Practice guidelines on migrants’ health: assessment of their quality and reporting

We did not restrict our eligibility to any specific language. When we identified two or more versions of the same guideline, we used the most recent one but kept record of all versions.

We electronically searched Medline and Embase for the period of 2006–2016. We also searched both the National Guideline Clearinghouse and the Canadian Medical Association’s Clinical Practice Guidelines Database (CPGs) in November 2016.

Additional file 1 shows the full search strategies of the different databases searched. The strategies used both text words such as migrant* or emigrant* or immigrant* or refugee*, and MeSH terms such as exp. practice guidelines/, exp. migrant/, exp. refugee/;and combined terms for guidelines with terms for migrants.

Two teams of two reviewers screened the titles and summaries of the guidelines (when available) in duplicate and independently. Then we retrieved the full texts of the guidelines assessed as potentially eligible by at least one of the two reviewers. The two teams of two reviewers screened in duplicate and independently the full texts and compared their results. They resolved disagreements through discussion, and when needed with the help of a third reviewer. We used a standardized and pilot tested full text screening form and conducted calibration exercises at the beginning of the process.

The two teams of two reviewers abstracted data from the included guidelines, in duplicate and independently. They compared their results and resolved any disagreement through discussion and when needed with the help of a third reviewer. We used a standardized and pilot tested data abstraction form and conducted calibration exercises.

We abstracted data on the following characteristics of the guidelines:

The two teams of two reviewers assessed the quality of the included guidelines using a duplicate and independent approach. They resolved their disagreements through discussion and input of a third reviewer as needed. They used the Appraisal of Guidelines for REsearch and Evaluation (AGREE) - II instrument [6]. This instrument consists of seven domains addressing different aspects of the guideline, including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence, and overall assessment [11]. In addition, we assessed the quality of reporting using the Reporting Items for practice Guidelines in HealThcare (RIGHT) checklist [4]. The checklist includes seven sections relating to basic information, background, evidence, recommendations, review and quality assurance, funding and conflict of interests as well as other information [4].

We conducted descriptive analysis for each of the variables we abstracted data for.

Table 2 shows the detailed characteristics of the 23 included individual guidelines.

All of the included guidelines addressed the migrants in the outpatient settings, three addressed them at the host country and one at the pre departure settings. Eleven guidelines addressed strictly NCDs, ten addressed CDs and two targeted both NCDs and CDs. Almost all guidelines (95%) addressed screening, half (52%) addressed prevention, and half (52%) addressed treatment. The population described in the guidelines was “migrants” in 67% of the guidelines; “migrants, drug users and inmates” in 5%; “migrants, children and non-pregnant women of reproductive age” in 5%; “migrants and women” in 14%; “pregnant women” in 5%; and “adult migrants” in 5%. 86% of the guidelines reported using GRADE methodology to assess quality of evidence. All but three guidelines reported their funding sources [13]. The developers of these guidelines were: Canadian Collaboration for Immigrant and Refugee Health (CCIRH) (n = 18); joint effort between the Italian Association for the Study of the Liver (AIST), Italian Society of Infectious and tropic Diseases (SIMIT), Italian Federation Department’s Operators and Addiction Services (FederSerD), Italian Prison Medicine and Healthcare Society (SIMSPe) (n = 1); European Psychiatric Association (n = 1); Korean Society of Infectious Diseases (n = 1); the Australiasian Society for Infectious Diseases and Refugee Health Network of Australia (n = 1); the Coordinating resources to assess and improve Health status of Migrants from Latin America (COHEMI) (n = 1). The production of guidelines related to migrants has decreased from 19 guidelines in 2011 to two guidelines in 2017, with one guideline in 2014 and one in 2015.

Table 3 shows the summary score by AGREE II domains across the 23 included guidelines. Of all AGREE II domains, ‘applicability’ had the lowest median score while ‘editorial independence’ had the highest median score across the included guidelines. Most guidelines reported on conflicts of interest, and reported the role of funding bodies. Moreover, we present the scores for each of the 23 included guidelines by the AGREE II domains in Table 2 and Fig. 2. The specific reason for the low score for the rigor of development is the failure of guidelines to describe the methods used to develop the recommendations and the procedures for updates. The specific reason for the low score for applicability is the failure of guidelines to provide advice on how to apply the recommendations or monitoring criteria.

Table 3: Summary of the AGREE II results per domain across the included guidelines (N = 23).

Figure 3 shows the findings for all individual item of the RIGHT checklist (Appendices 2 and 3) for each of the 23 included guidelines. The mean number of items met was 27, with a minimum of 16 and a maximum of 29. The basic information (items 1–4) was properly presented in the guidelines. For the background section (items 5–9), a large majority (86.9%) of articles failed to provide proper information regarding the selection and roles of contributors (item 9a). Twelve guidelines (52%) provided separate recommendations for important subgroups (item 7b). A majority of guidelines failed to report the intended primary users of the guidelines (65%) (item 8a), or the setting for which the guideline was created (56.5%) (item 8b). The majority of included guidelines completed the items regarding the Evidence (items 10–12) overall. Most of the guidelines were based on systematic reviews (95.6%) (item 11a). As for the Recommendations (items 13–15), we judged that all of the 23 included guidelines provided clear, precise and actionable recommendations (item 13a). A minority of the included guidelines (26%) reported considering the values and preferences of the target populations (item 14a) or the costs and resource implications (item 14b) (30%) in the formulation of recommendations. Only four guidelines (17%) described the processes and approaches used by the guideline development group to make decisions (item 15). Three guidelines (13%) mentioned whether the draft guideline underwent independent review (item 16). The guidelines consistently declared funding information as well as conflicts of interests, with a section average completion of 81% (items 20–22).

We identified 24 documents reporting on 23 published practice guidelines addressing migrants’ health. All the guidelines were published by professional societies, between 2011 and 2017 with the majority in 2011.

The majority of the 23 guidelines (57%) addressed NCDs. Almost all included guidelines addressed screening (95%), while half tackled prevention (vaccination) (52%) or treatment (52%). Of the 23 guidelines, all mentioned the setting to be primary care (outpatient), except one that did not report the setting. 87% of the included guidelines used the GRADE methodology.

Guidelines scored high on all the quality domains of the AGREE II instrument except for two: rigor of development and applicability. The guidelines adequately met the majority of items recommended by the RIGHT checklist (74% completed at least 26/35 items).

In alignment with our findings, the World Health Organization (WHO) reported that migrants (and refugees) have similar health problems to others [14]. The most common of these problems include cardiovascular events, diabetes, hypertension, hypothermia, accidental injuries, burns, gastrointestinal illnesses and complications of pregnancy and/or delivery. WHO states that the migrants are at increased risk for NCDs due to their exposure to the “risks associated with population movements” such as drug abuse, nutrition disorders, exposure to violence, psychosocial disorders and others [14]. Moreover, the WHO states that migrants who have NCDs can be more vulnerable because of the conditions during their movements [14]..

Our findings also suggest that only half of the guidelines addressed treatment. Migrants who have lost their homes and underwent interruption of their treatment of chronic diseases will require treatment of any disease they were being treated for or have been recently diagnosed with. Guidelines can protect migrants to have their right for health ensured at hosting countries.

While one might argue that the host countries are interested in their own protection from diseases rather than caring for the health of migrants, however, one could argue that one could not expect guidelines on treatment to vary with the different populations (host and refugees). The vast majority of the captured guidelines targeted screening because the population of interest is migrants, meaning that the intention of the guidelines is to deal with additional factors than usual ones, such as prevalence of disease in country of origin, endemic diseases and others.

To our knowledge, this is the first study aiming to identify and assess the quality of all published practice guidelines addressing migrants’ health. This will serve researchers, healthcare practitioners, policy-makers and other stakeholders involved in caring for migrants. Moreover, we have assessed the quality of these guidelines and the quality of their reporting using standardized and validated tools. One limitation is that we did not search the grey literature (e.g., the websites of the ministries of health of migrant-hosting countries). Another is that we did not address the effectiveness of pre-screening requirements because a series of systematic reviews for different diseases was lead by the European Center for Disease Control and addressed screening measures pre and post arrival [15].

Refugees are considered a vulnerable population that some guidelines addressed in their recommendations, and few guidelines were developed specifically to target this population. With the increasing number of refugees and migrants worldwide, it is important to develop guidelines or adopt developed guidelines to the different contexts in order to enhance care.

Migration can directly increase the cost of appropriate management [16]. This public health burden emphasizes the necessity of developing and implementing practice guidelines that enhance the care provided to the migrants [17], or reduces the unequal quality of care for migrants compared to nationals of the hosting countries [18]. Ultimately, these guidelines will contribute to the development and enhancement of public health [19‐21]. As for protection against communicable diseases, it is important for countries to have a pre-departure health assessment for potential migrants [22]. This assessment will help ensure the public health and safety of the recipient nation. In addition, it will reduce the potential burden on publicly funded health and social services [22]. Factors such as poor access to proper healthcare, low educational level, unsanitary living conditions, as well as inadequate nutrition and food hygiene interact to produce a vulnerability to infection in the migrant setting. This presents as a combination of challenges to every host country’s public health infrastructure [23]. Guidelines and public policies targeting the post-migration experiences of refugees and immigrants can minimize the negative effects of resettlement [23].

First, there is a need to conduct priority setting research to identify the guidelines topics that meet the needs and expectations of both migrants and actors of the healthcare system in host countries. Second, it is important to mention that while the numbers of refugees globally are increasing, the data reported by international organizations is not always available for researchers and decision makers to use. Having local data available allows development of targeted guidelines or adaptation in order to fit the context.

Third, given that the guidelines scored low on the domain of applicability, there is a need for more research to improve the items under this domain, e.g. supporting the guideline with tools for application.

There is a need for research on the uptake and implementation of these guidelines after their publication.