differences are marked bold in the
tables.
87
143
9,931
454
9,218
3-8 months**
>= 9 months
15
116
498
63
80
642
187,910
live
births
12.6
33.0
34.7
14.4
8.6
Abortion
rate per
1000/year
1
1.0 (0.4 to 2.1)
0.4 (0.2 to 0.7)
3.8 (2.3 to 6.3)

1.5 (1.2 to 1.8)
n/a
1.7 (1.4 to 2.0)

4.0 (2.1 to 8.1)
n/a
Ratio vs <3
months (95%
CI)
(95% CI)
Ratio vs nl
232.9
238.1
112.5
222.7
152.9
Abortion
ratio per
1000 live
births
1.5 (1.2 to 1.9)
1.6 (0.9 to 2.7)
0.7 (0.4 to 1.5)
1.5 (1.2 to 1.7)
(95% CI)
Ratio vs nl
2.1 (1.0 to 4.2)
2.1 (0.9 to 5.2)
n/a
n/a
Ratio vs <3 months

(95% CI)
* Numbers do not add up as for three abortions and one live birth the length of stay is unknown.
** Note that for this group the nominator of the abortion ratio reflects abortions for women that got pregnant after arrival in the reception facilities, whereas the
denominator reflects births for women that were pregnant on arrival at the reception facilities.
259
< 3 months
28,738
Abortions
3,337,665
Asylum by length of stay:
Total asylum*
Netherlands total
number of
Table 2.4.1 Abortion rate and abortion ratio for asylum seekers aged 15-49, comparing length of stay groups and with overall averages for the Netherlands (NL)
88
Section 2.4
RESulTS
The overall abortion rate and ratio for asylum seekers were about one and a half times
higher (Table 2.4.1) and the teenage birth rate more than eight times higher than average for the Netherlands (Table 2.4.2).
Table 2.4.2 Teenage birth rate for asylum seekers, comparing length of stay groups and with the average
for the Netherlands (NL)
number of
n Abortions
Netherlands 15-19
Asylum 15-19*
< 3 months
3-8 months
>= 9 months
live
births
Teenage birth
rate per 1000/
year
5.8
Ratio vs < 3
Ratio vs nl
(95% CI) months (95% CI)
479,103
3,713
2,795
n/a
1650
39
81
72
13
49.1
8.4 (6.8 to 10.4)
n/a
180.6
30.9 (18.9 to 5.7)
87
25
287.4 49.3 (35.3 to 68.7)
1.6 (0.9 to 2.9)
1,491
29
43
4.9 (3.7 to 6.7)
0.2 (0.1 to 0.3)
28.8
* Numbers do not add up as for one abortion the length of stay is unknown.
Comparison between length-of-stay groups

The abortion rates were much higher for women who were pregnant on arrival or got
pregnant in the first few months after arrival in the Netherlands than for asylum seekers
with length of stay nine months or more (Table 2.4.1). The abortion ratio for women
with length of stay less than three months was lower than for the other groups. The
same patterns were seen for the rates and ratios in all age groups (data not shown). Very
high teenage birth rates were considered for girls with length of stay less than three and
between three and eight months (Table 2.4.2). For girls with length of stay nine months
or more the birth rate was much lower, but still nearly five times higher than average in
the Netherlands (Table 2.4.2).
length of stay nine months or more

The abortion rate and the abortion ratio were strongly associated with age (rate t=2.169;
df-t 1840; p=0.03, ratio z=-2.093; p=0.04) with the highest rate among 15-19 year olds
(Table 2.4.3). Among asylum seekers aged 15-19 and 30-49 the abortion rates were
higher than average for the Netherlands in these age groups (Table 2.4.3). The abortion
ratio was only half the average for the Netherlands among 15-19 year olds and twice the
average for the Netherlands among 30-49 year olds.
89
3,060
2,583
CES Europe
M East/SW Asia
321
119
466
412
107
NEH Africa
CES Europe
M East/SW Asia
CES Asia
1,491
479 ,103
WCS Africa
Of which*:
Total asylum
Netherlands total
15-19
555
906
CES Asia
1,744
NEH Africa
9,218
3,337,665
WCS Africa
Of which**:
Total asylum
Netherlands total
Total 15-49
Age group
14
29
3,713
12
18
30
10
42
116
28 ,738
Abortions
live
births
29
43
2,795
24
124
98
63
174
498
187, 910
number of
37.4
4.9
15.0
16.8
43.6
19.5
7.7
21.6
7.0
9.8
11.0
24.1
12.6
8.6
Abortion
rate per
1000/year
1000.0
800.0
0.6 (0.2 to 2.5)
1400.0
2000.0
4.8 (1.8 to 12.6)
1.9 (0.9 to 4.0)
2.2 (0.5 to 8.6)
482.8
674.4
5.6 (3.4 to 9.4)
1328.4
500.0
2.5 (1.7 to 3.6)
145.2
0.8 (0.5 1.3)
306.1
158.7
2.5 (1.4 to 4.4)
1.1 (0.8 to 1.6)
1.3 (0.7 to 2.4)
241.4
232.9
2.8 (2.1 to 3.8)
152.9
Abortion
ratio per
1000 live
births
1.5 (1.2 to 1.8)
Ratio vs nl
(95% CI)
1.2 (0.3 to 4.4)
0.8 (0.1 to 5.3)
1.1 (0.3 to 3.3)
1.5 (0.1 to 16.6)
0.4 (0.2 to 0.7)
0.5 (0.3 to 0.8)
3.3 (1.6 to 6.5)
0.9 (0.6 to 1.6)
2.0 (1.3 to 3.0)
1.0 (0.5 to 2.0)
1.6 (1.1 to 2.2)
1.5 (1.2 to 1.9)
Ratio vs nl (95%
CI)
46.7
4.9
10.7
8.4
90.3
28.8
5.8
Teenage
birth rate
per 1000/
year
8.0 (3.4 to 18.9)
0.8 (0.2 to 3.3)
1.8 (0.8 to 4.4)
1.4 (0.2 to 10.1)
15.5 (10.9 to 21.9)
4.9 (3.7 to 6.7)
Ratio vs nl (95% CI)
Table 2.4.3 Numbers of abortions and births, abortion rate, abortion ratio, birth rates, and rate ratios (95% confidence interval) for asylum seekers with length of stay
>= 9 months in comparison with the Netherlands (NL) by age group and region of origin*
90
Section 2.4
776
676
170
CES Europe
M East/SW Asia
CES Asia
1,818
1,495
CES Europe
M East/SW Asia
5
12
17
46
12 ,110
22
41
12, 915
live
births
68
48
23
51
202
113, 452
12
54
45
39
94
253
71, 498
number of
Abortions
18.0
8.0
9.4
6.8
10.3
9.6
6.4
17.6
5.9
7.7
14.5
26.2
14.0
13.3
Abortion
rate per
1000/year
176.5
714.3
1.3 (0.7 to 2.2)
354.2
130.4
2.8 (1.2 to 6.7)
1.5 (0.9 to 2.3)
1.1 (0.3 to 3.3)
117.6
227.7
1.6 (0.7 to 3.6)
106.6
250.0
74.1
133.3
128.2
234.0
162.1
180.6
Abortion
ratio per
1000 live
births
1.5 (1.1 to 2.0)
1.3 (0.4 to 4.1)
0.5 (0.2 to 1.2)
0.6 (0.3 to 1.3)
1.1 (0.5 to 2.6)
2.0 (1.3 to 3.0)
1.1 (0.8 to 1.4)
Ratio vs nl
(95% CI)
6.7 (2.1 to 21.1)
1.7 (0.9 to 3.1)
3.3 (1.9 to 5.8)
1.2 (0.4 to 4.1)
1.1 (0.5 to 2.6)
2.1 (1.6 to 2.9)
1.4 (0.4 to 4.9)
0.4 (0.1 to 1.1)
0.7 (0.3 to 1.7)
0.7 (0.3 to 1.8)
1.3 (0.8 to 2.1)
0.9 (0.6 to 1.2)
Ratio vs nl (95%
CI)
Teenage
birth rate
per 1000/
year
Ratio vs nl (95% CI)
* Region of origin explanation, per region the two most frequent countries are included. WCS Africa (West, Central, Southern Africa): Angola, Democratic Republic of
Congo; NEH Africa (North, East, Horn of Africa): Somalia, Sudan; CES Europe (Central, East, Southern Europe): Azerbaijan, Former Yugoslavia; M East/SW Asia (Middle
East and South West Asia): Afghanistan, Iraq; CES Asia (Central, East, Southern Asia): China, Sri Lanka (complete overview online).
** Numbers do not add up as the region code for some abortions is unknown.
278
442
CES Asia
582
NEH Africa
4,808
WCS Africa
Of which*:
Total asylum
Netherlands total
1 884,344
345
30-49
841
NEH Africa
2,919
974 ,218
WCS Africa
Of which*:
Total asylum
Netherlands total
20-29
Age group

91
92
Section 2.4
The abortion rate differed significantly between regions of origin, even after correction
for age differences (dependent variable abortion rate, covariates age group and region
of origin entered simultaneously: Chi2=23.6, df=4, p<0.01). The highest rates were found
among women from WCS Africa and CES Asia. Abortion ratios also differed between
regions (Chi2=19.9, df=4, p<0.01), but these differences were no longer significant after
correction for age (dependent variable abortion ratio, covariates age group and region
of origin entered simultaneously: Chi2=9.3, df=4, p=0.05).
Stratified analysis by age and region of origin showed that specific subgroups are at
increased risk. In the age group 15-19 the abortion and teenage birth rates for asylum
seekers from WCS Africa and CES Asia were significantly very high in comparison with
Dutch indicators for this age group (Table 2.4.3).
In the 20-29 age group there were just slight differences in abortion rates and ratios, and
only women from WCS Africa had a significantly higher abortion rate in comparison with
the Dutch average. Among 30-49 year olds a significantly higher abortion rate and ratio
was found for women from CES Asia and a significantly higher abortion ratio for women
from CES Europe.
length of stay
The abortion rate decreased considerably as the stay lengthened (Table 2.4.4). This
decrease was not explained by age or region of origin. The birth rate also decreased
Table 2.4.4 Number of abortions and live births, abortion rate, abortion ratio and teenage birth rate by
length of stay in the reception facilities (length of stay >= 9 months)
Length of stay
in reception
facilities
N
15-49
Number of Number of Abortion rate

per 1000
abortions live births
15-49 aged 15-49 /
15-49
year*
Abortion
Ratio 1549**
Number Teenage birth

N of teenage rate per 1000/
year ***
births /
15-19
year
9 to 12 months
174
34
28.7
147.1
35
200.0
1 to 2 years
921
19
70
20.6
271.4
228
11
48.2
2 to 3 years
852
15
60
17.6
250.0
168
11
65.5
3 to 4 years
1467
28
102
19.1
274.5
197
10
50.8
4 to 5 years
2133
24
104
11.3
230.8
303
9.9
5 years or more
3671
25
128
6.8
195.3
560
1.8
Results of Poisson regression with the average value of length of stay intervals in the model as covariate:
* Dependent variable abortion rate, covariates length of stay and age: z=-4.258, p<0.01; controlling for region:
z=3.418, p<0.01.
** Dependent variable abortion ratio, covariate length of stay: not significant; covariates length of stay and
age: not significant; covariates length of stay and region of origin: not significant.
*** Dependant variable teenage birth rate, covariate length of stay: z=5.454, p<0.01.
with length of stay (number of births per 1000 women per year, data not presented). No
clear pattern was observed for the abortion ratio. The teenage birth rate was very high
for girls with length of stay of between nine and twelve months and decreased in groups
with longer stays.
DISCuSSIOn
The abortion rate and the teenage birth rate among asylum seekers were higher than
average for the Netherlands. Great differences were found between the subgroups by
age, region of origin, and length of stay at the reception facilities. Looking at age group
and region, 15-19 year olds from WCS Africa and CES Asia had the highest abortion and
teenage birth rates. Pregnancies among 30-49 year olds from CES Asia, and to a lesser
extent CES Europe, were aborted proportionally much more often than is seen on average in this age group in the Netherlands. Looking at the length of stay, the groups at
highest risk of an abortion and of a teenage birth were asylum seekers with a length of
stay less than three months and between three and eight months. Abortion and teenage birth rates decreased with increasing length of stay.
limitations
The birth statistics are assumed to be complete, but some abortions may not have come
to the knowledge of MOA staff or may not have been reported, causing an underestimate of the total number of abortions. This does not seem to affect the conclusions,
however, as this underestimation is unlikely to be related to the variables analysed. The
mid-study population data used are an accurate estimate of the person years spent at
reception facilities: the number of women aged 15-49 on 1 April 2005 (9,931) is similar
to the average monthly population (9,895). Comparison of the mid-year population for
various groups by age and region of origin with monthly averages did not reveal great
differences either. Indicators for unaccompanied minor asylum seekers (UMAs) could
not be calculated due to incompleteness of the UMA-status variable.
Interpretation and comparison with results from other studies

For the group with a length of stay less than three months the high abortion rate
may relate to unwanted pregnancies conceived shortly before or during the flight. An
unknown number of these women got pregnant because they were raped or forced
to have sex with police, border guards or other people who took advantage of their
vulnerability, had sex in exchange for safety or passage,21 or simply had a normal sex life
during the long journey.22 It is assumed that the low abortion ratio shortly after arrival is
mainly a consequence of the fact that, for some women in this group, their pregnancy
93
94
Section 2.4
is in a stage where abortion is no longer an option. It may, however, also mean that
women who recently arrived at the reception facilities were less aware of the availability
of abortion services.
The high abortion rate for women with a length of stay of three to eight months implies
a high incidence of unwanted pregnancies and therefore unprotected or insufficiently
protected sex in the first few months after arrival at the reception facilities. Specific approaches and methods may need to be developed to increase effective prevention of
unwanted pregnancies among newly arrived asylum seekers, especially teenagers, as
for most of them their first concerns are the asylum procedure and practical issues in
their new situation. To do so, more insight is required into why contraceptives are not
used or used incorrectly, the needs of the women concerned, and what they think of the
information and services provided.
The overall abortion rate for asylum seekers with a length of stay of nine months or more
(12.6/1000) is lower than the recent estimate by Sedgh and colleagues for the entire
world (29/1000) and close to the estimate for Western Europe (12/ 1000).14 The abortion
ratio of 232.9 per 1000 live births is lower than the estimate for the world (310/1000) and
at the same level as Western Europe (230/1000). The assumption that the reproductive
health status of asylum seekers is poor is not reflected in the abortion indicators for
female asylum seekers who have been at the reception facilities for a while. This may
be a consequence of the fact that the Netherlands grants asylum seekers full access to
reproductive health services.
The abortion rate and ratio are, as expected, associated with age, but the finding that the
15-19 age group had the highest abortion rate is striking, as the highest abortion rates
are in general found in women in their 20s.8,13 An explanation may be that socioeconomic disadvantage, disrupted family structure, social isolation, and mental vulnerability,
which are known to be risk factors for teenage pregnancy in the general population in
Europe,23,24 affect a large proportion of teenage asylum seekers. In addition, young girls
are assumed to be especially vulnerable to sexual abuse, and prostitution.25 The high
teenage birth rates may also be a consequence of the incorrect belief that women who
give birth after arriving in the host country will be granted a residence permit. For UMAs,
the desire to have something of their own may be a reason for the high birth rates.26
In line with the existence of worldwide variations in abortion indicators at a regional
or subregional level,14 considerable differences were found in abortion rates and ratios
between asylum seekers from different regions of origin. But the pattern was not consistent across groups by age, region, or length of stay. Some subgroups of asylum seekers,
especially those with longer lengths of stay, had lower abortion and teenage birth rates
than women in the countries of origin. This is also seen among labour migrants in Europe and women in refugee camps in the regions of origin.12 Whereas Eastern Europe is
the region with the highest abortion rate and ratio worldwide,14 the abortion rate found
among asylum seekers from this region was relatively low and the abortion ratio only
high among 30-49 year olds. The highest abortion and teenage birth rates were found
among teenage asylum seekers from WCS Africa and CES Asia. These are also the regions
with the highest teenage birth rates in the world.27 But although the teenage birth rate
for girls in NEH Africa and M East/SW Asia is high, the abortion and birth rates for asylum
seekers were relatively low. One explanation may be that childbearing among unmarried adolescents is more common in sub-Saharan Africa than in NEH Africa and M East/
SW Asia.27
The decrease of the abortion rate as the length of stay at reception facilities increased
implies that asylum seekers benefit from the reproductive health education and services
offered in the Netherlands. But the results in the Netherlands cannot automatically be
extrapolated to other countries as only very few countries provide asylum seekers with
full access to sexual and reproductive health services.7,9,28 It is worth investigating the
reproductive health outcomes among asylum seekers in other countries.
COnCluSIOnS
The present study identified subgroups with high abortion and teenage birth rates:
recently arrived women, especially young girls from WCS Africa and CES Asia, are at
increased risk. More insight should be generated into why the rates in these groups are
so high and good practices should be developed to address the reproductive health
needs of these groups. The considerable overlap between asylum seeker populations in
different host countries calls for international collaboration in this field.
ACknOwlEDGEMEnTS
We thank the nurse practitioners from the Community Health Services for Asylum Seekers (MOA) who provided the study data and the Central Agency for the Reception of
Asylum Seekers that provided the population data and the live birth data. We also thank
Chris Schouten, Irene van Oostrum, Mirjanne Kessels (Community Health Services for
Asylum Seekers) and Mandy Savage who commented on the manuscript.
95
96
Section 2.4
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
Commission for Healthcare Audit and Inspection. Performing better? A focus on sexual health
services in England. London: Commission for Healthcare Audit and Inspection, 2007.
Mayor S. Report calls for better data collection to improve sexual health in England. BMJ
2007;335:67.
EU Community Health Monitoring Programme. Reprostat: Reproductive health indicators in the
European Union; final technical report. Lisbon: Instituto de Medicina Preventiva, 2003. http://
ec.europa.eu/health/ph_projects/2001/monitoring/fp_monitoring_2001_a1_frep_02_en.pdf,
accessed Feb 2008.
Bernstein S, Edouard L. Targeting access to reproductive health: giving contraception more
prominence and using indicators to monitor progress. Reproductive Health Matters 2007;15:18691.
United Nations Population Fund. State of the world population 2006; a passage to hope, women
and international migration. New York: UNFPA, 2006.
Carballo M, Katic B, Miller R, et al. Migration and reproductive health in Western Europe. Geneva:
International Centre for Migration and Health, 2004.
Janssens K, Bosmans M, Leye E, et al. Sexual and reproductive health of asylum-seeking and refugee women in Europe: entitlements and access to health services. J Global Ethics 2006;2:183-96.
World Health Organization Regional Office for Europe. WHO regional strategy on sexual and
reproductive health. Copenhagen: WHO, 2001.
Janssens K, Bosmans M, Temmerman M. Sexual and reproductive health and rights of refugee
women in Europe. Rights, policies, status and needs (literature review). Ghent: Academia Press,
2005.
United Nations High Commission for Refugees. State of the worlds refugees 2006; human displacement in the new millennium. Geneva: UNHCR, 2006.
Save the Children. State of the worlds mothers, 2003; protecting women and children in war and
conflict. Westport: Save the Children, 2003.
McGinn T. Reproductive health of war-affected populations; what do we know. Int Fam Plan
Perspect 2000;26:174-80.
Bankole A, Singh S, Haas T. Characteristics of women who obtain induced abortion: a worldwide
review. Int Fam Planning Perspectives 999;25(supplement):30-8.
Sedgh G, Henshaw SK, Singh S, et al. Induced abortion: estimated rates and trends worldwide.
Lancet 2007;370:1338-45.
Adams KM, Gardiner LD, Assefi N. Healthcare challenges from the developing world: postimmigration refugee medicine. BMJ 2004;328:1548-52.
Wijsen C, Lee L van. National abortion registry (Landelijke abortus registratie 2005). Utrecht:
Rutgers Nisso Goep, the Dutch Expert Centre on Sexuality, 2006.
Statistics Netherlands. Statline, http://statline.cbs.nl, accessed Feb 2008.
United Nations High Commissioner for Refugees. State of the worlds refugees 2005. Geneva:
UNCHR, 2005. http://www.unhcr.org.
Rothman KJ, Greenland S. Modern Epidemiology. Philadelphia: Lippincott Williams and Wilkins,
1998.
Reynolds HT. The analysis of cross-classifications. New York, London: Free Press, Collier Macmillan,
1977.
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
United Nations High Commissioner for refugees. Sexual and gender-based violence against
refugees, returnees and internally displaced persons; guidelines for prevention and response.
Geneva: UNHCR, 2003. http://www.unhcr.org/publ/PUBL/3b9cc26c4.pdf, accessed Feb 2008.
Carling J. Migration, human smuggling and trafficking from Nigeria to Europe. Oslo: International
Peace Research Institute, 2007.
Imamura M, Tucker J, Hanaford P, et al. Reprostat 2: A systematic review of factors associated with
teenage pregnancy in the European Union; final report. Aberdeen: University of Aberdeen, 2006.
http://ec.europa.eu/health/ph_projects/2003/action1/docs/2003_1_27_frep_en.pdf, accessed
Feb 2008.
Tripp J, Viner R. ABC of adolescence, sexual health, contraception, and teenage pregnancy. BMJ
2005;330:590-3.
Brouns M, Burik A van, Kramer S, et al. The long wait for a safe future (Het lange wachten op een
veilige toekomst). Rijswijk: Central Agency for the Reception of Asylum Seekers, 2003.
Wijsen C, Lee L van. Child of two worlds; a qualitative study into the backgrounds of teenage
pregnancies in ethnic and cultural groups (Kind van twee werelden). Utrecht: Rutgers Nisso
Groep, the Dutch Expert Centre on Sexuality, 2006.
World Health Organization. Adolescent pregnancy - unmet needs and undone deeds; a review
of the literature and programmes. Geneva: WHO, 2007. http://whqlibdoc.who.int/publications/2004/9241591447_eng.pdf, accessed Feb 2008.
Bosmans M, Janssens K, Temmerman M. Sexual and reproductive health rights of asylum seeking
and refugee women still neglected in the European Union. BZgA Forum 2006;2:16-19.
97
Section 2.5
HIV prevalence among pregnant
asylum seekers in the netherlands;
a nationwide study based
on antenatal HIV tests
This study has been submitted as:

Goosen S. Hoebe JPA, Waldhober Q, Kunst AE. HIV prevalence among pregnant
asylum seekers in the Netherlands; a nationwide study based on antenatal HIV
tests.
100
Section 2.5
ABSTRACT
Background
Migrants are a key population for tackling HIV/AIDS in Europe. Data on the HIV prevalence among asylum seekers, however, are scarce. The aim of this study is to map the HIV
prevalence among pregnant asylum seekers in the Netherlands.
Methods
We used a nationwide electronic medical records database from the community health
services for asylum seekers (MOA). The study population consisted of 4,854 women who
delivered in asylum reception between 2000 and 2008. Case allocation was based on
ICPC-codes and health problem descriptions.
Results
The number of women that was HIV positive during their last pregnancy was 80, of which
79 originated from sub-Saharan Africa. The prevalence for women from this region of
origin was 3.4%. Among women from all other regions of origin, the prevalence was
0.04%. The highest HIV prevalence rates were found for women from Rwanda (17.0%)
and Cameroon (13.2%). HIV prevalence rates were higher among women who arrived
in reception without partner (RR=1.82; 95%CI 0.75-4.44) and unaccompanied minors
(RR=2.59; 95%CI 0.79-8.49) compared to women who arrived in reception with partner.
Conclusions
We conclude that the HIV prevalence is high among pregnant asylum seekers from
sub-Saharan Africa and at the same level as in the host population for asylum seekers
from other regions. The high HIV prevalence among sub-Saharan African asylum seekers
underlines the importance of offering all newly arriving sub-Saharan African asylum
seekers a voluntary HIV test.
HIV among pregnant asylum seekers
InTRODuCTIOn
The European Action Plan for HIV/AIDS 2012-2015 of the World Health Organization
(WHO) asserts that there is a pressing need to tackle the public health challenge of HIV
in Europe.1 Migrants are identified as a key population at high risk.1 In Western Europe
between 20 and 40% of the reported HIV infections concerns migrants.2 Ninety-three
percent of the 5,429 recorded cases of HIV cases among migrants in 2006 originated
from sub-Saharan Africa.2
In the Netherlands in 2007, the overall antenatal HIV prevalence was 0.05% and 67%
of the women with a positive antenatal HIV test originated from countries with a generalised HIV epidemic, mainly sub-Saharan Africa.3 Ninety-one percent of the children
born HIV positive in the Netherlands had one or both parents originating from an HIV
endemic country.4
High HIV prevalence rates among migrants are attributed to a combination of the HIV
epidemiology in the countries of origin, specific vulnerabilities associated with the
migration process, and inequalities in access to HIV prevention and treatment in the
host country.5 Asylum seekers may be particularly affected by HIV as their displacement
may have resulted in reduced access to HIV prevention services, disruption of social networks, and increased exposure to sexual violence and sex in return for food and shelter.6
Studies in the regions of origin show that the relationship between displacement and
HIV infection may vary depending on the context.7
Understanding the distribution and the determinants of HIV/AIDS in Europes migrant
population is crucial for developing appropriate preventive and healthcare services, and
informing public health policy.8 Nevertheless, very few countries have data on HIV prevalence among migrant populations.9 A recent review concluded that countries should
improve the availability of HIV prevalence data for migrants, especially for groups that
may be particularly vulnerable.10
Asylum seekers constitute a large population potentially at risk for HIV/AIDS. The
number of asylum requests in the 27 European Union countries was just over 300,000
in 2011. (Eurostat, accessed 16 Dec 2013). The few European studies that reported HIV
prevalence rates among asylum seekers are based on small samples. In a UK study 11
out of 288 asylum seekers were HIV positive (3.9%), in Italy 8 out of 529 (1.5%).11,12 In the
United States the HIV prevalence among 17,013 resettled refugees was 1.0%.13 In the
Netherlands the age standardised mortality ratio (SMR) due to AIDS for asylum seekers
compared to the general population was 14.04 for males (95%CI 6.75-25.90) and 39.99
for females (95%CI 14.68-87.06).14 Nearly all cases in these studies originated from Africa.
101
102
Section 2.5
Other studies did not provide data by for example age, country of origin, and family
composition although it is likely that considerable differences in HIV prevalence exist
within the asylum population.15
The aim of this study is to map the prevalence of HIV among pregnant asylum seekers
by age, country of origin, family composition, and the migration phase at the time of
conception.
METHODS
Context
Asylum seekers in the Netherlands are provided accommodation in centres managed by
the Central Agency for the Reception of asylum seekers (COA). They have similar healthcare entitlements as residents of the Netherlands.16 From January 2000 until December
2008 COA contracted the MOA for providing public health services and nursing care for
all asylum seekers in the Netherlands. MOA nurses and public health physicians worked
in close collaboration with family practitioners who were contracted by a health insurance company. Family practitioners referred pregnant asylum seekers to mainstream
midwives, who offered antenatal services in line with the Dutch standards.
MOA offered all asylum seekers a non-mandatory health assessment within six weeks
after arrival. HIV-counselling and testing were offered in case of risk factors, e.g. sexual
violence, paid sex. MOA also offered health promotion on HIV and Sexually Transmitted
Infections (STIs).
The antenatal HIV screening policy in the Netherlands up to 2004 was aimed at women
at increased risk of HIV, the so called targeted-selective-screening.17 As of January
2004 the policy changed to universal antenatal HIV testing.3,17 This means that at the
first antenatal visit, preferably before the 13th week of pregnancy, every woman was
offered an HIV test according the opt-out principle.3,17 The national participation rate for
HIV screening between 2006 and 2008 was 99.8%.3 No coverage data are available for
asylum seekers.
Study population and case definition

The MOA database contains nationwide longitudinal health care data of MOA and family
practitioners, and demographic and reception data of COA for the period 2000-2008.18
We selected all women who arrived in the Netherlands between 1 January 2000 and 31
December 2008 who gave birth to at least one child during their stay in reception.
MOA staff and family physicians used the problem-oriented record (POR) method.19 In
the POR method, main and chronic health problems are recorded on the problem list
along with the International Classification of Primary Care (ICPC) code, date of diagnosis, and a short open field description. MOA staff entered problem list data from paper
medical records in the electronic medical record system. The dataset contains a family
number that allows linkage between family members.
HIV case attribution started with identification of HIV status based on ICPC-code B90
or open field descriptions with the text HIV or AIDS. The consistency between the
ICPC-code and the open field description was manually checked. For 7 women their
medical record contained ICPC-code B90 but the open field text referred to a negative
HIV test without any further indication of HIV status. These women were not allocated
case status. The records of 6 women did not include B90 but the open field description
contained a clear description of HIV diagnosis. These women were allocated case status.
The total number of HIV positive women was 81. For 75 of these women the date of
diagnosis was before the date of their last delivery in reception; they were allocated case
status. For 3 women the date of HIV diagnosis was within two months after delivery; they
were also allocated case status. For 3 women the time between delivery and recording
of HIV status was longer. For 2 of these women, their child was also recorded to be HIV
positive with a diagnosis date around the same date as the mother (4 and 7 months after
delivery). These women were allocated case status because of the likelihood that they
were HIV positive during pregnancy. The third woman was diagnosed four years after
delivery and was not allocated case status.
A dataset was also made for the children who were born in reception in order to calculate the mother-to-child-transmission rate (MTCT). HIV case status allocation followed
the same approach as for the mothers.
Independent variables
Family composition distinguishes the women in the study at two levels. Firstly it distinguishes whether at arrival the woman was an unaccompanied minor asylum seeker
(UMA: a child who has been separated from both parents and relatives, and are not being cared for by an adult who, by law or custom, is responsible for doing so).20 Secondly,
for the non-UMA women it distinguishes women who arrived in reception with partner
from women who arrived without partner. The migration phase at the time of conception measures when the woman got pregnant: before arrival in the Netherlands, in the
first year after arrival in the Netherlands or longer after arrival.
103
104
Section 2.5
The HIV testing policy at first antenatal consultation distinguishes pregnancies for which
the first antenatal consultation theoretically fell before and after the implementation
of universal antenatal HIV testing in the Netherlands. It was based on delivery before
and after 1 July 2004 as the first consultation preferably takes place before 13 weeks of
pregnancy.
Country of origin is the country recorded by the immigration department; in general,
this is the country of nationality. Only countries with 30 or more women in the study
population were analysed separately. Regions were grouped following the World Bank
classification
(http://data.worldbank.org/about/country-classifications/country-andlending-groups).
Analysis
HIV-prevalence rates were calculated in percentages. Binary logistic regression was used
to calculate odds ratios (OR) that express associations with the likelihood of HIV/AIDS
for age, family composition, country of origin, migration phase and HIV testing policy
after correction for the other variables. Statistical Software SPSS (IBM Inc., Version 20.0,
Somers, NY, USA) was used for all analyses.
RESulTS
The study population consisted of 4,854 women who delivered during their stay in
reception. Demographic characteristics of these women are presented in Table 2.5.1.
The total number of HIV positive women was 80; the overall HIV prevalence for asylum
seekers at the time of the last delivery in reception was 1.6%. Seventy-nine of the HIV
positive women originated from sub-Saharan Africa (98.8%). The HIV prevalence among
the 2,308 women from sub-Saharan Africa was 3.4%. One HIV positive woman was
recorded among the 2,546 women from the other regions of origin (prevalence 0.04%).
The main countries of origin of these women were Afghanistan (454 women), Iran (129),
Iraq (470), China (242), countries of the former Soviet Union (518) and Syria (96).
Because of the concentration of the cases in sub-Saharan African women, further analyses were restricted to this group (Table 2.5.2). The HIV prevalence tended to be higher
among women who arrived in reception without partner (3.4%) and among UMAs (4.5%)
than among women who arrived with partner (1.7%). The differences were however, not
statistically significant (Table 2.5.2).
Table 2.5.1 Characteristics of asylum seekers who delivered during their stay in asylum reception in the
Netherlands, 2000-2008
number of women who
delivered in reception
% of all women
4,854
100.0
<= 19
831
17.1
20-29
2,654
54.7
30-49
1,369
28.2
Woman who arrived with partner*
1,178
36.6
Woman who arrived without partner*
2,250
46.4
Unaccompanied minor asylum seeker
826
17.0
All women
Age group at delivery
Family composition
Region of origin
Sub-Saharan Africa
2,308
47.5
871
17.9
753
15.5
South Asia
504
10.4
255
5.3
20
0.4
143
2.9
Before arrival in the Netherlands
2,028
41.8
Within 1 year after arrival
1,267
26.1
As of 1 year after arrival
1,559
32.1
Selective
3,145
64.8
Universal
1,709
35.2
Latin America and Caribbean

Stateless and unknown
Migration phase at time of conception
HIV testing policy at 1st antenatal consultation
* Excluding UMAs
Before the implementation of universal HIV testing in 2004, the HIV prevalence was 3.3%.
After implementation the prevalence was 3.6%. After correction for the demographic
variables, the small prevalence difference was not statistically significant (Table 2.5.2).
Only small prevalence differences were observed in relationship to time of conception
(Table 2.5.2).
The HIV prevalence for women from sub-Saharan Africa ranged from 1.1% for women
from Nigeria to 17.0% for women from Rwanda (Table 2.5.2). The highest prevalence
rates were found for women from Rwanda, Cameroon, and Burundi. The lowest rates
were found for women from Angola, Nigeria, Somalia and Sudan (Table 2.5.2). The
multivariate analysis shows that differences between the countries cannot be explained
105
106
Section 2.5
Table 2.5.2 HIV prevalence and association with demographic and pregnancy related variables among
women from sub-Saharan Africa
number
of HIVpositive
women
Total
number
of women
HIV
prevalence
(%)
Odds ratio*
95% CI
Age at delivery*
0-19
24
551
4.4
20-29
37
1,308
2.8
0.89
0.36-2.18
30-49
18
449
4.0
1.36
0.47-3.95
347
1.7
Woman who arrived without partner**
46
1,367
3.4
1.82
0.75-4.44
27
594
4.5
2.59
0.79-8.49
Family composition
Woman who arrived with partner**
Country of origin
Angola
497
1.8
Burundi
108
8.3
4.58
1.70-12.30
Cameroon
38
13.2
7.63
2.40-24.28
DR Congo
254
3.1
1.64
0.62-4.34
Eritrea
44
2.3
1.19
0.15-9.81
Guinea
154
3.9
1.76
0.60-5.21
Ivory Coast
51
7.8
3.65
1.04-12.79
Liberia
69
5.8
3.04
0.89-10.42
Nigeria
87
1.1
0.60
0.08-4.88
Rwanda
47
17.0
11.84
4.25-32.95
10
257
3.9
1.95
0.77-4.93
Somalia
401
1.7
0.94
0.33-2.66
Sudan
180
1.7
0.99
0.26-3.74
Togo
49
4.1
1.86
0.38-9.02
Other sub-Saharan countries
72
2.8
1.42
0.30-6.79
34
1,056
3.2
Within one year after arrival
22
588
3.7
1.15
0.66-2.01
As of one year after arrival
23
664
3.5
0.96
0.52-1.77
Sierra Leone
HIV testing policy at time 1st antenatal consultation

Selective
50
1,506
3.3
Universal
29
802
3.6
1.13
0.66-1.93
* Based on multivariate model including all variables in this table

** Excluding UMAs
by the other variables in the model like family composition and migration phase (Table
2.5.2).
Among the UMAs the highest prevalence rates were found for girls from Democratic Republic of Congo, Sierra Leone and the Other countries group (Table 2.5.3). The highest
prevalence was found among the UMAs who got pregnant in the first year after arrival in
the Netherlands (Table 2.5.3). The prevalence in this group (8.3%) was three times higher
than in UMAs that were pregnant at arrival (95%CI 1.17-7.75).
Among the 384 sub-Saharan Africa women who gave birth to more than one child during their stay in reception, 13 were HIV positive at the last delivery in reception (3.4%).
Four of these women (30.8%) were not recorded HIV positive at their first pregnancy in
reception.
Six of the children born to an HIV-positive mother were recorded to be HIV positive
at birth. They were all born before the implementation of the universal antenatal HIV
Table 2.5.3 HIV prevalence and association with demographic and pregnancy related variables among
unaccompanied minor asylum seekers from sub-Saharan Africa
number of
HIV-positive
women
HIV
number
of prevalence
(%)
women
Odds
ratio*
95% CI
Country of origin
Angola
130
1.5
DR Congo
56
7.1
5.22
0.92-29.68
Guinea
97
2.1
1.36
0.19-10.03
Sierra Leone
107
5.6
3.72
0.73-18.97
13
204
6.4
4.59
1.00-20.99
Other countries
Within one year after arrival
As of one year after arrival
260
3.1
11
132
8.3
3.00
1.17-7.75
202
4.0
1.50
0.52-4.38
HIV testing policy at time 1 antenatal consultation

st
Selective
20
401
5.0
Universal
193
3.6
0.68
0.26-1.83
* Based on multivariate model including all variables in this table
screening in July 2004. During this period of the study 62 children were born to an HIV
positive mother; the MTCT rate was 9.8%.
107
108
Section 2.5
DISCuSSIOn
The prevalence of HIV among pregnant women from sub-Saharan Africa who gave birth
during their stay in asylum reception was 3.4%. Among women from all other regions
the prevalence was 0.04%. Of all women who were HIV positive, 98.8% originated from
sub-Sahara Africa. The HIV prevalence among sub-Saharan African women was higher
among those who arrived in reception without partner and especially among UMAs. The
prevalence of HIV ranged from between 1% and 2% for women from Nigeria, Somalia
and Sudan to more than 10% for women from Cameroon and Rwanda.

Strengths of this study are the large number of women that could be included in the
study, the nationwide coverage, the availability of demographic and pregnancy data,
and the availability of data under a policy of universal antenatal HIV testing during the
second half of the study.
This study also has certain limitations. The results for subgroups (e.g. by country of origin)
have to be interpreted with caution in light of the wide confidence intervals. The recording of HIV diagnoses on the medical problem list may have been incomplete because
results from antenatal screening may not always have been communicated to MOA or
the family physician. This may have resulted in underestimation of HIV prevalence rates.
Furthermore the HIV prevalence rates may have been influenced by the absence of data
for pregnancies that were not carried to term. The induced abortion rate among asylum
seekers in the Netherlands has been reported to be 222 per 1,000 live births in 20042005.21 HIV positive women might have terminated their pregnancy more often than
other women. The influence of induced abortions may have differed between countries
of origin and age groups because of variations in abortion ratios.21
The change in HIV testing policy in July 2004 from selective to opting-out policies may
in theory have influenced the results. However, the data suggest that the uptake of HIV
testing was already high before 2004.
Rates of HIV infection among women attending antenatal care are generally considered
to be a proxy for the HIV prevalence in the general population.22,23 However, it is uncertain whether this also applies to asylum populations. Women may be particularly vulnerable to HIV infection in times of war and during their flight towards other countries.
In addition, asylum seekers are relatively young and more often male and single. The
association between the antenatal care and HIV prevalence may therefore be different
in this population compared to what is generally reported.
Interpretation
The HIV prevalence among women from sub-Saharan Africa (3.4%) was much higher than
the overall antenatal HIV prevalence in the Netherlands (prevalence 0.04%; OR=82.5;
95%CI 63.7-106.7). For the other regions of origin, the antenatal prevalence was similar
to the Netherlands (OR=0.92; 95%CI 0.13-6.52) although the number of deliveries was
too small to obtain a precise estimate of the HIV prevalence.
Table 2.5.4 shows the HIV prevalence rates we found for the sub-Saharan African countries together with prevalence rates for the countries of origin (for national populations
and for refugees from these countries in refugee camps in sub-Saharan Africa) as far
as available in the international literature. Although the size of this study is too small
Table 2.5.4 Comparison between antenatal HIV prevalence rates among women seeking asylum seeker in
the Netherlands, women in countries of origin and in refugee camps in the region of origin
Antenatal HIV prevalence (%)
wHO data for country
of origin
2003-200427
Data for refugees from

country in refugee
camps in the region7
17.0
4.6
13.2
[5.4]*
Burundi
8.3
4.8
1.6 4.8
Ivory Coast
7.8
8.3
Liberia
5.8
[2.0-5.0]*
Togo
4.1
3.6
Guinea
3.9
4.2
Sierra Leone
3.9
3.0
DR Congo
3.1
4.2
1.0 - 6.7
Eritrea
2.3
1.8
4.1
Angola
1.8
2.4
Sudan
1.7
[1.6]*
0.8 5.0
Somalia
1.7
[0.9]*
0.6 1.4
Nigeria
1.1
4.3
Country
Asylum seekers in the

netherlands
(this study)
Rwanda
Cameroon
* Estimates for adult population 15-49 years by UNAIDS in 2006
15
for strong conclusions results in table 2.5.4 suggest that the prevalence rates among
asylum seekers in the Netherlands are similar or somewhat higher than the prevalence
rates found in the countries of origin and in the refugee camps.
The mechanisms that may have caused the differences between prevalence rates in the
countries of origin and those found in our study can be manifold. Rwanda is a good
illustration. There is large difference between the prevalence found for Rwandese asy-
109
110
Section 2.5
lum seekers in the Netherlands (17.0%) and for Rwanda (4.6%). The Rwandese asylum
seekers in our study arrived in 2000 and 2001 whereas the comparative data are for
2003-2004. The difference may therefore reflect the strong decrease in HIV prevalence
observed in Rwanda between 1998 and 2003.24 In addition, urban-rural differences in
HIV prevalence may have played a role: in 2002 the antenatal HIV prevalence was 13% in
Kigali whereas it was 3% in rural settings.24
The prevalence rates also show variations between refugee camps.7 Overall, however,
there is little support for the assertions that conflict, forced displacement, and widescale rape increase the HIV prevalence in affected populations.7
For regions of origin other than sub-Saharan Africa, the antenatal HIV prevalence rate
was at the same level as in the Dutch population. The number of women in the study
was too small to obtain precise estimates. However, for countries from which most of
the asylum seekers originated (Afghanistan, Iran, Iraq, and Syria) the HIV prevalence estimates for the population aged 15-49 years in 2006 were 0.2% or less, which is similar to
or lower than the estimate for the Netherlands (0.2%).15 Only the estimated prevalence
in the Russian Federation was higher: 1.1%.15
Among women who got pregnant after arrival, HIV prevalence rates were slightly higher
than among women who were pregnant at the time of arrival. Although the difference
was not statistically significant, the results suggest a higher HIV prevalence among
UMAs, which may be a consequence of their particular vulnerability.
The high HIV prevalence among sub-Sahara African UMAs and women who arrived in
reception without partner in combination with the high rate of women in these groups
who get pregnant shortly after arrival,21 suggests that as of shortly after arrival interventions aimed at preventing unprotected sex are needed.
The decrease in the MTCT rate from 9.8% before the implementation of universal HIV
testing to 0% after implementation in 2004 suggests that this screening policy that was
shown to be effective in the general population was also effective in the asylum population.3
ith respect to the generalisability of the findings to other host countries it has to be
taken into account that the composition of the asylum population may differ from the
population in this study and that differences between host countries in e.g. reception
conditions and health care for asylum seekers may also have an effect on the HIV prevalence in the asylum population.25,26
COnCluSIOnS
The HIV prevalence among pregnant asylum seekers from sub-Saharan Africa is high
compared to the host population. Women from this region are a risk group with respect
to HIV transmission as of shortly after arrival in the host country. The HIV risk in pregnant
asylum seekers from other regions did not differ from the general antenatal population
in the Netherlands.
The high HIV prevalence among sub-Saharan African asylum seekers underlines the importance of offering all newly arriving sub-Saharan African asylum seekers a voluntary
HIV test.
111
112
Section 2.5
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
WHO Regional Office for Europe. European Action Plan for HIV/AIDS 2012-2015. Copenhagen;
2011.
European Centre for Disease Prevention and Control. Migrant health: Epidemiology of HIV and
AIDS in migrant communities and ethnic minorities in EU/EEA countries. Stockholm; 2010 Mar 1.
Op de Coul EL, Hahne S, van Weert YW, et al. Antenatal screening for HIV, hepatitis B and syphilis
in the Netherlands is effective. BMC Infect Dis. 2011;11:185.
Op de Coul EL, van Valkengoed I, van Sighem A, de Wolf F, van de Laar M. Trends in registered HIV/
AIDS cases in the Netherlands: rising number of immigrants with HIV. Euro Surveill. 2004;11
European Centre for Disease Prevention and Control. Improving HIV data comparability in
migrant populations and ethnic minorities in EU/EEA/EFTA countries: findings from a literature
review and expert panel. Stockholm; 2011.
United Nations High Commissioner for Refugees. Policy statement on HIV testing and counselling in health facilities for refugees, internally displaced persons and other persons of concern to
UNHCR. Geneva; 2009.
Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected
and displaced people in seven sub-Saharan African countries: a systematic review. Lancet.
2007;369:2187-95.
Del AJ, Broring G, Hamers FF, Infuso A, Fenton K. Monitoring HIV/AIDS in Europes migrant communities and ethnic minorities. AIDS. 2004;18:1867-73.
European Centre for DIsease Control. Thematic report: Migrants. Monitoring implementation of
the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm; 2013.
European Centre for DIsease Control. Evidence brief: Migrants; Monitoring implementation of the
Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 progress
report. Stockholm; 2013.
Clark RC, Mytton J. Estimating infectious disease in UK asylum seekers and refugees: a systematic
review of prevalence studies. J Public Health (Oxf). 2007;29:420-8.
Tafuri S, Prato R, Martinelli D, et al. Prevalence of Hepatitis B, C, HIV and syphilis markers among
refugees in Bari, Italy. BMC Infect Dis. 2010;10:213.
Lowther SA, Johnson G, Hendel-Paterson B, et al. HIV/AIDS and associated conditions among
HIV-infected refugees in Minnesota, 2000-2007. Int J Environ Res Public Health. 2012;9:4197-209.
van Oostrum IE, Goosen S, Uitenbroek DG, Koppenaal H, Stronks K. Mortality and causes of
death among asylum seekers in the Netherlands, 2002-2005. J Epidemiol Community Health.
2011;65:376-83.
UNAIDS. 2006 Report on the global AIDS epidemic; a UNAIDS 10th anniversary special edition.
Geneva; 2006.
Boer K, Smit C, van der Flier M, de WF. The comparison of the performance of two screening
strategies identifying newly-diagnosed HIV during pregnancy. Eur J Public Health. 2011;21:632-7.
Goosen S, Stronks K, Kunst AE. Frequent relocations between asylum-seekers centres are associated with mental distress in asylum-seeking children: a longitudinal medical record study. Int J
Epidemiol. 2013;doi:10.1093/ije/dyt233
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
United Nations High Commissioner for Refugees. UNHCR Guidelines on formal determination of
the best interests of the child. Geneva: UNHCR; 2008.
Goosen S, Uitenbroek D, Wijsen C, Stronks K. Induced abortions and teenage births among
asylum seekers in The Netherlands: analysis of national surveillance data. J Epidemiol Community
Health. 2009;63:528-33.
European Centre for Disease Prevention and Control. HIV testing: increasing uptake and effectiveness in the European Union. Stockholm; 2010.
Gouws E, Mishra V, Fowler TB. Comparison of adult HIV prevalence from national populationbased surveys and antenatal clinic surveillance in countries with generalised epidemics: implications for calibrating surveillance data. Sex Transm Infect. 2008;84 Suppl 1:i17-i23.
Kayirangwa E, Hanson J, Munyakazi L, Kabeja A. Current trends in Rwandas HIV/AIDS epidemic.
Sex Transm Infect. 2006;82 Suppl 1:i27-i31.
World Health Organization Regional Office for Africa. HIV/AIDS Epidemiological Surveillance
Report for the WHO African Region 2005 Update. Harare; 2005.
113
ChaPtEr 3
rIsk fActors for tHe HeAltH
of AsyluM seekers
Section 3.1
frequent relocations between
asylum-seeker centres are
associated with mental distress
in asylum-seeking children: a
longitudinal medical record study

Goosen S, Stronks K, Kunst AE. Frequent relocations between asylum-seeker
centres are associated with mental distress in asylum-seeking children: a
longitudinal medical record study. Int J Epidemiol. 2013 2013;111 doi:10.1093/
ije/dyt233
118
Section 3.1
ABSTRACT
Background
There are concerns about negative effects of relocations between asylum-seeker centres
on the mental health of asylum-seeking children. However, empirical evidence comes
from cross-sectional studies only. In this longitudinal medical record study, we aimed
to assess 1) whether relocations during the asylum process are associated with the
incidence of newly recorded mental distress in asylum-seeking children, and 2) whether
this association is stronger among vulnerable children.
Methods
Data were extracted from the electronic medical records database of the Community
Health Services for Asylum Seekers in the Netherlands (study period: 1 January 200031
December 2008). Included were 8,047 children aged 4 to 17. Case attribution was done
using International Classification of Primary Care codes for mental, behavioural, or psychosocial problems. The association between annual relocation rate and incidence of
mental distress was measured using relative risks (RR) estimated with multivariate Cox
regression models.
Results
A high annual relocation rate (>1 relocation/year) was associated with increased incidence of mental distress (RR=2.70; 95% confidence interval [CI] 2.30-3.17). The relative
risk associated with a high annual relocation rate was larger in children who had experienced violence (RR=3.87; 95% CI 2.79-5.37) and in children whose mothers had been
diagnosed with post-traumatic stress disorder (PTSD) or depression (RR=3.40; 95% CI
2.50-4.63).
Conclusions
The risk of mental distress was greater in asylum-seeking children who had undergone a
high annual relocation rate. This risk increase was stronger in vulnerable children. These
findings contribute to the appeal for policies that minimise the relocation of asylum
seekers.
Relocations and mental distress
InTRODuCTIOn
Asylum-seeking children and adolescents form a vulnerable group in Western host
countries.1-6 Experiences of war, violence, killing, or torture, as well as the losses suffered, increase the risk for mental distress and the development of psychiatric disorders.1,4,6-8 Not only do asylum seekers suffer from past losses or traumatic experiences,
they also face further difficulties upon arrival in a host country.1,2,4,6,8 Factors that have
been reported to negatively affect the mental health of asylum-seeking children are
parental psychosocial and psychiatric problems, perceived discrimination, resettlement
stressors, poor financial support and changes of residence in the host country.1,4,5,7-12
Reported protective factors are support from family and friends and positive school
experiences.1,4,6-8
The vulnerability of asylum-seeking children has been recognised by policymakers at the
European level. European Council Directive 2003/9/EC defines minimum standards for
the reception of asylum seekers, and states that Member States shall take into account
the specific situation of vulnerable persons such as minors. In this light, the Directive
states: The best interests of the child shall be a primary consideration for Member States
when implementing the provisions of this Directive that involve minors. To develop policies
that take the best interests of asylum-seeking children into account, it is essential to
have insight into which factors in the host country affect the health and well-being of
these children.
Residential mobility has been shown to be associated with increased behavioural and
mental health problems in children in the general population.13,14 Three studies have
described a negative association between relocations and the mental health of asylumseeking or refugee children. A cross-sectional study in Denmark showed that children
aged 4 to 16 who had been exposed to four or more relocations had an increased risk
of mental health problems.10 In a cross-sectional study among refugee children in
Denmark, there was a greater risk of mental health problems among children who had
changed schools several times.9 In a study among adolescent refugees in Canada, the
number of residences since birth was greater for boys with a mental health diagnosis
than for boys without such a diagnosis.11 This association was not found in girls. A crosssectional study in the Netherlands, however, did not find an association between the
number of relocations and mental health of 267 children measured with self-rated or
multi-informant Strengths and Difficulties Questionnaire (SDQ) scores.12
However, available data stem from cross-sectional studies only, which is a considerable
limitation when studying a time-dependent factor like relocations. In addition, the stud-
119
120
Section 3.1
ies involved rather small numbers of children, and had limited possibilities for looking
into the interplay with other factors and into different relocation-indicators.
A recent review in The Lancet states that longitudinal studies that provide insight into
the effect of the interplay of mental health predictor variables are needed to allow the
development of policies that keep the negative consequences for child and adolescent
health and well-being to a minimum.4 Our study provides such longitudinal analysis, and
includes data collected over a considerable time span (20002008) for a large number
of asylum-seeking children (8,047). The combination of individual, social unit, reception,
and health data allows for a unique analysis of the effect of relocations on the mental
health of asylum-seeking children and the interaction with other factors.
This study aimed to assess whether relocations affect the mental health of asylumseeking children and to identify whether the effect of relocations is greater in children
assumed to be particularly vulnerable to mental distress. The first hypothesis is that the
annual relocation rate and the number of relocations between asylum-seeker centres are
associated with an increased incidence of newly recorded mental distress problems
among asylum-seeking children. The second hypothesis is that the effect of relocations
on the incidence of newly recorded mental distress problems is greater in vulnerable
children.
METHODS
Context
During the asylum procedure, asylum seekers in the Netherlands are provided accommodation in an asylum seekers centre. Asylum-seeker centres in the Netherlands are
managed by the Central Agency for the Reception of Asylum Seekers (COA). Asylum
seekers are randomly allocated to the various centres in the country. In 2000 the COA
provided housing to approximately 78,000 asylum seekers in 236 asylum-seeker centres.
In 2008 approximately 20,000 asylum seekers were housed in 57 asylum-seeker centres.
(http://www.coa.nl/, accessed 13 September 2013)
Asylum seekers in the Netherlands have freedom of movement. All asylum-seeking children in the Netherlands are entitled to education. Depending on the local and individual
situation, they will attend a school in the asylum-seeker centre or in the community.
Health system
Entitlement to healthcare for asylum applicants in the Netherlands does not differ much
from the entitlements of residents of the Netherlands. All applicants under the care of
the COA have health insurance coverage through a contract between the COA and a
health insurer and are entitled to all available health care with the exception of in vitro
fertilisation and gender transformation.
During the study period, all newly arrived asylum seekers were offered a non-mandatory
health assessment by a youth health nurse and a youth health physician of the Community Health Services for Asylum Seekers (MOA) within six weeks after arrival. The
objective of this assessment was to assess the childs physical and mental health status
as well as potential health risks, and to provide health education. Official data on the
uptake of the initial health assessment were not available, but managers estimated the
uptake to be at least 90% during the study period.
During their stay in reception, all asylum-seeking children were also offered preventive child health care (PCH) assessments as defined in the basic package of the Dutch
standard PCH.15 Because of the vulnerability of asylum-seeking children, the assessment
frequency was the same as for children attending special needs schools. Standard PCH
assessments by the MOA nurses and physicians were offered once every two years. One
of the purposes of these assessments was early detection of parenting and developmental problems.
Primary curative health care was offered by family physicians and MOA nurse practitioners. Depending on the problem and needs, children with psychosocial and/or mental
health problems could be referred to social work, or mental health care services. During
the study period, preventive and primary care health services were provided at and all
other services outside the asylum-seeker centres.
Study population
The study population consisted of accompanied asylum-seeking children aged 4 up to
and including 17 years, who arrived in the Netherlands between 1 January 2000 and 31
December 2007, lived with at least a female caregiver, and stayed for at least one year.
Children in reception with a male caregiver only were excluded, as they were very small
in number and could not be included in the analysis of maternal risk factors. Children
were included from the age of four, as preventive health services for younger children
were offered by another organisation. Children born in the Netherlands were not included, as the number that met the selection criteria with respect to age was too small
for separate analysis. Unaccompanied minor asylum seekers (UMAS) were excluded, as
relocation arrangements and risk factors might be different for this group. During the
121
122
Section 3.1
study period, the reasons for relocating asylum seekers were generally administrative in
nature, and almost entirely related to the opening and closing of asylum-seeker centres
and the policy of keeping occupancy rates high. Occasionally, relocations may have
taken place on request (e.g. for family reasons) or for health reasons (e.g. proximity of a
specialised hospital).
Study data
Data were extracted from a unique electronic registration system that contains nationwide longitudinal demographic and reception data of COA, as well as health care data.
MOA staff and family physicians recorded health and psychosocial data, based on
their findings during preventive and curative consultations in paper medical records.
They used the problem-oriented record (POR) method.16 In the POR method, main and
chronic health problems are recorded on the problem list along with the International
Classification of Primary Care (ICPC) code, date of diagnosis, and a short open field description. Problem list information was entered in the MOA electronic medical record
system. All data from the MOA electronic records system were included in a database for
epidemiological analysis. The dataset contains a family number that allows for analysis
of demographic and health data on family members.
Case definition
Mental distress case attribution was done using a selection of ICPC codes that reflect
mental, behavioural, or psychosocial problems as well as the date the ICPC codes were
recorded on the childs problem list. The following ICPC codes were included: P01 (Feeling anxious/nervous/tense), P02 (Acute stress reaction), P03 (Feeling depressed), P04
(Feeling/behaving irritable/angry), P06 (Sleep disturbance), P20 (Memory disturbance),
P21 (Overactive child), P22 (Child behaviour symptom/complaint), P23 (Adolescent
behaviour symptom/complaint), P28 (Limited function/disability), P29 (Psychological
symptom/complaint other), P76 (Depressive disorder), P77(Suicide/suicide attempt),
and P82 (Post-traumatic stress disorder). SG checked the consistency between the
codes assigned by the MOA staff and the open field description concerned. If there was
inconsistency, the ICPC code was removed.
The longitudinal design of this study required the use of incidence data. Therefore, case
status allocation also depended on when the ICPC code was recorded on the problem
list. Diagnoses recorded in the first six months after arrival in reception were not used in
the case status allocation, as many of these problems were recorded during the initial
preventive health assessment offered by the PCH. This makes it unlikely that these mental distress problems are causally related to relocations.
Children for whom one of the mental distress ICPC codes was recorded in the first six
months were nevertheless included in the study population. Although repeated recording of the same ICPC code was not possible, new ICPC codes may have been recorded for
these children. Whether or not mental distress was recorded in the first six months after
arrival is included in the analysis as an independent variable. The date of case status
allocation was based on the diagnosis date of the first ICPC code included in the case
definition, recorded after six months in reception.
Time-dependent variables
To take the dynamics of the asylum population into account, we modified the dataset to
allow incidence calculations and an age-period-cohort analysis. We divided the data for
each individual child into length-of-stay intervals, and constructed separate records for
every interval. The following intervals were constructed: 0-5, 6-11, 12-23, 24-35, 36-47,
and 48 months or more. Time-dependent variables are interval-specific.
If mental distress was diagnosed during an interval, this automatically became the last
interval for that child, as this was the end point of the study. If mental distress was not
recorded, the last record for a child was the length-of-stay interval in which the date
of his or her eighteenth birthday fell, the date the child left reception, or the end date
of the study, whichever came first. The length of stay in that interval is the difference
between the starting date of the length-of-stay interval and the first of these dates,
expressed in months.
Relocation indicators
Earlier studies used the number of relocations between asylum-seeker centres that
children had undergone.10,12 However, we assumed that the effect of relocations may
also depend on the time between relocations. Therefore, we constructed the number of
relocations and the annual relocation rate. These relocation indicators were constructed
separately for each length-of-stay interval. The number of relocations is the number
up to and including the length-of-stay interval concerned. The annual relocation rate
is calculated as the number of relocations up to and including the interval concerned,
divided by the number of months between arrival in reception and the end date of the
length-of-stay interval and multiplied by 12. Categorisation of the relocation indicators
was based on a distribution of person years per category that was as equal as possible.
Fixed variables
The variable family composition is dichotomous, and reflects whether a male caregiver
was part of the social unit at any time during the study period. Changes in parental
composition during stay in reception were not taken into account. Number of children
123
124
Section 3.1
is the number of children under 18 years of age in the social unit at arrival in the Netherlands. The variable teenage mother is positive when the age difference between the
mother and the eldest child in the social unit is less than 19 years. Country of origin is
the country recorded by the immigration department; in general, this is the country
of nationality. Only countries with sufficient numbers of children represented were
analysed separately. The children from all other countries together formed the reference
group.
Personal exposure to violence and diagnosis of PTSD or depression in the childs mother
are used as vulnerability factors, as studies have shown that these factors are associated
with mental health problems in asylum-seeking children.1,3,4,7,12,17-19 The variable personal
exposure to violence of the child is dichotomous and labelled yes if the field personal
exposure to violence was filled in during the intake, or if ICPC code Z25 (Assault/harmful
event) or one of its sub-codes was recorded on the childs problem list. The variable
PTSD or depression in the mother is based on the presence of the ICPC code P02.3
(Post-traumatic stress disorder according to DSM IV criteria) or P76 (Depression) on the
mothers problem list. No distinction was made between whether these problems were
recorded before or after recording the mental distress problem for the child, as many
mothers will have suffered from these mental health problems some time before the
diagnosis.
Analyses
Incidence rates of newly recorded mental distress were calculated as the number of
recorded cases per 1,000 person years. Survival analysis methods were used to estimate
the likelihood of the dependent variable newly recorded mental distress.20 The time
variable is the number of months in an interval. The fixed independent variables were
sex, age at arrival, family composition, number of children in unit, teenage mother,
country of origin, mental distress recorded in the first six months after arrival, personal
exposure to violence, and diagnosis of PTSD or depression in the childs mother. Timerelated independent variables were age at start of interval, calendar year at start of
interval, length of stay at start of interval, number of relocations, and annual relocation
rate. We fit Cox regression models to estimate each independent variables association
with mental distress. Results of Cox regression models are shown as relative risks (RR)
with 95% confidence intervals (CI). Statistical Software SPSS (IBM SPSS Inc., Version 19.0)
was used for all analyses.
RESulTS
The total number of asylum-seeking children included in the study was 8,047. The average number of months that children were included in the study was 33. The study population consisted of slightly more boys than girls; nearly two-thirds were aged between 4
and 11 at arrival. The most common countries of origin were Afghanistan and countries
of the former Soviet Union (Table 3.1.1). Nearly 40% of the children had undergone three
or more relocations. Only 4.5% of the children had not been relocated during the study
period.
For 1,034 of the children (12.8%), one or more mental distress problems were recorded
in the first six months after arrival. For 26.3% of the children, at least one mental distress
problem was recorded during the study period. Table 3.1.1 presents the correlates of the
incidence of newly recorded mental distress problems after six-month length of stay.
The RR for newly recorded mental distress was higher for boys than for girls in children
aged 4 to 11, with an opposite pattern in children aged 12-17 (Table 3.1.2). The risk
increased with increasing age at arrival, was higher for single children than for children
who were in reception with brothers or sisters, and was higher in children with a teenage mother. Children from Iran had the highest RR for newly recorded mental distress
compared to the reference group in both age groups (Table 3.1.2). The lowest RRs were
found for children from Iraq in both age groups. Risk differences were found between
the calendar years, with 20002001 the period with the lowest risk. With increasing
length of stay the RR for recorded mental distress decreased in both age groups.
For children with an annual relocation rate of more than one per year, the RR was 2.70
times higher than for children with a low annual relocation rate (Table 3.1.3). The effect
was greater in 12 to 17 year olds than in the younger children; an increased risk for the
intermediate level of the annual relocation rate was found only for 12 to 17 year olds
(Table 3.1.3). The RR for recorded mental distress did not increase with the number of
relocations in both age groups (Table 3.1.3). As the risk for recorded mental distress did
not increase with the number of relocations, we analysed the effect of the vulnerability
factors for the annual relocation rate only.
A high annual relocation rate was associated with a larger increase in the relative risk
for recorded mental distress in children with mental distress recorded in the first six
months, children with recorded violence exposure and children with a mother diagnosed with depression of PTSD compared to children without these vulnerability factors
(Table 3.1.4). An intermediate relocation rate was associated with an increased risk for
125
48.1
23.8
1217 years
47.7
Single mother
58.0
28.0
2 or 3
4 or more
84.1
15.9
No
Yes
Teenage mother
14.0
number of children in unit
52.3
Two parents
Family composition
10.9
65.3
03 years
411 years
Age at arrival
50.8
Female
100.0
Male
Sex a
Total
2484
12 556
4087
9254
1699
6237
8803
n.a.
11 201
3839
7381
7416
15 040
% of study Number of person

population
years after 6
months
169
695
186
551
127
368
496
n.a.
684
180
359
490
864
68.0
55.4
45.5
59.5
74.7
59.0
56.3
n.a.
61.1
46.9
48.6
66.1
57.4
Number Incidence of newly

recorded mental
with newly
recorded mental distress per 1,000
children/year
distress
411 years
n.a.
831
6093
2030
3896
998
3139
3785
3716
51
352
91
227
85
185
218
243
61.4
57.8
44.8
58.3
85.2
58.9
57.6
65.4
49.9
n.a.
160
n.a.
3207
63.1
54.5
58.2
Incidence of newly
recorded mental
distress per 1,000
children/year
207
194
403
Number
with newly
recorded
mental distress
1217 years
3281
3559
6924
Number of
person years
after 6 months
Age group at start of study interval
Table 3.1.1 Characteristics of the study population and incidence of newly recorded mental distress as of 6 months after arrival
126
Section 3.1
20.1
Afghanistan
n.a.
n.a.
n.a.
2002 or 2003
2004 or 2005
2006, 2007, or 2008

n.a.
n.a.
n.a.
n.a.
n.a.
6 months
1 year
2 years
3 years
4 years or more
length of stay at start of interval
n.a.
2000 or 2001
year at start of interval
12.7
Iraq
15.9
Former Soviet Union

7.1
6.8
Former Yugoslavia
Iran
7.9
29.5
Angola
Other countries
Country of origin
3174
2005
2982
4246
2634
869
4366
5873
3932
2903
1685
1003
2320
1410
1369
4350

population
years after 6
months
143
124
170
244
183
61
243
358
202
138
58
74
182
67
93
252
45.1
61.9
57.0
57.5
69.5
70.2
55.7
61.0
51.4
47.5
34.4
73.8
78.4
47.5
67.9
57.9
1646
1115
1368
1751
1043
434
2244
2631
1615
1343
688
627
1607
552
322
1784
Number of
person years
after 6 months

recorded mental
with newly
children/year
distress
411 years
76
40
94
118
75
31
110
159
103
78
17
50
114
32
15
97
Number
with newly
recorded
mental distress
1217 years
46.2
35.9
68.7
67.4
71.9
71.5
49.0
60.4
63.8
58.1
24.7
79.8
70.9
57.9
46.6
54.4
Incidence of newly
recorded mental
distress per 1,000
children/year

127
30.7
20.5
18.9
4 or more
12.8
Yes
20.5
Yes
Sex unknown for 1.1% of children n.a.= not applicable
14.1
Yes
85.9
No
Diagnosis of PTSD or depression in the childs mother
79.5
No
Personal exposure to violence
87.2
No
Mental distress recorded in first 6 months
29.8
0 or 1
Overall number of relocations
2371
12 668
2549
12 491
1685
13 355
3087
3199
4732
4023

population
years after 6
months
238
626
218
646
107
757
127
151
261
325
100.4
49.4
85.5
51.7
63.5
56.7
41.1
47.2
55.2
80.8

recorded mental
with newly
children/year
distress
411 years
1250
5674
1630
5293
1078
5845
1463
1559
2130
1771
Number of
person years
after 6 months
124
279
128
265
80
323
69
80
120
134
Number
with newly
recorded
mental distress
1217 years
99.2
49.2
78.5
50.1
74.2
55.3
47.2
51.3
56.3
75.6
Incidence of newly
recorded mental
distress per 1,000
children/year
128
Section 3.1
Table 3.1.2 Associations of demographic characteristics, time variables, and vulnerability factors with the
incidence of newly recorded mental distress
Age group at start of interval
All children
RR a
95% CI
411 years
RR
95% CI
1217 years
RR
95% CI
Gender
Male
Female
1
0.86
1
0.78-0.96
0.75
1
0.65-0.86
1.15
0.95-1.40
Age at arrival
03 years
411 years
1.19
1.00-1.42
1.24
1217 years
1.33
1.00-1.76
n.a.
0.88-1.12
0.98
n.a. b
1.04-1.47
1
1.02
0.80-1.29
Family composition
Two parents
Single mother
1
1.00
1
0.85-1.14
1.02
0.83-1.26
number of children in unit

1
2 or 3
0.81
0.69-0.95
0.86
0.70-1.05
0.73
0.56-0.94
4 or more
0.67
0.55-0.82
0.72
0.56-0.92
0.61
0.44-0.84
1.06-1.44
1.23
1.04-1.45
1.29
Teenage mother
No
Yes
1.24
1
0.95-1.74
Country of origin
Other countries
Angola
1.14
0.91-1.43
1.17
0.91-1.50
0.94
0.54-1.63
Former Yugoslavia
0.81
0.64-1.02
0.74
0.56-0.99
0.97
0.64-1.46
Former Soviet Union
1.18
1.00-1.39
1.19
0.97-1.46
1.19
0.89-1.58
Iran
1.32
1.07-1.63
1.28
0.98-1.67
1.46
1.02-2.07
Iraq
0.59
0.46-0.77
0.63
0.47-0.85
0.50
0.30-0.85
Afghanistan
0.95
0.79-1.13
0.86
0.69-1.06
1.14
0.84-1.55
year at start of interval

2000 or 2001
2002 or 2003
1.26
1.07-1.49
1.35
1
1.10-1.65
1.09
1
0.80-1.48
2004 or 2005
1.52
1.22-1.90
1.67
1.28-2.18
1.29
0.87-1.92
2006, 2007, or 2008
1.59
1.24-2.03
1.60
1.18-2.17
1.56
1.01-2.41
length of stay at start of interval

6 months
1 year
0.95
0.80-1.13
0.94
0.76-1.15
1.00
0.73-1.36
2 years
0.86
0.70-1.06
0.81
0.63-1.04
0.96
0.66-1.41
3 years
0.72
0.57-0.91
0.86
0.66-1.13
0.48
0.30-0.76
4 years or more
0.62
0.46-0.83
0.64
0.45-0.91
0.59
0.35-0.98
129
130
Section 3.1
Age group at start of interval

All children
RR a
95% CI
411 years
RR
95% CI
1217 years
RR
95% CI
Mental distress within

6 months
No
Yes
0.90
1
0.77-1.06
0.86
1.43-1.85
1.63
1.75-2.26
1.99
1
0.70-1.07
0.95
1.39-1.92
1.63
1.70-2.33
1.97
0.73-1.23
Personal exposure to
violence
No
Yes
1.63
1
1.31-2.03
Diagnosis of PTSD
or depression in the
childs mother
No
Yes
1.99
a
b
1
1.58-2.45
RRs estimated in multivariate models including the variables shown in the table
n.a. = not applicable
recorded mental distress in children with, but not in children without these vulnerability
factors (Table 3.1.4).
DISCuSSIOn
A high annual relocation rate between asylum-seeker centres was associated with an
increased risk for newly recorded mental distress in asylum-seeking children. The risk
increase associated with a high relocation rate, was higher in vulnerable children compared to children without the vulnerability factors.
Strengths and weaknesses

The large size of the study population, the national coverage, the combination of data
from preventive and curative consultations and the length of the study period are strong
features of our study. Further advantages are the availability of detailed individual, social
unit, and reception data, which allowed inclusion of a considerable number of potential
risk factors. In addition, the influence of confounding in this study was limited as the
reasons for relocation were almost entirely administrative in nature and consequently
the allocation of the exposure (relocations) may be considered random.
Besides the important advantages, some disadvantages of using registry data must be
mentioned. Despite the availability of data from preventive and curative consultations,
RR a
6353
5183
10 427
1
2.70
1.10
6862
4758
4550
4 or more
0.61
0.67
0.75
0.50-0.75
0.57-0.80
0.65-0.86
3087
3199
4732
4023
3555
7183
4302
Person
years*
RR
0.53
0.61
0.72
2.55
1.02
411 years
0.41-0.68
0.50-0.76
0.60-0.85
2.10-3.10
0.85-1.23
95% CI
1463
1559
2130
1771
1628
3244
2051
Person
years
RR
0.84
0.81
0.82
3.19
1.33
1217 years
By age group at start of interval
0.60-1.18
0.60-1.09
0.64-1.06
2.38-4.28
1.00-1.77
95% CI
RRs estimated in multivariate Cox regression models including sex, family composition, number of children in unit, teenage mother, country of origin, calendar year
at start of interval, and length of stay at start interval
5794
0 or 1
2.30-3.17
0.95-1.29
95% CI
Overall number of relocations (up to and including current interval)
High (> 1.0 per year)
Intermediate (> 0.5 and <= 1.0 per year)
Low (<= 0.5 per year)
Annual relocation rate (up to and including current interval)
Person
years
All children
Table 3.1.3 Relative risks for newly recorded mental distress according to number of relocations, annual relocation rate, and age group

131
132
Section 3.1
Table 3.1.4 Relative risks for newly recorded mental distress according to vulnerability factors and annual
relocation rate
Person
years
Annual relocation rate (rate per
year)
Low (<= 0.5)
RR a
95% CI
no mental distress recorded b

in first 6 months
5476
Person
years
RR
95% CI
Mental distress recorded

in first 6 months
877
Intermediate (> 0.5 and <= 1.0)
9206
1.06
0.90-1.26
1220
1.39
0.91-2.13
High (> 1.0)
4518
2.64
2.22-3.14
665
3.12
2.02-4.80
no personal exposure to
violence c
Low (<= 0.5)
5224
Personal exposure to violence

1130
8494
1.03
0.86-1.23
1932
1.38
0.99-1.92
High (> 1.0)
4066
2.33
1.93-2.81
1117
3.87
2.79-5.37
no diagnoses of PTSD or
depression in the childs
mother d
Diagnosis of PTSD or
depression in the childs
mother
Low (<= 0.5)
5145
1209
8760
1.05
0.87-1.26
1667
1.35
1.01-1.80
High (> 1.0)
4438
2.59
2.14-3.13
745
3.40
2.50-4.63
a
Estimated with multivariate Cox regression models including sex, family composition, number of
children in unit, teenage mother, country of origin, calendar year at start of interval, and length of stay at
start interval
b
model change with interaction factor mental distress first six months x relocation rate: X2=1.95, df=2,
p=0.378
c
model change exposure to violence x relocation rate: X2=7.32, df=2, p=0.026
d
model change PTSD or depression mother x relocation rate: X2=2.67, df=2, p=0.263
mental distress problems may have been missed, and this may be associated with the risk
factors studied. Relocations might decrease the chances of diagnosing mental distress,
for example, because the stay in a centre may be too short to allow health professionals
to get to know a child, and because parents and children might be less likely to share
mental distress with new health staff. On the other hand, relocations might increase
the chance of diagnosis and recording of new mental distress symptoms, because a
consultation or home visit is scheduled after each relocation. This might explain why
the incidence of recorded mental distress decreased with an increasing total number
of relocations. However, this does not explain our finding that recorded incidence is
positively related to the annual relocation rate.
The use of information recorded by health care providers implies that no stringent
case definitions were used to describe childrens mental distress symptoms. We studied a broad group of mental distress diagnoses that includes different mental health
problems and different levels of severity. The effect of relocations might be different for
different mental health problems (e.g. PTSD, depression, and anxiety) and for different
levels of severity of mental distress. To study the existence and size of such differences,
larger study populations would be required.
Because of differences in reception conditions as well as health care provision, it might
not be possible to generalise the results of this study to asylum-seeking children in other
countries.21,22
Effects of relocations on mental distress

The negative associations we observed between mental health and the annual relocation
rate were not observed for relocations in terms of total numbers. This contrast is related
to the different associations between these two relocation indicators and length of stay
in reception. High rates of relocations were observed particularly during the first two
years of residence, while high cumulative numbers of relocations were observed mainly
when children lived three years or more in asylum-seeker centres. As previous studies
were based on cross-sectional data, they could measure the occurrence of relocations
only in terms of total number of relocations. The negative associations observed in these
cross-sectional studies between the number of relocations and mental health may actually reflect the effect of high annual relocation rates in the first years of residence.
Relocations may have a negative effect on potential protective factors such as peer support, forming close relationships with caring adults, school connectedness, and sense
of belonging.4,9 Especially with frequent relocations, children might start to feel that
making new friends and establishing other connections is not worthwhile. Relocations
may also affect the parents. Furthermore, those children and their families who have
not stayed in a centre for an extended period may have been less likely to have received
adequate care and support, as relocations interrupt their contact with health and other
professionals.
With frequent relocation, children who had been exposed to violence and children
whose mothers had been diagnosed with PTSD or depression seemed to be at increased
risk of newly recorded mental distress. This adds to the theory that cumulative adversities exert more powerful effects than a single factor alone, and that the most harmful
pathways for mental health are those that involve exposure to violence.4 Parents with
PTSD and depression can be emotionally and functionally unavailable to their children.18
Their absence might be felt particularly among frequently relocated children, who might
have a greater need for parental support in a new environment.
133
134
Section 3.1
The decrease in the risk for recorded mental distress over time is in line with findings in a
longitudinal study in refugee children in Denmark, where after 8 9 years a reduction in
the prevalence of psychological problems was observed.9 Other studies, however, found
an increase in mental distress with length of stay or did not observe an association with
length of stay.10,12 An explanation for these findings could be the cross sectional design
of these studies. More longitudinal studies are needed to get insight into the development of mental distress over time and into factors that may contribute to the prevention
of mental distress.
COnCluSIOnS AnD IMPlICATIOnS

A high frequency of relocations between asylum-seeker centres was associated with an
increase in mental health problems among asylum-seeking children. The risk increase
was especially high in vulnerable children. These findings lend support to the evidence
that the accumulation of adversities that asylum-seeking children face worsens their
health outcomes.
The results of our study suggest that policies aimed at minimising relocations in the host
country could contribute to the prevention of mental distress among asylum-seeking
children. Health professionals might contribute to the health and well-being of asylum
seekers by monitoring whether relocated asylum-seeking children and their parents
need extra support, especially in the case of vulnerable children.
ACknOwlEDGEMEnTS
We would like to thank Kirsten Slinger and Hennie Nijsingh for critically reading the
drafts of this paper and for their valuable suggestions. Special thanks to Colleen Higgins
for language editing the text.
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)

Daud A, af KB, Rydelius PA. Resilience and vulnerability among refugee children of traumatized
and non-traumatized parents. Child Adolesc Psychiatry Ment Health. 2008;2:7.
Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87:366-70.
Leavey G, Hollins K, King M, Barnes J, Papadopoulos C, Grayson K. Psychological disorder amongst
refugee and migrant schoolchildren in London. Soc Psychiatry Psychiatr Epidemiol. 2004;39:191-5.
Montgomery E, Foldspang A. Seeking asylum in Denmark: refugee childrens mental health and
exposure to violence. Eur J Public Health. 2005;15:233-7.
Ehntholt KA, Yule W. Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma. J Child Psychol Psychiatry. 2006;47:1197-210.
Lustig SL, Kia-Keating M, Knight WG, et al. Review of child and adolescent refugee mental health.
J Am Acad Child Adolesc Psychiatry. 2004;43:24-36.
Montgomery E. Trauma and resilience in young refugees: a 9-year follow-up study. Dev Psychopathol. 2010;22:477-89.
Nielsen SS, Norredam M, Christiansen KL, Obel C, Hilden J, Krasnik A. Mental health among
children seeking asylum in Denmarkthe effect of length of stay and number of relocations: a
cross-sectional study. BMC Public Health. 2008;8:293.
Tousignant M, Habimana E, Biron C, Malo C, Sidoli-LeBlanc E, Bendris N. The Quebec Adolescent
Refugee Project: psychopathology and family variables in a sample from 35 nations. J Am Acad
Child Adolesc Psychiatry. 1999;38:1426-32.
J Nerv Ment Dis. 2011;199:85-90.
Jelleyman T, Spencer N. Residential mobility in childhood and health outcomes: a systematic
review. J Epidemiol Community Health. 2008;62:584-92.
Rumbold AR, Giles LC, Whitrow MJ, et al. The effects of house moves during early childhood on
child mental health at age 9 years. BMC Public Health. 2012;12:583.
Vogels AGC. The identification by Dutch Preventive Child Health Care of children with psychosocial problems: do short questionnaires help? Groningen: University of Groningen; 2008.
Anstiss H., Ziaian T, Procter N, Warland J, Baghurst P. Help-seeking for mental health problems
in young refugees: a review of the literature with implications for policy, practice, and research.
Transcult Psychiatry. 2009;46:584-607.
Ee Ev, Kleber RJ, Mooren TTM. War trauma lingers on: associations between maternal posttraumatic stress disorder, parent-child interaction, and child development. Infant mental health
journal. 2012;33:459-68.
McMullen JD, OCallaghan PS, Richards JA, Eakin JG, Rafferty H. Screening for traumatic exposure
and psychological distress among war-affected adolescents in post-conflict northern Uganda.
Soc Psychiatry Psychiatr Epidemiol. 2012;47:1489-98.
Clayton D, Schifflers E. Models for temporal variation in cancer rates. II: Age-period-cohort models. Stat Med. 1987;6:469-81.
135
136
Section 3.1
(21)
(22)
Section 3.2
Increased risk of physical child
abuse in asylum-seeking families
in which the mother suffers from
This study has been submitted as:

Goosen S, Stronks K, Teeuw AH, Brilleslijper-Kater SN, Kunst AE. Increased risk of
physical child abuse in asylum-seeking families in which the mother suffers from
mental health problems.
140
Section 3.2
ABSTRACT
Background
Maternal mental health problems are reported to be predictors of child abuse. Post
traumatic stress disorder (PTSD), depression, and past exposure to violence are highly
prevalent among asylum seekers. Evidence on the association between these factors
and physical child abuse among asylum seekers might guide prevention, but is scarce.
Objectives
The main aim of this study was to analyse whether maternal exposure to violence and
maternal diagnosis of PTSD or depression are associated with the risk of physical child
abuse in asylum-seeking children.
Methods
Data were extracted from the electronic medical records database of the Community
Health Services for Asylum Seekers in the Netherlands. The study included children
aged < 18 years who lived in an asylum seeker centre with at least their mother for
at least six months between 2000 and 2008. Physical child abuse case attribution was
done using the International Classification of Primary Care (ICPC). Only cases recorded
as of six months after arrival were included. Associations were measured in relative risks
(RR) estimated with multivariate Cox regression models to correct for demographic and
reception variables.
Results
Among the 17,780 children in the study population, there were 98 cases of newly
recorded physical child abuse. The rate of newly recorded physical child abuse as of
six months length of stay was 2.5 per 1,000 person years. The relative risk was higher
in children whose mothers had been exposed to violence (RR=1.61; 95%CI 1.06-2.44)
and in children whose mothers had been diagnosed with PTSD or depression (RR=1.74;
95%CI 1.03-2.92) compared with other children. For both maternal factors a significant
association was only observed for children of single mothers (violence RR=2.88; 95%CI
1.47-5.66; PTSD or depression RR=2.31; 95%CI 1.11-4.81).
Conclusion
Asylum-seeking children whose mothers had been exposed to violence or had PTSD or
depression were at increased risk of newly recorded physical child abuse, especially in
single-mother families. Early identification and support is indicated for asylum-seeking
families affected by violence exposure, PTSD or depression.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
InTRODuCTIOn
Child abuse is a global public health problem with serious life-long consequences.1-5
Several studies in Western countries report that child abuse is more common in migrant
families.5-8 In the Netherlands, new immigrant groups (of which a large proportion was
asylum-seeker or refugee), were significantly overrepresented among child abuse cases,
especially single-parent families.6,8 A qualitative study in Australia also suggests that
asylum-seeking and refugee children may be at increased risk of child abuse.9
Asylum seekers have left their country of origin, applied for protection as a refugee in
another country, and are awaiting a decision on their application.10 Worldwide close
to one million individuals were awaiting a decision on their asylum claim by January
2010.11 Of the asylum seekers in Europe, about 30% is below the age of 18.11
Child abuse is widely recognized to be determined by a variety of factors.1-4,12,13 Risk
factors for child abuse that are highly prevalent among asylum seekers are single
parenthood, parental mental health problems, and social isolation.3,5,14 The stress and
coping model of Hillson and Kuiper suggests that caregiver stress plays a critical role in
determining child abuse.15 Post-traumatic stress disorder (PTSD) and depression are associated with an increased risk for child maltreatment.5,14,16-20 Larger social conflicts and
war have been suggested to be risk factors for child abuse.3 In the context of organized
violence, an intergenerational cycle of violence may persist.20
Due to an accumulation of stressors over the preflight, flight, and asylum procedure
periods, mental health problems are common among asylum seekers.21-25 High prevalence rates of PTSD depression, anxiety disorders, and related conditions have been
reported.22,23,25-27 Parental PTSD and depression are reported to have a negative influence
on asylum-seeking families and the mental health of asylum-seeking children.8,9,28,29
A qualitative clinical study among asylum-seeking families in the Netherlands showed
that parental symptoms of PTSD were associated with aggression towards the children.30,31 However, the association between child abuse and violence exposure, PTSD,
and depression in asylum-seeking parents has not been studied using quantitative
methods.6,8,9,32 As these factors are highly prevalent in asylum seekers, insight into the
impact of these factors on the occurrence of physical child abuse could inform policies
and practices to prevent child abuse in asylum-seeking families.33
141
142
Section 3.2
The main aim of this study was to assess whether maternal violence exposure and
maternal diagnosis of PTSD or depression are associated with the risk of physical child
abuse among asylum-seeking children.
We used a unique longitudinal dataset containing demographic, reception, and health
data for all asylum seekers who lived in asylum-seeker centres in the Netherlands between 2000 and 2008. The study focused on physical child abuse because we expected
that the influence of risk factors might differ between child abuse types, and the number
of recorded cases of other types of child abuse were too small for separate analysis.
METHODS
Context
During the asylum procedure, asylum seekers in the Netherlands are provided accommodation in an asylum-seeker centre managed by the Central Agency for the Reception
of Asylum Seekers (COA). Asylum seekers in the Netherlands have freedom of movement. Asylum-seeking children as of four years are entitled to attend school.
Health system
Entitlements to healthcare for asylum applicants in the Netherlands are similar to the
entitlements of residents of the Netherlands.34 All asylum seekers have health insurance
coverage through a contract between the COA and a health insurer.
During the study period, the Community Health Services for Asylum Seekers (MOA)
offered all asylum seekers a non-mandatory health assessment within six weeks after arrival. For children the objective of this assessment was to assess the childs physical and
mental health status as well as potential health risks, and to provide health education.
Official data on the uptake of the initial health assessment were not available but it was
estimated to be at least 90% during the study period.
In addition to the initial health assessment, preventive child health care (PCH) assessments as defined in the basic package of the Dutch standard PCH were offered to all
asylum-seeking children.35 Because of their vulnerability the assessment frequency
was the same as for children attending special needs schools: once every two years.
Purpose of these assessments was amongst others early detection of parenting and developmental problems. MOA nurse practitioners were, in close collaboration with family
practitioners also the first point of contact for curative health care for asylum seekers.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
A child abuse protocol was in use by the MOA as of 2000. The definition of child abuse
in the protocol was: every form of threatening or violent behavior towards minors of
a physical, psychological or sexual nature. This behavior is forced on minors actively
or passively by parents or other persons towards whom minors feel dependent and
lack freedom. This behavior threatens to cause serious harm in the form of physical or
psychological damage. The MOA protocol distinguished five types of abuse: physical
abuse, psychological abuse, physical neglect, emotional neglect, and sexual abuse. The
protocol stated that the medical record of the child should document signs or symptoms
as well as issues discussed with the parents or caregivers in relation to the suspected
abuse, should be documented in the medical record of the child.36
Study population
We selected all children aged less than 18 years who lived a minimum of six months with
at least their mother in an asylum-seeker centre in the Netherlands between 1-1-2000
and 31-12-2008. Children whose parent(s) arrived in the Netherlands before 1-1-2000
were not included as the health services before 2000 were offered by another organisation.
Data were extracted from a unique electronic registration system that was in use between 2000 and 2008. It contains nationwide longitudinal demographic and reception
data of COA, as well as health care data of MOA and family physicians. More details are
given in another publication.37
We labelled a child as a case of recorded physical child abuse if the problem list contained ICPC-code Z16.1 (abuse of child by parents) with description of physical abuse
in the open field, or if the problem list contained an open field description indicating
physical child abuse under another ICPC-code. Two researchers independently went
through the open field descriptions and assigned case-status.
For children with more than one physical abuse record, the first record was used as case
record. Diagnoses recorded in the first six months after arrival in reception were not
allocated case status as many of these cases were recorded during the initial preventive
health assessment and may refer to child abuse that took place before arrival in the
Netherlands.
Fixed variables
The fixed independent variables were sex, age at arrival, family composition, number
of children in unit, teenage mother, and region of origin. The variable age at arrival
refers to the arrival in asylum reception in the Netherlands. The variable family composi-
143
144
Section 3.2
tion measured whether a male caregiver was part of the family at any time during the
study period. Number of children is the number of children under 18 years of age in
the family at the end of the study period. The variable teenage mother is positive when
the age difference between the mother and the eldest child in the social unit was less
than 19 years. Region of origin is based on the country recorded by the immigration
department; in general, this is the country of nationality. Grouping into regions followed
the World Bank classification (http://data.worldbank.org/about/country-classifications/
country-and-lending-groups). For reasons of statistical power regions with less than1,000
children in the study population were combined into the group of other regions.
Time-dependent variables
To take the dynamics of the asylum population into account, we modified the dataset
to allow for risk calculations and age-period-cohort analyses in line with the method
developed for another study on the same database.37 The data for each individual child
were divided into length-of-stay intervals, and we constructed separate records for
every interval. The following intervals were constructed: 0-5, 6-11, 12-23, 24-35, 36-47,
and 48 months or more.
The time-related dependent variable was physical child abuse. If physical child abuse
was diagnosed during an interval, this automatically became the last interval for that
child. For other children the last record was the length-of-stay interval in which the date
of his or her eighteenth birthday fell, the date the child left reception or died, or the end
date of the study period, whichever came first.
Time-related independent variables were age at start of interval, calendar year at start
of interval, length of stay at start of interval, maternal violence exposure, and maternal
diagnosis of PTSD or depression. Maternal violence exposure and maternal diagnosis
of PTSD or depression were labelled positive if they were recorded on the problem list
of the mother before the end of the length-of stay interval or, for cases, before the date
of diagnosis of physical child abuse.
The variable maternal violence exposure was based on the distinct field personal exposure to violence or ICPC code Z25 (Assault/harmful event) or one of its sub-codes. Maternal PTSD and maternal depression were combined in one variable as these diagnoses
often co-occur and because of the limited number of cases. The variable maternal PTSD
or depression was based on the presence of the ICPC code P02.3 (Posttraumatic stress
disorder according to DSM-IV criteria) or P76 (Depression) on the mothers problem list.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
Analysis
Rates of newly recorded physical child abuse were calculated as the number of recorded
cases per 1,000 person years. Cox regression was used to estimate the likelihood of
newly recorded physical child abuse.38 The offset variable was the number of months in
an interval.
We fitted univariate and multivariate Cox regression models to estimate the association
of the independent variables with the risk of newly recorded physical child abuse. We
also analysed whether the effect of maternal violence exposure and maternal PTSD differed between children in reception with two parents and with single mothers. Results
of Cox regression models are shown as relative risks (RR) with 95% confidence intervals
(CI). Statistical Software SPSS (IBM Inc., Version 20.0, Somers, NY, USA) was used for all
analyses.
RESulTS
Table 3.2.1 shows the demographic characteristics of the 17,780 asylum-seeking children in the study population. There were slightly more boys than girls, and the mean age
at arrival was 5.4 years. Approximately half of the study population lived in single-parent
families (51.6%). A quarter of the children (24.9%) was born during their mothers stay in
asylum reception. The childrens parents originated from nearly one hundred different
countries. Countries of origin with the largest numbers of children were Afghanistan
(3,197), Iraq (2,885), former Soviet Union (2,412), Angola (1,712), and Somalia (1,663). The
number of person-years was lower in 2006-2008 than in earlier years due to a decrease
in the number of asylum seekers in reception in the Netherlands. The mothers of more
than a third of the children (38.4%) reported personal exposure to violence. Maternal
PTSD or depression was recorded for 9.2% of the mothers.
The rate of newly recorded physical child abuse was 2.5 cases per 1000 person-years
(Table 1). The risk of recorded physical child abuse was higher for girls compared with
boys (RR=1.56; 95%CI 1.04-2.35, Table 3.2.2). No risk difference was found between
children with two parents and children with single mother (RR=1.11; 95%CI 0.70-1.74).
Children of teenage mothers were at increased risk compared with children with older
mothers (RR=1.88; 95%CI 1.21-1.93). The rate of newly recorded physical child abuse
was lower in the 6 to 12 months interval and in the last length-of-stay interval compared
with the intermediate intervals. The higher risk for girls was seen in children with two
parents (RR=2.04; 95%CI 1.17-3.55) but not in children with mother only (RR=1.13; 95%CI
0.62-2.08, data not in table).
145
146
Section 3.2
Table 3.2.1 Characteristics of the study population and rate of newly recorded physical child abuse as of 6
months after arrival
% of children
(n=17,780)
number of person- number with recorded

years after 6 months
physical child abuse
Rate of newly recorded

physical child abuse
per 1,000 person years
Total
100
39911
98
Sex*
Male
51.2
20317
39
1.9
Female
48.8
19109
59
3.1
0 - 3 years
n.a.
12153
34
2.8
4 11 years
n.a.
19396
43
2.2
12 17 years
n.a.
8363
21
2.5
No
75.1
30308
78
2.6
Yes
24.9
9604
20
2.1
Two parent
48.4
21849
56
2.6
Single mother
51.6
18061
42
2.3
Age at start interval**
2.5
Born in reception
Family composition
Teenage mother
No
80.6
32444
69
2.1
Yes
19.4
7467
29
3.9
number of children
1
20.8
6705
24
3.6
2 or 3
57.1
24188
51
2.1
4 or more
22.1
9017
23
2.6
10587
22
2.1
Region of origin
Sub-Saharan Africa
31.4
Middle East & North Africa
21.9
8195
15
1.8
Europe
23.7
11528
38
3.3
South Asia
17.0
6815
18
2.6
6.0
2694
1.9
2000 or 2001
n.a.
8534
20
2.3
2002 or 2003
n.a.
14587
36
2.5
2004 or 2005
n.a.
12390
30
2.4
2006, 2007 or 2008
n.a.
4401
12
2.7
Other regions
year at start interval**
length stay at start interval**
6 months
n.a.
8485
16
1.9
1 year
n.a.
10988
34
3.1
2 years
n.a.
7528
23
3.1
3 years
n.a.
5094
17
3.3
4 years or more
n.a.
7816
1.0
Maternal violence exposure

No
61.6
23603
44
1.9
Yes
38.4
16308
54
3.3
No
90.8
35358
78
2.2
Yes
9.2
4553
20
4.4
Maternal PTSD or depression
* Sex unknown for 0.8% of children ** % distribution not applicable (n.a.) for time-dependent variables
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
Table 3.2.2 Associations of demographic characteristics, time variables and potential maternal risk factors
with the rate of newly recorded physical child abuse
univariate Cox Regression
RR*
95% CI
Multivariate Cox regression

RR
95% CI
Sex*
Male
Female
1
1.56
1
1.07-2.40
1.56
1.04-2.35
Age at start interval

0 - 3 years
4 11 years
0.95
0.61-1.50
0.69
0.38-1.25
12 17 years
1.04
0.60-1.80
0.68
0.34-1.37
0.47-1.26
0.50
0.81-1.80
1.11
1.16-2.76
1.88
Born in reception
No
Yes
0.77
1
0.25-0.98
Family composition
Two parent
Single mother
1
1.20
1
0.70-1.74
Teenage mother
No
Yes
1.79
1
1.21-2.93
number of children
1
2 or 3
0.63
0.39-1.03
0.59
0.36-0.98
4 or more
0.77
0.43-1.37
0.75
0.40-1.38
Region of origin
Sub-Saharan Africa
Middle East & North Africa
0.93
0.48-1.79
1.14
0.57-2.29
Europe
1.78
1.05-3.01
1.74
0.95-3.18
South Asia
1.36
0.73-2.54
1.54
0.77-3.06
Other
0.98
0.37-2.60
1.00
0.37-2.70
year at start interval

2000 or 2001
2002 or 2003
1.13
0.66-1.96
0.97
1
0.52-1.82
2004 or 2005
1.54
0.87-2.74
1.68
0.82-3.42
2006, 2007 or 2008
1.21
0.59-2.48
1.43
0.65-3.14
length stay at start interval

6 months
1 year
2.20
1.20-4.05
2.20
1.19-4.08
2 years
2.18
1.14-4.19
2.09
1.02-4.30
3 years
2.37
1.18-4.76
1.94
0.89-4.22
4 years or more
1.27
0.49-3.27
0.87
0.30-2.55
1.21-2.68
1.61
1.39-3.71
1.74

No
Yes
1.80
1
1.06-2.44

No
Yes
2.27
1
1.03-2.92
147
148
Section 3.2
The RR associated with maternal violence exposure was 1.80 (95%CI 1.21-2.68) in the
univariate model and 1.61 (95%CI 1.06-2.44) in the multivariate model with maternal
PTSD or depression (Table 3.2.2). The RR associated with maternal PTSD or depression
was 2.27 (95%CI 1.39-3.71) in the univariate model and 1.74 (95%CI 1.03-2.92) in the
multivariate model with maternal violence exposure.
In theory, the association between maternal violence exposure and newly recorded
physical child abuse could have been mediated by maternal PTSD or depression. However, there was no important mediation effect: the RR in the multivariate model that
includes maternal PTSD or depression (RR=1.61; 95%CI 1.06-2.44) differed only slightly
from the multivariate model without PTSD or depression (RR=1.72; 95%CI 1.14-2.59,
data not in table).
Table 3.2.3 shows that maternal violence exposure was associated with an increased risk
of newly recorded physical child abuse for children of single mothers (RR=2.88; 95%CI
1.47-5.66) but not for children in reception with two parents (RR=1.18; 95%CI 0.69-2.03).
In both groups maternal PTSD or depression slightly attenuated the effect (Table 3). The
association between maternal PTSD or depression, and newly recorded physical child
abuse was stronger in children of single mothers (RR=2.31; 1.11-4.81, Table 3.2.3) than in
children with two parents (1.36; 95%CI 0.64-2.92).
Table 3.2.3 Rates and relative risks for recorded physical child abuse according to family composition,
maternal violence exposure and maternal diagnosis of PTSD or depression
Partially controlled
model*
Family
composition
Independent
variable
number
of cases
Relative
risk*
Person
years
Rate per
1000
person years
5,604
2.3
Fully controlled
model*
95% CI Relative
risk*
95% CI

Two parents
Single mother
No
31
Yes
25
3,001
3.0
1.18
No
13
5,348
1.3
Yes
29
3,828
3.7
2.88
47
7,624
2.5
1
0.69-2.03
1.14
0.66-1.97
1
1.47-5.66
2.57
1.30-5.10

Two parents
Single mother
No
Yes
980
3.3
1.41
No
31
8,434
1.9
Yes
11
742
6.0
2.83
1
0.67-1.98
1.36
0.64-2.92
1
1.38-5.80
2.31
1.11-4.81
* Estimated with Cox regression models including all variables presented in table 3.2.2, in the partially
controlled model with the other maternal factor, in the fully controlled model with the other maternal factor
Association
PTSD and
diabetes
Maternal risk
factors physical
child
abuse
DISCuSSIOn
In this nationwide study maternal violence exposure and maternal diagnosis of PTSD
or depression were associated with an increased risk of physical child abuse in asylumseeking children. The association was stronger in children who were in reception with
mother only compared with children with two parents.

Unique features of this study are the size of the study population, the longitudinal
design, the nationwide coverage and the availability of demographic and reception
variables for children and their parents.
The study also has limitations. Despite the large population size the statistical power
of the study was limited due to the small number of cases. In addition there are several
ways in which observation bias may have influenced the results. As in other studies
based on health care utilization data, we could not measure the overall extent of the
problem of child abuse.13 It has been demonstrated that only a fraction of the cases of
child abuse comes to the knowledge of professionals.39
Furthermore, the dates of recording of physical child abuse, maternal violence exposure,
and maternal PTSD or depression may have been considerably later than the date of
onset of these conditions.40 As a consequence, it is not certain that for all cases we
adequately measured the time sequence in which the independent and dependent
study variables occurred.
Missed diagnoses of maternal violence exposure, PTSD, and depression may have resulted in dilution of the effect of these factors on the risk of physical child abuse. On the
other hand, contacts with care providers in relation to maternal diagnosis of PTSD or
depression may have increased the chance of identification of physical child abuse, and
therefore an overestimation of the effect.
The combination of maternal PTSD and depression in one variable has potentially
masked differences in the effect of the two conditions on the risk for physical child abuse.
However, as both conditions are strongly associated within asylum-seeking populations,
their independent effects cannot be adequately studied on the basis of primary care
medical record data.41,42
Associations with maternal factors

This study provides evidence that among asylum-seeking children maternal violence exposure and maternal PTSD and depression are associated with a higher risk for physical
149
150
Section 3.2
child abuse. This is in line with the evidence for other populations.5,14,16-20 The size of
the effect of maternal violence exposure and maternal PTSD or depression differed
considerably between children in reception with a single mother or with two parents.
Various explanations can be suggested. First of all single parenthood can involve a range
of stressors that increase the risk of physical abuse, such as social isolation, and a lack of
emotional and instrumental support.5 The accumulation of these stressors and PTSD or
depression might have adverse effects on parenting. Moreover, they may increase the
symptoms of PTSD, which is associated with increased hostility towards the children.31
Furthermore, father involvement might reduce mothers parenting stress.43 Moreover,
single mothers are more likely to have been exposed to sexual and gender-based violence, and to have children born of rape.44 Children born of rape have been reported to
face an increased risk of a poor parent-child relationship and this relationship may come
under further pressure in case of maternal PTSD or depression.45
Associations with demographic factors

Although not the main aim of this study, some findings with respect to demographic
factors may, as they differ from what is generally reported, be of interest. The higher risk
found for girls is surprising as in low-income countries boys are reported to be at higher
risk of harsh physical punishment.1-3,39 Explanations for this discrepancy may be sought
in problems that asylum-seeking parents are reported to have with the independence
of children in Western society, which may apply even more problematically to girls than
to boys.46
The absence of a risk difference between children of single mothers and mothers with
partner is remarkable, as in developing as well as industrialized countries the prevalence
of physical abuse is reported to be higher in single parent families.3,47 An explanation
might lie in the living situation of families in asylum reception centres, and a possible
influence of paternal violence exposure and paternal PTSD or depression.
Another remarkable finding is the higher risk for children born before arrival in the
Netherlands. Several explanations for this difference can be suggested. Firstly, abuse of
children before or during the flight may have continued during the stay in the reception
facilities and not have been identified in the first months after arrival. Secondly, these
children may have been exposed to adverse experiences in the country of origin and
during the flight, which may have resulted in mental distress and behavioral problems,
which are risk factors for physical child abuse.37,48,49 Thirdly, parenting practices may be
better for children born in reception, as their parents may have established contacts
with professionals and established a social network during pregnancy and child birth,
and may consequently receive more parenting support.
Association
PTSD and
diabetes
Maternal risk
factors physical
child
abuse
IMPlICATIOnS FOR POlICy AnD PRACTICE

In light of the increased risk for physical child abuse associated with maternal violence
exposure and diagnosis of PTSD or depression, particular attention may be paid to the
prevention of physical child abuse in asylum-seeking families in which the mother bears
these risk factors.
Supporting families to establish or re-establish a family environment that is marked by
predictability and security will contribute to the prevention of physical child abuse and
the improvement of health outcomes in general.31 To achieve this, early identification
of families with parental mental health problems and disturbed family processes due
to violence exposure is a prerequisite. However, routine screening for child abuse in
asylum-seeking families is not recommended, as the harms of screening are reported
to outweigh the benefits in migrant families.33,50 In addition clinical treatment plans for
asylum-seeking parents with PTSD or depression should take parenting processes into
account.31
Interventions will need to address asylum-seeking families as well as refugee families
who have received a positive decision on their asylum request and have settled in a
municipality as the effects of violence exposure, PTSD and depression may linger on
long after resettlement.25,51
ACknOwlEDGEMEnTS
The authors would like to thank the Central Agency for the Reception of Asylum Seekers
for providing the demographic and reception data, and the medical professionals for
the recording of the health data. We are grateful to F. de Vries for exploring the analysis
of the child abuse data, and to K. Slinger and H. Nijsingh for their contribution to the
interpretation of the results.
151
152
Section 3.2
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
Akmatov MK. Child abuse in 28 developing and transitional countriesresults from the Multiple
Indicator Cluster Surveys. Int J Epidemiol. 2011;40:219-27.
Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of
child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS
Med. 2012;9:e1001349.
World Health Organization. World Report on Violence and Health. Geneva: World Health Organization; 2002.
World Health Organization and International Society for Prevention of Child Abuse and Neglect.
Preventing child maltreatment: a guide to taking action and generating evidence. Geneva; 2006.
World Health Organization Regional Office for Europe. European report on preventing child
maltreatment. Copenhagen: WHO Regional Office for Europe; 2013.
Alink L, IJzendoorn vMH, Bakermans-Kranenburg MJ, Pannebakker F, Vogels T, Euser S. Child
maltreatment in the Netherlands 2010. Leiden: University of Leiden; 2011.
Annerback EM, Wingren G, Svedin CG, Gustafsson PA. Prevalence and characteristics of child
physical abuse in Sweden - findings from a population-based youth survey. Acta Paediatr.
2010;99:1229-36.
Euser EM, van Ijzendoorn MH, Prinzie P, Bakermans-Kranenburg MJ. Elevated child maltreatment
rates in immigrant families and the role of socioeconomic differences. Child Maltreat. 2011;16:6373.
Lewig K, Arney F, Salveron M. Challenges to parenting in a new culture: Implications for child and
family welfare. Eval Program Plann. 2010;33:324-32.
United Nations High Commissioner for Refugees. UNHCR Statistical Online Population Database:
Sources, Methods and Data Considerations. 2011.
United Nations High Commissioner for Refugees. UNHCR Statistical yearbook 2009; Trends in
displacement, protection and solutions. 2010.
Belsky J. Etiology of child maltreatment: a developmental-ecological analysis. Psychol Bull.
1993;114:413-34.
http://www.who.int/mediacentre/factsheets/fs150/en/index.html
Stith SM, Liu TL, .Davies C, et al. Risk factors in child maltreatment: A meta-analytic review of the
literature. Agression and Violent Behavior. 2009;14:13-29.
Hillson JMC, Kuiper NA. A stress and coping model of child maltreatment. Clinical Psychology
Review. 1994;14:261-85.
Boeckel MG, Blasco-Ros C, Grassi-Oliveira R, Martinez M. Child Abuse in the Context of Intimate
Partner Violence Against Women: The Impact of Womens Depressive and Posttraumatic Stress
Symptoms on Maternal Behavior. J Interpers Violence. 2014;29:1201-27.
Chemtob CM, Gudino OG, Laraque D. Maternal posttraumatic stress disorder and depression in
pediatric primary care: association with child maltreatment and frequency of child exposure to
traumatic events. JAMA Pediatr. 2013;167:1011-8.
Miranda JK, de la Osa N, Granero R, Ezpeleta L. Maternal childhood abuse, intimate partner violence, and child psychopathology: the mediator role of mothers mental health. Violence Against
Women. 2013;19:50-68.
Plant DT, Barker ED, Waters CS, Pawlby S, Pariante CM. Intergenerational transmission of maltreatment and psychopathology: the role of antenatal depression. Psychol Med. 2013;43:519-28.
Association
PTSD and
diabetes
Maternal risk
factors physical
child
abuse
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
Saile R, Ertl V, Neuner F, Catani C. Does war contribute to family violence against children?
Findings from a two-generational multi-informant study in Northern Uganda. Child Abuse Negl.
2014;38:135-46.
Hallas P, Hansen AR, Staehr MA, Munk-Andersen E, Jorgensen HL. Length of stay in asylum centres
and mental health in asylum seekers: a retrospective study from Denmark. BMC Public Health.
2007;7:288-94.
Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, de Jong JT. Impact of a long asylum procedure
on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment
Dis. 2004;192:843-51.
Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental
health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294:602-12.
Dudley M, Steel Z, Mares S, Newman L. Children and young people in immigration detention. Curr
Opin Psychiatry. 2012;25:285-92.
Fazel M, Stein A. The mental health of refugee children. Arch Dis Child. 2002;87:366-70.
Ee E.van, Sleijpen M, Kleber RJ, Jongmans MJ. Father-involvement in a refugee sample: relations
between posttraumatic stress and caregiving. Fam Process. 2013;52:723-35.
Ee Ev, Kleber RJ, Mooren TTM. War trauma lingers on: associations between maternal posttraumatic stress disorder, parent-child interaction, and child development. Infant mental health
journal. 2012;33:459-68.
Kalebic JK, Ajdukovic M. Risk factors of child physical abuse by parents with mixed anxietydepressive disorder or posttraumatic stress disorder. Croat Med J. 2011;52:25-34.
Hassan G, Thombs BD, Rousseau C, et al. Child maltreatment: evidence review for newly arriving
immigrants and refugees; appendix 12. CMAJ. 2011;
Vogels AGC. The identification by Dutch Preventive Child Health Care of children with psychosocial problems: do short questionnaires help? Groningen: University of Groningen; 2008.
Baat de M, Linden van der P, Kooijman K, Vink C. Combating child abuse and neglect in the Netherlands . Utrecht, The Netherlands: Netherlands Youth Institute; 2011.
Epidemiol. 2014;43:94-104.
Clayton D, Schifflers E. Models for temporal variation in cancer rates. II: Age-period-cohort models. Stat Med. 1987;6:469-81.
Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of
child maltreatment in high-income countries. Lancet. 2009;373:68-81.
153
154
Section 3.2
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
Fallon B, Trocme N, Fluke J, Maclaurin B, Tonmyr L, Yuan YY. Methodological challenges in measuring child maltreatment. Child Abuse Negl. 2010;34:70-9.
Goenjian AK, Steinberg AM, Najarian LM, Fairbanks LA, Tashjian M, Pynoos RS. Prospective study
of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence.
Am J Psychiatry. 2000;157:911-6.
Javidi H, Yadollahie M. Post-traumatic Stress Disorder. Int J Occup Environ Med. 2012;3:2-9.
Nomaguchi KM, Brown SL, Layman TM. Father involvement and Mothers Parenting Stress: The
Role of Relationship status. Fragile Families Working Paper: 12-07-FF, editor. 2012.
Keygnaert I, Vettenburg N, Temmerman M. Hidden violence is silent rape: sexual and genderbased violence in refugees, asylum seekers and undocumented migrants in Belgium and the
Netherlands. Cult Health Sex. 2012;14:505-20.
Ee E.van, Kleber RJ. Growing up under a shadow: Key issues in research and treatment of children
born of rape. Child abuse review. 2013;22:386-97.
Lewig K, Arney F, Salveron M. Challenges to parenting in a new culture: Implications for child and
family welfare. Eval Program Plann. 2010;33:324-32.
Waldfogel J, Craigie TA, Brooks-Gunn J. Fragile families and child wellbeing. Future Child.
2010;20:87-112.
Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and
refugees. CMAJ. 2011;183:E824-E925.
Lamkaddem M, Stronks K, Gerritsen AAM, Devill WLJM, Essink-Bot L.M. Gezondheid en zorggebruik onder vluchtelingen; Vervolgonderzoek onder mensen met een verblijfsvergunning in
Nederland. Ned Tijdschr Geneeskd. 2012;2013;157:A5604
Section 3.3
relationship between posttraumatic stress disorder and
diabetes among 105,180 asylum
seekers in the netherlands

Agyemang C, Goosen S, Anujuo K, Ogedegbe G. Relationship between posttraumatic stress disorder and diabetes among 105,180 asylum seekers in the
Netherlands. Eur J Public Health. 2012;22:658-62.
158
Section 3.3
ABSTRACT
Background
Several reports have demonstrated a relationship between post traumatic stress disorder
(PTSD) and type 2 diabetes (T2DM) mainly in combat veterans. The relationship between
PTSD and T2DM has not been evaluated among vulnerable migrant populations. The
main objective of this study was therefore to assess the relationship between PTSD and
T2DM among asylum seekers in the Netherlands.
Methods
Analysis of a national electronic database of the Dutch Community Health Services for
Asylum seekers aged 18 years (N=105,180).
Results
Asylum seekers with PTSD had a higher prevalence of T2DM compared to those without
PTSD. The age-adjusted prevalence ratios (APR) were 1.40 (95% CI, 1.12-1.76) in men and
1.22 (95% CI, 0.95-1.56) in women compared with individuals without PTSD, respectively.
There was an interaction between PTSD and co-morbid depression (P<.05) in men and
women, indicating that the effect of PTSD and comorbid depression on T2DM differed.
When the analyses were stratified by depression status, among non-depressed group,
individuals with PTSD had a higher prevalence of T2DM compared to those without
PTSD (APR=1.47 (95% CI, 1.15-1.87) in men and APR=1.27 (95% CI, 0.97-1.66) in women).
Among the depressed individuals, however, there was no association between PTSD
and T2DM (APR=0.87 (95% CI, 0.43-1.76) in men, and APR=1.00, (95% CI, 0.54-1.83) in
women).
Conclusion
The findings suggest that history of PTSD is related to high levels of T2DM among asylum
seekers independent of comorbid depression. Clinicians and policy makers need to take
PTSD into account when assessing and treating diabetes among vulnerable migrant
populations.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
InTRODuCTIOn
Migration from less to more affluent countries has been associated with increased
incidence and prevalence of type 2 diabetes mellitus (T2DM).1 The available data from
several European countries suggest that T2DM rates are higher in ethnic minority and
migrant groups than in Whites for reasons that are still not yet fully understood.2-5 To
date, there are still no clear answers as to why T2DM is more common among some
ethnic minority and migrant groups. Unhealthy behaviour following migration has been
suggested as possible factor underlying the relatively high prevalence of T2DM among
ethnic minority and migrant populations.6-8 Given the difficulty in explaining ethnic
inequalities in T2DM, it becomes imperative to examine other factors.
Recent studies have reported an increase in risk of diabetes associated with posttraumatic stress disorder (PTSD).9-12 Potential mechanisms linking depression and PTSD
to diabetes might involve the stress response associated with these conditions contributing to inflammation and insulin resistance.13,14 Migrant populations particularly those
seeking refuge (i.e. asylum seekers) are particularly prone to mental health disorders
such as PTSD.15 The increased vulnerability to poor or deteriorating health may be a result of experiences before, during or after arrival in the receiving country.15-18 Moreover,
barriers to health care access in the receiving countries may also have a detrimental
effect on the health of migrant populations.19 Consequently, high rates of mental health
disorders have been reported among those seeking refuge in Western countries.20-23
Although both PTSD and diabetes are highly prevalent among ethnic minority and
migrant populations in Europe and North America, no study has yet assessed the relationship between PTSD and T2DM among vulnerable migrant populations from lowincome countries such as asylum seekers. Furthermore, the analyses of the relationship
between PTSD and T2DM in previous studies were based on self-reported data rather
than physician-made diagnosis. The aim of this study was therefore to evaluate the
relationship between PTSD and T2DM among asylum seekers in the Netherlands using
a national database of asylum seekers. In addition, we assessed whether the association
between PTSD and T2DM was independent of depression among asylum seekers.
METHODS
Sample
Data for this study were obtained from the national electronic database of the Community Health Services for Asylum Seekers in the Netherlands. An asylum seeker refers
159
160
Section 3.3
to a person who has applied for asylum and is awaiting a decision on their application.
The Community Health Services for Asylum Seekers provides preventive care to asylum
seekers as well as referral to health care providers throughout the Netherlands. Services
for adults were provided by nurse practitioners and public health physicians in close collaboration with family practitioners. The total number of asylum seekers with complete
data in the electronic database from 2000 to 2008 was 181,000. Of these, 105,180 (58%)
were >=18 years and were included for this analysis.
Diagnostic criteria
Asylum seekers were given a diagnosis of T2DM, PTSD and other health problems if
during their stay at the reception facilities, the respective diagnoses were recorded in
their medical notes by either a general practitioner or a specialist. All information on
diagnoses was classified according to the International Classification of Primary Care
(ICPC), which is compatible with both the International Classification of Diseases and the
Diagnostic and Statistical Manual of Mental Disorders, fourth Edition (DSM-IV).24
Dependent variable
The ICPC diagnosis of T2DM requires an elevated glucose level (fasting plasma glucose
levels of 7.0 mmol/l, a fasting capillary glucose level of 6.0 mmol/l, or non-fasting
plasma or capillary glucose level of 11.0 mmol/l) that is confirmed using a fasting
glucose level a few days later.
Independent variables
The diagnosis of PTSD and depression was based on the DSM-IV criteria.25 PTSD refers to
stress arising after exposure to a terrifying event in which grave physical harm occurred
or was threatened.25 Traumatic events that may activate PTSD include violent personal
assaults such as rape, physical and sexual abuse, loss of family members, natural or
human caused disasters, motor vehicle accidents and others.25 According to ICPC the
criteria for depressive disorder include at least three of the following six criteria in the
absence of psychosis: (i) sadness or melancholy more than can be explained by psychosocial stress, (ii) suicidal thoughts or attempt, (iii) indecisiveness, decreased interest in
usual activities or diminished ability to think, (iv) feelings of worthlessness, self-reproach,
or inappropriate or excessive guilt, (v) early morning wakening, hypersomnia, or early
morning fatigue, or (vi) anxiety, hyperirritability, or agitation.
Body mass index (BMI) was calculated as weight (kg) divided by height (m2). Obesity
was defined as BMI 30 kg/m2. Smoking status was categorized into current smoker
and non-smoker. In addition to the presented health problems, data on the following
demographic characteristics were available: gender, age, number of years lived in the
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
Netherlands and country of origin. As our data were completely anonymized ethical
approval was deemed unnecessary.
Data analysis
Baseline data were expressed as percentages. Chi-square tests were used to assess
differences in categorical variables. Prevalence rate ratios and their 95% confidence
intervals (95% CI) were estimated by means of Poisson regression with robust variance,26
to examine the association between PTSD and T2DM with adjustment for available
individual factors that were associated with T2DM in the univariate analysis. All statistical analyses were performed using STATA 11 for Windows (Stata Corporation, College
Station, TX, USA).
RESulTS
Characteristics of the study population
Table 3.3.1 shows the distribution of the study population by sex. Over 80% of the study
population was <40 years of age. The largest group was from Middle-East and South
West Asia. Smoking was less common, but obesity, T2DM, depression and PTSD were
more common in women than in men. Table 3.3.2 shows the characteristics of the study
groups by T2DM status. T2DM was more prevalent among the older age groups, those
with longer length of stay and obese individuals in both men and women. People with
PTSD were more likely than those without PTSD to have T2DM. There were no association between comorbid depression, smoking and T2DM in both men and women.
Relationship between PTSD, depression and T2DM

Table 3.3.3 shows adjusted prevalence ratios and their corresponding 95% CI for T2DM
by PTSD. People with PTSD were more likely than those without PTSD to have T2DM in
both men [age-adjusted prevalence ratio (APR) = 1.40, 95% CI, 1.12-1.76] and women
(APR = 1.22, 95% CI, 0.95-1.56). Further adjustments for length of stay, world region of
origin and obesity attenuated the difference in women, but not in men. There was an
interaction between PTSD and depression (P < 0.05), indicating that the effects of PTSD
and depression on T2DM are independent of each other in both men and women. Given
the interaction between PTSD and depression, we further stratified the analyses by
depression status (figure 3.3.1a and b). Among non-depressed group, individuals with
PTSD had higher prevalence ratios of T2DM than their non-PTSD counterparts: (APR =
1.47, CI, 95% 1.15-1.87 in men and APR = 1.27, 95% CI, 0.97-1.66 in women). However,
among the depressed individuals, there was no association between PTSD and T2DM
(APR = 0.87, 95% CI, 0.43-1.76) in men and APR = 1.00, 95% CI, 0.54-1.83 in women).
161
162
Section 3.3
Table 3.3.1 Characteristics of the study population

Men (n = 68,747)
women (n = 36,433)
(%)
(%)
18-29
59.1
52.3
30-39
28.1
29.9
40-49
8.3
9.9
50-59
2.5
4.5
60
1.4
3.4
West, Central & Southern Africa
17.1
15.6
North, East & Horn Africa
16.8
17.2
Central, East & Southern Europe
19.8
26.5
Middle East & South West Asia
37.4
32.0
Central, Eastern & Southern Asia
6.4
5.8
Other
2.5
2.9
<2 yrs
44.6
42.4
2-4 yrs
34.6
34.1
5 yrs
20.8
23.5
No
99.3
97.3
Yes
0.7
2.7
No
98.3
97.1
Yes
1.7
2.9
No
69.7
90.7
Yes
30.3
9.3
No
97.5
95.0
Yes
2.5
5.0
No
96.1
94.6
Yes
3.9
5.4
Age group
World regions
Length of stay
Obesity (BMI 30 kg/m )

2
T2DM
Smoking
Comorbid depression
PTSD
BMI, body mass index
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
Table 3.3.2 Prevalence of diabetes by study characteristics

Men (n = 68,747)
(%)
women (n = 36,433)
PR (95% CI)
(%)
PR (95% CI)
Age group
18-29
0.3
0.5
30-39
1.6
4.82 (3.95-5.88)
1.9
3.90 (3.05-4.98)
40-49
6.0
17.58 (14.45-21.38)
6.6
13.60 (10.72-17.26)
50-59
13.9
40.80 (33.24-50.07)
15.7
32.40 (25.68-40.89)
60
18.4
53.86 (43.1066. 26)
19.9
41.12 (32.58-5190)
World regions
West, Central & Southern Africa
1.0
1.3
North, East & Horn Africa
2.0
1.33 (1.07-1.65)
3.1
1.42 (1.10-1.85)
Central, East & Southern Europe
1.8
0.70 (0.56-0.86)
2.9
0.85 (0.66-1.10)
Middle East & South West Asia
1.9
0.79 (0.65-0.97)
3.5
0.95 (0.74-1.21)
Central, Eastern & Southern Asia
1.9
0.90 (0.68-1.18)
2.7
0.92 (0.66-1.27)
Other
2.1
0.79 (0.55-1.12)
2.7
0.77 (0.51-1.17)
Length of stay
<2 yrs
1.4
2.1
2-4 yrs
1.6
1.21 (1.06-1.39)
2.7
1.22 (1.05-1.41)
2.8
1.83 (1.60-2.09)
4.5
2.08 (1.80-2.39)
5 yrs
Obesity (BMI 30 kg/m )
2
No
1.6
2.5
Yes
20.4
4.98 (4.13-6.00)
16.9
3.18 (2.71-3.73)
Comorbid depression
No
1.7
2.8
Yes
2.5
1.15 (0.85-1.54)
3.3
1.05 (0.80-1.36)
No
1.7
2.8
Yes
2.7
1.40 (1.12-1.76)
3.3
1.22 (0.95-1.56)
No
1.7
2.9
Yes
1.9
1.06 (0.95-1.20)
2.5
0.94 (0.75-1.16)
PTSD
Smoking
BMI, body mass index
163
Section 3.3
Table 3.3.3 Prevalence ratios of T2DM (95% CI) by PTSD, and stratified by non depression and chronic
depression
Men
women
Model 1
Model 2
Model 1
Model 2
PR (95% CI)
PR (95% CI)
PR (95% CI)
PR (95% CI)
All
No
Yes
1.40 (1.12-1.76)
1.34 (1.07-1.69)
1.22 (0.95-1.56)
1.10 (0.85-1.40)
Depression status
Non-depressed
No
Yes
1.47 (1.15-1.87)
1.42 (1.12-1.81)
1.27 (0.97-1.66)
1.14 (0.86-1.51)
Depressed
No
Yes
0.87 (0.43-1.76)
0.87 (0.42-1.79)
1.00 (0.54-1.83)
1.06 (0.58-1.92)
PR, prevalence ratio; *model 1: adjusted for age; model 2: plus world region, length of stay and obesity
7
6
T2DM,%
5
4
3
2
1
0
NoPTSD
YesPTSD
NoPTSD
YesPTSD
Non-depressedDepressed
7
6
5
T2DM,%
164
4
3
2
1
0
NoPTSD
YesPTSD
NoPTSD
YesPTSD
Non-depressedDepressed
Figure 3.3.1 Prevalence of T2DM by PTSD in non-depressed and depressed individuals in men (a) and
women (b)
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
DISCuSSIOn
In this study, we found that among migrants on asylum status in the Netherlands, those
with PTSD have a higher prevalence of T2DM compared with those without PTSD. The association between PTSD and T2DM was stronger in those without comorbid depression
compared with those with comorbid depression. To our knowledge, this is the first study
to determine the relationship between PTSD and T2DM among asylum seekers. Previous
studies understandably focused on military service men and women rather the general
population. Similar to previous studies, our findings confirm those of other investigators
who documented a strong positive relationship between PTSD and T2DM.9-11
A potential mechanism linking PTSD to T2DM may be via increased levels of stress that
is often associated with PTSD,13,14 and asylum status.15-18 The effect of stress, which manifests as fluctuations in blood glucose levels, is triggered primarily by the normal physiological activities in humans.13 Stress induced by a sense of loss of control can result in
the activation of the hypothalamo pituitary adrenal (HPA) axis that results in the increase
of glucocorticoids, most notably, cortisol, whose prolonged activation results in insulinresistance and immunosuppression.27 For example, Bjrntorp et al.28 postulated that
stressful experiences lead to activations of the HPA axis with resultant excess cortisol
production, which in turn leads to metabolic abnormalities including abdominal adiposity, insulin resistance, and diabetes. Although we did not assess cortisol production or
stress levels in our study, there is ample evidence documenting the high levels of stress
in asylum seekers and other immigrant populations.16-18 Migration, even when voluntary
has been associated with stress-attributable in part, to the social, economic and political marginalization of immigrants and refugees.29 Resettlement in a new environment
poses major challenges to new immigrants for them to adapt to new values, language,
financial strain, changes in economic and gender roles.20-23 This process of acculturative stress is mediated by the ability of the migrants to harness individual, cultural and
material resources to resist the strain of adaptation and integration.29 The relationship
between PTSD and T2DM was stronger in men than in women. The explanation for this is
unclear, but may relate to differences in biologic responses in PTSD and T2DM.30
Unhealthy lifestyles such as sedentary behaviour, smoking and poor dietary habits may
also contribute to the high rate of diabetes found in individuals with PTSD. For example,
PTSD has been linked to an increased rate of smoking,31 which in turn is associated with
increased risk of diabetes.32 Additionally, there is evidence of a possible link between
PTSD, physical inactivity and poor dietary habits.33,34 In Assis et al.s study, substantial
reduction in physical activity was observed after the onset of PTSD among adults in Brazil.33 Vulnerable migrant populations may be particularly prone to unhealthy lifestyle due
165
166
Section 3.3
to adaptation to new and often harsh social conditions in their new environment.35 The
strong relationship between PTSD and T2DM suggests that the increased prevalence of
T2DM noted in migrant populations may be influenced, at least in part, by psychological
factors, and interventions aimed at stress coping strategies may lead to better glycaemic
control.36 Stress management improves long-term glycemic control in T2DM patients.36,37
These findings clearly suggest the need to take history of PTSD into account when
assessing and treating migrant populations or asylum seekers for diabetes especially
among those aged 40 years who are at high risk of T2DM. The prevalence rate found
among those aged 40 years far exceeded those reported among the White-Dutch
population and several ethnic minority groups in the Netherlands,3,38,39 and highlights
the urgent need for public health interventions among this disadvantaged population.
The lack of association between depression and T2DM is consistent with current reports,9,10 but contrasts earlier reports.11 The studies by Goodwin et al.9 and Boyko et al.10
found positive association between PTSD and T2DM, but failed to demonstrate any relationship between depression and T2DM. In contrast, a meta-analysis of observational
studies found a higher risk of diabetes associated with depression.11 Explanation for the
discrepancy between earlier studies and recent studies are unclear. Nevertheless, previous studies did not take into account the presence of PTSD in their analyses.11 It is likely
that depression may serve as a proxy marker for PTSD and possibly not be otherwise
independently related to diabetes.10
The main strength of our study is the large sample size of our study population. In addition, our data were based on the whole of the Netherlands and therefore included
all individuals that applied for asylum in the period 2000-2008. Furthermore, there
are important similarities between populations seeking asylum in different European
countries, and therefore the results can be extrapolated to other European countries.
Limitations of our study include its cross-sectional nature, which makes causal inference
impossible. Also, our data were based on ICPC-code taken from the electronic medical
records. This means that our results depend largely on the quality and the reliability
of registration by health professionals. Furthermore, the dataset lacked information on
other important factors such as dietary habits and physical activity levels and health
status of asylum seekers prior to migration, socioeconomic status and the length of
stay at the time diabetes was developed, which may contribute to the observed differences.2,3,40,41 Despite these limitations, our current study provides important information
on the relationship between two important risk factors, PTSD and diabetes, in a vulnerable population of asylum seekers.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
COnCluSIOnS
In conclusion, our findings suggest that history of PTSD is related to high levels of
diabetes among asylum seekers independent of comorbid depression. Clinicians and
policy makers need to take PTSD into account when assessing and treating diabetes
among vulnerable migrant populations. Taking measures to improve stress coping
strategies may help with glycemic control among these populations.
167
168
Section 3.3
REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
International Diabetes Federation (IDF). IDF Diabetes Atlas. 4th edn, 2009. Available at http://
diabetesatlas.org (19 December 2010, date last accessed).
Oldroyd J, Banerjee M, Heald A, Cruickshank K. Diabetes and ethnic minorities. Postgrad Med J
2005;81:486-90.
Bindraban NR, van Valkengoed IG, Mairuhu G, et al. Prevalence of diabetes mellitus and the performance of a risk score among Hindustani Surinamese, African Surinamese and ethnic Dutch: a
cross-sectional population-based study. BMC Public Health 2008;8:271.
Jenum AK, Holme I, Graff-Iversen S, Birkeland KI. Ethnicity and sex are strong determinants of
diabetes in an urban Western society: implications for prevention. Diabetologia 2005;48:435-9.
Agyemang C, Addo J, Bhopal R, et al. Cardiovascular disease, diabetes and established risk factors
among populations of sub-Saharan African descent in Europe: a literature review. Global Health
2009;5:7.
Misra A, Ganda OP. Migration and its impact on adiposity and type 2 diabetes. Nutrition
2007;23:696-708.
Cruickshank JK, Mbanya JC, Wilks R, et al. Sick genes, sick individuals or sick populations with
chronic disease? The emergence of diabetes and high blood pressure in African-origin populations. Int J Epidemiol 2001;30:111-7.
Sniderman AD, Bhopal R, Prabhakaran D, et al. Why might South Asians be so susceptible to
central obesity and its atherogenic consequences? The adipose tissue overflow hypothesis. Int J
Epidemiol 2007;36:220-5.
Goodwin RD, Davidson JR. Self-reported diabetes and posttraumatic stress disorder among
adults in the community. Prev Med 2005;40:570-4.
Boyko EJ, Jacobson IG, Smith B, et al. Risk of diabetes in U.S. military service members in relation
to combat deployment and mental health. Diabetes Care 2010;33:1771-7.
Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a
meta-analysis. Diabetes Care 2008;31:2383-90.
Raja M, Onofri A, Azzoni A, et al. Post-traumatic stress disorder among people exposed to the
Ventotene street disaster in Rome. Clin Pract Epidemiol Ment Health 2008;4:5.
Black PH. The inflammatory consequences of psychologic stress: relationship to insulin resistance,
obesity, atherosclerosis and diabetes mellitus, type II. Med Hypotheses 2006;67:879-91.
Golden SH. A review of the evidence for a neuroendocrine link between stress, depression and
diabetes mellitus. Curr Diabetes Rev 2007;3:252-9.
Burnett A. Peel M Health needs of asylum seekers and refugees. BMJ 2001;322:544-7.
Hondius AJ, van Willigen LH, Kleijn WC, van der Ploeg HM. Health problems among LatinAmerican and middle-eastern refugees in The Netherlands: relations with violence exposure and
ongoing sociopsychological strain. J Trauma Stress 2000;13:619-34.
Laban CJ, Gernaat HB, Komproe IH, et al. Postmigration living problems and common psychiatric
disorders in Iraqi asylum seekers in the Netherlands. J Nerv Ment Dis 2005;193:825-32.
Lindencrona F, Ekblad S, Hauff E. Mental health of recently resettled refugees from the Middle
East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to
handle stress. Soc Psychiatry Psychiatr Epidemiol 2008;43:121-31.
Union-a comparative study of country policies. Eur J Public Health 2006;16:286-90.
Maternal risk
factors physical
child
abuse
Association
PTSD and
diabetes
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
Favaro A, Maiorani M, Colombo G, Santonastaso P. Traumatic experiences, posttraumatic stress

disorder, and dissociative symptoms in a group of refugees from former Yugoslavia. J Nerv Ment
Dis 1999;187:306-8.
Hermansson AC, Timpka T, Thyberg M. The mental health of war-wounded refugees: an 8-year
follow-up. J Nerv Ment Dis 2002;190:374-80.
Lie B. A 3-year follow-up study of psychosocial functioning and general symptoms in settled
refugees. Acta Psychiatr Scand 2002;106:415-25.
Steel Z, Silove D, Phan T, Bauman A. Long-term effect of psychological trauma on the mental health
of Vietnamese refugees resettled in Australia: a population-based study. Lancet 2002;360:105662.
Classification Committee of WONCA in collaboration with the World Health Organization. An
International Glossary for Primary Care, 3rd edn. ICHPPC-2 Defined, Oxford: Oxford University
Press, 1984.
American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders, 3 rd edn, revised. Washington, DC: American Psychiatric Association, 1987.
Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol
2003;3:21.
Surwit RS, Feinglos MN. Stress and autonomic nervous system in Type II diabetes: a hypothesis.
Diabetes Care 1988;11:83-5.
Bjrntorp P, Holm G, Rosmond R. Hypothalamic arousal, insulin resistance and type 2 diabetes
mellitus. Diabet Med 1999;16:373-83.
Scott W, Scott R. The Adaptation of Immigrants: Individual Differences and Determinants. Oxford:
Pergamon Press, 1989.
Ogilvie KM, Rivier C. Gender difference in hypothalamic-pituitary-adrenal axis response to alcohol
in the rat: activational role of gonadal steroids. Brain Res 1997;766:19-28.
Beckham JC, Kirby AC, Feldman ME, et al. Prevalence and correlates of heavy smoking in Vietnam
veterans with chronic posttraumatic stress disorder. Addict Behav 1997;22:637-47.
Willi C, Bodenmann P, Ghali WA, et al. Active smoking and the risk of type 2 diabetes: a systematic
review and meta-analysis. JAMA 2007;298:2654.
Assis MA, Mello MF, Scorza FA, et al. Evaluation of physical activity habits in patients with posttraumatic stress disorder. Clinics 2008;63:473-8.
Shalev A, Bleich A, Ursano RJ. Posttraumatic stress disorder: Somatic comorbidity and effort tolerance. Psychosomatics 1990;31:197-203.
Rock M. Sweet blood and social suffering: rethinking cause-effect relationships in diabetes,
distress and duress. Med Anthropol 2003;22:131-74.
Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in patients with type 2
diabetes. Lancet 2004;363:1589-97.
Surwit RS, van Tilburg MA, Zucker N, et al. Stress management improves long-term glycemic
control in type 2 diabetes. Diabetes Care 2002;25:30-4.
Ujcic-Voortman JK, Schram MT, Jacobs-van der Bruggen MA, et al. Diabetes prevalence and risk
factors among ethnic minorities. Eur J Public Health 2009;19:511-5.
Agyemang C, Kunst AE, Bhopal R, et al. Diabetes prevalence in populations of South Asian Indian
and African Origins: a comparison of England and The Netherlands. Epidemiology 2011;22:563-7.
169
170
Section 3.3
(40)
(41)
Agardh E, Allebeck P, Hallqvist J, et al. Type 2 diabetes incidence and socio-economic position: a
systematic review and meta-analysis. Int J Epidemiol 2011;40:804-18.
Espelt A, Arriola L, Borrell C, et al. Socioeconomic position and type 2 diabetes mellitus in Europe
1999-2009: a panorama of inequalities. Curr Diabetes Rev 2011;7:148-58.
ChaPtEr 4
GenerAl dIscussIon
General discussion
GEnERAl DISCuSSIOn
affect their health. Based on the results of the studies in this thesis and the scientific
literature, we will explore the implications for policies and practices aimed at promoting
the health of asylum seekers and refugees.
This chapter starts with an overview of the principal findings of the individual papers in
section 4.1 and in Table 4.1.1. In section 4.2 we discuss several general methodological
considerations with respect to the studies in this thesis. In section 4.3 we reflect on three
themes that cut across the individual studies and propose focus areas for promoting
the health of asylum seekers and refugees. In section 4.4, we present reflections and
recommendations with respect to research. At the end of Chapter 4, we present the
overarching conclusions of this thesis regarding the distribution of diseases and conditions among asylum seekers and risk factors that affect their health.
4.1 PRInCIPAl FInDInGS

The study on mortality and causes of death reports on deaths in the total asylumseeking population in the Netherlands during the years 2002-2005 (section 2.1). The
overall mortality in these years was similar among asylum seekers and the population
of the Netherlands after correction for sex and age. However, risk differences with the
Dutch population varied considerably between subgroups by sex, age group, region of
origin, and causes of death. Compared with the population of the Netherlands, mortality
among asylum seekers was higher below the age of 40, and lower above the age of 40.
Women from the combined region of West, Central and Southern Africa below the age
of 40 were found to have the highest mortality risk compared with the population of the
Netherlands. The most common causes of death among asylum seekers were cancer,
cardiovascular diseases, and external causes of death. Causes for which increased risks
were found among male and female asylum seekers were infectious diseases (HIV, hepatitis and TB), accidents, and drowning. Among male asylum seekers suicide mortality
was increased. Among female asylum seekers, maternal mortality was increased. The
main conclusions of this study are that overall mortality is similar among asylum seekers
compared with the general population, but that mortality is higher among asylum seekers up to 40 years of age and for infectious diseases, external causes, and pregnancy- and
childbirth-related causes.
175
176
Chapter 4
The study on suicide and suicidal behaviour among asylum seekers covers the years
2002-2007 (section 2.2). In male asylum seekers, the suicide death rate was two times
higher than in the general population of the Netherlands; no difference was found
among women. For asylum-seeking men and women from Europe and the Middle East/
South-West Asia, the incidence of hospital-treated suicidal behaviour was high, and for
men and women from Africa low compared with the reference population (city of The
Hague). Health professionals knew about mental health problems prior to the suicidal
behaviour for 80% of the hospital-treated suicidal behaviour cases in asylum seekers. In
conclusion, compared with the general population male asylum seekers are at increased
risk of suicide and several subgroups of asylum seekers are at increased risk of suicidal
behaviour.
The main finding of the study on diabetes (section 2.3) is that, among both men and
women after correction for age, the prevalence of recorded diabetes was approximately
two times higher among asylum seekers than in the population of the Netherlands.
The highest recorded prevalence ratios were found for men and women from Somalia,
Sudan, and Sri Lanka. From the age of 30-39, diabetes prevalence was high among
asylum seekers compared with the general population in the Netherlands. Six months
after arrival, the prevalence of diabetes among asylum seekers was already higher than
in the population of the Netherlands. Incidence rates of recorded diabetes were higher
for asylum seekers compared with the host population throughout the stay in asylum
reception. The main conclusions of this study are that asylum seekers from the majority
of countries of origin are at increased risk compared with the general population in the
Netherlands, and that asylum seekers from Somalia are particularly at risk.
The study on induced abortions and teenage pregnancies in 2004-2005, shows an
induced abortion rate among asylum seekers that is one and a half times higher than
the average in the Netherlands. Large differences were found between subgroups. High
induced abortion rates were seen among women who were pregnant on arrival or who
got pregnant in the first months after arrival in the Netherlands. Abortion and teenage
birth rates were particularly high among asylum seekers aged 1519 from West, Central,
and Southern Africa and Central, East, and Southern Asia. The ratio of the number of
induced abortions and the number of live births (abortion ratio) was also higher than
the average in the Netherlands. The induced abortion ratio was particularly high among
asylum-seeking women aged 3049 from Europe and Asia. With increasing length of
stay, the induced abortion rate and teenage birth rates decreased. In conclusion, the
highest induced abortion and teenage birth rates were found shortly after arrival, and
African and Asian teenage girls were particularly at risk.
General discussion
In the study on HIV among pregnant asylum seekers (section 2.5) 79 out of 80 women
who were HIV positive during their last pregnancy in asylum reception originated from
sub-Saharan Africa. The HIV prevalence of 3.4% among sub-Saharan African women was
much higher than the overall antenatal HIV prevalence in the Netherlands (0.04%). Only
one HIV case was recorded among women from all other regions of origin; the prevalence of 0.04% was the same as overall in the Netherlands. The highest HIV prevalence
was found for women from Rwanda (17.0%), and Cameroon (13.2%). HIV prevalence
rates were highest among women in reception without a male partner, and UMAs. In
conclusion, HIV prevalence among pregnant asylum seekers was high in women from
sub-Saharan Africa, but not in women from other regions of origin. Variations in HIV
prevalence between asylum seekers from African countries showed parallels with variations in HIV prevalence rates between the African countries of origin.
Risk factors for the health of asylum seekers

The study on the association between relocations and mental distress (section 3.1)
shows that an annual relocation rate of one or more per year was associated with a
more than two and a half times increased incidence of mental distress. The risk increase
associated with frequent relocations was larger in children who had experienced violence and in children whose mothers had been diagnosed with PTSD or depression. No
association was found between the absolute number of relocations and mental distress.
The main conclusions of the study are that frequent relocations place the mental health
of asylum-seeking children at risk, and that the negative effect of frequent relocations is
greater in vulnerable children.
The study in section 3.2 reports on maternal risk factors for physical child abuse among
asylum seekers. The study shows that, compared with other children, the relative risk
(RR) for recorded physical child abuse was more than one and a half times higher in children whose mother had been exposed to violence and in children whose mother had
been diagnosed with PTSD or depression. The association between maternal violence
exposure and physical child abuse was stronger in children of single mothers compared
with children with two parents. The association with maternal violence exposure was
stronger in children of single mothers compared with children with two parents. The
same applies to the associations with maternal PTSD or depression. In conclusion,
asylum-seeking children whose mothers have been exposed to violence or have PTSD
or depression are at increased risk of physical child abuse, especially in single-mother
families.
The study in section 3.3 on the relationship between PTSD and diabetes shows that
asylum seekers with PTSD had a higher prevalence of diabetes compared with those
177
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Chapter 4
without PTSD. The effect of PTSD on the prevalence of diabetes differed between individuals with and without a diagnosis of depression. In the non-depressed group, asylum
seekers with PTSD had a higher diabetes prevalence compared with those without
PTSD. This was the case in both men and women. Among the individuals diagnosed with
depression, however, there was no association between PTSD and diabetes. The main
conclusion of this study is that history of PTSD is associated with high levels of diabetes
among asylum seekers.
Table 4.1.1 gives an overview of the main conclusions and recommendations as formulated in the respective studies.
4.2 METHODOlOGICAl COnSIDERATIOnS

This section addresses the general methodological considerations regarding the studies
in this thesis. The methodological issues of individual studies have been discussed in
Chapters 2 and 3.
The registry data that were used in the studies in this thesis had several advantages: the
availability of data for large numbers of asylum seekers, the nationwide coverage, the
considerable time span for which data are available, and the limited costs of data collection. Specific advantages of the database of the MOA are the availability of high-quality
demographic, reception and health data for every asylum seeker and the possibility to
link family-member data. The longitudinal character of this database allowed for the
development of statistical models that made it possible to analyse and correct for associations with length of stay.
However, the use of registry data also comes with some limitations.1 The main limitation
for the registry data in this thesis is that health care-based data only give insight into
health problems that have been presented to health professionals. Another limitation
is the absence of information on the quality and completeness of the data generated
by the health professions. Furthermore data on several variables that could have had
added value were unavailable or not sufficiently complete. Examples are data on the
status of the asylum procedure and the lifestyle of asylum seekers.
Below, we will first discuss the factors that determine the degree to which the results of
a study are true for the target population: the internal validity. Then we will discuss the
external validity, which is the degree to which the results of the studies can be generalised to other than the population under study.
General discussion
Table 4.1.1 Overview of the main conclusions and recommendations of the studies in this thesis
Section Study
Main conclusions
Main recommendations
Chapter 2. Diseases and conditions

2.1
- Overall mortality among asylum seekers is similar to - In policies and practices, address both
Mortality
the causes for which asylum seekers
the general population. Mortality is higher among
and causes
are at increased risk compared with
asylum seekers up to age 40 and for infectious
of death
the general population (e.g. infectious
diseases, external causes, and pregnancy- and
diseases, suicide, drowning) as well as
childbirth-related causes.
causes with large numbers of deaths
(e.g. cardiovascular diseases).
2.2
Suicide and - Male asylum seekers are at increased risk of suicide. - Train health professionals and
- Several subgroups of asylum seekers are at increased personnel of asylum-seeker centres to
suicidal
risk of suicidal behaviour compared with the general recognize suicide ideation and to take
behaviour
appropriate action.
population.
2.3
- Create conditions that encourage

Prevalence - Asylum seekers from the majority of countries
physical activity and healthy diets
of origin are at increased risk compared with the
and
among asylum seekers starting
incidence of general population in the Netherlands.
shortly after arrival, and inform health
- Asylum seekers from Somalia are particularly at risk.
diabetes
professionals about the increased
diabetes risk among asylum seekers.
2.4
Abortions - The highest induced abortion and teenage birth

rates were found shortly after arrival.
and
- African and Asian teenage girls were particularly
teenage
pregnancies at risk.
2.5
- HIV prevalence among pregnant asylum seekers was - Offer all asylum seekers from subHIV
Saharan Africa a voluntary HIV test
high in women from sub-Saharan Africa but not in
prevalence
shortly after arrival in the Netherlands.
women from other regions of origin.
among
- Differences in HIV prevalence between asylum
pregnant
seekers from African countries showed parallels with
asylum
variations in HIV prevalence rates in the countries
seekers
of origin.
- Invest in the prevention of unintended

pregnancies among newly arrived
asylum seekers, especially teenage girls.
Chapter 3. Risk factors for the health of asylum seekers

3.1
Relocations - Frequent relocations are a risk factor for the mental - Policy makers are recommended to
take into account that minimizing
health of asylum-seeking children.
and mental
- The negative effect of frequent relocations is greater relocations in the host country could
distress
contribute to the prevention of mental
in vulnerable children.
distress among asylum-seeking
children.
3.2
- In policies and practices, pay special

Risk factors - The rate of recorded physical child abuse is higher
attention to the prevention and
among asylum-seeking children whose mother has
for physical
identification of child abuse in asylumbeen exposed to violence or has been diagnosed
child abuse
seeking children whose mothers have
with PTSD or depression than among other
asylum-seeking children, especially in single-mother been exposed to violence or have
mental health problems, particularly in
families.
single-mother families.
3.3
Association - History of PTSD among asylum seekers is associated - Consider an integrated approach for
with high rates of diabetes.
the reduction of stress and mental
between
health problems in the prevention and
PTSD and
treatment of diabetes among asylum
diabetes
seekers.
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Chapter 4
Internal validity
The use of nationwide health service data has a number of strengths with respect to
internal validity. The risk of selection bias, (which may threaten internal validity), was
minimal as the use of health service data allowed for the inclusion of the full target
population in the studies. In addition, the completeness and validity of the demographic
and reception data were good, especially for the data from the MOA database.
There are also concerns associated with the use of health service data with respect to
the internal validity. The main concern is that cases may have been missed. Reasons for
this may be the absence of symptoms, not seeking health care, not being diagnosed or
not being recorded as such. Consequently, the incidence and prevalence rates are likely
to be underestimations of the actual rates. It is difficult to estimate the level of underestimation and to indicate whether the underestimation may have differed between
the asylum-seeking population and the reference population, or differed between
subgroups of asylum seekers. This issue has been discussed for the individual studies.
Another aspect that may have influenced the internal validity of the results, relates to
length of stay. Several studies in this thesis showed an association between length of
stay and the occurrence of the disease or condition. As shown in the study on diabetes,
for example, length of stay was also associated with region of origin, and has influenced
the comparability between the countries of origin. The longitudinal analysis allowed
comparison with correction or length of stay. However, in studies in which length-ofstay data were not available (such as the mortality and suicide studies), length of stay
may have influenced the comparisons.
External validity
The generalisability of the results of our studies to asylum-seeking populations in the
Netherlands in later years as well as to asylum-seeking populations in other countries,
also needs to be considered.
Generalisation to asylum-seeking populations in the Netherlands in later years requires
caution. The prevalence and incidence of diseases and conditions may be influenced by
changes in for example the distribution by country of origin, and in changes in asylum,
reception, and health policies. For example, the large influx of Syrian asylum seekers in
2013-2014, the decrease in the duration of the asylum procedure, changes in relocation
policies, and drowning prevention may have influenced the health outcomes of asylum
seekers.
General discussion
The considerable similarities between asylum-seeking populations in industrialised

countries with respect to countries of origin, shared background of fleeing ones country, and the uncertainty of the asylum procedure positively influence the possibilities for
generalisation. However, there are also important differences between host countries
in housing conditions, duration of the asylum procedure, and access to health care,
amongst others. Therefore, careful consideration is required when generalising epidemiological indicators from our studies to other countries.
However, given the considerable parallels between asylum-seeking populations, we
think that even though the details may differ, the overall conclusions of our studies
provide important lessons for other host countries. This is illustrated by a commentary
on our study on relocations in which the Australian authors emphasize the importance
of the findings and generalise them to implications for policy-makers worldwide.2
4.3 REFlECTIOnS AnD RECOMMEnDATIOnS

We will reflect on three overarching themes: a good start, mental health of asylumseeking and refugee children and noncommunicable diseases. We have extended the
scope of the reflections to refugees because the health status of asylum seekers is the
precursor for the health status of refugees and because there is a need for more insight
into the health of refugees in the Netherlands.
A good start
A good start is characterized by the following: a mother who is in a position
to make reproductive choices, is healthy during pregnancy, and gives birth to
a baby of healthy weight, [].
Review of social determinants and the health divide in the WHO European Region (2013)3
Available evidence suggests that asylum seekers and refugees are at increased risk of
adverse pregnancy outcomes compared with the general population and compared
with other migrant groups. Our study on mortality and causes of death showed a tenfold
increased risk for maternal mortality (section 2.1). Furthermore, compared with the general population in the Netherlands, the risk for congenital anomalies was two and a half
times increased for asylum-seeking girls; for boys the risk increase was not significant
(section 2.1). In addition, in 2009-2010 the perinatal mortality among asylum seekers
was twice as high as in the general population.4 We also found high induced abortion
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Chapter 4
rates and ratios for asylum seekers, which is indicative of a high rate of unintended
pregnancies (section 2.4).
A clinical study in the Netherlands suggests that the risk for acute maternal morbidity
among asylum seekers was four and a half times higher than in the general population
of the Netherlands, and three and a half times higher than among other non-Western
immigrant women.5 Studies in other countries have found increased risks for adverse
maternal and perinatal outcomes for asylum seekers as well as refugees compared with
the host population and other migrant groups.6,7 Women from Africa were found to be
particularly at risk.6,7
Explanations for the increased risk of unfavourable maternal and perinatal outcomes
are sought in an accumulation of adverse factors. Risk factors that are reported to be
prevalent among asylum-seeking as well as refugee women include unintended and
teenage pregnancies, pregnancies in women who have already delivered five or more
times, single motherhood, poor health status, history of gender-based violence, female
genital mutilation, prior Caesarian sections, limited social contacts, low socio-economic
status, mental health problems, language barriers, and limited health capabilities and
understanding of the health care system.5-9
Based on these characteristics, we propose three focus areas for promoting a good start
for asylum seekers and refugees.
I.
The first and most fundamental focus area addresses the prevention of
unintended pregnancies, teenage pregnancies, and pregnancies in women who
have already delivered five or more times.
For asylum seekers and refugees limited knowledge of sexual and reproductive health,
negative individual and community attitudes and behaviours towards contraception,
and the often vulnerable position of asylum-seeking women are given as explanations
for the increased risk for induced abortions, teenage pregnancies, and pregnancies in
women who have delivered already five or more times.10-13 Family planning contributes
to birth spacing, lowers infant mortality risk, reduces the number of induced abortions,
and lowers maternal mortality and maternal morbidity associated with unintended
pregnancy.14
Empowerment of asylum-seeking and refugees women, men and adolescents with
respect to sexual and reproductive health is needed, in order to enable them to make
informed choices and to prevent unintended pregnancies.2,15-17
General discussion
We recommend investing in interventions that contribute to the empowerment of

asylum seekers and refugees with respect to sexual and reproductive health.
II. The second focus area relates to the general health status of asylumseeking and refugee women, and early identification of diseases and
conditions.5,9,18-20
The health status of women preceding a pregnancy strongly influences the outcomes
the health of the mother and the child.3,9,21 Iron deficiency anaemia, nutritional deficiencies, TB, hepatitis B, HIV infection, female genital mutilation, exposure to sexual violence,
and mental health problems are diseases and conditions that negatively influence the
health outcomes of asylum seekers and refugees.5,9,18-20 Some of these diseases and
conditions are more prevalent in asylum-seeking and refugee women in general (e.g.
anaemia, nutritional deficiencies, and mental health problems) and others have been
reported to be increased in women from a selection of countries of origin (e.g. HIV and
female genital mutilation).9,18,19,22-24
Whereas in the Netherlands newly arrived asylum seekers are tested routinely only for
TB, guidelines in the USA and Canada recommend that all asylum seekers and refugees
from endemic countries be tested shortly after arrival for TB, HIV, and hepatitis B, and
that asylum-seeking and refugee women and girls of reproductive age be tested for iron
deficiency anaemia.25,26 It is beyond the scope of this thesis to answer the question as
to when testing is indicated (for which diseases and conditions and for which groups of
asylum-seeking and refugee women).
We recommend the development of evidence-based clinical guidelines with respect
to health assessment of asylum-seeking and refugee women and girls to ensure early
detection of diseases and conditions that may affect their pregnancy outcomes.
III. The third focus area relates to the special factors and needs associated with
the background and current context of pregnant asylum-seeking and refugee
women.
Our review of the needs of pregnant asylum seekers reported several needs expressed
by pregnant asylum seekers: information about pregnancy and about healthcare in the
host country, health care professionals who pay attention to their problems, and mothers groups for social contacts and information exchange (appendix 1).27 Special needs
were reported in relation to the high rates of exposure to sexual violence, female genital
mutilation and HIV infection. In their evaluation of the care for pregnant asylum seekers
in 2013, the Dutch Health Care Inspectorate stresses that some of the pregnant asylumseeking women lack the ability to manage all aspects of pregnancy themselves.28
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Chapter 4
The IGZ report states that, in light of the specific risks of pregnant asylum seekers, strong
pregnancy care networks, timely transfer of pregnancy-related information and the use
of professional interpreters are essential.
Although the needs of refugee women have, to our knowledge, not been studied in the
Netherlands, studies abroad indicate that their needs are similar to the needs identified
for asylum seekers.9,27,29 This may particularly be the case for women who have only been
in asylum reception for a few months and for women who get pregnant shortly after
settlement in a municipality.
We recommend increasing the awareness among professionals involved in the care of
pregnant asylum-seeking and refugee women on the special needs that these women
may have due to their background and current situation.
Mental health of children

Asylum-seeking and refugee children are a vulnerable group with respect to their mental health due to experiences in their countries of origin, during the flight, and also after
arrival in host countries.30-33 A few studies in the Netherlands provide insight into the
level of mental health problems among asylum-seeking children. In our study on the
association between mental distress and relocations, we found that for more than half
of the asylum-seeking children at least one of the conditions under the composite variable mental distress had been recorded (section 3.1). A strengths and difficulties questionnaire (SDQ)-based study showed high prevalence rates of psychosocial problems
among asylum-seeking children in the northern part of the Netherlands: the parental
SDQ showed an elevated score for nearly 40% of the children, the teacher SDQ for nearly
25% of the children.33
Epidemiological studies on the mental health of accompanied refugee children have,
to our knowledge, not been carried out in the Netherlands. The few studies that have
been done in other countries show considerable improvements in the mental health of
refugee children with length of stay.31,34-36 The studies illustrate the remarkable resilience
of asylum-seeking and refugee children to the effects of war.30,31,37 However, the studies
also show that years after arrival, mental health problems are still more prevalent than
in the general population.32,36
With respect to the mental health of asylum-seeking and refugee children, we propose
two focus areas:
General discussion
I.
The first focus area relates to reception and resettlement conditions associated
with the mental health of asylum-seeking and refugee children.
Our longitudinal study shows that frequent relocations between asylum-seeker centres
are associated with an increased likelihood of mental distress (section 3.1). Adverse effects have also been reported for the long-drawn-out uncertainty associated with long
asylum procedures.31 Furthermore, several studies report that children who have family
members who have had to stay in the country of origin are more likely to have mental
health problems.31,33 This implies that quick family reunification will contribute positively
to the health of asylum-seeking and refugee children.31,33 Evidence suggests that in children with an accumulation of adversities, the effects of adverse factors are larger.31,32,38
This evidence implies that asylum and resettlement policies may have considerable
impact on the mental health of asylum-seeking and refugee children.2,31,38
We recommend that policy makers take into account that reduction of relocations, rapid
resolution of asylum claims and quick family reunification will positively contribute to
the mental health and development of asylum seekers and refugees.
II. The second focus area relates to the association between parental mental
health and the mental health and development of asylum-seeking and refugee
children.
Parental support is one of the strongest protective factors for the mental health of
asylum-seeking and refugee children.30-32,37,39,40 Parents with mental health problems are
less able to provide parenting support which poses a threat to the social and emotional
development of their children.30-32,37,39,40 Our studies on mental distress in children and
physical child abuse illustrate the increased risks for children of mothers with mental
health problems (section 3.2 and 3.3). In our study on the effect of relocations, asylumseeking children whose mother had been diagnosed with PTSD or depression were
nearly twice as likely as other children to have a record of mental distress (RR = 1.81;
95%CI 1.53-2.13, unpublished data). The study also showed that the negative impact of
relocations was stronger in children whose mother had been diagnosed with PTSD or
depression (section 3.1). Especially the children of single mothers who had been diagnosed with PTSD or depression were at higher risk of recorded physical child abuse. In a
study by others, asylum-seeking children in the Netherlands whose mother had mental
health problems were four times more likely to have elevated SDQ-levels.33
To our knowledge, no studies have been carried out on the mental health of refugee
children who are in the Netherlands with parents. Studies in other countries, though,
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Chapter 4
show a similar influence of parental mental health problems for refugee children as
observed in asylum-seeking children.31,32,40
The high rates of mental health problems among adult asylum seekers and refugees
(e.g. rates of PTSD are reported to be ten times higher compared with the general
population), imply that many asylum-seeking and refugee children will be at risk of
adverse effects of parental mental health problems.41-43 Early detection of families where
parental mental health problems are a threat to the health and development of their
children, is important in order to prevent onset and aggravation of mental distress in
asylum-seeking and refugee children.
In light of the importance of early detection preventive child health assessments (JGZ)
and the vulnerability of asylum-seeking children, the assessments follow an intensified
schedule (like for children attending special needs schools). For refugee children, the
intensified schedule may be indicated for several reasons. First of all, the resettlement
phase is known to pose considerable challenges to families who are being resettled, especially in the presence of mental health problems.44 Special processes may be needed
during this phase to link refugee families to preventive health services.44
We recommend investing in the early identification of and provision of support to
asylum-seeking and refugee families who are affected by mental health problems and
to ensure continuity of preventive and curative care during the resettlement process.
noncommunicable diseases
Very few studies on noncommunicable diseases among asylum seekers and refugees
have been published. However, cancers and circulatory diseases were the cause-ofdeath categories with the largest numbers of deaths in our study on mortality and
causes of death among asylum seekers (section 2.1). In addition, professionals who
provide preventive and curative care for asylum seekers expressed concerns about the
prevalence of diabetes among asylum seekers. Therefore, we believe it is important to
reflect on the characteristics of asylum seekers and refugees with respect to diabetes,
cardiovascular diseases, and cancer.
Asylum-seeking men and women from most countries of origin were found to be at
increased risk of diabetes compared with the general population in the Netherlands
(section 2.3). The study suggests that the diabetes risk may differ between countries
of origin, and suggests that men and women from Somalia may be particularly at risk.
A worrisome increase in the prevalence of diabetes over a period of seven years was
found among asylum seekers and refugees in the Dutch longitudinal study Gevlucht-
General discussion
Gezond? II.45 For refugees, an increased diabetes risk has been found in studies in other
countries.46,47
With respect to circulatory diseases the longitudinal study Gevlucht-Gezond? showed
a marked increase in the prevalence of hypertension between the two rounds of the
study (from 13% to 24%).45 In the USA, the prevalence of hypertension among more
than 13,000 Iraqi refugees aged 20 years and above who were screened before resettlement was comparable to the rate for the general population (33%).48 The age-adjusted
cardiovascular disease mortality among asylum seekers did not differ significantly from
the general population in our mortality and cause-of-death study.49 For refugees, a
longitudinal study in Sweden reported a one and a half times higher risk for cardiovascular causes of mortality for refugee men compared with non-refugee immigrant men;
for women, the statistical power was too low to draw conclusions.50 In Denmark, the
cardiovascular disease mortality was lower among refugee men compared with Danish
men; no significant difference was found for women.51
Data on cancer among asylum seekers and refugees are particularly scarce. Cancer mortality among asylum seekers in the Netherlands was lower compared with the general
population (section 2.1). In Denmark, the cancer mortality among refugees was lower
than in native Danes; in Sweden, no difference was found with the general population.50,51 A study in the UK suggests that increased risks for specific cancers may occur
in specific refugee groups, as in Vietnamese refugees mortality for stomach cancer was
greatly increased.52
Several of the factors suggested to be associated with the increased diabetes risk among
asylum seekers and refugees are also risk factors for other noncommunicable diseases.
We will discuss three factors that can be addressed in the host countries: overweight
and obesity, physical activity, and mental health problems.
Data on overweight and obesity among adult asylum seekers and refugees have been
collected in several studies in the Netherlands and abroad. The study Gevlucht-Gezond?
shows significant increases between the two rounds in the rates of overweight (from
38% to 48%) and obesity (from 9% to 13%) in refugees in the Netherlands.53 The report
Refugee groups in the Netherlands shows that, for all countries of origin included in
the study (Afghanistan, Iran, Iraq and Somalia), the prevalence rates for overweight
were significantly higher among refugees compared with the general population in the
Netherlands.54 The highest risk difference was found for refugees from Iraq (2.4 times
higher).55 Studies in other countries suggest that the rates of overweight and obesity
may differ considerably between regions of origin, and that the risk difference between
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Chapter 4
certain migrant groups and the host population may continue to increase for at least 15
years after arrival.46,56
Regarding children, a nutritional survey in the Netherlands shows a worrisome increase
in the proportion of asylum-seeking children with overweight and obesity in the first
years after arrival.57 The proportion of overweight and obese children increased from
15% at arrival to 21% after a follow-up time of 2.5 years on average.57
Of the respondents of the first round of the study Gevlucht-Gezond?, 58% reported a
level of physical activity that met the norm of moderate physical activity for at least
30 minutes at least five days a week.53 At the time of the second round of the study
seven years later, however, the percentage had decreased to 40%. The study Refugee
groups in the Netherlands showed levels of physical activity among refugees that were
unfavourable compared with the population of the Netherlands.54 The proportion that
did not take part in any sports was twice as high among refugees, and the proportion
that was physically inactive during winter (< 1 day/week 30 minutes moderate physical activity) was more than three times higher compared with the population of the
Netherlands after correction for gender, age and educational level.55
For children of asylum seekers and refugees, no studies on physical activity have been
reported to our knowledge.
The last risk factor for noncommunicable diseases that can be addressed in the host
country is mental health problems. The high prevalence of mental health problems
among asylum seekers and refugees has already been addressed in earlier chapters.
With respect to noncommunicable diseases we propose two focus areas:
I.
The first focus area relates to physical activity.
Physical activity directly and indirectly contributes to the prevention of noncommunicable diseases.58,59 The indirect pathway of physical activity passes through the reduction
of stress and mental health problems.59,60
For asylum seekers and refugees, however, developing a physically active lifestyle is not
self-evident.61-63 There are several barriers to physical activity including costs, embarrassment about exercising in public, competing priorities, and the weather.64 Interventions
to promote physical activity among refugee women, though, have shown a high acceptability to the women and promising outcomes.63,65,66 No studies were found that report
on physical activity interventions among men and children.
General discussion
We recommend the implementation of policies and interventions that encourage physical activity among asylum seekers and refugees.
II. The second focus area relates to healthy diet.
Policies that promote the consumption of foods low in saturated and trans fats, salt,
and sugar (particularly in soft drinks) will lead to wide-ranging health gains, including
the prevention of overweight, diabetes, cardiovascular diseases, and some cancers.58
Asylum seekers and refugees are faced with an overabundance of choices, but have
difficulty finding foods that are familiar or that they know are healthy.61,63
The few available studies suggest that asylum seekers and refugees are, in general,
eager to learn about healthy foods available in the new country and how to prepare
them.61,63,67 Prevention initiatives early after arrival may help recently arrived refugees
retain some of their own healthy cultural habits and reduce the tendency to adopt
detrimental ones.61 Promotion of healthy eating and drinking habits may be particularly
important in families with children, as studies have shown that asylum-seeking children
are particularly vulnerable to the development of unfavourable dietary habits.61,63,68
We recommend investment in interventions that promote healthy eating habits among
asylum seekers and refugees, with a focus on families with children.
Table 4.3.1 gives a summary of the themes, focus areas and recommendations.
4.4 REFlECTIOnS AnD RECOMMEnDATIOnS wITH RESPECT TO RESEARCH

The studies in this thesis illustrate that health care registry data can provide important
insights into the health of asylum seekers, and that they can be a valuable source for the
analysis of risk factors. However, the studies show that large study populations are required to be able to calculate disaggregated epidemiological indicators and analyse risk
factors. With data on more than 115,000 asylum seekers, the MOA database is unique in
this respect.
As indicated in the previous section, the continuous changes in the composition of the
asylum-seeking population and in the asylum context may lead to incessant changes in
the health profile and the risk factors for asylum seekers. The system of notifications for
mortality and suicidal behaviour has continued since the changes to the health system
for asylum seekers in 2009. The potential of the health information system of the GC A
still needs to be explored with regard to epidemiological studies.
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Chapter 4
Table 4.3.1 Overview of the cross-cutting themes and recommendations to promote the health of asylum
seekers and refugees
Theme and focus areas
Recommendations
A good start
Unintended pregnancies, teenage
pregnancies, and grand multiparity*
Invest in interventions that contribute to the empowerment

of asylum seekers and refugees with respect to sexual and
reproductive health.
Health status of asylum-seeking and

refugee women and early identification
of diseases and conditions
Development of clinical guidelines with respect to health

assessment of asylum-seeking women and girls based on the
evidence with respect to diseases and conditions for which
asylum-seeking and refugee women are at increased risk.
Special factors and needs associated with

the background and current context of
pregnant asylum-seeking and refugee
women
Increase awareness among professionals involved in the care for

pregnant asylum-seeking and refugee women about the special
needs that these women may have due to their background and
current situation.
Mental health of children

Reception and resettlement conditions
associated with the mental health of
asylum-seeking and refugee children
Policy makers could take into account that reduction of

relocations, rapid resolution of asylum claims, and quick family
reunification will positively contribute to the mental health and
development of asylum-seeking and refugee children.
Association between parental mental

health and the mental health and
development of asylum-seeking and
refugee children
Invest in the early identification of and provision of support

to asylum-seeking and refugee families who are affected by
mental health problems and ensure continuity of preventive
and curative care during the resettlement process.
noncommunicable diseases
Physical activity
Implement policies and interventions that encourage physical

activity among asylum seekers and refugees.
Healthy nutrition
Invest in interventions that promote healthy eating habits

among asylum seekers and refugees, with a focus on families
with children.
* Pregnancies of a woman who has given birth five or more times.
With respect to refugees we want to highlight the scarcity of data on their health status
and risk factors. Because of the dispersal of refugees in municipalities, data collection
will need a different approach than for asylum seekers. Health registry data may offer
opportunities; for refugee children, for example, using data from the electronic records
of the preventive child health assessments (digitaal dossier JGZ) may be considered.
Lastly we would like to note that studies are needed that provide insight into the needs,
health literacy, health behaviours, and health abilities of different groups of asylum
seekers and refugees. Furthermore, insight is needed into the effectiveness of interventions for asylum seekers and refugees, amongst others for the themes addressed in the
previous section.
General discussion
4.5 MAIn COnCluSIOnS

We conclude that, overall, asylum seekers and refugees are at increased risk of adverse
outcomes with respect to sexual and reproductive health, mental health and specific
noncommunicable diseases compared with the general population in the Netherlands.
Within these groups, there are large risk differences when stratified by gender, age, family composition, country of origin and length of stay. The risk distribution varies between
diseases and conditions.
The reasons for the increased risks of health problems are diverse too, and include
exposure to violence, limited health literacy, genetic predisposition, and conditions in
the host country.
We also conclude that there is a serious lack of insight into the health status of and risk
factors for refugees in the Netherlands. For the refugee population as well as for the
asylum-seeking population, more insight is needed into the distribution of diseases and
conditions, the reasons behind these distributions, and the effectiveness of interventions.
Insight into the main risks and the effectiveness of interventions may guide policies and
practices that will increase the chances of a safe and healthy future for asylum seekers
and refugees.
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REFEREnCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
Thygesen LC, Ersboll AK. When the entire population is the sample: strengths and limitations in
register-based epidemiology. Eur J Epidemiol. 2014;
Zwi K, Mares S. Commentary: Reducing further harm to asylum-seeking children. The global human rights context. Int J Epidemiol. 2014; 43:104-6.
World Health Organization Regional Office for Europe. Review of social determinants and the
health divide in the WHO European Region; Final report. Copenhagen: WHO Regional Office for
Europe; 2013.
Oostrum IEA van, Goosen S. Sterfte en doodsoorzaken onder asielzoekers 2009-2010. Utrecht:
GGD Nederland; 2012.
Hanegem N.van, Miltenburg AS, Zwart JJ, Bloemenkamp KW, Van RJ. Severe acute maternal
morbidity in asylum seekers: a two-year nationwide cohort study in the Netherlands. Acta Obstet
Gynecol Scand. 2011;90:1010-6.
Gagnon AJ, Zimbeck M, Zeitlin J, et al. Migration to western industrialised countries and perinatal
health: a systematic review. Soc Sci Med. 2009;69:934-46.
Gissler M, Alexander S, Macfarlane A, et al. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstet Gynecol Scand. 2009;88:134-48.
Bollini P, Pampallona S, Wanner P, Kupelnick B. Pregnancy outcome of migrant women and integration policy: a systematic review of the international literature. Soc Sci Med. 2009;68:452-61.
Carolan M. Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature. Midwifery. 2010;26:407-14.
Kurth E, Jaeger FN, Zemp E, Tschudin S, Bischoff A. Reproductive health care for asylum-seeking
women - a challenge for health professionals. BMC Public Health. 2010;10:659.
Ngum Chi Watts MC, Liamputtong P, Carolan M. Contraception knowledge and attitudes: truths
and myths among African Australian teenage mothers in Greater Melbourne, Australia. J Clin
Nurs. 2013;
refugees; Appendix 18: Contraception: evidence review for newly arriving immigrants and refugees. CMAJ. 2011;183:E824-E925.
Rasch V, Knudsen LB, Gammeltoft T, et al. Contraceptive attitudes and contraceptive failure
among women requesting induced abortion in Denmark. Hum Reprod. 2007;22:1320-6.
Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev. 2010;32:152-74.
Grose RG, Grabe S, Kohfeldt D. Sexual Education, Gender Ideology, and Youth Sexual Empowerment. J Sex Res. 2013;
Inter-agency Working Group on Reproductive Health in Crises. Inter-agency Field Manual on
Reproductive Health in Humanitarian Settings. Geneva; 2010.
Wilson R, Sanders M, Dumper H. Sexual health, asylum seekers and refugees; A handbook for
people working with refugees and asylum seekers in England. London: The Family Planning Association; 2007.
Benson J, Skull S. Hiding from the sun - vitamin D deficiency in refugees. Aust Fam Physician.
2007;36:355-7.
Benson J, Phillips C, Kay M, et al. Low vitamin B12 levels among newly-arrived refugees from
Bhutan, Iran and Afghanistan: a multicentre Australian study. PLoS One. 2013;8:e57998.
General discussion
(20)
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
Reddick KL, Jhaveri R, Gandhi M, James AH, Swamy GK. Pregnancy outcomes associated with viral
hepatitis. J Viral Hepat. 2011;18:e394-e398.
McGinn. Reproductive health of war-affected populations: what do we know. Int Fam Plan Perspect. 2000;26:174-80.
Goonewardene M, Shehata M, Hamad A. Anaemia in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2012;26:3-24.
refugees; Appendix 15; Iron-deficiency anemia: evidence review for newly arriving immigrants
and refugees. CMAJ. 2011;183:E824-E925.
Skull SA, Ngeow JY, Biggs BA, Street A, Ebeling PR. Vitamin D deficiency is common and unrecognized among recently arrived adult immigrants from The Horn of Africa. Intern Med J. 2003;33:4751.
Centers for Disease Control and Prevention. Public Health Action Plan to Integrate Mental Health
Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011-2015. Atlanta:
U.S. Department of Health and Human Services; 2011.
refugees. CMAJ. 2011;183:E824-E925.
Goosen S, van Oostrum IE, Essink-Bot ML. [Obstetric outcomes and expressed health needs of
pregnant asylum seekers: a literature survey]. Ned Tijdschr Geneeskd. 2010;154:A2318.
Inspectie voor de gezondheidszorg. Inzet professionele tolken en overdracht bij overplaatsing
moeten beter voor verantwoorde geboortezorg aan asielzoekers. Den Haag: Ministerie van
Volksgezondheid,Welzijn en Sport; 2014.
National Collaborating Centre for Womens and Childrens health. Pregnancy and Complex Social
Factors: A model for service provision for pregnant women with complex social factors. London:
Royal College for Obstetricians and Gynaecologists; 2010.
Montgomery E. Trauma, exile and mental health in young refugees. Acta Psychiatr Scand Suppl.
2011;1-46.
J Nerv Ment Dis. 2011;199:85-90.
Dura-Vila G, Klasen H, Makatini Z, Rahimi Z, Hodes M. Mental health problems of young refugees:
duration of settlement, risk factors and community-based interventions. Clin Child Psychol Psychiatry. 2013;18:604-23.
Hjern A, Angel B. Organized violence and mental health of refugee children in exile: a six-year
follow-up. Acta Paediatr. 2000;89:722-7.
Drury J, Williams R. Children and young people who are refugees, internally displaced persons or
survivors or perpetrators of war, mass violence and terrorism. Curr Opin Psychiatry. 2012;25:27784.
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Chapter 4
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
(52)
(53)
(54)
(55)
Epidemiol. 2013; 43:94-104.
Ee E van. A new generation: How refugee trauma affects parenting and child development (thesis). Diemen: Arq Psychotrauma expert groep; 2013.
Hjern A, Angel B, Jeppson O. Political violence, family stress and mental health of refugee children
in exile. Scand J Soc Med. 1998;26:18-25.
Riggs E, Davis E, Gibbs L, et al. Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers. BMC Health Serv Res. 2012;12:117.
Lamkaddem M, Stronks K, Gerritsen AAM, Devill WLJM, Essink-Bot L.M. Gezondheid en zorggebruik onder vluchtelingen; Vervolgonderzoek onder mensen met een verblijfsvergunning in
Nederland. Ned Tijdschr Geneeskd. 2012;2013;157:A5604
Creatore MI, Moineddin R, Booth G, et al. Age- and sex-related prevalence of diabetes mellitus
among immigrants to Ontario, Canada. CMAJ. 2010;182:781-9.
Oza-Frank R, Narayan KM. Overweight and diabetes prevalence among US immigrants. Am J
Public Health. 2010;100:661-8.
Yanni EA, Naoum M, Odeh N, Han P, Coleman M, Burke H. The health profile and chronic diseases
comorbidities of US-bound Iraqi refugees screened by the International Organization for Migration in Jordan: 2007-2009. J Immigr Minor Health. 2013;15:1-9.
Oostrum IEv, Goosen S, Uitenbroek DG, Koppenaal H, Stronks K. Mortality and causes of
death among asylum seekers in the Netherlands, 2002-2005. J Epidemiol Community Health.
2011;65:376-83.
Hollander AC, Bruce D, Ekberg J, Burstrom B, Borrell C, Ekblad S. Longitudinal study of mortality
among refugees in Sweden. Int J Epidemiol. 2012;41:1153-61.
Norredam M, Olsbjerg M, Petersen JH, Juel K, Krasnik A. Inequalities in mortality among refugees
and immigrants compared to native Danesa historical prospective cohort study. BMC Public
Health. 2012;12:757.
Swerdlow A. Mortality and cancer incidence in Vietnamese refugees in England and Wales: a
follow-up study. Int J Epidemiol. 1991;20:13-9.
Lamkaddem M, Essink-Bot ML, Stronks K. Gevlucht-Gezond? II; Ontwikkelingen in gezondheid
en zorggebruik van vluchtelingen in Nederland. Amsterdam: Academisch Medisch Centrum,
Universiteit van Amsterdam; 2013.
Netherlands Institute for Social Research (SCP). Refugee groups in the Netherlands; The integration of Afghan, Iraqi, Iranian and Somali immigrants (Vluchtelingengroepen in Nederland). The
Hague: The Netherlands Institute for Social Research (SCP); 2011.
Netherlands Institute for Social Research (SCP). Refugee groups in the Netherlands; The integration of Afghan, Iraqi, Iranian and Somali immigrants (Vluchtelingengroepen in Nederland);
Annexe to chapter 7. The Hague: The Netherlands Institute for Social Research (SCP); 2011.
General discussion
(56)
(57)
(58)
(59)
(60)
(61)
(62)
(63)
(64)
(65)
(66)
(67)
(68)
Oza-Frank R, Narayan KM. Effect of length of residence on overweight by region of birth and age
at arrival among US immigrants. Public Health Nutr. 2010;13:868-75.
Stellinga-Boelen AA, Wiegersma PA, Bijleveld CM, Verkade HJ. Obesity in asylum seekers children
in The Netherlandsthe use of national reference charts. Eur J Public Health. 2007;17:555-9.
Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis.
Lancet. 2011;377:1438-47.
Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major
non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
Lancet. 2012;380:219-29.
Huang CJ, Webb HE, Zourdos MC, Acevedo EO. Cardiovascular reactivity, stress, and physical
activity. Front Physiol. 2013;4:314.
Haley HL, Walsh M, Tin Maung NH, Savage CP, Cashman S. Primary prevention for resettled refugees from Burma: where to begin? J Community Health. 2014;39:1-10.
Renzaho AM, McCabe M, Swinburn B. Intergenerational differences in food, physical activity, and
body size perceptions among African migrants. Qual Health Res. 2012;22:740-54.
Wieland ML, Weis JA, Palmer T, et al. Physical activity and nutrition among immigrant and
refugee women: a community-based participatory research approach. Womens Health Issues.
2012;22:e225-e232.
Mohamed AA, Hassan AM, Weis JA, Sia IG, Wieland ML. Physical activity among Somali men in
Minnesota: barriers, facilitators, and recommendations. Am J Mens Health. 2014;8:35-44.
Guerin PB, Elmi FH, Corrigan C. Body composition and cardiorespiratory fitness among refugee
Somali women living in New Zealand. J Immigr Minor Health. 2007;9:191-6.
Sundquist J, Hagstromer M, Johansson SE, Sundquist K. Effect of a primary health-care-based
controlled trial for cardiorespiratory fitness in refugee women. BMC Fam Pract. 2010;11:55.
Kruseman M, Barandereka NA, Hudelson P, Stalder H. Post-migration dietary changes among
african refugees in Geneva: a rapid assessment study to inform nutritional interventions. Soz
Praventivmed. 2005;50:161-5.
Stellinga-Boelen AA. Nutritional assessment of asylum seekers children in the Netherlands
(Thesis). Groningen; 2007.
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ChaPtEr 5
suMMAry / sAMenVAttInG
Summary
5.1 SuMMARy
affect their health. Based on this knowledge and the scientific literature, we will explore
the implications for policies and practices aimed at the promotion of the health of asylum seekers and refugees.
Chapter 1 gives background information on asylum seekers and refugees, and on the
organisation of the reception and health care system in the Netherlands. This chapter
also provides a brief overview of the literature with respect to the health of asylum seekers, followed by the need for epidemiological information and the aims of this thesis.
The chapter ends with information on the data sources used for the studies in this thesis.
Asylum seekers and refugees have fled their country of origin. Asylum seekers are awaiting a decision on their asylum request while refugees have been granted a temporary
or permanent residence permit. Asylum seekers are housed in asylum-seeker centres
that are managed by the Central Agency for the Reception of Asylum Seekers (COA). The
highest number of asylum seekers living in asylum-seeker centres in the Netherlands at
one time was more than 80,000 in the year 2001.
The number of asylum requests lodged in the Netherlands has changed considerably
over the years. While the number of asylum requests was 43,900 in the year 2000, it was
only 9,730 in 2007, and then increased again to 17,190 in 2013. Countries of origin with
the largest numbers of asylum seekers in the Netherlands in the last two decades were
Afghanistan, Iraq, and Somalia.
Once a residence permit has been granted, refugees are allocated a house in a municipality. The number of refugees in the Netherlands depends on the definition used. According to CBS Statistics Netherlands, on 1 January 2010, 69,620 persons had arrived in
the Netherlands as asylum seekers and were living in the Netherlands with a permanent
or temporary residence permit. According to the SCP around 38,000 people of Afghan
origin, 52,000 people originating from Iraq, 31,000 from Iran and 27,000 from Somalia
were living in the Netherlands in 2010.
Entitlement to health care for asylum seekers in the Netherlands is similar to the entitlement of residents of the Netherlands. The current organisation of the health services
dates from 1 January 2009. Because the studies in this thesis are based on data for the
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years 2000 - 2008, the description of the health systems focuses on the organisation of
the health system in these years.
Starting in 2000, the COA contracted local community health services (GGDs) and a
health care insurer to provide health services for all asylum seekers in the Netherlands.
For administrative reasons, the local GGDs set up separate foundations called Community Health Services for Asylum Seekers (Medische Opvang Asielzoekers, MOA). The
main responsibility of the MOAs was to provide the regular public health services to
asylum seekers, such as health education, preventive child health care (JGZ), infectious
diseases control, testing for TB, hygiene and safety inspections, and epidemiology.
In addition to the regular tasks of public health services, nurse practitioners from the
MOA were the first point of health care contact for asylum seekers. The nurse practitioners worked in close collaboration with family physicians contracted by the health care
insurer. The health care insurer also contracted other standard health care providers,
such as pharmacists, dentists, midwives, hospitals, mental health care providers, and
home health care services.
As soon as asylum seekers receive a residence permit and are allocated a house in a
municipality, they are obliged to get a health insurance like any other resident of the
Netherlands. They will have access to the same health services as residents of the Netherlands. The public health services for refugees are provided by the local GGD in the
municipality in which they were allocated a house.
Section 1.2 gives a brief overview of the literature on the health of asylum seekers
published until 2009. The overview shows that there were few studies available, and
that they were dominated by studies on mental health. To inform policies and practices,
more information was needed on the distribution of diseases and conditions among
asylum seekers and refugees compared with the population of the Netherlands, on
which subgroups of asylum seekers and refugees were particularly at risk, and on specific risk factors for their health.
Section 1.3 describes the aims of this thesis. Section 1.4 describes the data sources for
the studies in this thesis. The first data source consists of the notification forms that were
filled out nationwide by health professionals of the MOA. The second data source is an
electronic database that contains medical data from the MOA and family physicians as
well as demographic data from the COA. This database, which is referred to as the MOA
database contains data on all asylum seekers, who lived in the Netherlands between
2000 and 2008.
Summary
The studies are presented in two chapters. Chapter 2 contains five studies that address
the distribution of specific diseases and conditions among asylum seekers in the Netherlands. Chapter 3 consists of three studies that analyse risk factors for the health of
asylum seekers.
Chapter 2 starts with a study on mortality and causes of death among asylum seekers
(section 2.1). The main aim of the study was to compare overall and cause-specific
mortality between asylum seekers and the population of the Netherlands, and to
identify subgroups at high risk for overall mortality and specific causes. The study was
based on MOA death notification forms for the total asylum-seeking population in the
Netherlands in the years 2002-2005. The indicator used was the standardised mortality
ratios (SMR).
The number of recorded deaths was 346; the number of person years lived in asylumseeker centres during the years 2002-2005 was 222,217. Twenty-eight stillborns were
reported for 4,327 deliveries. The mortality among asylum seekers was, after correction
for age, similar to that of the population of the Netherlands during the years 2002-2005
for men (SMR = 0.93; 95% CI 0.75-1.12) and women (SMR = 1.14; 95% CI 0.86-1.43). Considerable differences were observed, however, between causes of death and between
subpopulations by sex, age, and region of origin. Compared with the general population
of the Netherlands, mortality among asylum seekers was higher below the age of 40,
and lower above the age of 40. Women from the combined region West, Central and
Southern Africa below the age of 40 were found to have the highest mortality ratio
compared with the population of the Netherlands. The most common causes of death
among asylum seekers were cancer, cardiovascular diseases, and external causes of
death. Male and female asylum seekers were at increased risk compared with the population of the Netherlands for the cause-of-death categories infectious diseases (HIV,
hepatitis and TB), accidents, and drowning. Among men suicide mortality was higher,
among women maternal mortality.
The main conclusions of this study are that certain but not all subgroups of asylum
seekers have a higher mortality risk compared with the host population and that the
mortality risk is increased for some but not all causes of death. The main recommendation of this study is to address both the causes for which asylum seekers are at increased
risk compared with the general population (e.g. infectious diseases, suicide, drowning)
as well as causes with large numbers of deaths (e.g. cardiovascular diseases) through
policies and practices.
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The aim of the study in section 2.2 was to assess the prevalence of suicide and suicidal
behaviour among asylum seekers. The study population consisted of all asylum seekers
aged 15 years and older who lived in asylum-seeker centres in the Netherlands during
the years 2002-2007. The study was based on MOA notification forms for deaths and
suicidal behaviour for the total asylum-seeking population in the Netherlands. Suicide
death data for asylum seekers were compared with data for the population of the Netherlands; for suicidal behaviour reference data from the city of The Hague were used.
The study included 35 suicide deaths and 290 cases of hospital-treated suicidal behaviour. The number of person years was 199,942. Among men, the suicide death rate was
twice as high among asylum seekers as in the population of the Netherlands (SMR =
2.00; 95% CI 1.37-2.83); among women, no difference was found (SMR = 0.73; 95% CI
0.15-2.07). The incidence of hospital-treated suicidal behaviour was high for asylumseeking men and women from Europe and the Middle East/South West Asia and low for
men and women from Africa compared with the reference population. Health professionals knew about mental health problems prior to the suicidal behaviour for 80% of
the hospital-treated suicidal behaviour cases in asylum seekers.
In conclusion, compared with the general population, male asylum seekers are at increased risk of suicide, and several subgroups of asylum seekers are at increased risk of
suicidal behaviour. The main recommendation of this study is to train health professionals and the personnel of asylum-seeker centres to recognize suicide ideation and to take
appropriate action.
The study on the prevalence and incidence of diabetes in section 2.3 is based on data
from the MOA database and included all asylum seekers aged 20 to 79 years who arrived in the Netherlands between 2000 and 2008. Reference data were provided by the
Netherlands Information Network of General Practice (LINH).
The number of recorded cases of diabetes among asylum seekers in the study population of 59,380 asylum seekers was 1,227. The age-adjusted prevalence of recorded diabetes was approximately two times higher among asylum seekers compared with the
host population among both men (standardised prevalence ratio (SPR) = 1.85; 95% CI
1.71-1.99) and women (SPR = 2.26; 95% CI 2.08-2.45). The highest recorded prevalence
ratios were found for men and women from Somalia, Sudan and Sri Lanka. From the age
of 30-39, diabetes prevalence among asylum seekers was high compared with the general population in the Netherlands. Six months after arrival, the prevalence of diabetes
among asylum seekers was already higher than in the population of the Netherlands.
Summary
Incidence rates of recorded diabetes were higher for asylum seekers compared with the
host population throughout the stay in asylum reception.
The main conclusions of this study are: asylum seekers from the majority of countries
of origin are at increased risk compared with the general population in the Netherlands
and asylum seekers from Somalia are particularly at risk. The main recommendations
of the study are to create conditions that encourage physical activity and healthy diets
among asylum seekers starting shortly after arrival, and to inform health professionals
about the increased diabetes risk among asylum seekers.
Chapter 2 also contains two studies on sexual and reproductive health issues among
asylum seekers. The main aim of the study in section 2.4 was to analyse the indicators
for induced abortions and teenage pregnancies among asylum-seeking women and girls.
The study included all women aged 1549 who lived in asylum-seeker centres in the
Netherlands between September 2004 and August 2005. Information about induced
abortions was collected from notification forms and electronic patient files of the MOA.
Population and birth data were provided by the COA.
The number of births was 498, the number of recorded induced abortions 116, and the
total number of women in the study 9,931. The induced abortion rate was 14.4 induced
abortions per 1,000 women per year, and the induced abortion ratio was 222.7 induced
abortions per 1,000 live births. The induced abortion rate was 1.7 times (95%CI 1.4-2.0)
higher and the abortion ratio 1.5 times higher (95%CI 1.2- 1.7) among asylum seekers
than the average in the Netherlands. Large differences were found between subgroups.
High abortion rates were seen among women who were pregnant on arrival or got pregnant in the first months after arrival in the Netherlands. Teenage induced abortion rates
were particularly high among girls from West, Central, and Southern Africa (43.6/1,000)
and Central, East, and Southern Asia (37.4/1,000). The highest induced abortion ratios
were found among women aged 3049 from Europe (354.2/1,000 live births) and Asia
(714.3/1,000 live births). The teenage birth rates were high for girls from West, Central
and Southern Africa (90.3/1.000 girls per year) and from Central, East and Southern Asia
(46.7/1.000). With increasing length of stay, the abortion rate and teenage birth rates
decreased.
In conclusion, the study identified several subgroups that have high induced abortion
indicators, especially shortly after arrival in the Netherlands and African and Asian
teenage girls are particularly at risk of induced abortion and teenage pregnancy. The
principal recommendation of this study is to increase investments in the prevention of
unintended pregnancies among newly arrived asylum seekers, especially teenage girls.
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Section 2.5 reports on a study with the main aim of mapping the prevalence of HIV
among pregnant asylum-seeking women in the Netherlands. The study population
consisted of all asylum-seeking women who delivered in asylum reception in the Netherlands between 2000 and 2008.
Eighty women were HIV-positive during their last pregnancy in asylum reception; the
study included data on 4,854 women. Seventy-nine of the HIV positive women originated
from sub-Saharan Africa. The HIV prevalence of 3.5% among women from sub-Saharan
Africa was much higher than the overall antenatal HIV prevalence in the Netherlands
(0.04%). Only one HIV case was recorded among women from all other regions of origin;
at 0.04% the prevalence was the same as in the general population in the Netherlands.
The highest HIV prevalence was found for women from Rwanda (17.0%) and Cameroon
(13.2%). HIV prevalence rates were highest among UMAs and women in reception without a male partner.
In conclusion, HIV prevalence among pregnant asylum seekers was high in women
from sub-Saharan Africa but not in women from other regions of origin. The principal
recommendation of this study is to offer all asylum seekers from sub-Saharan Africa a
voluntary HIV test shortly after arrival in the Netherlands.
Chapter 3 starts with a study on the association between relocations and mental distress
(chapter 3.1). In this longitudinal medical record study, we aimed to assess whether
relocations during the asylum process are associated with the incidence of newly
recorded mental distress in asylum-seeking children, and whether this association is
stronger among vulnerable children. The study is based on data extracted from the MOA
database on children aged 4 to 17 years. Children for whom one or more diagnoses
of mental, behavioural or psychosocial problems had been recorded during their stay
in asylum-seeker centres were classified as cases of mental distress. The association
between the annual relocation rate and the incidence of mental distress was measured
using relative risks (RR) estimated with multivariate Cox regression models.
The number of children in the study was 8,047, and the number of cases of mental distress as from six months after arrival was 1,267. An annual relocation rate of one or more
per year was associated with a 2.70 times greater incidence of mental distress (95% CI
2.30-3.17). The risk increase associated with frequent relocations was larger in children
who had experienced violence (RR = 3.87; 95% CI 2.79-5.37) and in children whose
mother had been diagnosed with post-traumatic stress disorder (PTSD) or depression
(RR = 3.40; 95% CI 2.50-4.63). The number of relocations was not associated with mental
distress in asylum-seeking children.
Summary
The main conclusions of this study are that frequent relocations place the mental health
of asylum-seeking children at risk and that the negative effect of frequent relocations is
greater in vulnerable children. The main recommendation is that policy makers should
take into account that minimizing relocations in the host country could contribute to
the prevention of mental distress among asylum-seeking children.
Section 3.2 describes a study on maternal risk factors for physical child abuse among
asylum seekers. The main aim of this study was to analyse whether personal exposure to
violence and diagnosis of PTSD or depression in asylum-seeking mothers are associated
with an increased rate of physical child abuse in asylum-seeking children. Data were
extracted from the MOA database. The study included all asylum-seeking children aged
< 18 years who, between 2000 and 2008, lived in an asylum-seeker centre with at least
their mother, for at least six months. The association between the maternal factors and
the incidence of physical child abuse was measured using relative risks (RR) estimated
with multivariate Cox regression models.
Among the 17,780 children in the study population, there were 98 documented cases of
physical child abuse as of six months length of stay. The rate of newly recorded physical
child abuse was 2.5 per 1,000 person years. The relative risk for recorded physical child
abuse was higher in children whose mothers had been exposed to violence (RR = 1.61;
95% CI 1.06-2.44) and in children whose mothers had been diagnosed with PTSD or
depression (RR = 1.74; 95% CI 1.03-2.92) compared with other children. The association
between maternal violence exposure was stronger in children of single mothers (RR =
2.88; 95% CI 1.47-5.66) compared with children with two parents (RR = 1.18; 95% CI 0.692.03). The association between maternal PTSD or depression and physical child abuse
was also stronger in children of single mothers (RR = 2.31; 95% CI 1.1-4.81) compared
with children with two parents (RR = 1.36; 95% CI 0.64-2.92).
The main conclusion of this study is that the rate of recorded physical child abuse is
higher among asylum-seeking children whose mothers had been exposed to violence
or had been diagnosed with PTSD or depression than among other asylum-seeking
children, especially in single-mother families. The main recommendation of this study is,
to pay special attention in policies and practices to the prevention and identification of
child abuse in asylum-seeking children whose mothers have been exposed to violence
or have mental health problems, particularly in single-mother families.
The study in section 3.3 assesses the association between PTSD and diabetes. Data on all
asylum seekers aged 18 years or older were extracted from the MOA database for the
years 1998-2008. Associations were assessed with age-adjusted prevalence ratios (APR).
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Chapter 5
There were a total of 105,180 asylum seekers in the study. Asylum seekers with PTSD
had a higher prevalence of diabetes compared with those without PTSD. Compared
with individuals without PTSD, the prevalence ratios of diabetes for asylum seekers
with a diagnosis of PTSD compared with asylum seekers without a diagnosis of PTSD
were 1.40 (95% CI 1.121.76) in men and 1.22 (95% CI 0.951.56) in women. There was
an interaction between PTSD and depression, indicating that the effect of PTSD on the
prevalence of diabetes differed between individuals with and without a diagnosis of
depression. When the analyses were stratified by depression status, asylum seekers in
the non-depressed group with PTSD had a higher prevalence of diabetes compared
with those without PTSD in men (APR = 1.47; 95%CI 1.151.87) and women (APR = 1.27;
95%CI 0.971.66).
The main conclusion of this study is that a history of PTSD is associated with high levels
of diabetes among asylum seekers. The main recommendation of this study is to consider an integrated approach for the reduction of stress and mental health problems and
the prevention and treatment of diabetes among asylum seekers and refugees.
Chapter 4 starts with a summary of the main findings and conclusions of the studies
presented in this thesis and a discussion of the general methodological considerations
(section 4.1). Section 4.2 consists of general methodological considerations. This is followed by reflections on three themes that overarch the individual studies (sections 4.3).
In the first theme a good start we address issues concerning sexual and reproductive
health. The first focus area for this theme relates to the reduction of unintended pregnancies, teenage pregnancies, and grand multiparity. For this focus area, the recommendation is investing in interventions that contribute to the empowerment of asylum
seekers and refugees with respect to sexual and reproductive health. The second focus
area relates to the improvement of the health status of asylum-seeking and refugee
women. We recommend the development of clinical guidelines with respect to health
assessment of asylum-seeking women and girls based on the evidence with respect to
diseases and conditions for which asylum-seeking and refugee women are at increased
risk. The third focus relates to the special factors and needs of pregnant asylum seekers and refugees. The recommendation is to increase awareness among professionals
involved in the care for pregnant asylum-seeking and refugee women about the special
needs that these women may have due to their background and current situation.
The second theme is the mental health of children. The first focus area for this theme
relates to the association between asylum reception and resettlement conditions. The
recommendation for this first area is that policy makers take into account that reduction of relocations, rapid resolution of asylum claims, and quick family reunification
Summary
will positively contribute to the mental health and development of asylum-seeking

and refugee children. The second focus area relates to the influence of parental mental
health on the mental health of asylum-seeking children. We recommend investing in the
early identification of and provision of support to asylum-seeking and refugee families
who are affected by mental health problems and ensure continuity of preventive and
curative care during the resettlement process.
In the third theme, we address noncommunicable diseases, with a focus on diabetes,
circulatory diseases and cancer. The focus areas entail the promotion of physical activity and a healthy diet. We recommend implementing policies and interventions that
encourage physical activity among asylum seekers and refugees. Furthermore we recommend investing in interventions that promote healthy eating habits among asylum
seekers and refugees, with a focus on families with children.
Section 4.4 addresses reflections and recommendations with respect to research. We
discuss that the studies in this thesis have illustrated that health care registry data can
provide important insights into the health of asylum seekers. With respect to refugees,
we highlight the scarcity of data on their health status and risk factors. We also noted that
studies are needed that provide insight into the needs, health literacy, health behaviours,
and health abilities of different groups of asylum seekers and refugees. Furthermore, we
argue that insight is needed into the effectiveness of interventions for asylum seekers
and refugees, amongst others for the themes addressed in the previous section.
The chapter ends with the general conclusions of this thesis (section 4.5).
We conclude that, overall, asylum seekers and refugees are at increased risk of adverse
outcomes with respect to sexual and reproductive health, mental health, and specific
noncommunicable diseases when compared with the general population in the Netherlands. Within these groups, there are large risk differences when stratified by gender,
age, family composition, country of origin and length of stay. The risk distribution varies
between diseases and conditions.
The reasons for the increased risks of health problems are diverse, and include exposure
to violence, limited health literacy, genetic predisposition, and conditions in the host
country.
We also conclude that there is a serious lack of insight into the health status of and risk
factors for refugees in the Netherlands. For the refugee population, as well as for the
asylum-seeking population, more insight is needed into the distribution of diseases and
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conditions, the reasons behind these distributions, and the effectiveness of interventions.
Insight into the main risks and the effectiveness of interventions may guide policies and
practices that will increase the chances of a safe and healthy future for asylum seekers
and refugees.
Samenvatting
5.2 SAMEnVATTInG
Dit proefschrift geeft inzicht in hoe vaak ziekten en aandoeningen vrkomen bij
asielzoekers in Nederland en wat specifieke risicofactoren voor hun gezondheid zijn. Op
basis van de onderzoeksresultaten worden aanbevelingen gedaan voor het bevorderen
van de gezondheid van asielzoekers en van vluchtelingen.
Hoofdstuk 1 geeft achtergrondinformatie over asielzoekers en vluchtelingen in Nederland en over de organisatie van opvang en gezondheidszorg voor deze groepen
(paragraaf 1.1).
Asielzoekers en vluchtelingen zijn gevlucht uit hun land van herkomst en hebben in
een ander land een asielverzoek ingediend. Asielzoekers zijn nog in afwachting van de
beslissing over hun asielverzoek. Met vluchtelingen bedoelen we de mensen die op
basis van een asielverzoek een verblijfsvergunning hebben gekregen.
Asielzoekers wonen in asielzoekerscentra die beheerd worden door het Centraal Orgaan
opvang asielzoekers (COA). In 2001 was de bezetting van de centrale opvang het hoogst:
op 1 januari 2001 woonden er 83.800 asielzoekers in asielzoekerscentra. Het aantal
asielzoekers daalde vervolgens. Op 1 januari 2014 woonden er 15.300 asielzoekers in
de centrale opvang. Het aantal asielverzoeken in Nederland varieert per jaar. In het jaar
2000 werden er 43.900 asielverzoeken gedaan, het aantal verzoeken daalde tot 9.730 in
2007 en nam weer toe tot 17.190 in 2013.
Vluchtelingen die een verblijfsvergunning hebben gekregen, krijgen een huis toegewezen in een gemeente. Volgens het Centraal Bureau voor de Statistiek (CBS) woonden er
op 1 januari 2010 ca. 70.000 personen in Nederland die op basis van een asielverzoek
een tijdelijke of permanente verblijfsvergunning hadden gekregen. Wanneer we afgaan
op het aantal eerste en tweede generatie migranten in Nederland die afkomstig zijn uit
landen waarvan de meerderheid van de migranten zijn of haar land ontvluchtte, is het
aantal veel hoger. Zo waren er in 2010 circa 38.000 personen van Afghaanse, 52.000 van
Irakese, 31.000 van Iraanse en 27.000 van Somalische origine in Nederland.
Asielzoekers hebben vergelijkbare toegang tot gezondheidszorg als andere inwoners
van Nederland. Hoe is de toegang geregeld? We beschrijven dit voor de periode 20002008 - de periode waarop de onderzoeken in dit proefschrift betrekking hebben. (Per
2009 is de organisatie van de zorg voor asielzoekers gewijzigd).
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Voor de zorgverlening aan asielzoekers contracteerde het COA vanaf het jaar 2000 de
GGDen en een zorgverzekeraar. De GGDen richtten voor de zorg voor asielzoekers om
administratieve redenen de stichtingen Medische Opvang Asielzoekers (MOA) op. De
hoofdtaak van de MOA was het uitvoeren van de publieke gezondheidszorg taken voor
asielzoekers, zoals gezondheidsvoorlichting, jeugdgezondheidszorg, infectieziektebestrijding, tuberculose screening, hygine- en veiligheidsinspecties, en epidemiologie.
De MOA was daarnaast ook het eerste aanspreekpunt voor asielzoekers bij gezondheidsvragen of -problemen. MOA-praktijkverpleegkundigen werkten daarvoor nauw samen
met huisartsen, die gecontracteerd werden door de zorgverzekeraar. De zorgverzekeraar contracteerde daarnaast ook andere zorgverleners zoals apothekers, tandartsen,
verloskundigen, ziekenhuizen, GGZ- en thuiszorginstellingen.
Vanaf het moment dat vluchtelingen een verblijfsvergunning krijgen en zich vestigen in
een gemeente, zijn zij net als andere inwoners van Nederland verplicht een zorgverzekering af te sluiten. Voor de publieke gezondheidszorg vallen zij dan onder de GGD in
de gemeente van vestiging.
Het beknopte overzicht van de wetenschappelijke literatuur tot 2009 in paragraaf 1.2
laat zien dat het aantal onderzoeken naar de gezondheid van asielzoekers en vluchtelingen in Nederland beperkt is. Daarbij is er een oververtegenwoordiging van onderzoeken naar psychische aspecten van gezondheid. Om te komen tot onderbouwing van
beleid en praktijk is meer inzicht nodig in hoe vaak gezondheidsproblemen vrkomen
in vergelijking met de Nederlandse bevolking en in specifieke risicofactoren voor de
gezondheid van asielzoekers en vluchtelingen.
Paragraaf 1.3 beschrijft de hoofddoelstellingen van dit proefschrift. In paragraaf 1.4
worden de gegevensbronnen voor de onderzoeken in dit proefschrift beschreven. De
eerste bron betreft registraties die zijn gebaseerd op meldingsformulieren die werden
ingevuld door medewerkers van de MOA bij overlijden, sucidepogingen en abortussen
bij asielzoekers. De tweede bron betreft een digitale database die de belangrijkste medische gegevens bevat voor alle asielzoekers in Nederland in de jaren 2000-2008. Deze
database (verder aangeduid als MOA-database) bevat naast gegevens uit contacten met
de MOA ook gegevens afkomstig uit contacten met huisartsen. De MOA-database bevat
verder demografische en opvanggegevens van het COA.
Hoofdstuk 2 bestaat uit vijf studies naar hoe vaak gezondheidsproblemen vrkomen
bij asielzoekers in Nederland. De studie in paragraaf 2.1 beschrijft sterfte en doodsoorzaken bij asielzoekers in de periode 2000-2005. Het doel van deze studie was om de
Samenvatting
totale sterfte bij asielzoekers en de sterfte uitgesplitst naar doodsoorzaak te vergelijken

met de Nederlandse bevolking. Tevens is nagegaan of er subgroepen zijn met een
verhoogd risico om te overlijden. De studie is gebaseerd op meldingsformulieren van
overlijden in de totale groep asielzoekers in Nederland in de jaren 2002-2005.
Het aantal gemelde overlijdens was 346. De sterfte onder asielzoekers bleek, na correctie
voor leeftijd, vergelijkbaar te zijn met de sterfte in de Nederlandse bevolking bij zowel
mannen als vrouwen. Wel werden er aanzienlijke verschillen gevonden tussen subgroepen naar geslacht, leeftijd en land van herkomst. Tot 40 jaar was de sterfte bij asielzoekers
hoger en vanaf 40 jaar lager dan in de Nederlandse bevolking. De hoogste sterfterisicos
werden gevonden voor vrouwen tot 40 jaar uit de regio West, Centraal en Zuidelijk Afrika.
De meest voorkomende doodsoorzaken bij asielzoekers waren kanker, hart- en vaatziekten en niet-natuurlijke doodsoorzaken. Mannen en vrouwen hadden in vergelijking
met de Nederlandse bevolking een verhoogde kans om te overlijden aan infectieziekten
(hiv, hepatitis en tbc), ongevallen en verdrinking. Bij mannelijke asielzoekers was bovendien de sterfte door sucide verhoogd, bij vrouwen gold dit voor de sterfte gerelateerd
aan zwangerschap en bevalling.
De studie in paragraaf 2.2 beschrijft hoe vaak sucide en sucidepogingen vrkomen
bij asielzoekers. De studie is gebaseerd op meldingen van overlijden en sucidepogingen
bij asielzoekers van 15 jaar en ouder gedurende de jaren 2002-2007 in heel Nederland.
Gegevens over sucidesterfte bij asielzoekers werden vergeleken met gegevens voor de
algemene bevolking van Nederland. Gegevens over sucidepogingen werden vergeleken met gegevens van ziekenhuizen in Den Haag.
Bij mannelijke asielzoekers was de sterfte door sucide 2,0 keer zo hoog als in de algemene bevolking, bij vrouwen werd geen verschil gevonden. Sucidepogingen waarvoor
behandeling in het ziekenhuis nodig was, kwamen in vergelijking met de algemene
bevolking vaker voor bij mannelijke en vrouwelijke asielzoekers uit Oost en Zuid Europa,
het Midden-Oosten en Zuidwest Azi. Bij mannen en vrouwen uit Afrika kwamen sucidepogingen juist minder vaak voor. Bij 80% van de asielzoekers die een sucidepoging
deden, was het medisch personeel voorafgaand aan de sucidepoging op de hoogte van
het bestaan van psychische problemen.
De studie in paragraaf 2.3 beschrijft hoe vaak diabetes vrkomt bij asielzoekers. Het
onderzoek is gebaseerd op gegevens van bijna 60.000 asielzoekers tussen de 20 tot 79
jaar die tussen 2000 en 2008 in asielzoekerscentra woonden. Er werd gebruik gemaakt
van gegevens uit de MOA-database. De gegevens zijn vergeleken met huisartsgegevens
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die representatief zijn voor de algemene bevolking van Nederland. Het aantal asielzoekers waarbij gedurende hun verblijf in de centrale opvang diabetes werd geregistreerd
was 1.227. Dit komt neer op 2 gevallen van diabetes per 100 asielzoekers. Diabetes
bleek bij asielzoekers twee keer zo vaak voor te komen als in de algemene Nederlandse
bevolking na correctie voor leeftijd. Bij vrouwen was het verschil met de algemene
Nederlandse bevolking (2,3 keer zo vaak) groter dan bij mannen (1,9 keer zo vaak).
Diabetes kwam relatief het meest voor bij asielzoekers uit Somali, Soedan en Sri Lanka.
Diabetes kwam bij asielzoekers vaker voor dan in de algemene bevolking in alle leeftijdsgroepen vanaf 30 jaar. Het verschil in het vrkomen van diabetes tussen asielzoekers
en de algemene bevolking nam toe met de verblijfsduur van asielzoekers in Nederland.
Uit andere onderzoeken kan worden afgeleid dat het risicoverschil met de algemene
bevolking na het verkrijgen van een verblijfsvergunning waarschijnlijk verder toeneemt.
Hoofdstuk 2 bevat ook twee studies over verschillende aspecten van seksuele en reproductieve gezondheid onder asielzoekers. Het belangrijkste doel van het onderzoek in
paragraaf 2.4 was het in kaart brengen van abortussen en tienerzwangerschappen bij
vrouwen en meisjes in de asielopvang. De studie bevatte gegevens over vrouwen van
15-49 jaar die in de periode 2004 - 2005 in asielzoekerscentra in Nederland woonden.
Gegevens over abortus werden verzameld uit meldingsformulieren en elektronische
patintendossiers van de MOA. Het aantal abortussen per 1.000 vrouwen per jaar was
bij asielzoeksters 1,7 keer zo hoog als gemiddeld in Nederland. Het aantal abortussen
per 1.000 geboortes was 1,5 keer zo hoog. Er werden grote verschillen gevonden tussen
subgroepen. Abortus kwam relatief vaak voor bij vrouwen die bij aankomst in Nederland
al zwanger waren. Abortussen en tienergeboorten kwamen bij vrouwen en meisjes die
nog maar kort in Nederland waren vaker voor dan bij vrouwen en meisjes die langer in
Nederland waren. Abortussen en tienergeboorten kwamen het vaakst voor bij vrouwen
uit Afrika en Azi. Het aantal abortussen ten opzichte van het aantal geboortes was het
hoogst bij vrouwen tussen 30-49 jaar uit Europa en Azi.
Paragraaf 2.5 bestaat uit een studie naar hoe vaak hiv vrkomt onder zwangere asielzoeksters in Nederland in de periode 2000 - 2008. Er bleken 80 asielzoeksters hiv-positief`op
een totaal van 4.854 asielzoeksters die in deze periode n of meer kinderen kregen in de
centrale opvang. Van deze 80 hiv-positieve vrouwen waren er 79 afkomstig uit sub-Sahara
Afrika. Onder vrouwen uit sub-Sahara Afrika was het percentage dat hiv-positief was met
3,5% veel hoger dan het percentage onder alle zwangere vrouwen in Nederland (0,04%). Bij
vrouwen uit andere regios van herkomst werd n maal hiv geregistreerd; met 0,04 % was dit
percentage hetzelfde als in de algemene bevolking in Nederland. De hoogste percentages
hiv-postieven werden gevonden voor vrouwen uit Rwanda (17,0 %) en Kameroen (13,2%).
Samenvatting
Hoofdstuk 3 bevat drie studies die erop gericht zijn om inzicht te krijgen in risicofactoren
die mogelijk een specifieke rol spelen bij de gezondheid van asielzoekers. Paragraaf
3.1 beschrijft een onderzoek naar het effect van overplaatsingen op de psychische en
psychosociale gezondheid van asielzoekerkinderen. Daarbij werd gekeken of het effect
van overplaatsingen groter was bij kwetsbare asielzoekerkinderen, zoals kinderen met
geweldservaringen en kinderen met een moeder met depressie of posttraumatische stress
stoornis (PTSS). Wij waren vooral genteresseerd in de gevolgen van frequente overplaatsingen, gemeten in termen van hoe vaak een kind gemiddeld per jaar is overgeplaatst.
Hoe vaak psychische klachten vrkomen hing samen met de frequentie van overplaatsingen maar niet met het aantal keren dat een kind tijdens de gehele opvangperiode
werd overgeplaatst. Bij asielzoekerkinderen die vaker dan n keer per jaar werden
overgeplaatst, kwamen 2,5 keer zo vaak psychische of psychosomatische klachten voor
als bij kinderen die minder dan n keer per twee jaar werden overgeplaatst. Bij kwetsbare kinderen was dat zelfs 3,5 keer zo vaak.
In de studie in paragraaf 3.2 is onderzocht of er een verband bestaat tussen geweldservaringen en psychische problemen van moeders en hoe vaak fysieke kindermishandeling vrkomt bij asielzoekerkinderen. Psychische problemen van de moeder waren in
deze studie gedefinieerd als het hebben van de diagnose PTSS of depressie. Vergelijking
met het voorkomen van fysieke kindermishandeling bij andere kinderen in Nederland is
op basis van dit onderzoek helaas niet mogelijk.
Fysieke kindermishandeling werd 1,6 keer vaker geregistreerd bij asielzoekerkinderen
van wie de moeders geweldservaringen hadden dan bij andere asielzoekerkinderen. Bij
asielzoekerkinderen van wie de moeder gediagnosticeerd was met PTSS of depressie
kwam fysieke kindermishandeling 1,7 zo vaak voor als bij andere asielzoekerkinderen.
Het verband tussen deze risicofactoren bij de moeder en fysieke kindermishandeling
was sterker bij kinderen van alleenstaande moeders dan bij kinderen die met twee
ouders in de opvang waren.
Paragraaf 3.3 beschrijft een onderzoek naar de relatie tussen PTSS en diabetes. Hiervoor werden gegevens uit de MOA-database gebruikt voor ruim 100.000 asielzoekers
van 18 jaar of ouder. Bij mannelijke asielzoekers met diagnose PTSS werd 1,4 keer zo
vaak diabetes gediagnosticeerd als bij mannelijke asielzoekers zonder PTSS diagnose.
Bij asielzoeksters met diagnose PTSS werd 1,2 keer vaker diabetes gediagnosticeerd dan
bij andere asielzoeksters.
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De belangrijkste aanbevelingen op basis van de individuele studies zijn op een rij gezet
in kader 5.1.
kader 5.1 Belangrijkste aanbevelingen uit de individuele studies
Zet in op preventie van de doodsoorzaken die bij asielzoekers vaker voorkomen

dan in de Nederlandse bevolking (infectieziekten, moedersterfte, sucide, ongevallen en verdrinking) n op preventie van de meest voorkomende doodsoorzaken (hart- en vaatziekten, kanker).
Train zorgverleners en mensen die met asielzoekers werken in het herkennen
van sucidale gedachten bij asielzoekers en in het nemen van adequate actie.
Creer, om diabetes te voorkmen, omstandigheden in asielzoekerscentra die
fysieke activiteit en gezonde voeding stimuleren en informeer zorgverleners
over het hoge risico op diabetes bij asielzoekers.
Investeer in het voorkmen van onbedoelde zwangerschappen bij asielzoekers
vanaf kort na aankomst in Nederland, vooral bij tienermeisjes.
Bied asielzoekers uit Afrika een vrijwillige hiv-test aan, kort na aankomst in
Nederland.
Neem het negatieve effect van frequente overplaatsingen op de psychische en
psychosociale gezondheid van asielzoekerkinderen mee in de overwegingen bij
het opstellen van opvangbeleid.
Besteed speciale aandacht aan de preventie van fysieke kindermishandeling bij
asielzoekerkinderen waarvan de moeder blootgesteld is geweest aan geweld of
symptomen van PTSS of depressie heeft.
Overweeg een gentegreerde benadering voor de preventie en behandeling van
diabetes in combinatie met de preventie van stress en psychische problemen bij
asielzoekers.
Samenvatting
Hoofdstuk 4 begint met een samenvatting van de belangrijkste bevindingen van de

studies beschreven in dit proefschrift (paragraaf 4.1). In paragraaf 4.2 worden methodologische aspecten besproken.
Paragraaf 4.3 bestaat uit reflecties op drie themas die de afzonderlijke studies overstijgen.
Het eerste thema is een goede start. Het bevat reflecties over de seksuele en reproductieve gezondheid van asielzoekers. Aanleiding voor dit thema is het hogere risico
op ongunstige zwangerschapsuitkomsten bij asielzoeksters en vluchtelingenvrouwen.
Het eerste en meest fundamentele aandachtsgebied voor dit thema betreft de preventie van onbedoelde zwangerschappen, tienerzwangerschappen en veelvoudige
zwangerschappen (meer dan vijf keer bevallen). Zulke zwangerschappen komen relatief vaak voor bij vluchtelingen en asielzoekers als gevolg van onder andere beperkte
kennis van seksuele en reproductieve gezondheid, negatieve attitudes ten aanzien
van anticonceptie, en de kwetsbare positie van een deel van de asielzoeksters. Het
tweede aandachtsgebied betreft de preventie van de negatieve effecten die specifieke
gezondheidsproblemen en een slechte algemene gezondheidstoestand kunnen hebben op het verloop van zwangerschappen van asielzoeksters en vluchtelingenvrouwen.
Het derde aandachtsgebied betreft de preventie van de negatieve invloed die uit kan
gaan specifieke achtergrondkenmerken en de huidige omstandigheden. Zwangerschapsuitkomsten kunnen bijvoorbeeld worden benvloed door psychische klachten
die ontstaan in de vlucht- en asielperiode, en door beperkte gezondheidsvaardigheden
en sociale contacten kort na aankomst in Nederland.
Het tweede thema betreft de psychische gezondheid van asielzoeker- en vluchtelingenkinderen. Aanleiding voor dit thema is het vaker vrkomen van psychische en
psychosociale problemen bij asielzoeker- en vluchtelingenkinderen. De invloed van
asiel-, opvang- en vestigingsbeleid op de psychische gezondheid van asielzoeker- en
vluchtelingenkinderen is het eerste aandachtsgebied. Het tweede aandachtsgebied
betreft de invloed van de psychische gezondheid van ouders op de psychische gezondheid van asielzoeker- en vluchtelingenkinderen.
Het derde thema is chronische ziekten. Dit thema gaat in op het vrkomen van diabetes, hart- en vaatziekten en kanker bij asielzoekers en vluchtelingen. Uit beschikbare
onderzoeken blijkt dat asielzoekers en vluchtelingen uit veel landen van herkomst een
hoog risico op diabetes hebben. Ook zijn er aanwijzingen voor een verhoogd risico op
hart- en vaatziekten voor verschillende groepen. Onderzoeken in Nederland en andere
landen laten een toename van overgewicht zien bij volwassen en jeugdige asielzoekers
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en vluchtelingen. Factoren die kunnen bijdragen aan het verhoogde risico op chronische ziekten onder andere genetische factoren, snelle verandering van sociaal economische status, stress en andere psychische klachten, gebrek aan lichaamsbeweging en
ongezonde voeding.
Het eerste aandachtsgebied voor het thema chronische ziekten is het stimuleren van
fysieke activiteit bij asielzoekers en vluchtelingen. De samenhang tussen bewegen, psychische problemen en chronische ziekten is daarbij een belangrijk aspect. Het tweede
aandachtsgebied voor dit thema is het bevorderen van gezonde voedingsgewoonten,
vooral in gezinnen met kinderen.
kader 5.2 Aanbevelingen op basis van de reflecties

Thema 1: Een goede start
Investeer in interventies die vanaf kort na aankomst in Nederland bijdragen aan de
kennis van asielzoekers en vluchtelingen over seksuele en reproductieve gezondheid en hun vermogen om op dit gebied genformeerde keuzes te maken.
Ontwikkel professionele richtlijnen die bijdragen aan het kort na aankomst in
Nederland opsporen van ziekten en aandoeningen die gerelateerd zijn aan ongunstige zwangerschapsuitkomsten bij asielzoeksters en vluchtelingenvrouwen.
Vergroot bij professionals interculturele competenties en kennis over de omstandigheden en specifieke behoeften van asielzoeksters en vluchtelingenvrouwen.
Thema 2: Psychische gezondheid van asielzoekerkinderen
Neem bij de overwegingen bij het maken van keuzes in het opvangbeleid mee, dat
beperking van het aantal verhuizingen, snelle besluitvorming over asielaanvragen,
en spoedige gezinshereniging een positieve bijdrage kunnen leveren aan de psychische gezondheid en de ontwikkeling van asielzoeker- en vluchtelingenkinderen.
Investeer in de preventie van psychische en psychosociale problemen bij asielzoekerkinderen door vroegsignalering en behandeling van psychische problemen in
asielzoeker- en vluchtelingengezinnen. Zorg voor continuteit van de preventieve
en curatieve zorg voor deze gezinnen bij verhuizingen en vestiging in een gemeente.
Thema 3: Chronische ziekten
Creer in asielzoekerscentra en bij vestiging van vluchtelingen in gemeenten
omstandigheden die fysieke activiteit bevorderen.
Stimuleer gezonde voeding bij asielzoekers en vluchtelingen, vooral in gezinnen
met kinderen.
Samenvatting
Paragraaf 4.4 bestaat uit reflecties en aanbevelingen met betrekking tot wetenschappelijk onderzoek naar de gezondheid van asielzoekers en vluchtelingen. De studies in
dit proefschrift laten zien dat de analyse van gegevens uit zorgregistraties belangrijke
inzichten kan geven in de gezondheid van asielzoekers. We constateren dat er nog maar
weinig bekend is over de gezondheidstoestand van en risicofactoren bij vluchtelingen.
Er is meer inzicht nodig in de behoeften, gezondheidsvaardigheden en gezondheidsgedrag van zowel asielzoekers als vluchtelingen. Verder is het van belang dat de effectiviteit van interventies voor asielzoekers en vluchtelingen wordt onderzocht, onder andere
voor de themas die in de vorige paragraaf zijn beschreven.
Paragraaf 4.5 beschrijft de algemene conclusies van dit proefschrift. We concluderen
dat asielzoekers en vluchtelingen over het geheel genomen een hoger risico hebben
op ongunstige zwangerschapsuitkomsten, op psychische problemen en op specifieke
chronische ziekten in vergelijking met de algemene bevolking in Nederland. De hoogte
van de risicos varieert naar onder meer geslacht, leeftijd, gezinssamenstelling, land
van herkomst en de lengte van het verblijf. De precieze risicopatronen verschillen naar
gezondheidsprobleem. De verhoogde risicos zijn deels toe te schrijven aan specifieke
achtergronden en omstandigheden van asielzoekers en vluchtelingen, zoals geweldservaringen, beperkte gezondheidsvaardigheden en onzekerheden over de toekomst.
De inzichten en aanbevelingen gepresenteerd in dit proefschrift beogen bij te dragen
aan beleid en praktijk gericht op het bevorderen van een safe and healthy future voor
asielzoekers en vluchtelingen.
217
Abbreviations
ABBREVIATIOnS
AMC
APR
GC A
COA
GGDs
MOA
CI
IGZ
HIV
ICPC
METC
GGD Nederland
LINH
PTSD
JGZ
POR
RR
SMR
SPR
SDQ
TB
T2DM
UMA
UNHCR
WHO
Academic Medical Center

Age-adjusted prevalence ratio
Asylum Seekers Health Centre (Gezondheidscentrum Asielzoekers)
Central Agency for the Reception of Asylum Seekers
Community Health Services
Community Health Services for Asylum Seekers (Medische Opvang
Asielzoekers)
Confidence interval
Dutch Health Care Inspectorate
Human immunodeficiency virus
International Classification of Primary Care
Medical ethics review committee
Netherlands Association for Community Health Services
Netherlands Information Network of General Practice
Post-traumatic stress disorder
Preventive child health care
Problem-oriented record
Relative risk
Standardised mortality ratio
Standardised prevalence ratio
Strengths and difficulties questionnaire (SDQ)
Tuberculosis
Diabetes mellitus type 2
United Nations High Commissioner for Refugees
World Health Organization
219
aPPENdix 1
ZwAnGerscHApsuItkoMsten en
ZorGbeHoeften bIj AsIelZoeksters
Een literatuuroverzicht
This literature survey has been published in Dutch as:
Goosen S, van Oostrum IE, Essink-Bot ML.Zwangerschapsuitkomsten en

zorgbehoeften bij asielzoeksters. Ned Tijdschr Geneeskd. 2010;154:A2318
222
Appendix 1
ABSTRACT
Obstetric outcomes and expressed health needs of pregnant asylum seekers: a
literature survey
Objective
To analyse whether specific attention is needed for the improvement of health for pregnant asylum seekers by producing an overview of obstetric outcomes, risk factors and
expressed health needs of asylum seekers in the Netherlands and other Western host
countries.
Design
Literature study.
Method
A search was performed in Medline, Embase and PsycInfo for empirical studies about
pregnancy and delivery specifically among asylum seekers in Western host countries
and published since 1995. Picarta and the authors literature collections were used to
find Dutch studies. Google was used to find grey literature.
Results
Published empirical studies on pregnancy outcome indicators specific for asylum seekers were scarce and limited to the Netherlands. The studies found revealed an increased
risk of perinatal and maternal mortality and severe maternal morbidity. These studies,
however, were based on small numbers of cases. Qualitative studies revealed that pregnant asylum seekers expressed the following needs: a) information about pregnancy
and about healthcare in the host country, b) healthcare professionals who pay attention
to their problems and c) mothers groups for social contacts and information exchange.
Conclusion
Specific attention must be paid to improving the care for pregnant asylum seekers,
since the limited number of studies suggest that asylum seekers are at increased risk
of perinatal mortality, maternal mortality and severe maternal morbidity. More studies
are needed into risk factors and quality of care for pregnant asylum seekers. The publications studied contain recommendations for an improved matching of the care with
the needs expressed. The recommendations concern provision of information, cultural
competencies of care providers, identification of risk factors, health networks approach,
continuity of care and organising mothers groups.
Zwangerschapsuitkomsten en zorgbehoeften
SAMEnVATTInG
Doel
Nagaan of specifieke aandacht nodig is voor het verbeteren van de zorg voor zwangere
asielzoeksters door het in kaart brengen van zwangerschapsuitkomsten, risicofactoren
en zorgbehoeften van zwangere asielzoeksters in Nederland en andere westerse opvanglanden.
Opzet
Literatuurstudie.
Methode
In Medline, Embase en PsycInfo werd gezocht naar empirisch onderzoek over zwangerschap en bevalling specifiek voor asielzoeksters in westerse opvanglanden, gepubliceerd sinds 1995. Nederlandse studies werden gezocht met behulp van Picarta en in de
verzamelingen van de auteurs. Met Google werd grijze literatuur gezocht.
Resultaten
Gepubliceerde empirische studies over zwangerschapsuitkomsten specifiek voor
asielzoeksters waren schaars en alleen afkomstig uit Nederland. De studies wezen op
verhoogde risicos op perinatale en maternale mortaliteit en ernstige maternale morbiditeit. De studies betroffen echter kleine aantallen. Kwalitatieve studies lieten zien
dat zwangere asielzoeksters behoefte hadden aan: a) informatie over zwangerschap en
gezondheidszorg in het opvangland; b) zorgverleners die aandacht hebben voor hun
problemen; en c) moedergroepen voor sociale contacten en informatie-uitwisseling.
Conclusie
Er is specifieke aandacht nodig voor het verbeteren van de zorg voor zwangere asielzoeksters, omdat de schaarse studies suggereren dat asielzoeksters een verhoogd risico
lopen op perinatale sterfte, maternale sterfte en ernstige maternale morbiditeit. Er is
meer inzicht nodig in de risicofactoren en kwaliteit van zorg voor zwangere asielzoeksters. De bestudeerde publicaties bevatten aanbevelingen voor een betere aansluiting
van de zorg op de zorgbehoeften. De aanbevelingen betreffen informatievoorziening,
culturele competenties van zorgverleners, het identificeren van risicofactoren, ketensamenwerking, continuteit van zorg en het organiseren van moedergroepen.
223
224
Appendix 1
InlEIDInG
Onder asielzoeksters in Nederland is de maternale mortaliteit veel hoger dan in de
algemene bevolking, zo vonden wij bij eerder onderzoek naar sterfte en doodsoorzaken
onder asielzoekers in Nederland (relatief risico (RR): 10,1; 95%-BI: 8,0-12,8).1 Deze bevinding was gebaseerd op 3 gevallen van maternale sterfte en moet dus voorzichtig worden
genterpreteerd, maar past bij het internationale beeld dat asielzoeksters een kwetsbare
groep zijn voor wat betreft hun seksuele en reproductieve gezondheid.2 De gevonden
maternale mortaliteit en daaruit voortkomende beleidsvragen waren aanleiding om
middels literatuuronderzoek meer inzicht te krijgen in zwangerschapsuitkomsten en
zorgbehoeften bij asielzoeksters.
Asielzoekers zijn personen die om uiteenlopende redenen hun land van herkomst
hebben verlaten, asiel hebben aangevraagd in een opvangland en in afwachting zijn
van het besluit op hun asielverzoek (www.unhcr.org.au/ basicdef.shtml). In Nederland
worden asielzoekers opgevangen door het Centraal Orgaan Opvang Asielzoekers. Op
1 januari 2010 maakten 5100 vrouwelijke asielzoeksters in de leeftijd van 15-49 jaar
gebruik van de centrale opvang asielzoekers (tabel A.1). In 2009 werden in totaal 669
kinderen geboren uit asielzoeksters. Asielzoeksters behoren tot de groep vrouwen in
achterstandssituaties, die volgens de Stuurgroep Zwangerschap en Geboorte specifieke
en intensieve aandacht behoeft bij de zorg rond zwangerschap en geboorte.3
Tabel A.1 Aantal vrouwelijke asielzoeksters in de leeftijdsgroep 15-49 jaar op 1 januari 2010 en totaal
aantal geboortes in de centrale opvang asielzoekers naar land van herkomst
land*
Somali
Aantal vrouwen
(n=5100)
Aantal geboortes
(n=669)
1812
248
Irak
726
80
Voormalige Sovjet-Unie
536
67
Afghanistan
377
34
China
161
28
Guine
129
43
Eritrea
123
13
Democratische Republiek Congo
105
18
Mongoli
97
21
Sierra Leone
84
17
Nigeria
72
12
Angola
59
11
819
77
Overige landen (totaal)
Om na te gaan of specifieke aandacht nodig is voor het optimaliseren van de zorg rondom zwangerschap en bevalling bij asielzoeksters in Nederland, en zo ja, wat er nodig
is, voerden wij een literatuurstudie uit met als doelstelling het in kaart brengen van: a)
zwangerschapsuitkomsten en risicofactoren onder asielzoeksters in westerse landen, b)
ervaren zorgbehoeften van zwangere asielzoeksters en c) aanbevelingen voor de zorg
voor zwangere asielzoeksters.
METHODE
Met behulp van Ovid SP 2010 zochten we in de literatuurdatabases Medline, Embase en
PsycInfo over de periode 1995-maart 2010. Er werd gezocht met de volgende zoekterm:
refugee AND (pregnancy OR maternal OR perinatal OR stillbirth OR midwifery). De
zoekterm refugee werd gekozen omdat deze breder is dan asylum seeker maar soms
wel wordt gebruikt voor asielzoekers.
De zoekactie leverde 239 publicaties op. Hieruit selecteerden wij handmatig wetenschappelijke publicaties gebaseerd op primaire dataverzameling of meta-analyse
over a) zwangerschapsuitkomsten bij asielzoeksters in westerse opvanglanden, of b)
ervaren zorgbehoefte bij asielzoeksters in westerse opvanglanden. Wij vonden enkele
publicaties waarvan de titel suggereerde dat ze over asielzoeksters gaan, maar die bij
bestudering geen onderscheid bleken te maken naar verblijfsstatus. Deze werden niet
meegenomen.
Verder zochten we met behulp van Google (UK, zoektermen refugees of asylum seekers
in combinatie met pregnancy of maternity care) naar grijze literatuur. Nederlandse
publicaties en rapporten werden gezocht in Nederlandse vaktijdschriften (Nederlands
Tijdschrift voor Geneeskunde, Tijdschrift voor Verloskundigen, Nederlands Tijdschrift voor
Obstetrie & Gynaecologie en Tijdschrift voor Gezondheidswetenschappen), door middel
van Picarta en in de literatuurverzamelingen van de auteurs.
In de resultatensectie beschrijven we naast onderzoeksresultaten ook de aanbevelingen
die de auteurs van de oorspronkelijke publicaties doen op grond van hun onderzoeksresultaten, voor zover relevant voor de Nederlandse situatie. Deze hebben we geordend
naar de themas uit het advies Een goed begin van de Stuurgroep Zwangerschap en
Geboorte.3
225
RESulTATEn
Omvang empirische informatie
We vonden 2 artikelen die perinatale en maternale mortaliteitsindicatoren rapporteren
specifiek voor asielzoeksters in Nederland.1,4 Tijdens de literatuurstudie voerden we de
analyse uit van de sterfteregistratie van de Medische Opvang Asielzoekers (MOA) over
2006-2008; de resultaten hiervan zijn meegenomen in dit literatuuroverzicht. Van de
onderzoekers van de landelijke studie naar etnische determinanten van maternale morbiditeit in Nederland (LEMMoN) kregen we gegevens over ernstige maternale morbiditeit bij asielzoeksters in Nederland.5,6 Er werd 1 buitenlands rapport gevonden waarin
specifieke uitspraken over maternale mortaliteit bij asielzoeksters werden gedaan.7 Voor
zorgbehoeften werden 6 artikelen en 5 rapporten gencludeerd.8-18
Zwangerschapsuitkomsten en risicofactoren
In Nederland registreerde de MOA in de periode 2002-2005 3 gevallen van maternale
sterfte onder asielzoeksters op een totaal van 4327 geboortes.1 De moedersterfte onder
asielzoeksters was met 69,3 per 100.000 geboortes veel hoger dan in de totale Nederlandse bevolking (RR: 10,1; 95%-BI: 8,0-12,8). Tijdens een eerdere en tijdens de recentste
registratieperiode (1998-1999 en 2006-2008) werd 1 geval van moedersterfte gerapporteerd. De maternale sterftecijfers waren in de twee periodes respectievelijk 39,9 en
61,2 per 100.000 levendgeborenen.4
Het aantal gevallen van perinatale sterfte dat de MOA registreerde in de periode 20062008 was 19. Waarschijnlijk werden niet alle gevallen van doodgeboorte gemeld. De
perinatale sterfte was 11,6/1000 levendgeborenen. Dit is 2 maal zo hoog als voor de
Nederlandse bevolking (RR: 2,0; 95%-BI: 1,3-3,1), maar gezien de onderrapportage is het
relatieve risico eigenlijk nog hoger. In eerdere registratieperiodes (1998-1999 en 20022005) was de perinatale sterfte vergelijkbaar met de Nederlandse bevolking. Ook hier
was volgens de onderzoekers sprake van onderrapportage.1,4
De LEMMoN studie vond 40 gevallen van ernstige maternale morbiditeit (gedefinieerd
als onder andere uterusruptuur, eclampsie, ernstige fluxus) bij asielzoeksters in Nederland in de periode augustus 2004-augustus 2006 (schriftelijke mededeling J. Zwart,
2010).5,6 Dit betekent een incidentie van 31 per 1000 bevallingen, 4,5 keer zo hoog als
voor de Nederlandse populatie (RR: 4,5; 95%-BI: 3,36,1) en 3,6 keer zo hoog als voor
niet-westerse migranten vrouwen (RR: 3,6; 95%-BI: 2,6-5,0).
Voor Groot-Brittanni concludeerde de Confidential Enquiry into Maternal and Child
Health (CEMACH, 2003-2005) dat voor asielzoeksters het risico op maternale sterfte
verontrustend hoog was.7 De bestudeerde publicaties gaven geen kwantitatief inzicht

in risicofactoren.
Ervaren zorgbehoeften en benodigde competenties in de zorg
Uit diepte-interviews met 4 zwangere asielzoeksters in Nederland bleek dat deze
vrouwen de volgende zorgbehoeften hadden: tijdige informatie over het zorgsysteem,
positieve communicatie, het overwinnen van de taalbarrire en het ontwikkelen van
sociale netwerken.8 Discontinuteit van zorg door overplaatsingen, beperkte consulttijd,
beperkte financile middelen en de asielprocedure werden genoemd als belemmerende
factoren. Overigens benadrukten de onderzoekers ook de kracht en vindingrijkheid van
asielzoeksters.
Het verslag van een focusgroepgesprek met 11 asielzoeksters in 1 asielzoekerscentrum
rapporteerde als ervaren zorgbehoeften: informatie over zwangerschap en gezondheidszorg, zorgverleners die luisteren en stress serieus nemen, en de mogelijkheid
om deel te nemen aan zwangerschaps- of moedergroepen om ervaringen te delen en
contacten te leggen.9
Nederlands onderzoek wijst op specifieke behoeften bij bepaalde risicofactoren die bij
asielzoeksters relatief vaak voorkomen, namelijk infectie met hiv, ervaring met seksueel
geweld en vrouwelijke genitale verminking. Hiv-genfecteerde zwangere asielzoeksters
hadden behoefte aan kennis over hiv en behandelingsmogelijkheden, aan meer privacy
zodat hun hiv-status niet algemeen bekend zou worden en aan sociale contacten.10
Ervaringen met seksueel geweld komen vaak voor als gevolg van de kwetsbaarheid van
vrouwen in oorlogssituaties en tijdens de vlucht.11 Onderzoek laat zien dat vrouwen die
seksueel geweld hebben meegemaakt de neiging hebben om over deze ervaringen te
zwijgen, maar wel behoefte hebben aan een context om er over te praten.12 Vrouwelijke
genitale verminking wordt relatief vaak gezien bij asielzoeksters uit risicolanden, zoals
Somali, Soedan, en Guine.13 De vrouwen zelf ervaren hun besnijdenis niet altijd als
een gezondheidsprobleem in relatie tot hun zwangerschap, omdat ze uit landen komen
waar het merendeel van de vrouwen besneden is, en uiten daarom geen bijzondere
zorgbehoeften.14
Buitenlandse artikelen Uit het Verenigd Koninkrijk, Ierland, Griekenland en Australi
waren artikelen en rapporten afkomstig over de ervaren zorgbehoeften van zwangere
asielzoeksters. In deze publicaties werd benadrukt dat het essentieel is de taalbarrire te
slechten door het inzetten van professionele tolken.15-18 Ook het belang van lichaamstaal
werd benadrukt.15 Onderzoek in Ierland wees op de zorgwekkende emotionele situatie
en het ontbreken van steun uit sociale netwerken.16 Een longitudinaal casusonderzoek,
227
228
Appendix 1
Tabel A.2 Synthese van aanbevelingen voor de zorg voor zwangere asielzoeksters uit wetenschappelijk
onderzoek; ingedeeld naar themas en aandachtspunten voor zwangerschap in achterstandssituaties
beschreven in het advies Een goed begin
Thema
Aandachtspunten
zwangerschap in
achterstandssituaties
Aanbevelingen specifiek voor de zorg voor zwangere

asielzoeksters
Goed
genformeerde
zwangere
Doelgroep voor specifieke

voorlichting
Zorg voor informatieverstrekking snel na aankomst in de opvang

over zorg tijdens de zwangerschap, risicofactoren, signalen van
zwangeschapscomplicaties
Houd rekening met:
- Taalbeperkingen en ongeletterdheid
- Ontbrekende kennis van het lichaam en zwangerschap
- Onbekendheid met Nederlandse gezondheidszorg
- Onbekendheid met het belang van kraamzorg en/of
jeugdgezondheidszorg
Bevorder lokale netwerken
Stimuleer netwerken van zwangeren en moeders in

asielzoekerscentra om informatie-uitwisseling en sociale
contacten te bevorderen
Strakke begeleiding door

casemanager (in het
algemeen de verloskundige)
Benader actief de zwangere asielzoeksters die niet in zorg of niet

op afspraak komen
Zorg op maat
Aandacht voor psychosociale Heb aandacht voor sociale of psychosociale problemen, stress en
zorgen die aan de asielsituatie gerelateerd zijn
en psychiatrische
Identificeer en ondersteun positieve copingfactoren, kracht en
problematiek
weerbaarheid van asielzoeksters
Risicosignalering
en risicoselectie
Extra aandacht en maatwerk Zorg bij zwangere asielzoeksters voor een uitgebreide medische,
voor bijzondere risicogroepen obstetrische en familie anamnese en doe op indicatie nader
onderzoek naar risicofactoren
Bespreek vroeg in de zwangerschap vrouwelijke genitale
verminking en ervaringen met seksueel geweld
Schat specifieke risicofactoren in: voedingstoestand,
onvolledige vaccinatie, infectieziekten, erfelijke bloedziekten en
medicatiegebruik
Goed toegeruste
professional
Vaardigheden om taalbarrire Schakel een professionele tolk in wanneer communicatie in een

voor de zwangere begrijpelijke taal niet mogelijk is*
te slechten
Kennis van psychosociale en Wees genformeerd over asielprocedure, opvangcondities en
regelingen voor de zorg
interculturele aspecten
Wees genformeerd over risicofactoren en behandeleffecten in
verschillende etnische groepen
Kennis en vaardigheden om Zorg voor kennis en vaardigheden om om te gaan met mogelijke
behoeften bloot te leggen en invloed van traumatische ervaringen, vlucht en opvang
te beantwoorden
Samen
Cruciale rol case manager in
verantwoordelijk** de zorgketen
Zorg voor goede overdracht tussen zorgverleners, in het

bijzonder bij overplaatsing
Bevorder naast goede samenwerking in de zorgketen ook goede
samenwerking met de opvangketen
Zorg voor overdracht naar de jeugdgezondheidszorg
* De WGBO legt de verantwoordelijkheid voor het inzetten van een tolk bij de professional; zie ook
de veldnormen voor het inzetten van tolken in de gezondheidszorg (http://www.rijksoverheid.
nl/onderwerpen/kwaliteit-van-de-zorg/tolk-en-vertaaldiensten-in-de-zorg/veldnormen-tolk-envertaaldiensten) en Taalproblemen? Bel TVcN (Tijdschrift voor Verloskundigen maart 2010: 43-44).
** Bedoeld wordt onder andere verloskundige samenwerkingsverbanden
uitgevoerd in Londen, beschreef het belang van het herkennen en erkennen van de
positieve copingfactoren van asielzoeksters en het ondersteunen van hun kracht en
weerbaarheid.17 Volgens de onderzoekers waren een empathische houding en culturele
sensitiviteit bij zorgverleners essentieel. In een andere studie in London gaven zorgverleners aan dat zij informatie over de context van de doelgroep en goed voorlichtingsmateriaal nodig hadden.15 Verder werd goede ketensamenwerking binnen en tussen de
eerste en tweede lijn beschouwd als essentieel voor verbetering van verwijzingen en
informatieoverdracht.15
Aanbevelingen uit de literatuur
Tabel A.2 geeft een overzicht van de aanbevelingen uit de literatuur, ingedeeld naar
relevant geachte themas uit het advies Een goed begin en uitgesplitst naar aanbevelingen specifiek voor vrouwen in achterstandssituaties.3
BESCHOuwInG
De beschikbare gegevens suggereren dat asielzoeksters een verhoogd risico lopen op
perinatale en maternale mortaliteit en ernstige maternale morbiditeit. Zwangere asielzoeksters ervaren naast de zorgbehoeften die zij delen met andere zwangere vrouwen,
ook zorgbehoeften die samenhangen met hun asielstatus, verblijf in de centrale opvang
en recente migratie.
Een beperking van dit literatuuroverzicht is dat er weinig empirische gegevens over
zwangerschapsuitkomsten zijn die specifiek zijn voor asielzoeksters. Het aantal ongunstige zwangerschapsuitkomsten (adverse events) is klein. Er is meer onderzoek nodig
naar de incidentie van ongunstige zwangerschapsuitkomsten en risicofactoren bij asielzoeksters. Hiervoor zou zoveel mogelijk gebruik moeten worden gemaakt van gegevens
uit bestaande registraties, zoals de perinatale registratie Nederland (www.perinatreg.nl).
Om meer inzicht te krijgen in specifieke risicofactoren, onderliggende doodsoorzaken
en de kwaliteit van zorg bij asielzoeksters, zou een landelijke thematische audit kunnen
worden uitgevoerd (www. perinataleaudit.nl). Vanwege de kleine aantallen kan worden
overwogen ook audits te doen voor een aantal zwangerschappen waarbij sprake is van
ernstige morbiditeit.
De zorgbehoeften van de asielzoeksters blijken deels te worden bepaald door de
asielcontext en het zorgsysteem in het opvangland. Desondanks vonden we grote overeenkomsten in ervaren zorgbehoeften. Deze waren goed onder te brengen onder de
themas en aandachtspunten uit het rapport Een goed begin (zie tabel A.2). Onderzoek
naar de mate waarin de aanbevelingen van de Nederlandse studies gemplementeerd
229
230
Appendix 1
zijn in de praktijk, viel buiten deze literatuurstudie. Dat onderzoek is wel wenselijk, mede
omdat het zorgsysteem voor asielzoekers in Nederland per 1 januari 2009 is veranderd
(tabel A.3).
Tabel A.3 Overzicht van de gezondheidszorg voor asielzoekers in Nederland

Nederland heeft de voorzieningen voor asielzoekers, inclusief gezondheidszorg, vastgelegd in de Regeling
Verstrekking Asielzoekers (RVA ).
Het Centraal Orgaan Opvang Asielzoekers (COA) is verantwoordelijk voor het inkopen van de zorg en
heeft daarvoor overeenkomsten afgesloten met een zorgverzekeraar en GGD Nederland (www.coa.nl).
Uitgangspunt daarbij is dat de zorg aan asielzoekers maximaal aansluit op de reguliere zorg in Nederland.
Het Gezondheidscentrum Asielzoekers (GC A) draagt sinds 1 januari 2009 zorg voor de toegang
van asielzoekers tot de curatieve zorg (www.gcasielzoekers.nl). GGDen voeren de publiekegezondheidszorgtaken uit, inclusief de integrale jeugdgezondheidszorg, onder de naam Publieke
Gezondheidsheidszorg Asielzoekers.
Voor de verloskundige zorg heeft GC A verloskundige praktijken in de nabijheid van de asielzoekerscentra
gecontracteerd. De tweedelijnszorg rondom zwangerschap en bevalling wordt ingekocht bij ziekenhuizen.
Asielzoeksters bevallen in principe in het ziekenhuis. Zij hoeven daarvoor
geen eigen bijdrage te betalen; die wordt vergoed in het kader van de ziektekostenregeling voor asielzoekers
(www.rzasielzoekers.nl/web/ RegelingZorgAsielzoekers/Vergoedingen.htm).
De Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV), het GC A en het COA hebben onlangs
nieuwe afspraken gemaakt met betrekking tot de verloskundige zorg voor asielzoeksters.20 Vanwege de
specifieke omstandigheden van zwangere asielzoeksters, voeren verloskundigen een aantal logistieke taken
uit in aanvulling op de standaard verloskundige taken.
Het kwantitatieve bewijs voor een verhoogd risico op ongunstige zwangerschapsuitkomsten is weliswaar beperkt van omvang, maar de uitkomsten sluiten aan bij
wat verwacht mag worden op basis van inzicht in risicofactoren bij vrouwen uit de
herkomstlanden en -regios van asielzoeksters. Dat kan worden afgeleid uit studies
die niet werden meegenomen in de resultaten van dit literatuuronderzoek omdat ze
geen onderscheid maakten naar verblijfsstatus.5,7,21-25 Het betreft risicofactoren aan de
zijde van de vrouwen, zoals slechte algemene gezondheid, ondervoeding, vrouwelijke
genitale verminking, psychische problemen,6,25 gebrekkige kennis over gezondheid en
de gezondheidszorg,6 beperkte sociale netwerken,6 laat contact opnemen met zorgverleners,14 en weigeren van spoedkeizersnede.14 Maar het betreft ook zorgfactoren zoals
het niet gebruiken van tolken,14 het niet gesignaleerd hebben van aanwezige gezondheidsproblemen en risicofactoren,7 en discontinuteit in de zorg bij overplaatsingen.6,7
De behoeften van zwangere asielzoeksters kunnen worden ingedeeld naar a) informatie
over zwangerschap en gezondheidszorg in het opvangland; b) zorgverleners die aandacht hebben voor hun (psychische) problemen en c) moedergroepen voor sociale con-
tacten en informatie uitwisseling. Ook komt in alle studies naar voren dat zorgverleners
over culturele competenties moeten beschikken. De aanbevolen competenties passen
in grote lijnen binnen het raamwerk culturele competenties (tabel A.4).26
Tabel A.4 Raamwerk culturele competenties voor zorgverleners26
kennis van epidemiologie en de effecten van behandeling in verschillende etnische groepen

bewustzijn van hoe cultuur individueel gedrag en denken bepaalt
bewustzijn van de sociale context waar de vrouwen in leven
bewustzijn van de eigen vooroordelen en de neiging om in stereotypen te denken
vaardigheid om informatie over te dragen op een voor de patint te begrijpen
wijze en wanneer nodig externen in te schakelen, bijvoorbeeld een tolk
vaardigheid om zich als professional aan te passen aan nieuwe omstandigheden
Specifiek voor de zorg voor zwangere asielzoeksters is dat zorgverleners moeten beschikken over kennis van de situatie in de herkomstlanden en tijdens de vlucht, van de
asielprocedure en van de voorzieningen in de opvang. Deze specifieke aspecten komen
overeen met een bredere beschrijving van culturele competenties die noodzakelijk zijn
in de zorg voor asielzoekers; die beschrijving is gebaseerd op onderzoek onder praktijkverpleegkundigen van de MOA.27
De vergaande aanbeveling van de Britse CEMACH om alle zwangere asielzoeksters een
uitgebreid onderzoek naar risicofactoren aan te bieden, namen we niet over omdat de
onderbouwing hiervan voor de Nederlandse situatie ontbreekt. In plaats daarvan werd
het advies overgenomen van de Commissie Maternale Sterfte van de Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG), dat ook tot doel heeft de signalering
van risicofactoren te verbeteren.28
COnCluSIE
Er is specifieke aandacht nodig voor het verbeteren van de zorg voor zwangere asielzoeksters, omdat ze een verhoogd risico hebben op ongunstige zwangerschapsuitkomsten
en specifieke zorgbehoeften hebben. Wij vonden concrete aanbevelingen voor zorgverleners om beter te kunnen voorzien in de zorgbehoeften van zwangere asielzoeksters.
Centraal daarin staat dat zorgverleners over culturele competenties moeten beschikken
om zwangere asielzoeksters de juiste vragen te stellen, de antwoorden te interpreteren
en de benodigde informatie te verschaffen om zwangere asielzoeksters adequaat te
ondersteunen bij zwangerschap en bevalling. Andere aanbevelingen voor zorgverleners betreffen het verstrekken van informatie over zwangerschap en het Nederlandse
zorgsysteem, het identificeren van risicofactoren en continuteit van zorg.
231
232
Appendix 1
Ook beleidsmakers en beroepsorganisaties in de zorgen opvangketen kunnen bijdragen door voorwaarden te scheppen voor goede zorg. Dit kan bijvoorbeeld door het
bevorderen van culturele competenties bij zorgverleners, bereikbaarheid en continuiteit van zorg, ketenafspraken, beschikbaarheid van professionele tolken en gericht
wetenschappelijk onderzoek, door overplaatsingen te beperken en mogelijkheden te
creren voor zwangerschapsgroepen voor asielzoeksters.
Zowel de praktijk als het beleid kunnen bijdragen aan het beperken van de risicofactoren voor zwangere asielzoeksters, zodat ook zij een zo groot mogelijke kans hebben op
een gezonde zwangerschap en bevalling.
DAnkwOORD
Het Centraal Orgaan Opvang Asielzoekers stelde de bezettingsgegevens van de centrale
opvang beschikbaar; Joost J. Zwart stelde de resultaten van de LEMMoN-studie beschikbaar. Marianne P Amelink-Verburg, Franka Cade, Ank de Jonge, Hennie Nijsingh, Relinde van der Stouwe, Kirsten Slinger, Karien Stronks, Quita Waldhober, Hajo IJ. Wildschut
en Joost O.M. Zaat droegen bij aan dit artikel.
literatuur
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
Van Oostrum IE, Goosen S, Uitenbroek D, Koppenaal H, Stronks K. Mortality and causes of death
among asylum seekers in the Netherlands. J Epidemiol Community Health. 2011;65:376-383.
United Nations Population Fund. State of the world population 2006; a passage to hope, women
and international migration. New York: UNFPA, 2006.
Stuurgroep zwangerschap en geboorte. Een goed begin; Veilige zorg rond zwangerschap en
geboorte. Den Haag: Stuurgroep zwangerschap en geboorte; 2009.
Koppenaal H, Bos CA, Broer J. Hoge sterfte door infectieziekten en niet natuurlijke doodsoorzaak
onder asielzoekers in 1998-1999. Ned Tijdschr Geneeskd. 2003;147:391-5.
Zwart JJ, Richters JM, ry F, de Vries JIP, Bloemenkamp KWM, van Roosmalen J. Ernstige maternale
morbiditeit tijdens, zwangerschap, bevalling en kraambed in Nederland. Ned Tijdschr Geneeskd.
2009;153:B113.
Zwart JJ, Jonkers MD, Richters A, et al. Ethnic disparity in severe acute maternal morbidity: a
nationwide cohort study in the Netherlands. Eur J Public Health. 2011; 21 (2): 229-234.
Lewis G (ed). The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers
lives: reviewing maternal deaths to make motherhood safer, 2003-2005. The Seventh Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007.
Ascoly N, van Halsema I, Keysers L. Refugee women, pregnancy, and reproductive health care in
the Netherlands. J Refug Stud. 2001;14:371-93.
Medische Opvang Asielzoekers. Methodiek voor het ontwikkelen van ketenrichtlijnen gezondheidszorg asielzoekers. Utrecht: GGD Nederland; 2006.
Timmer-van Noordenburg CJ, Tiesinga LJ, De Groot F, Jansen GJ. Gezondheidsgerelateerde
problemen bij hiv-genfecteerde zwangere asielzoekers. Tijdschr Gezondheidswetenschappen.
2008;86:102-7.
United Nations High Commissioner for refugees. Sexual and gender based violence against
refugees, returnees and internally displaced persons; guidelines for prevention and response.
Geneva: UNHCR, 2003.
Tankink M. Vluchtelingenvrouwen met ervaringen van seksueel geweld; Zwijgen als gezondheidsstrategie. Bijblijven. 2009;25:44-50.
Korfker D, Rijnders M, Detmar S. Retrospectief onderzoek naar de prevalentie van Vrouwenbesnijdenis of VGV (Vrouwelijke Genitale Verminking) in de verloskundigenpraktijk in 2008. Leiden:
TNO; 2009.
Essn B, Johnsdotter S, Hovelius B, et al. Qualitative study of pregnancy and childbirth experiences in Somalian women resident in Sweden. BJOG.2000;107:1507-12.
Gaudion A, Allotey P. Maternity care for asylum seekers and refugees in Hillingdon: A needs assessment. Uxbridge: Centre for Public Health Research, Brunel University; 2008.
Kennedy P, Murphy-Lawless J. The maternity care needs of refugee and asylum seeking women in
Ireland. Fem Rev. 2003;73:39-53.
Briscoe L, Lavender T. Exploring maternity care for asylum seekers and refugees. British Journal
Midwifery. 2009;17:17-23.
Nabb J. Pregnant asylum-seekers: perceptions of maternity service provision. Royal College of
Midwives-Evidence-Based Midwifery. december 2006.
De Jong K. Taalproblemen? Bel TVcN. Tijdschr Verloskundigen. 2010;35:43-4.
Cade F, van der Stouwe R. Zorg voor zwangere asielzoeksters; Nieuwe afspraken. Tijdschr Verloskundigen. 2010;35:8-10.
233
234
Appendix 1
(21)
(22)
(23)
(24)
(25)
(26)
(27)
(28)
Gagnon AJ, Zimbeck M, Zeitlin J. ROAM Collaboration. Migration to western industrialised countries and perinatal health: A systematic review. Soc Sci Med. 2009;69:934-946.
Gissler M, Alexander S, Mac-Farlane A, et al. Stillbirths and infant deaths among migrants in
industrialized countries. Acta Obstet Gynecol Scand. 2009;88:134-48.
Small R, Gagnon A, Gissler M, et al. Somali women and their pregnancy outcomes post-migration:
data from six receiving countries. BJOG. 2008;115:1630-40.
Carolan M. Pregnancy health status of sub-Saharan refugee women who have resettled in developed countries: a review of the literature. Midwifery. 2010;26:407-4.
Essn B, Bodker B, Sjoberg NO, et al. Are some perinatal deaths in immigrant groups linked to
suboptimal perinatal care services? BJOG. 2002;109:677-82.
Suurmond J, Seeleman C, Rupp I, Goosen S, Stronks K. Cultural competence among nurse practitioners working with asylum seekers. Nurse Educ Today. 2010;30:821-26. .
Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for teaching
and learning. Med Educ. 2009;43:229-37.
Schutte JM, Steegers EAP, Schuitemaker NWE, et al. The Netherlands Maternal Mortality Committee. Rise in maternal mortality in the Netherlands. BJOG. 2010;117:399-406.
aPPENdix 2
About tHe AutHor
pHd portfolIo
dAnkwoord (AcknowledGeMents)
About the author
ABOuT THE AuTHOR

Simone Goosen was born in 1967 in Bergen op Zoom, the Netherlands. After completing her secondary education at the Roncalli College there, she studied health sciences
at the Radboud University Nijmegen. In 2002, she graduated and received her MSc in
Epidemiology.
After completing her MSc, Simone briefly worked at the Radboud University. In 2003,
she joined the department of infectious disease epidemiology at the National Institute
of Public Health (RIVM). She worked for nearly three years on the epidemiology of gastroenteritis. In January 1996, she joined the World Health Organization (WHO) in Africa.
She first worked for the WHO office in Mauritius as an advisor to the Ministry of Health
on health information systems, from 1996 to 1998. Subsequently, she worked at WHOs
Regional Office for Africa in Harare, Zimbabwe, until 2000. She worked amongst others
on a self-assessment tool for district health teams, the use of participatory approaches
in health promotion, the establishment of databases for regional programs, and training
courses in health systems research. Her work brought her to a range of countries across
Africa.
Back from Africa, Simone joined the Netherlands Association of Community Health
Services (then called GGD Nederland, now called GGD GHOR Nederland). As of 2001,
she has been responsible for the national level health research tasks of the Community
Health Services for Asylum Seekers (MOA between 2000 and 2008 and PGA from 2009
onwards). The health research task of MOA and PGA entails the conversion of healthrelated questions from policy-makers and professionals to researchers as well as the
translation of research results into information for policy-makers and professionals. Furthermore, it involves the monitoring of mortality, causes of death and suicidal behaviour
among asylum seekers in the Netherlands. Simone was amongst others involved in the
participation project A Healthy Asylum Seeker Centre (funded by ZonMw), the evaluation of ASERAG (a participatory method for hiv prevention among asylum seekers), and
the studies Gevlucht-Gezond? I and II.
To bring her epidemiological studies on the health of asylum seekers to an academic
level, Simone sought the collaboration of the Department of Public Health at the Academic Medical Centre (AMC) of the University of Amsterdam. This collaboration has been
the basis for this PhD thesis, on which she started working in 2008, while she continued
working for GGD Nederland.
Simone is married to Johan Verburg. They have two sons: Tibo (2000) and Juma (2002).
239
PhD Portfolio
PHD PORTFOlIO
PhD student:
Simone Goosen
PhD period:
January 2008 June 2014
PhD supervisors: Prof. dr. K. Stronks and dr. A.E. Kunst
1. PhD training
(International) conferences and presentations
Year
Workload*
Lodz, Poland
Suicide and suicidal behaviour among asylum seekers in the Netherlands
2009
0.5
Amsterdam, The Netherlands

Pregnancy outcomes and needs among asylum seekers (poster presentation)
2010
0.5
Malta
Physical child abuse among asylum seekers (oral presentation)
2012
0.5
2008
0.5
2010
0.5
2014
0.5
2008
0.5
2011
0.8
2012
0.5
Conferences of the European Public Health Association
Conferences on migrant and ethnic minority health in Europe

Malm, Sweden
Induced abortion and teenage pregnancies among asylum seekers
Pecs, Hungary
Evaluation of a participatory method of STI/HIV prevention among asylum
seekers
Granada, Spain
Diabetes among asylum seekers in the Netherlands (oral presentation)
Conference of the International Society on Suicide and Suicidal Behaviour
Glasgow, Scotland
Suicide and suicidal behaviour among asylum seekers
World Congress of Epidemiology
Edinburgh, Scotland
Physical child abuse among asylum seekers (poster presentation)
Association between PTSD and depression (poster presentation)
EU COST meeting on migrant health
Utrecht, The Netherlands
Suicide and suicidal behaviour among asylum seekers (oral presentation)
Nederlands Congres Volksgezondheid
Amsterdam, The Netherlands
Sexual and reproductive health of asylum seekers and refugees (workshop)
2011
0.5
Nationale Diabetes Dag

The Hague, The Netherlands
Diabetes among asylum seekers and refugees
*ECTS=European Credit Transfer and Accumulation System; 1 ECTS = 28 hours
2014
0.5
241
242
Appendix 2
2. Teaching
Supervising
Evelien van Meel (Erasmus University), Haemoglobinopathy among asylum
seekers
2012
2.0
3. Other
Member of the editorial board of Cultuur, Migratie en Gezondheid
Board Member of the Avicenna Foundation
2011
2013 - present
Dankwoord
DAnkwOORD (ACknOwlEDGEMEnTS)
Sinds ik begon aan dit promotietraject, ben ik nog scherper gaan zien hoe belangrijk
het is asielzoekers en vluchtelingen te ondersteunen om hun kansen op een gezonde
toekomst te vergroten. Ik hoop met dit proefschrift een verdiepingsslag te hebben
gegeven aan het inzicht in verschillende themas die hierbij aandacht verdienen. Veel
mensen leverden een bijdrage aan dit proces. Enkele mensen wil ik bijzonder bedanken.
Allereerst Karien Stronks en Anton Kunst, mijn promotor en co-promotor. De interesse,
het enthousiasme en de deskundigheid waarmee jullie me ondersteund hebben, waardeer ik enorm. Karien, je zei direct ja op mijn vraag of ik mijn werk bij GGD Nederland
zou kunnen verbreden tot een promotietraject. Je nodigde me uit om een dag in de
week naar het AMC te komen om tussen onderzoekers te zijn. Het was heel stimulerend
om zo deel van je team te zijn. Dank dat ik heb mogen profiteren van je grote kennis en
ervaring van de epidemiologie en de publieke gezondheidszorg. Met je scherpe vragen
en je positieve, overstijgende blik, was het een plezier om met je samen te werken.
Anton, met jouw grote kennis van onderzoeksmethoden en statistiek hielp je me om
tot gedegen analyses te komen. Bij het maken van het model voor de longitudinale
analyses had ik regelmatig het gevoel aan een enorme sudoku te werken. Als ik vastliep
in het puzzelen, hielp jij me weer doelgericht naar de oplossing. Verder was je altijd
bereid om bij te dragen aan het scherp formuleren van onze artikelen. Ook voor jou veel
dank voor je kritische blik, je opbouwende vragen en je suggesties. Zo vind je voorop
mijn proefschrift de halsbandparkieten terug die ook als migranten naar Nederland zijn
gekomen.
Beste mede-auteurs Ad, Barend, Charles, Christian, Ciel, Daan, Gbenga, Hetty, Irene, Kenneth, Marie-Louise, Quita, Rian en Sonja, bedankt voor jullie waardevolle inhoudelijke
bijdragen aan de onderzoeken. Het was fantastisch enthousiaste experts aan boord te
hebben bij het werken aan de zware onderwerpen in dit proefschrift enthousiaste.
Beste leden van de promotiecommissie, prof. dr. M.W. Borgdorff, prof. dr. W.L.J.M. Devill,
prof. dr. M.C.H. Donker, dr. M.E.T.C. van den Muijsenbergh en prof. dr. ir. G.A. Zielhuis,
hartelijk dank voor het beoordelen van mijn proefschrift.
Chris, bij het begin van dit promotietraject was je een enorme motivatiebron voor me,
die dit promotietraject vanuit GGD Nederland mogelijk maakte. Hennie, je steunde me
met je overtuiging van het belang van wetenschappelijke onderbouwing en droeg
vanuit je kennis van beleidskaders, politiek en zorgpraktijk bij aan alle artikelen. Kirsten,
243
244
Appendix 2
je deelde je praktijkervaring om de artikelen over asielzoekerkinderen scherp te krijgen.

Jan en Christiaan, jullie dachten vanuit het COA mee over de beleidsimplicaties. Dank
jullie wel.
Dank ook aan alle MOA- en PGA-medewerkers die bijdroegen aan de gegevens waarop
de onderzoeken zijn gebaseerd. Jullie dachten mee over onderzoeksvragen, resultaten
en conclusies, vanuit de betekenis die ze kunnen hebben voor de praktijk en het beleid.
Zo ontstond een levendige wisselwerking tussen onderzoek en praktijk. Ik bedank ook
alle andere collegas en vrienden die me steunden in deze uitdaging maar die ik hier niet
allemaal met naam noem.
Beste Inge en Quita, het geeft me vertrouwen dat jullie mijn paranimfen wilden zijn en
naast me zullen staan bij de verdediging. Dank voor al jullie steun. Inge, ik geniet ervan
om op zondagavond even lekker mn hoofd leeg te maken tijdens het squashen en
daarna de week te overdenken. Quita, bedankt voor het mee organiseren van het minisymposium, voor je hulp bij de planning en je mentale steun op belangrijke momenten.
Marcela, dank je wel voor onze vriendschap, jouw eigen verhaal en dat van je familie
in Bosni en Kroati en je vaardigheid om ideen om te zetten in mooie beelden. Zo
maakte je het kunstwerk voor mijn proefschrift. En Angelique, bedankt dat je met je
grafische kwaliteiten de omslag nog mooier hebt gemaakt. Ik ben heel blij met het resultaat.
Lieve papa en mama, Kai en Femke, veel dank voor jullie steun en liefde. Jullie gaven me
de basis om dit werk te kunnen doen en het vermogen om als het pittig is toch altijd
weer kansen en mooie dingen te zien.
Lieve Tibo en Juma, vooral de afgelopen maanden zat ik vaak, t vaak, met mijn hoofd in
het werk. Gelukkig trokken jullie me er regelmatig even uit zodat ik met en van jullie kon
genieten. Samen lachen, mooie bouw- en tekenwerken bewonderen, spelletjes doen en
denken over moeilijke vragen, skaten, basketballen, koken en lekker eten; het is altijd
weer een feest met jullie.
Lieve Johan, dank voor al je steun bij deze uitdaging. Gelukkig zijn we er nu bijna. Hoogste tijd om samen weer eens lekker een paar echte bergen op te fietsen.

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A safe and healthy future?

Epidemiological studies on the health of asylum

A safe and healthy future?

A safe and healthy future?

2014 ESM Goosen, Utrecht, The Netherlands

A safe and healthy future?

ter verkrijging van de graad van doctor

Prof. dr. K. Stronks

Prof. dr. M.W. Borgdorff

Faculteit der Geneeskunde

The health status of asylum seekers and refugees

Aims of this thesis

Diseases and conditions

Mortality and causes of death among asylum seekers in the

Suicide death and hospital-treated suicidal behaviour in

High diabetes risk among asylum seekers in the Netherlands

Induced abortions and teenage births among asylum

HIV prevalence among pregnant asylum seekers in the

Risk factors for the health of asylum seekers

Frequent relocations between asylum-seeker centres are

Increased risk of physical child abuse in asylum-seeking

Relationship between post-traumatic stress disorder and

Reflections and recommendations

Reflections and recommendations with respect to research

Box 1.1.1 Definition of asylum seeker and refugee5

Number of persons (1st and 2nd generation)

Health care for asylum seekers and refugees

1.2 THE HEAlTH STATuS OF ASyluM SEEkERS AnD REFuGEES

Diseases and conditions

Sexual and reproductive health

The need for more information

1.3 AIMS OF THIS THESIS

1.4 DATA SOuRCES

Table 1.1.1 Overview of the studies in this thesis

Chapter 2. Diseases and conditions

Mortality and causes of

Suicide death and hospital- Notifications 179,942 person

High diabetes risk among

Induced abortions and

Notifications 9,218 women,

Chapter 3. Risk factors for the health of asylum seekers

Increased risk of physical

- Physical child - Maternal violence

* Database of the Community Health Services for Asylum Seekers (MOA).

Bronstein I, Montgomery P. Psychological distress in refugee children: a systematic review. Clin

This study has been published as:

Mortality and causes of death

Referral of asylum seekers to mainstream healthcare professionals and institutions and

Mortality and causes of death

Box 2.1.2. Regions of origin of asylum seekers in the Netherlands

Major contributing countries of origin

West, central and southern Africa

Democratic Republic of Congo, Angola

North, east and Horn of Africa

Central, eastern and southern Europe

Azerbaijan, former Yugoslavia

Middle East and southwest Asia

Central, east and southern Asia

China, Sri Lanka

Stateless persons, South and Middle

Percentage of all asylum seekers

Percentage of total deaths

Cause-specific mortality: main primary cause-of-death categories