Title: EUropean Refugees-HUman Movement and Advisory Network

The international refugee crisis has reached a critical point and many European countries are developing policy and plan to better define their role in supporting refugees entering Europe. The aim of this proposal is to enhance the capacity of European member states who accept migrants and refugees in addressing their health needs, safeguard them from risks, and minimize cross-border health risks. This initiative will focus on addressing both the early arrival period and longer-term settlement of refugees in European host countries. The existing European and international experience will be systematically reviewed to identify effective interventions to vulnerable groups and tools for the initial health care needs assessment of the arriving refugees including mental, psychosocial and physical health. Established approaches including Participatory and Learning Action and Normalization Process Theory will be used to gain new understanding regarding the needs and opinions of both refugees and stakeholders in regards to the measures needed for health care assessment, and preventive activities including vaccinations, general health hygiene measures, chronic disease management, and psychosocial support. The content of the services that an early or late hosting multi-disciplinary center could offer in the countries that they will accept refugees will be discussed and defined by an international expert panel. Clinical protocols, guidelines together with health education and promotion material and as well as a training programme will be developed for staff serving the refugees and migrants health care centre and tailored protocols and pilot testing in six implementation settings in Greece, Italy, Croatia, Hungary, Austria and Slovenia with contribution from experts and stakeholders from Turkey, Cyprus, Ireland and Belgium. Finally, all these efforts will be evaluated and a final report for implementation in Europe.

Over the past few years, the international refugee crisis reached a critical point. Many European countries are developing policy to better define their role in supporting refugees en¬tering Europe, and to help address the multiple capacity issues to better address the needs of these vulnerable populations. The EUR-HUMAN Project Proposal was submitted in response to a Call launched under the 3rd Health Programme (Specific Call HP-HA-2015; Project Proposal number 717319). The receiving countries have to prioritise support regarding the health needs of these populations. The level of care to define and address the needs of these populations naturally falls under the primary care level. Additionally, there is ample evidence that strong primary health care (PHC) and the timely provision thereof results in better health outcomes and lower overall costs and burden for the healthcare system. Therefore, the decision was made to select PHC services as the core element to improve capacity in terms of healthcare service delivery to refugees reaching Europe. There are multiple reasons why programs are needed to assess feasibility and acceptability of proposed actions prior to large-scale implementation of such actions. Namely, the unprecedented influx of refugees has created conditions that necessitate optimal resource allocation, high degree of feasibility and acceptability, as well as flexible design, for the successful implementation and high transferability of proposed actions. This is particularly true for first-port-of-entry countries, where austerity had already depleted resources, but, also for transit or longer-term-of-stay countries facing similar challenges and/or additional issues emerging during integration stages. The EUR-HUMAN project “EUropean Refugees - HUman Movement and Advisory Network” (Specific Call HP-HA-2015; Project Proposal number 717319), is an integrated project under the “3rd Health Programme”for the action of the European Union in the field of health for the period 2014-2020. The duration of the project was 12 months. The overall objective of the EUR-HUMAN project was to enhance the capacity, knowledge and expertise of European Member-States (MSs) which accept refugees and migrants in addressing their health needs and safeguarding them from risks, while at the same time attempting to minimize cross-border health risks. A primary objective of this project was to identify, design and assess interventions to improve PHC delivery for refugees and mi-grants, the focus of such interventions being vulnerable groups. The target audience of the current project encompasses all healthcare professionals who provide PHC services to refugees and migrants across different settings. The EUR-HUMAN project has focused particularly on strengthening PHC as first-point-of-entry countries for refugees and migrants. In the context of its primary objective, EUR-HUMAN aimed to provide the tools for the provision of good and affordable comprehensive person-centred and integrated care for all ages and all ailments, taking into account the trans-cultural settings and the needs, wishes and expectations of the newly arrived individuals.

The EUR-HUMAN project comprised of seven Work Packages (WPs) (Figure 1). WP1 focused on the overall management and coordination of the project. The WP1 leader, for all activities under WP1, was the team at the University of Crete (UoC).

Figure 1: Graphical representation of the WPs of the EUR-HUMAN project

Overview of the project at a glance
1. Establish relevant theoretical inputs from the current research evidence base to underpin the selection of interventions to be combined. Given the relevance of the topic, elements were also extracted from the Chronic Care Model (Ackerman, 1997; DeRiemer, 1998; Walker and Jaranson, 1999)
2. Select and implement actions focusing on person-centred methodological approaches for needs assessment, as for example Participatory and Learning Action (PLA) (O’Reily et al, 2010)  WP2
3. Systematically review the existing literature. Supplement output of systematic review of the body of evidence with online survey of and interviews with experts and professionals.  WP3
4. Establish an Expert Consensus Panel and convene sessions to reach consensus agreement regarding best practices, guidelines, tools and services. WP4
5. Development of a model and protocol for rapid assess¬ment of mental health and psychosocial needs of refugees and psychosocial. WP5
6. Assess the status of local resources and capacities available regarding PHC for refugees and other migrants.  WP 6
7. Draft evidence-based training material in a modular form appropriate for use by PHC practitioners in seven European languages (English, Greek, German, Italian, Slovenian, Hungarian and Croatian) as well as in Arabic  WP6
8. Deploy educational interventions across settings in six European countries (Greece, Austria, Italy, Hungary, Slovenia and Croatia)  WP6
9. Evaluate interventions utilising an evidence-based, validated approach; tools encompassing a range, including the normalization process theory NoMad (Finch et al, 2013).  WP7
10. Implement a pilot, encompassing interventions deemed most appropriate and lessons learned from interventions across settings, in Greece


- Coordination with other projects or activities at European, National and International level

The EUR-HUMAN project collaborated closely with the other EU funded projects and especially with SH-CAPAC (participation on two separate project meetings and providing information on PHC service provision and current state in Greece; participation of SH-CAPAC members in Expert Consensus and Evaluation Meetings) and CARE projects. The EUR-HUMAN coordinator conducted several teleconferences (TCs) and videoconferences (TCs) (see below) and established a regular communication via email and through meetings to discuss collaboration, present main findings, develop synergies and avoid duplication. Furthermore, the coordinator of EUR-HUMAN participated in two meetings (meeting of the Coordination Committee on Refugees' Health) that took place in Luxemburg (8 July 2016 and 20 January, 2017) as well as in the Preconference Event at the 9th Public Health Conference Vienna 2016 (9th November, 2016). Additionally, the EUR-HUMAN coordinator and the members of the UoC team developed a close collaboration with the IOM. Several TCs were held and communication in tactical base was established (via emails). Furthermore, UoC team participated in the online demonstration of the IOM e-PHR, provided in the discussion with suggestions and comments to improve the IOM e-PHR and based on this, the UoC team developed an electronic health record (offline mode). At national level, the project coordinator and the UoC team was in close collaboration with Greek Ministry of Health, the Greek Ministry of Migration as well as the NGO Médecins du Monde (MdM). One meeting was held in Athens with Greek Minister of Health (Mr. Andreas Xanthos) and also two meetings with the General Secretary of Public Health (Mr. Ioannis Baskozos) in Athens. Additionally, collaboration was establi

WP1 (WP Leader: UoC)
Under WP1 the UoC team coordinated the entire project. Setting up and maintaining communication and dissemination mechanisms project web site, creating a YouTube channel – also functioning as means of training – and Twitter handle accounts, drafting leaflet, newsletters and press releases was performed under this WP. The Kick-off Meeting (KoM), as well as the Steering Committee Meetings (SCMs), and meetings between partners, were all organised and conducted under WP1. In addition, the UoC team organized two Advisory Board Meetings (AdBoards) and disseminated material regarding project output and activities at local, national and international levels. The UoC team organized also meetings and established communication the other projects funded under this particular call, as well as the International Organization of Migration (IOM), to ensure a maximum level of synergy and information exchange, but, also, to ensure duplication was avoided. In addition, the UoC team, in close collaboration with WP4 and WP7 leaders, organised the two-day Expert Consensus Meeting (June 2016; Athens, Greece) and the Project Evaluation Meeting (December 2016; Heraklion, Greece).

WP2 (WP Leader: Radboud UMC)
During WP2 we conducted a qualitative, comparative case study across hotspots, transit centres, intermediate- and longer-stay first-reception centres in seven EU countries (Austria, Croatia, Greece, Hungary, Italy, Slovenia, and the Netherlands) using the PLA research methodology (February-March 2016). The local sites were chosen as they represented points that can be used to map the journey refugees make as the enter and make their way into and across Europe; they do differ in terms of how long and where newly arriving individuals stay (Table 1). Due to the importance of the “PLA - mode of engagement” and the need for mastery of PLA techniques prior to deploying the interventions, steps were taken to ensure the necessary expertise had been acquired. Out of the local teams involved in fieldwork, 16 staff members were trained during a two-day course (6th and 7th February, 2016; Ljubljana). The training was specifically designed for this project and delivered by staff members of RUMC.

In accordance with the legal requirements, all countries acquired approval by the appropriate Ethics Committees (ECs) prior to the qualitative study (Table 2). The participants were recruited at the local implementation settings. Participant recruitment was performed on the basis of purposive sampling, using a combination of network and snowball sampling strategies. The number of sessions and the number of participants included in the fieldwork depended on the type of centre at the local sites. Such number was highly dependent of the time available for a certain group of migrants to be able stay and to participate. All participants received a letter (in English, Arabic and Farsi) explaining the purpose and content of the research. Data were generated using PLA-style flexible brainstorm discussions and PLA-style interviews. PLA charts were used throughout to ensure that verbal and visual forms of data were recorded in a consistent manner across all stakeholder groups. All PLA charts were digitalised after each data generation session in order to facilitate data recording, processing and maintenance. Verbal data were recorded on Post-It notes in point form or short phrases rather than in full verbatim quotes.


WP3 (WP Leader: NIVEL)
WP3: In this WP, the current dynamic and unprecedented situation regarding refugees and other migrants in EU was captured through collecting and analysing all means of information available to researchers. The information and results presented came from a literature search as well as an online survey and interviews with several experts and PHC providers in different EU settings (triangulation). The search strings were entered in 6 databases (PsychINFO; Sociological Abstracts; Cochrane; Pilots; PubMed; Embase)

During the fieldwork in WP2, we managed to involve numerous refugees during their journey in so many countries over the same period of time. Our approach enabled us to get a snap shot of the health needs and experiences of refugees with healthcare system in their chain of travel through Europe during the first 3 months of 2016. In contrast with most of the studies conducted among refugees about their health problems in long-stay refugee centres, we also included hotspots, intermediate and transit centres. A new and very important finding of our study is that time pressure is the most difficult barrier in accessing healthcare at hotspots or transit centres something that is relevant for the development of suitable rapid assessment tools (developed in WP3, WP4, and WP5). The results of WP2 had a significant association in providing services to this vulnerable population based on their needs, wishes and preferences. All the results of WP2 assisted us in the development of tools and questionnaires for rapid health assessment, as well as in the development of training material in WP6.

These results are significant because we gained better knowledge on their health needs, wishes, problems and expectations. This was quite important as it supported both health policy makers and the healthcare providers in decision making process. Knowing all the aforementioned, is a key point in health system because it increases service utilisation rates and assist in decision making. Additionally, based on their needs, health policy makers could add or withdraw necessary/unnecessary services and at the same time have the capacity to inform priority setting and primary care planning. All these have a significant impact on decrease of hospitalization, morbidity and mortality. At the same time, available resources are better managed, while healthcare expenditure are decreased. To sum up, knowing health needs, wishes and preferences promote effective and equitable care and in general improve health of this vulnerable population.

The results achieved by WP3 have a significant impact on improving health status of refugees and other migrants. Initially we found the factors that could help or hinder the implementation of interventions and measures by defining barriers or enablers. Knowing these factors (i.e. values, wishes, beliefs, physical and mental ability, socioeconomic, etc.), enables providers, policy makers and institutions to understand and integrate/abolish these factors into the delivery and structure of the health care systems. The goal is to provide the highest quality of care to every refugee or migrant, regardless of race, ethnicity, cultural background and health literacy. Due to the fact that the present report contributes to our understanding and awareness of factors that influence refugee health care optimization efforts in the EU, the contents of this report is relevant for a broad audience in different countries for adaptation and utilization. ATOMiC toolkit focuses on the route between appraisal of a promising idea or plan and the decision to proceed with its implementation. The checklist encourages users (health care professionals, managers, policy-makers and implementation advisors) to carefully contemplate recurring implementation factors and identify issues that require special attention when proceeding.

In WP4, we found the most rigorous tools, checklists, and guidelines that can help PHC personnel in the provision of care for refugees and migrants (e.g. guidance for the vaccination of children, assessment of malnutrition, and guidelines on sexual violence). All these tools are available in a comprehensive guidance for PHC workers in order to provide optimal primary care. All the tools found, could be used in the European countries after an adaptation to the local context. In D4.2, we provide a simple guidance for adaptation of the tools according local circumstances, the nature and amount of refugees, the composition of th

WP1: Coordination and management of the project was intensive, due to the inter-dependence of WPs in terms of content and timing. Next to the formal Steering Committee Meetings, many emails and bilateral exchanges and TC meetings were conducted. A Dissemination Plan was developed from the start of the project, encompassing various actions. The dissemination plan was developed as a rolling plan, since additional opportunities for dissemination were added as they arose. A separate Publication Plan was developed as part of the dissemination actions and the overall Dissemination Plan. For the Publication Plan, an authorship policy with common Terms of Reference (ToR) was developed by the UoC agreed upon by the consortium partners. All partners contributed to the dissemination of the project and of its results in multiple occasions (see below). The Consortium is also in the process of publishing papers in a number of journals. Additionally, the UoC team, in close collaboration with the consortium, developed the “Workflow” which includes three main domains, illustrating how health needs of population groups can be addressed by, health care professionals (see below). All milestones and deliverables were reached as planned and on time.

WP2: This WP aim was to gain insight in the health needs and social problems, as well as the experiences, expectations, wishes and barriers regarding accessing PHC and social services, of refugees and other newly arriving migrants throughout their journey through Europe - from the hotspots via the transit centres to the first longer stay reception centres. The information and insights have been collected through group sessions with refugees in seven (7) countries: Greece, Slovenia, Croatia, Italy, Hungary, Austria and the Netherlands. These sites were chosen so as to represent a variation in contexts and to reflect a part of the journey of refugees. The group sessions were conducted through the PLA research methodology. Local staff members from all intervention sites had to be trained in the application and ground rules of the PLA method. A total of forty-three (43) group sessions were held, with a total of ninety-eight (98) refugee-participants from nine (9) countries and with twenty-five (25) health care workers in Croatia. One site for the PLA sessions has been added to the original plan (Netherlands). In Croatia, sessions with refugees could not be held due to their very fast transit. Therefore, six PLA sessions were held with experienced care providers from various agencies that had been working with refugees in the transit centres. All milestones and deliverables have been achieved as planned and in time.

WP3: This WP aim was to learn from the literature and the experts on measures and interventions and the factors that help or hinder their implementation in European healthcare settings. After the development of a heuristic framework, a systematic search of literature databases and an online survey among experts were done. 81 experts and health professionals responded to the survey. This was followed by interviews with 10 international experts. The original plan was to deliver a report with an overview of effective interventions that address health needs of refugees. This was delivered. However, in order to facilitate implementation, the WP has delivered also a follow up, a checklist, called “ATOMiC: Appraisal Tool for Optimizing Migrant Health Care”. It provides practical guidance for improving health care services for oftenvulnerable groups. The checklist helps users – health care professionals, managers, policymakers, implementation advisors – to consider the various contextual and resource factors and to identify priority interventions and issues that require special attention when proceeding with improving the services. All milestones and deliverables have been achieved.

WP4: The overall aim of this WP was to provide a series of support tools for primary care practitioners who

During the fieldwork in WP2, we managed to involve numerous refugees during their journey in so many countries over the same period of time. Our approach enabled us to get a snap shot of the health needs and experiences of refugees with healthcare system in their chain of travel through Europe during the first 3 months of 2016. In contrast with most of the studies conducted among refugees about their health problems in long-stay refugee centres, we also included hotspots, intermediate and transit centres. A new and very important finding of our study is that time pressure is the most difficult barrier in accessing healthcare at hotspots or transit centres something that is relevant for the development of suitable rapid assessment tools (developed in WP3, WP4, and WP5). The results of WP2 had a significant association in providing services to this vulnerable population based on their needs, wishes and preferences. All the results of WP2 assisted us in the development of tools and questionnaires for rapid health assessment, as well as in the development of training material in WP6.

These results are significant because we gained better knowledge on their health needs, wishes, problems and expectations. This was quite important as it supported both health policy makers and the healthcare providers in decision making process. Knowing all the aforementioned, is a key point in health system because it increases service utilisation rates and assist in decision making. Additionally, based on their needs, health policy makers could add or withdraw necessary/unnecessary services and at the same time have the capacity to inform priority setting and primary care planning. All these have a significant impact on decrease of hospitalization, morbidity and mortality. At the same time, available resources are better managed, while healthcare expenditure are decreased. To sum up, knowing health needs, wishes and preferences promote effective and equitable care and in general improve health of this vulnerable population.

The results achieved by WP3 have a significant impact on improving health status of refugees and other migrants. Initially we found the factors that could help or hinder the implementation of interventions and measures by defining barriers or enablers. Knowing these factors (i.e. values, wishes, beliefs, physical and mental ability, socioeconomic, etc.), enables providers, policy makers and institutions to understand and integrate/abolish these factors into the delivery and structure of the health care systems. The goal is to provide the highest quality of care to every refugee or migrant, regardless of race, ethnicity, cultural background and health literacy. Due to the fact that the present report contributes to our understanding and awareness of factors that influence refugee health care optimization efforts in the EU, the contents of this report is relevant for a broad audience in different countries for adaptation and utilization. ATOMiC toolkit focuses on the route between appraisal of a promising idea or plan and the decision to proceed with its implementation. The checklist encourages users (health care professionals, managers, policy-makers and implementation advisors) to carefully contemplate recurring implementation factors and identify issues that require special attention when proceeding.

In WP4, we found the most rigorous tools, checklists, and guidelines that can help PHC personnel in the provision of care for refugees and migrants (e.g. guidance for the vaccination of children, assessment of malnutrition, and guidelines on sexual violence). All these tools are available in a comprehensive guidance for PHC workers in order to provide optimal primary care. All the tools found, could be used in the European countries after an adaptation to the local context. In D4.2, we provide a simple guidance for adaptation of the tools according local circumstances, the nature and amount of refugees, the composition of the