Adiposity is a growing public health problem, already affecting more than 2 billion adults worldwide. Of these, over 650 million individuals have obesity (body mass index (BMI) ≥ 30.0 kg/m2) [1]. Current projections indicate that by the year 2030, about 58% of the world's adult population will have overweight or obesity (BMI ≥ 25.0 kg/m2) [2]. This will fuel the development of diabetes mellitus, cardiovascular disease, and cancers [3,4]. Among the growing group of sub-Saharan African migrant populations in Europe, overweight and obesity occur more frequently than in the European host populations [5,6]. Already, more than half a million people of African origin live in Germany [7] and their numbers are anticipated to increase rapidly [8]. Ghanaians form one of the largest groups of sub-Saharan African migrants in Europe [9,10]. In fact, around 46,000 Ghanaian migrants live in Germany [10,11] of whom 20% reside in Berlin [10]. General obesity (BMI ≥ 30.0 kg/m2) is prevalent in 14% of Ghanaian men and in 39% of Ghanaian women living in Berlin. For abdominal obesity (waist circumference > 102 cm for men and >88 cm for women), these figures are 15% in men and 71% in women [12].

Lifestyle modification constitutes the first-line treatment for obesity because it is safe and usually effective [13], but dietary interventions often fail among migrant populations because specific cultural needs are neglected [14]. Evidence from African Americans and Asian migrants in Europe emphasize the importance of cultural adaptations for weightloss programs to produce better outcomes than generalized interventions [15–17]. These strategies may not be transferrable to West-African migrants in Europe because of their linguistic, educational and migration-related characteristics.

Given the obesity-related health problems and no previous interventions targeting migrants from sub-Saharan Africa in Germany, this feasibility study aimed at evaluating the practicability and the acceptability of a culturally adapted dietary weight-loss intervention among a group of well-characterized Ghanaian adults in Berlin. As a secondary objective, we aimed at exploring the weight-loss effect on changes in cardio-metabolic risk factors.

#### **2. Materials and Methods**

#### *2.1. Study Population and Design*

For the present ADAPT study (Feasibility of a Culturally Adapted Dietary Weight-Loss Intervention Among Ghanaian Migrants in Berlin), participants of the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) study [18] were re-invited in Berlin via telephone in September 2017. Owing to the wellestablished difficulties of enrolling migrant groups in population-based studies [12], we used documented contact details of previous RODAM participants in Berlin (*n* = 547) who were eligible (*n* = 93). Shopping vouchers (10 €) were offered for each completed examination visit as incentives to participate. In brief, the RODAM study was implemented between 2012 and 2015 and comprised Ghanaians aged 25–70 years living in rural and urban Ghana as well as in Amsterdam, Berlin and London. The study used standardized instruments for data collection at all the study sites, comprising questionnaire-based interviews, physical examination, and biological sample collection.

The inclusion criteria were BMI ≥ 25.0 kg/m2 or waist circumference >94 cm for men or >80 cm for women, Ghanaian migrant status (defined as being born in Ghana or having two parents born in Ghana), age ≥ 25 years, and the cooperation of the family cook or volunteer supporting the participant's behavioral change. The exclusion criteria were known diabetes, receiving long-term oral corticosteroids or weight-loss medication, and current pregnancy.

#### *2.2. Ethics Statement*

The study protocol was reviewed and approved by the Ethics Committee of Charité-Universitaetsmedizin Berlin (EA1/151/17). The study was registered retrospectively at the German Registry for Clinical Trials (DRKS00013767). Prospective registration was not performed, because the study has not been planned as a randomized controlled trial. Therefore, the study was registered after the participants were recruited. The authors confirm that all ongoing and related trials for this intervention are registered. In order to finish the program before Christmas, the baseline assessments started on 2 October 2017, and the last visit was performed on 18 December 2017. All participants gave informed written consent prior to their enrolment.

#### *2.3. Intervention Program*

We adapted the guidelines for the treatment of adiposity by the German Society of Adiposity [19] (Table 1). To achieve behavioral changes at the individual level, we applied goal setting, behavioral contracting, and tailored health communication. These strategies were drawn from the Social Cognitive Theory of behavioral changes [20] and the stages of change construct of the Transtheoretical Model [21]. The adaptations of the treatment guidelines were based on the concept of Resnicow et al. [22], entailing an appropriate structure, process and strategy in adaptation.

**Table 1.** Adaptations of the guidelines for the treatment of adiposity by the German Society of Adiposity (DAG).

Linguistic, constituent-involving and socio-cultural adaptations seem to be the most successful for weight-loss and dietary changes [15,16,23]. Therefore, we focused on the socio-cultural context and the languages of Ghanaians living in Berlin (Table 1). In this regard, trained personnel conducted questionnaire-based interviews in the participant's preferred language, either English or a local Ghanaian language. The goal of this culturally adapted dietary intervention was to achieve weight-loss of at least 2.5 kg [24] which is based on international guidelines of a minimum 5% weight-loss of body weight during the 3-month period. The individual schedule for the study participants is shown in Table 2.

In brief, the participants and their family volunteers received group counselling by an ethnically matched dietician. The counselling focused on the reduction of energy-dense foods, fewer eating occasions, and smaller portion sizes. Participants were encouraged to increase the consumption of fruits and vegetables. In addition, they received an information poster about a healthy Ghanaian diet and regular physical activity. The latter followed the recommendations of moderate to vigorous physical activity for at least 30 min per day. We organized monthly home-based cooking sessions with a dietician, and sent weekly smartphone reminders covering the participants' dietary and activity goals. Lifestyle was monitored by culture-sensitive dietary assessment methods and by subjective and objective measurements of physical activity, respectively.

**Table 2.** Individual intervention and examination schedule of the ADAPT study.

X represents the week in which an activity was undertaken.

#### *2.4. Recruitment*

We used documented contact details of previous RODAM participants in Berlin (*n* = 547) [12] who fulfilled the inclusion criteria (*n* = 93). We invited them by phone. Reasons for non-participation were documented. Upon agreement, an appointment at the study center was scheduled for the baseline examination. The individual schedule for interviews and physical examinations is presented in Table 2. Figure 1 provides the CONSORT flow chart of the recruitment success. Of the 93 invited eligible participants, 16 were scheduled for the baseline examination. Finally, 6 individuals and 4 family volunteers were enrolled in the intervention study, translating into a participation rate of 6.5%.

#### *2.5. Assessments of Demographics, Acceptability, and Lifestyle*

Trained personnel conducted questionnaire-based interviews with the active study participants but not the family volunteers. These were performed in the participant's preferred language, either English or a local Ghanaian language. Demographic characteristics included age and sex.

#### 2.5.1. Acceptability

The acceptability questionnaire was administered in weeks 7 and 12. We used a questionnaire that was based on the theoretical framework of acceptability, comprising seven component constructs [25]:

There were six response categories to avoid the possibility of neutral answering, ranging from "strongly disagree" to "strongly agree".

**Figure 1.** CONSORT Flow chart.

#### 2.5.2. Dietary Behavior

For information about the baseline habitual diet, we used data of the previous RO-DAM study, that had been collected with the semi-quantitative Ghana-Food Propensity Questionnaire (Ghana-FPQ) [26]. The Ghana-FPQ queries about the usual intake frequencies of food groups in predefined portion sizes during the preceding 12 months. It covers 134 items reflecting both indigenous Ghanaian and typical German foods. The German Nutrient Database (BLS) and the West African Food Composition Table were used to calculate the intakes of energy (kcal/d) and macronutrients (% of daily energy intake). During the course of the ADAPT study, 24-h dietary recalls (24HDRs) were conducted according to the 5-Steps Multiple Pass Method [27] at two points in time. Participants provided information on eating times, types of foods and beverages consumed in the past 24 h, and portion sizes. Specific information about brands and recipes were also recorded. Common Ghanaian household utensils were used to estimate the portion sizes.

#### 2.5.3. Physical Activity

Again, we used self-reported physical activity data of the previous RODAM study as our baseline information. Physical activity had been assessed by means of the WHO STEPwise approach to chronic disease risk factor Surveillance (STEPS) questionnaire [28]. The same tool was applied in the present ADAPT study in weeks 7 and 12. The STEPS questionnaire gathers information on physical activity in three settings (at work, travel to and from places and recreational) and sedentary behavior. Metabolic equivalents of task (MET)-hours were calculated. In addition to the self-reported physical activity data, we carried out objective measurements using a monitoring device (ActivPAL activity monitor; PAL Technologies Ltd., Glasgow, UK). This tool collects information about static and dynamic acceleration. The measurements were done for a week's period on three different occasions. The lightweight device was worn discretely on the participants' thigh for up to one week to quantify sedentary, upright and ambulatory activities as well as total MET-hours/day.

#### *2.6. Physical Examinations*

Similar to the questionnaire-based interviews, physical examinations were conducted only among the active study participants but not their family volunteers. A trained nutrition scientist conducted the physical examinations among participants in light clothes and without shoes. The measurements comprised body weight (kg; SECA 877), height (cm; SECA 217), waist circumference (cm) and hip circumference (cm) using a measuring tape. Systolic and diastolic blood pressures (mmHg) were measured (Boso Medicus Control; Bosch + Sohn GmbH, Jungingen, Germany) in triplicates after an appropriate resting time. The mean of the last two measurements was used for analysis.

#### *2.7. Statistical Analysis*

Baseline characteristics are presented as median and range for continuous variables and as percentage for categorical data. We calculated differences between baseline and follow-up data for secondary outcomes, i.e., weight-loss and lifestyle factors. All analyses were performed using Microsoft Excel 2016 (Microsoft Cooperation, Washington, DC, USA).

#### **3. Results**

#### *3.1. Study Population*

Two men and four women attended the ADAPT baseline examination. Table 3 presents the characteristics of the participants of the year 2014 (RODAM Study) and September 2017 (ADAPT baseline examination). The median age at baseline was 51 years (range: 25–62 years). The median BMI was 29.9 kg/m2 (range: 23.3–35.1 kg/m2) and the median waist circumference was 98.3 cm (range: 86.0–100.0 cm).

**Table 3.** Baseline characteristics of the participants of the ADAPT feasibility study.

\* Energy intake was calculated based on the Ghana Food Propensity Questionnaire (Ghana). MET, metabolic equivalents of task.

#### *3.2. Practicability and Acceptability*

We contacted 93 eligible individuals by phone. As depicted in Figure 1, the main reasons for non-participation were change of residence (13%), lack of time to attend clinicbased examinations (as opposed to their nearest Ghanaian practitioner; 10%), or no interest (9%); 64% of the non-participants did not want to give reasons for their decision. After the baseline examination, one individual actively withdrew from the study, because the person reported previous weight-loss and did not want to lose more weight. Thus, the analytical sample for all follow-up assessments comprised 5 individuals.

Figure 2 shows the acceptability of the intervention programme according to the 7-items acceptability questionnaire in week 7 (Figure 2A) and week 12 (Figure 2B), using a 6-points Likert scale. In week 7, intervention coherence, opportunity costs, and self-efficacy reached the maximum score points, followed by perceived effectiveness (5.0), affective attitude (4.0), burden (4.0), and ethicality (4.0). These figures further improved until week 12 (Figure 2B).

#### *3.3. Weight-Loss and Lifestyle Characteristics*

The changes in anthropometric measures, lifestyle characteristics and clinical variables between baseline examination and follow-up are shown in Table 4.

**Table 4.** Differences in anthropometric and lifestyle characteristics between the ADAPT baseline and follow-up.

\* Energy intake at baseline was measured by the Ghana Food Propensity Questionnaire and at follow-up by 24-h dietary recall. Δ-Change in values.

(**B**)

**Figure 2.** Acceptability of the culturally adapted dietary weight-loss intervention in week 7 (**A**) and in week 12 (**B**). Black dots indicate means. SEM, standard error of the mean.

> After 12 weeks, the median weight-loss was −0.6 kg (range: +0.5; −3.6 kg), and median BMI and median waist circumference tended to be lower (Table 4). For lifestyle characteristics, the RODAM data served as the baseline information: median energy intake had been 2384 kcal/d (range: 992, 3361 kcal/d), and median energy expenditure had been 195 MET-h/week (range: 0–392 MET-h/week) (Table 3). The median difference in energy intake between these baseline data and the ADAPT follow-up information was −1480 kcal/d (range: −3330, −127 kcal/d). For physical activity, the median difference was 65 MET-h/week (range: −24, 249 MET-h/week) (Table 4).

(**A**)

Figure 3 presents the food group consumption and macronutrient intakes during study conduct. In the 3-months intervention period, the dominating food groups were carbohydrate-rich items (bread, cereals, potatoes, rice and pasta), vegetables, meat and fish. The participants rarely consumed fruits and convenience foods, and never consumed energy-containing beverages (Figure 3A). Carbohydrates, fat and protein contributed each 39%, 24% and 18% to daily energy intake (Figure 3B).

**Figure 3.** Median intakes of food groups (g/d) (**A**) and macronutrients (energy %) (**B**), based on the means of two 24-h dietary recalls. Error bars represent standard errors of the mean (SEM).

Figure 4 presents the individual physical activity of the participants during the course of the ADAPT study, based on self-report and by objective measurements. The median self-reported energy expenditure was 144 MET-h/week (range: 20, 478 MET-h/week), while the median energy expenditure by ActivPAL was 249 MET-h/week (range: 238, 270 MET-h/week).

**Figure 4.** Median physical activity of weeks 7 and 12 for each ADAPT Study participant (participants codes, *y*-axis) by questionnaire-based self-report (black bars) and by objective measurement (white bars) (MET-hours per week).

#### **4. Discussion**

This feasibility study examined the practicability and the acceptability of a 12-weeks culturally adapted, dietary weight-loss intervention among Ghanaian migrants with overweight in Berlin. Our study was the first attempt in Germany to provide a culturally adapted lifestyle intervention for West-African migrants. Innovative adaptations comprised linguistic, constituent-involving and socio-cultural components: a Ghanaian research team and an ethnically matched dietician to facilitate culturally appropriate communication and culinary knowledge to deliver nutrition education, respectively. Nudging, through regular text and image messaging, enhanced self-empowering and frequent assessments of dietary behavior and physical activity during the intensive intervention period facilitated self-contracting to achieve the individual weight-loss goals.

#### *4.1. Practicability and Acceptability*

For ethnic minorities in the United States, Nierkens et al. have reported response rates ranging from 31% to 97% for culturally adapted interventions aiming at smoking cessation, diet, and physical activity [16]. The lower participation rate of 6.5% in the present study was similar to the one seen in the RODAM baseline recruitment in 2015 [12], and may be attributed to mistrust and competing demands, as indicated in other African American population groups, too [29]. Indeed, in the previous RODAM Study, we experienced initial response rates of less than 5% following written invitation. In the ADAPT study, 19% of the contacted individuals claimed to have no time or no interest for such a program. This was also seen among Asian migrant populations in the UK, where community-orientated personal approaches for recruitment were most successful (83% response rate) [30]. Also, early sensitization and involvement of community leaders have contributed to enhanced enrolment of African migrants into health interventions in the Netherlands and in the UK [31,32]. Therefore, the present study has built on the documented contacts from former RODAM participants in Berlin.

Still, this target population appears to be highly mobile as indicated by the proportions of individuals who moved (8/93) or traveled (3/93). The poor intervention uptake may also stem from unawareness in the target population for adiposity as a risk factor of chronic diseases. In fact, in a qualitative study with Ghanaian migrants in Amsterdam (*n* = 46), few respondents associated hypertension with adiposity, even though many had overweight [33]. Moreover, Ghanaian adults perceive a certain degree of overweight as a sign of wealth, fertility, and beauty, particularly for and among women [34]. From this perspective, there seems to be no evidential need to engage in weight-loss activities. Lastly, food choices are not only influenced by individual factors, such as biological, demographic, psychosocial and situational aspects. Rather, interpersonal, environmental and political determinants take a growing role in the decision for food [35]. This system's pressure might have generated reservations in the Ghanaian community about participating in the offered dietary intervention.

With regard to mistrust, this may be manifest regarding the German health system and its actors. Study participants rather preferred Ghanaian practitioners as study physicians. Therefore, future intervention studies aiming at dietary weight-loss among Ghanaian migrants should focus on early stakeholder involvement and evidential communication to create trust. In addition, we need to offer low-threshold interventions that minimize the time, the costs, and the potential of mistrust in the participants by employing ethnically matched practitioners, nurses and dieticians.

Notably, the intervention program was rated as highly convenient by those individuals who completed the program. While this could indicate selection of the most motivated people, it may also signal the cultural acceptability of our adapted program.

#### *4.2. Weight-Loss and Lifestyle*

The present feasibility study indicates that the culturally adapted dietary intervention may reduce body weight, BMI and waist circumference in this population over a period of 12 weeks, although the study lacks a comparison group. This corroborates previous findings that culturally tailored and facilitated interventions produce better outcomes than generalized interventions [15–17,36]. For instance, a tailored study among African Americans showed that body weight was reduced in the intervention group (mean difference: −2 ± 3.2 kg), but not in the standard care group (mean difference: 0.20 ± 2.9 kg, *p* = 0.02) over a period of 6 months [15]. To establish the actual health effects of the present intervention, a larger study with a comparison group is definitely required.

Regarding the dietary behavior among Ghanaian migrants, core food items of the traditional diet are maintained even several years after migration, including starchy roots and tubers, bread, rice, and leafy vegetables [26]. These typical dietary habits are still seen during the present intervention, and also cover low intakes of health-beneficial fruits and dairy products. This indicates that intensified efforts are required that go beyond the implemented dietary modifications, aiming at meals to support the integration of new, healthy food groups, paralleling the reduction of portion sizes for a negative energy balance. Also, there were hardly any changes to physical activity, indicating that additional promotion of regular physical activity is required.

#### *4.3. Limitations*

Since the study did not aim to test an effect of the intervention, no sample size calculations were performed. Owing to the small sample size, which impairs external validity of our findings, we refrained from concluding any effects of the intervention regarding biomedical data. The lack of a comparison group limits the interpretation of our acceptability results, because the poor participation rate could either result from the intervention program per se or from the reported reasons. Selection bias might have occurred, if study participants differ from non-participants in unobserved characteristics. The acceptability questionnaire used in this study may involve subjectivity bias in which the participants might have different interpretations of items resulting in different endorsements of ratings. For the assessment of dietary intake, detailed information about eating times, portion sizes, recipes and their preparations were gathered by culture-specific assessment tools [26]. However, two 24HDRs may not have captured day-to-day and weekend-to-weekday variations of food consumption. Different instruments were used during the RODAM study and the ADAPT project, which also complicated the comparison of energy intakes and macronutrients consumption.

#### **5. Conclusions**

This feasibility study examined the practicability and the acceptability of a 12-weeks culturally adapted, dietary weight-loss intervention among Ghanaian migrants with overweight in Berlin. The study showed a low participation rate, but 5 out of 6 enrolled participants completed the intervention and rated the program as highly convenient. The dietary behavior during the intervention period still relied on starchy foods and animal-based products and was low in fruit consumption. Yet, the proportions of consumed vegetables and the contributions of macronutrients to energy intake adhered to international dietary guidelines.

The present culturally adapted dietary weight-loss intervention for Ghanaian migrants in Germany has the potential to reduce adiposity and, thus, to prevent cardio-metabolic conditions in this vulnerable population group. In future studies, early stakeholder involvement, advocacy by community leaders, and sensitization of the Ghanaian community prior to the implementation are key factors for the success of this program. For the establishment of the actual weight-loss and its cardio-metabolic effects, a randomized, controlled trial is required.

**Author Contributions:** Conceptualization, I.D.; Formal analysis, S.A., R.E., K.S., A.S., T.P., F.P.M. and I.D.; Funding acquisition, I.D.; Investigation, S.A., R.E., K.S. and I.D.; Methodology, F.P.M. and I.D.; Project administration, S.A., R.E. and K.S.; Resources, A.S. and T.P.; Supervision, F.P.M. and I.D.; Writing—original draft, S.A.; Writing—review & editing, R.E., K.S., A.S., T.P., F.P.M. and I.D. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Diabetes-Stiftung, grant number 392/12/16.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Charité-Universitaetsmedizin Berlin (EA1/151/17, 10 August 2017).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to information that can potentially reveal the participants' identity.

**Acknowledgments:** The authors are very grateful to the dietician and Ghanaian volunteers for participating in this project.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

### *Article* **Eritrean Refugees' and Asylum-Seekers' Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study**

**Yonas Semere Kidane 1, Sandra Ziegler 2, Verena Keck 1, Janine Benson-Martin 1,3, Albrecht Jahn 1,\*, Temesghen Gebresilassie <sup>1</sup> and Claudia Beiersmann <sup>1</sup>**

**Abstract:** Oral health concerns in Eritrean refugees have been an overlooked subject. This qualitative study explored the access of Eritrean refugees and asylum-seekers (ERNRAS) to oral health care services in Heidelberg, Germany, as well as their perceptions and attitudes towards oral health care. It involved 25 participants. We employed online semi-structured interviews (*n* = 15) and focus group discussions (*n* = 2). The data was recorded, transcribed, and analysed, using thematic analysis. The study found out that most of the participants have a relatively realistic perception and understanding of oral health. However, they have poor dental care practices, whilst a few have certain misconceptions of the conventional oral hygiene tools. Along with the majority's concerns regarding psychosocial attributes of poor oral health, some participants are routinely consuming Berbere (a traditional spice-blended pepper) to prevent bad breath. Structural or supply-side barriers to oral healthcare services included: communication hurdles; difficulty in identifying and navigating the German health system; gaps in transculturally, professionally, and communicationally competent oral health professionals; cost of dental treatment; entitlement issues (asylum-seekers); and appointment mechanisms. Individual or demand-side barriers comprised: lack of self-sufficiency; issue related to dental care beliefs, trust, and expectation from dentists; negligence and lack of adherence to dental treatment follow-up; and fear or apprehension of dental treatment. To address the oral health burdens of ERNRAS, it is advised to consider oral health education, language-specific, inclusive, and culturally and professionally appropriate healthcare services.

**Keywords:** oral health care; dental; access; attitude; Eritrea; refugees; asylum-seekers; qualitative

#### **1. Introduction**

To date, literature regarding the magnitude of oral health burdens of the widely dispersed Eritrean refugees and asylum seekers is scarce. The world is experiencing a surging number of forcefully displaced persons with 70.8 million in 2019. They were either refugee (25.9 million), internally-displaced persons (41.3 million), or asylum-seekers (3.6 million) [1]. The UN High Commissioner for Refugees (UNHCR) defined a refugee as "someone who is unable or unwilling to return to their country of origin owing to a wellfounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion [2]". An asylum-seeker, though, is "someone whose claim has not yet been finally decided on by the country in which the claim is submitted [3]". By the end of 2018, 10% of the world's refugees resided in Europe [4] with Germany hosting the largest number [5]. Eritrea, despite its small population of

Keck, V.; Benson-Martin, J.; Jahn, A.; Gebresilassie, T.; Beiersmann, C. Eritrean Refugees' and Asylum-Seekers' Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study. *Int. J. Environ. Res. Public Health* **2021**, *18*, 11559. https:// doi.org/10.3390/ijerph182111559

**Citation:** Kidane, Y.S.; Ziegler, S.;

Academic Editor: Takaaki Tomofuji

Received: 27 September 2021 Accepted: 1 November 2021 Published: 3 November 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

an estimated 3.5 million in 2018 [6], is ranked ninth as a country of origin of refugees with almost 15% of its population living in the diaspora [5]. By the end of 2018, there were 55,300 Eritrean refugees in Germany [1] and Eritreans were ninth by nationality of all applicants seeking protection in Germany [7].

Even as many refugees were able to escape from threats of persecution; many often failed to avoid the risks associated with poor health conditions. There is evidence to suggest that the general health of refugees is inferior in comparison to that of the host population [8–10]. Correspondingly, the oral health of refugees and asylum-seekers was poor in comparison to that of the general host country's population [11–14]. Though data is scarce, it was found that refugees and asylum seekers have a higher prevalence of oral disease and lower oral health status than their counterpart native Germans [15,16].

According to the World Health Organization (WHO), oral disease burdens are one of the leading health problems that refugees experience [17]. Among refugees, there is a high prevalence of major oral diseases such as dental caries, periodontal disease, malocclusion, missing and fractured teeth, orofacial trauma, and orofacial malignancies [11,13,18–21]. A study among newly-arrived refugees in Massachusetts indicated that oral diseases were the most common complaint in children and the second most common in adults [22]. Another study in Brussels, Belgium, also showed that dental conditions were the second most frequent diagnosis following respiratory tract infections [23]. This suggests that dental care is suggested as a pressing healthcare need of many refugees and asylum seekers [14,24,25].

Among the principal factors contributing to poor oral health are: ill-equipped or inaccessible dental healthcare in their Country of Origin (COO); lack of dental care in migration transit or refugee camps; and poor personal or cultural dental care practice [24,26–28]. While many appear to have reasonable perceptions and understanding regarding the significance of good oral health as holistic health [28], their overall oral health knowledge, attitudes, and good practice remain unsatisfactory [29–31]. Literature indicates, however, that the principal source of poor oral health status among refugees is, more often than not, actually related to limited access to dental care in the host country [24,26,28]. The German legislation is restrictive. For example, in Germany, access to dental care services according to *'§4 and § 6 Asylum-Seekers' Benefits Act (AsylbLG)* is limited during the first 18 months after arrival [32]. In essence, the legislation severely limits access to general and oral health care [32]. Other barriers described as limitations to care in the host country include language and communication issues; fear of dental treatment; anxiety and trust issues; high treatment costs; low income; distance to a dental clinic; quality of care; restricted treatment choice; long waiting lists and time; low oral health literacy; and other cultural and psychological barriers [12,28,30,33–35].

According to the WHO, oral health is a crucial indicator of overall health, wellbeing, and quality of life [36]. Many of the oral conditions, comprising periodontitis, tooth loss, dental caries, and oropharyngeal infections, share modifiable risk factors (high-sugar diets, poor oral hygiene and care, and excessive alcohol and tobacco use) with the leading noncommunicable diseases including diabetes, cancer, and cardiovascular and respiratory diseases [37–40]. When the connection of oral health to quality of life was measured [36], the Oral Health-Related Quality of Life (OHRQoL) of refugees was found to be very low [41,42]. Despite this knowledge, oral health care is frequently neglected and undervalued as a vital healthcare service to refugees [43]. The UNHCR has yet to assign it within the significant health framework for the refugee population [44]. To date, Canada remains the only country ever to develop specific guidelines for oral health screening of refugees and immigrants [45]. While refugees' oral health care remains a pressing issue, studies are scarce [24,30]. In addition, almost all of the studies concluded that oral health is less understood and above all less accessible to these disadvantaged populations [15,24,28,29].

Thus far, no qualitative research has been published in Germany looking at the refugees' perspectives, understanding, experience, and the main difficulties associated with oral healthcare access and utilization. In particular, no study has focused on these aspects of oral health among Eritrean refugees in Europe or in Germany.

Therefore, this study aims to close this research gap. It explores the access of Eritrean refugees and asylum-seekers (ERNRAS) to oral health care services in Heidelberg, Germany, as well as their perceptions and attitudes towards oral health care.

#### **2. Materials and Methods**

This study was conducted using the qualitative research method. As this study seeks to understand an individual's experiences regardless of any preconceived ideas [46], as such, when describing and interpreting the data, participants' own perceptions, understandings, and perspectives were taken into account.

#### *2.1. Study Setting*

The study took place in the city of Heidelberg, Baden-Württemberg, Germany. Due to the influx of refugees in 2015 and Baden-Württemberg being the second largest state, it received a high number of asylum applications for three consecutive years (2016–2018) [47,48]. On the outskirts of the city of Heidelberg, the Patrick Henry Village (PHV), a former US army housing area, is used as a refugee arrival and registration centre [49]. Heidelberg city itself is the home to more than 450 refugees and asylum seekers, including many ERNRAS [50].

#### *2.2. Sampling Procedures*

Participants were selected through exponential non-discriminative snowball sampling, in which the first participant recruited provides multiple referrals. Each new reference offers further information for referral until sufficient participants are enlisted [51]. As the principal researcher (Y.S.K.) is Eritrean, he was able to socialise and exchange addresses with potential participants before the COVID-19 pandemic. He visited places where Eritreans usually gather such as Eritrean restaurants, and Eritrean church services in Heidelberg. After a series of snowballing and referrals, the first author had invited 31 ERNRAS to participate in the study of which 25 finally participated.

Of these, 84%, were refugees (individuals granted a refugee status), and 16% were asylum seekers. On average, participants had lived in Germany for 4.4 years (range: 2–7 years), and the majority, 76%, have lived there for more than three years. The study sample consisted mostly of men, 76%; the mean age of participants was 29 years (Range: 19–52); with more than half having a secondary level education. The majority of participants (60%) were employed at the time of the interview. Most of them, 72%, are unmarried. The sample characteristics are shown in Table 1.

#### *2.3. Data Collection Instrument and Procedures*

Data collection took place in April and May 2020. The principal researcher (Y.S.K.) carried out fifteen individual in-depth interviews (IDI) and two focus group discussions (FGDs) (with 6 participants each) in Tigrinya (Eritrean official language). The data collection tools consisted of a semi-structured in-depth interview (IDI), as well as a focus group discussion (FGD) guide. These guides were developed by the principal researcher with assistance from the co-authors (C.B., J.B.M.). A pilot test was performed among three Eritreans (friends and colleagues of Y.K.S.) before final adoption. The guides covered a wide range of topics within the following subject areas: perception of oral healthcare, understanding of oral health determinants, dental care behaviour, and barriers of access to oral healthcare services (see Appendix A, Table A1).

Data collection was originally planned face-to-face, however was conducted online via video conference software (Skype or WhatsApp) because of the COVID-19 pandemic restrictions. Each interview lasted an average of 40 min, with the FGDs lasting one hour and fifteen minutes. The FGDs were protocolled by an assistant (T.G.). The conversations were audio-recorded in Tigrinya, transcribed in Tigrinya, and translated into English for analysis by the first author (Y.S.K.).

**Table 1.** Socio-demographic characteristics of participants.

#### *2.4. Data Analysis*

In order to organize, process, and manage the data, NVivo 12 (QSR International, Melbourne, Australia), a qualitative data analysis programme, was used. Data were analysed using thematic content analysis. This method supports identifying, analysing, and interpreting patterns of meanings (themes) within qualitative data [52]. A framework developed by Levesque and colleagues in 2013 [53], comprehensively addresses access to health care. The framework was used to code deductively for predefined themes in the data. According to the framework, healthcare accessibility involves five supply-side dimensions (provider-side): Approachability, Availability and Accommodation, Acceptability, Affordability, and Appropriateness. Correspondingly, there are also five dimensions (conceptualized as abilities) paralleling on the demand-side (user-side): the Ability to perceive, the Ability to seek, the Ability to reach, the Ability to pay, and the Ability to engage [53]. In addition to this deductive coding, the researcher read, explored, and coded the dataset for patterns and themes that emerged inductively.

Finally, eight major themes could be identified—three themes, mainly on the perception of oral healthcare, understanding of oral health determinants, and dental care behaviour of ERNRAS. The five subsequent themes depicted are in line with the five principal dimensions of access to healthcare and their equivalent users' abilities adopted from the aforementioned conceptual framework developed by Lévesque et al. (see Figure 1).

**Figure 1.** Conceptualization of oral healthcare access among ERNRAS in Heidelberg, Germany, adopted from the access framework of Levesque et al. (2013) [53].

#### *2.5. Ethical Consideration*

This study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethical Commission of the Medical Faculty of Heidelberg, Germany (protocol number: S-207/2020). Study participation was voluntary, and all had given their written informed consent. Confidentiality was protected by the use of pseudonyms when storing, analysing, and reporting the data. No incentives or compensation was given to the participants.

#### **3. Results**

The findings of this study are presented according to eight emerging themes and sub-themes. For a detailed overview please see Appendix B, Table A2.

#### *3.1. Perception of Oral Health Care*

In exploring the perception and perspective of Eritrean refugees and asylum seekers, good oral health was described as having white teeth, a pleasing smile without any decayed, broken or crooked teeth, and also no gum bleeding or bad breath: *"I would say, we shouldn't have a dental cavity, bleeding gums, bad mouth odour, or neither broken nor crooked tooth" (FGD-1).* They further commented on the vital significance of oral hygiene as part of personal hygiene and the valuable benefit of regular oral healthcare in boosting self-esteem and social approval.  *]. I used to feel so embarrassed in public and I used to cover my mouth all the time. It was so awful to see your tooth missing" (FGD-1).* Commenting on social uneasiness and suffering from bad breath, some participants also cited and believed that eating a traditionally prepared spice-blended pepper (Berbere) neutralises bad breath.  As for me, I am getting Berbere from home [Eritrea] solely prepared by my mother, and I am consuming it every day.  Understanding of oral Health Determinants*

The study sought participants' views on the determinants of oral healthcare. The majority noted the close association between oral health and general health and remarked critically on the seriousness of oral diseases. One member of the discussion said: *"As molar tooth pain can go the head [* ... *], it makes it so dangerous and risky to your life. And from what I heard and also experienced [* ... *], there is no other pain cause more anguish than dental pain" (FGD-2)*. Most of the participants believed that the risk factor for their poor oral health was related to their lifestyle: poor oral hygiene routine, sweet and starchy food consumption, trauma, and tobacco smoking. The majority, however, have stressed that the dietary transition from a fibrous and low-sugar traditional diet back in Eritrea to a high-sugar or processed food in Germany as the major risk factor:

*"Life in Europe is somehow different from our country. Most of us here [in Germany] we tend to change our lifestyle. We start to eat differently, like sweet and packaged food that are not common in our country; starting from me, smoking isn't also uncommon. I believe that those things are the reason for my poor oral health" (IDI-4)*.

#### *3.3. Dental Care Behaviour*

As we enquired about personal and professional dental care practices, most of the respondents acknowledged the fundamental function of routine oral cleanness in preventing and reducing dental diseases. Almost all mentioned exercised some form of oral hygiene routines that varied from once, 6 (24%), or twice, 16 (64%), a day to an irregular basis, 3 (12%), using toothbrushes and toothpaste. In addition, eight (32%), also spoke about their habit of mouth washing in addition to toothbrushing or separately. However, the majority are either not using, or unaware of, dental flossing as a complementary oral hygiene method: "*I have no comments on this method of cleaning teeth. [* ... *] honestly, I know nothing and have also never used it" (FGD-2).*

Few participants, five (20%), have been using tooth twigs (Mewets), a traditional Eritrean teeth cleaning tool, similar to Miswak (Asia, Africa, and the Middle East) [54], which is prepared mainly from two tree branches, those of the Olive tree (Olea Europea subspecies. Africana) and of the Sand olive (Dononaea Angustifolia). The dimensions are 6–10 cm long and 4–10 mm thick. The stick is applied to the teeth to scrub the surface in a horizontal or vertical motion until the twig split thereby allowing one to clean between the teeth as well as massaging and cleaning the gums [55]. When asked about their perception of using Mewets in Germany, their responses were mixed, as most of them acknowledged their habit of applying Mewets as the only tooth cleaning tool in Eritrea but had now changed to other methods: *"I have never used the twig in this country [Germany]; I couldn't find the right tree. I don't have any choice but to use the toothbrush" (IDI-6).*

Regarding the frequency of dental attendance, only, two (8%), participants cited visiting the dentist regularly and diligently on a bi-annual basis while two (8%) admitted that they have never attended a dental clinic in their lifetime. The majority's main reason for a dental visit was as a result of dental emergencies: *"The only time I went to my dentist was [..], the day that I experienced very serious dental pain" (FGD-2).*

Some participants raised doubts over their current regular oral hygiene tools and materials. Two (8%), participants of the FGD commented negatively regarding the regular use of toothbrush and paste: *"If we use the toothbrush frequently, with toothpaste after every meal, I believe that it may damage our tooth" (FGD-1).* One female participant also assumed that the regular utilization of a dental toothbrush widened the gaps between her teeth. As well, irregular, or intermittent use of a toothbrush was considered as a risk factor for bad breath by another participant: "*If we habitually brush our teeth and stop, we may expose ourselves to bad mouth odour" (IDI-13).* Most of the participants also voiced their concerns regarding dental flossing: *"I know about the thread [* ... *], I believe, if you keep on doing it, you can harm your gums now and then" (FGD-1)*.

#### *3.4. Approachability and Ability to Perceive*

This theme refers to the capacity of refugees or asylum-seekers to discover dental care services and the availability of adequate oral health information sources that influence an individual's judgment of access to dental care facilities [53]. Obtaining clear information, locating dental services, and navigating the German health system, was found to be a complex and inconsistent endeavour for most of the ERNRAS. Many of the newly arrived ERNRAS remarked on the challenges associated with finding reliable information on health services, or a person to guide them through the health system. A recently-arrived mother of three, asylum-seeker, commented: *"No one would show or take you to a dental clinic. You have to find it on your own; and it was so difficult to understand and to find out where the dental clinics are" (IDI-2).* The majority of the respondents also reported on their difficulties of navigating the health system in Germany in general: "*You have no idea [* ... *]! it is so challenging to understand how the health system works. There is limited or no information about where, how, and when to approach the eye clinic, the dental clinic and so on" (IDI-6)*.

Although the majority of the participants believed that they have basic oral healthcare literacy, few said anything about how far their lack of exposure to proper professional dental care in Eritrea, had impacted their overall oral healthcare mentality in Germany. They also expressed their strong beliefs in traditional medicine such as potions, herbs, or prayers, as influences on their oral healthcare perception:

*"Back in our country [Eritrea], if we experience any kind of illness, we don't simply go to the clinic [* ... *]. Our parents and community healers used to give us any traditional herbs, potions, and spells. Then we wait for God to heal us. Likewise, here [in Germany] even though I am not using the herbs and potions [* ... *], I simply don't go to the clinic, I just pray at home and wait for God to heal me from my misery" (FGD-1).*

Most participants spoke highly of and trusted their dentists: *"My dentist is so reliable and honest [* ... *]. She is always helpful and she treated almost all of the dental problems I had" (IDI-2).* Some participants, however, disagreed with their health providers' treatment decisions, as well as the bureaucracy involved in dental healthcare for ERNRAS in Germany. They also reported their concerns about the unforeseen forthcoming financial burden associated with dental health care:

*"Sometimes though, the dentists work on a tooth that you have not complained about and we might not be comfortable with it too. As far as I am concerned, I don't like it" (IDI-13).*

*"For some of us, it is like we don't even trust some of the dentists in Germany. I think that when they [dentists] are taking out our teeth, they want to do so in their own interest, and to replace ours with artificial teeth, which is not in our interest" (FGD-1)*.

*"I don't trust the dentists too. I have a trust issue! I mean [* ... *], the bureaucracy is very tedious [* ... *], they tell you to sign here, and there [* ... *], I don't know what we are sometimes saying. Who knows, later they [dentists] might ask us to pay all (laughter)?" (FGD-1)*.

#### *3.5. Acceptability and Ability to Seek*

This theme conveys the intercultural and social competencies of oral healthcare providers to accept refugees, and the ability of refugees to seek dental care services [53]. In addressing that, some participants mentioned a lack of interculturally proficient dental care professionals. One participant iterated:

*"The dentists should try to understand our difficulties in learning the new culture here [Germany]. In our country [Eritrea], we have a different background and practice for tooth care. We don't know much about the new way of dental care in Germany [* ... *], but we used to treat dental pain with herbs. Thus, the doctors should show some kindness and teach us calmly the correct way [* ... *]. My dentist expects me to comply to whatever*

*he said, and he is very rigid and strict [* ... *]. I really didn't understand his instructions and he once yelled at me too (sigh)" (FGD-1)*.

The majority of the participants are satisfied with the services that they obtain at the dental clinics: *"As my former dentist is so cooperative, I also take many of my fellow Eritreans, who don't understand about their dental health, to her and get the treatment" (IDI-1).* A few, however, have commented on communication and conduct issues of some dental professionals: *"My former dentist had a very arrogant receptionist. I wasn't really comfortable with her. I was discouraged from going to the clinic as I couldn't stand her discriminating look; I take only pain killers and stay at home" (IDI-2)*.

Some participants reported a great deal of uncertainty in their capacity to seek dental care. They mentioned that they either were not confident or not independent: "*I once wanted to visit a dental clinic but I couldn't. I honestly had no enough confidence to talk about my complaint" (IDI-6)*. Furthermore, despite understanding the need for regular dental visits, some participants admitted to negligence or indifference. They believed that this was deeply rooted because their upbringing in Eritrea most often did not emphasise the significance of regular dental check-ups and care. One participant also alluded to the widespread and serious suffering on his migration journey (Sahara-Libya-Mediterranean Sea) and using this to relativise and justify his non-use of dental care:

*"As far as I am concerned, the reason behind my hesitation in visiting a dental clinic, despite experiencing marked dental problems, is that I had been through a very bad experience on my way to Europe. I saw and witnessed a lot of awful distress and health problems along my way in Sahara, Libya or at sea [Mediterranean]. Comparing to those, I consider my teeth problem as a simple discomfort and I just resist the pain until it resolves itself" (FGD-1)*.

The majority of the participants explained why they opt out of regular dental visits. They usually related this with the presumptive or experienced fear and apprehension of dental instruments or physical dental pain.

*"I chose not to go back after six months because I hate the machines that trim the teeth. Do you know how annoying are the rotating machines and the other sharp instruments that they [dentists] use? For example, one day, I had experienced a severe headache because of the instruments that they had stuck into my teeth; honestly, I hated it. Now that I am treated, thanks God it's over [* ... *]. It has been three years since I have experienced any kind of dental problem, and I never been in a dental surgery after that too" (IDI-15)*.

#### *3.6. Availability and Accommodation and Ability to Reach*

This theme relates to the availability of services that enable refugees or asylumseekers to access dental care, as well as their abilities to reach the dental care facilities [53]. Communication is found to hamper ERNRAS access to oral healthcare. This was either a result of a language barrier or the non-availability of a translator. Participants confirmed that language problems were the most significant challenge in accessing dental care or support: *"It is the language problem; I can't tell a dentist what is really happening to me, and that is why I didn't go to them [dentists]" (IDI-6).* In addition, nearly all of the participants were concerned about the unavailability of interpreter service and believed that visiting a dentist without a translator could be a source of both misinformation and non-compliance with instruction: *"For example, I had severe dental pain, and I was waiting for artificial teeth. I had to go for several successive appointments, and I asked for a translator, but they [dental team] couldn't find me one. Thus, I missed several instructions from the dentists" (IDI-3).* Furthermore, dependency on an interpreter and the issue of privacy and confidentiality was also mentioned as a barrier by some participants: *"I might find a translator who can help me translate, but I also don't want to share my health problems with people of my own community as he or she might publicise my health issues" (IDI-14).*

The majority of ERNRAS expressed satisfaction with dental services in Germany. However, some were discontented over rigid clinic working hours, long waiting lists or

times, inflexibility of dental appointments, and the long-distances or mobility issues as a hindrance to access to dental care:

*"Most of the appointments that you get are on weekdays [* ... *], where most of us are busy at work or school [* ... *]. They [dentists] won't see you at weekends. So, if we need further visits, we couldn't miss work or classes so often [* ... *]. Thus, we often miss follow-up appointments" (FGD-1)*.

*"I can say that there is some problem, especially for those who reside in villages, where train transport is unpredictable [* ... *]. Pregnant mothers have some access problems. My friend's wife was once caught up in such a difficulty" (FGD-1)*.

#### *3.7. Affordability and Ability to Pay*

This theme describes the financial ability of refugees or asylum seekers to devote enough funds and time to expend on dental care services and their ability to generate capital to finance the services [53]. Although some participants mentioned the free-of-fee primary dental care services, which are covered by insurance, the majority, however, made it clear that cost is a significant impediment to obtaining dental services. They reported that most of the dental treatments except regular check-ups, teeth cleaning, and tooth filling, are out-of-pocket or require co-payment. Indirect costs like those of transport, dental products, and opportunity costs were also mentioned by some participants as a detrimental factor in accessing dental services:

*"In my opinion, comparing with the other services, dental care is expensive, and it always requires several consecutive appointments so that you need to skip work, pay for trains, and dental products like tooth brush, paste or mouthwash" (IDI-1)*.

Participants acknowledge the complexity of health insurance eligibility and entitlement procedures, i.e., how, where, and when to approach or access dental care services. Many participants experienced that eligibility for free dental services depended on factors such as age and refugee status (asylum application decisions). They also remarked on the impact of employment status when seeking dental care:

*"I haven't had enough money to get the treatment [orthodontic treatment], because I have no work or income" (IDI-4)*.

#### *3.8. Appropriateness and Ability to Engage*

Here the compatibility of the dental service with the needs of refugees and their involvement in decision-making and treatment decisions were explored [53]. Most participants were content with their dentists' diagnosis, management, and communication competence: *"My doctor is so good and tells you everything about your oral health. She effectively treated all my dental problems and also cleaned my teeth" (IDI-2)*. Some, however, have perceived, and complained about, the technical and interpersonal inadequacy and incompetence of the service providers: *"I can say that my former dentist could have done more [* ... *]. Not only did he treat my complaint badly, but he also forced me to go along with his decisions. That's why I always complain about him, the treatments that he gave me were neither appropriate nor satisfying" (IDI-3).*

Some participants indicated that some of their providers (dentists) were not only uncooperative and bad-tempered, but also difficult to build relationships with. One participant complained about a significant amount of money that she was forced to pay for unsuccessful treatment: *"I couldn't express my feelings. I wanted to sue the dentist [* ... *], but I don't know how everything works, and I don't know the court and how to take people to court too. I was so frustrated and depressed (sigh)" (IDI-12)*. Many participants though admitted to their own lack of adherence to regular dental visits and appointments: *"I have never been in the dental clinic for the last two years, after I had received a dental treatment that actually relieved me from the pain that I had. To speak from experience [* ... *], once my dentist strongly advised me to visit a dentist every six months. She told me that I am entitled to two check-ups a year and teeth cleaning [i.e., scaling and polishing]. Still, I am not adhering to her advices (laughter)" (FGD-2).*

When participants were probed about their role in decision-making regarding their treatment options, many of them reported having limited enthusiasm to engage in their treatment decisions. This, they believe, affected their motivation to become involved in dental care and commit to finishing their treatment:

*"My dentist once informed me that my tooth was decayed and suggested to extract it, and I simply agreed. Then when he [the dentist] attempted the extraction, it took him six hours. Since the tooth was decayed only on the upper part not at root, I should have asked him to restore it. It was my mistake. I was looking for a temporary solution but it cost me a lot and my left cheek was really numb for the following six months" (IDI-3)*.

As results have been summarized in Figure 2, the oral healthcare attitude attributes of Eritrean refugees and asylum-seekers not only make proper self and dentist dental care difficult but also appear to negatively affect directly or indirectly the accessibility and utilisation of oral healthcare services as much as the supply (structural) side barriers do.

**Figure 2.** The effect of individual and structural barriers on oral healthcare accessibility and utilization of ERNRAS.

#### **4. Discussion**

This qualitative research identifies the major oral health concerns and barriers to dental care services among Eritrean refugees and asylum-seekers living in Heidelberg, Germany. In addressing those concerns, the results of our study indicate that the participants defined good oral health as the absence of any condition that involves problems with teeth, gums, jaws, cheeks, lips, or breath. This finding is consistent with a qualitative study carried out among newly arrived refugees in Canada, where the assessment of participants on what represents good oral health comprised absence of swelling, missing, broken, decayed or painful teeth [56]. As it has been documented in several studies among African refugees [28,57,58], ERNRAS also acknowledged the physical, mental, and social benefits of regular oral healthcare. The WHO pointed out that the oral cavity is not an isolated organ, and consequences of poor oral health are not only limited to the teeth but also affect general health [36]. In line with that report, the current study revealed that most of the participants were conscious of good oral health as part of holistic health, including the need to avoid the possible life-threatening consequences of untreated oral diseases. Compared to findings reached by Keboa and colleagues [28], our study identified the psychosocial concerns of bad breath and further new insight into a custom followed by some ERNRAS, mainly to prevent oral malodour by routine consumption of a traditional pepper (Berbere). The metal chelating activity (to stabilize and remove harmful metals), antioxidant properties, and enhancing effect on the carbohydrate-hydrolysing enzyme (hypoglycemic activity) of spice

blend Berbere has been scientifically established [59]. However, the anti-halitosis element perceived and hypothesized by ERNRAS is yet to be researched.

When refugees are settling in Western countries, they are introduced to a higher-sugar diet than they were accustomed to in their COO [60]. Our findings confirm this dietary transition into the consumption of readily available 'carb-heavy' foods (concentrated with sugar and fat) in Germany and are perceived as a leading cause of their dental diseases. The nutritional transition and its negative impacts on the overall oral health of refugees and asylum seekers had been identified in several studies [15,29,30,61].

Dental care is the preservation of a healthy oral cavity, and it relates to regular personal and professional oral healthcare [36]. However, our study found that the majority of participants do not comply regularly with all the recommended dental care practices [15,24,28,30,61,62]. Almost all of the participants accepted toothbrushes and mouthwash, while none of them acknowledged dental floss as a significant oral hygiene tool. This result builds on the existing evidence, where a study reported that refugees were barely utilizing dental floss as a complementary device to clean their interdental areas [15]. In addition, unlike in Germany, most ERNRAS disclosed their utilisation of twig (Mewets) as a sole oral hygiene tool when they were in Eritrea. A study in Eritrea has shown the antimicrobial and anti-cariogenic (caries prevention) effect of Mewets [63]. The study might suggest the change in practice (from Mewets to a toothbrush) reflects the belief or attitude change. However, considering findings in similar studies of East African refugees [29,61], a more plausible explanation is the inconvenience and unavailability of the right tree in Germany. Regarding reasons for dental attendance, the results demonstrate that the majority only seek treatment in times of dental emergency or pain. This finding mirrors several studies amongst East African refugees living in the U.S.A [61], Australia [30], and Canada [28].

Misperception related to oral hygiene tools and methods among many East African refugees has been highlighted in previous studies [29,61]. Nevertheless, the findings from the current study go beyond previous reports, showing that some ERNRAS have negative perceptions about regular use of a toothbrush, toothpaste, and dental floss. However, they also believed that discontinuation of the routing toothbrushing could lead to halitosis (bad breath). The plausible explanation of this erroneous assumption is that users were unable to notice their halitosis before they started using toothpaste; they might not have known that an oral malodour already existed. Since our sense of smell is a learned behaviour [64], they start to differentiate bad breath from normal breath following the discontinuation or skipping of regular toothbrushing. Revisiting the belief that some ERNRAS rely on the hypothetical concept of Berbere's advantage in preventing bad breath, brushing is not only replaced as an important means to prevent oral malodour, but also considered to be detrimental to oral health.

This study found that ERNRAS had or have difficulty in obtaining information, locating oral healthcare services, and navigating the health system in Germany. A similar conclusion was reached on recently-arrived refugees in Finland [25], and East African refugees in Australia [58]. As well, participants with limited oral health literacy and undesirable health beliefs might also hamper their dental care-seeking behaviour as a study conducted in Eritrea by Andegiorgish and colleagues shows [65]. Furthermore, since stress and psychological insecurity are endemic among refugees [13,26], a dentist and trust-based dental treatment seem to be largely unachievable [58]. Consistent with previous findings [26,57], fear of dental pain, anxiety, or past negative dental experiences of oneself, friends, or family members influenced the care-seeking behaviour of ERNRAS. Additionally, the current study goes beyond that some ERNRAS present with certain trust issues towards provider's possible dental malpractice and unpredicted future financial implications of the current dental treatments.

The reported lack of interculturally competent professionals was a significant finding in this study. The perceived experienced discrimination, lack of empathy, and misconduct were also identified in related studies [58,66]. This underlines the importance of a dentist who understands and accepts his or her patient's diverse cultural beliefs and background. Furthermore, in line with similar research [67,68], this study found that apart from personal dental care disregard and negligence, reduced autonomy and self-reliance are also some of the participants' hurdles for seeking dental care.

This study suggests that communication features, language barriers, or unavailability of translators, negatively affect participants' accessibility. This finding mirrors other studies in Europe [8,69], and in Germany [70]. It is understood to be a major barrier to seeking oral healthcare services for the majority of ERNRAS. Moreover, our findings confirm that the patent's dependence on translators not only interferes with an effective conversation, diagnosis, and follow-up but also raises concerns on confidentially and privacy [71,72].

This study established that ERNRAS faces difficulties in understanding the working hours and appointment procedures of dental clinics. This correlates reasonably well with a study conducted by Mattila et al. [25], and further supports existing findings on the challenges of refugees' to secure and attend dental appointments, cope with long waiting times, and make the right treatment choices [30,58,67].

Many of the participants of this study report either postponing or avoiding dental treatments because of direct or indirect costs (transport, dental products, and opportunity costs). Evidence from other studies in Germany (direct payment) [16], Australia (copayment and indirect payment) [67], and North America (direct and indirect payment) [28], all suggested that financial difficulties discourage refugees from seeking dental treatment. Analogously, a lack of health insurance and entitlement, as well as unemployment seems to pose challenges for asylum-seekers whose legal asylum status were still being processed. Age and refugee status are factors that affect the health entitlement of refugees to publicly funded health insurance. Minors (children and young people under the age of eighteen) and refugees fully covered, whereas asylum-seekers, during their first 18 months in Germany have restricted access (*§4 and § 6 Asylum-Seekers' Benefits Act (AsylBLG))* [32], that in turn complicate assess and delay integration into the German health system. This result reflects findings from Australia [58], and Germany [73,74]. These show that eligibility criteria based on refugee status not only complicated access to health care but also resulted in delayed care, affect treatment outcomes, and increase expenditures.

This research identified access and follow-up issues of some participants related to professional inadequacies. This includes perceived failure to competently convince, agree on, and accommodate patients' treatment demands. A similar pattern of results was obtained in a systematic review compiled by Keboa and colleagues [28]. As indicated by Hobbs [58], the evidence that we found confirmed that a poor relationship between participants and providers acts as a barrier to seeking dental care. Furthermore, in line with research conducted in Australia [30], access to dental care was inhibited because participants were found to show less adherence to dental treatment. Many of them were found to be poorly motivated and to be less engaged or involved in their own oral health decision-making, including the choice of alternative treatments.

#### *4.1. Study Strengths and Limitations*

To back up the credibility of our research, we applied the concept of trustworthiness by Lincoln and Guba (1985) [75] with its four components: Credibility, Dependability, Confirmability, and Transferability. Credibility, which relates to the researchers' ability accurately to identify and describe the study participants [75], was reached through triangulation (both IDI and FGD), prolonged and persistent observations of participants until thematic saturation, and member checking with three participants to verify and provide feedback for their transcript and interpretation of the findings. Dependability, which refers to the consistency of data with time and conditions [75], was appreciated by auditing the rich and thick data set (transcript) against the recorded audio by another Tigrinya-speaking co-author (T.G.) and experienced supervising researcher (C.B.). Confirmability, which closely refers to the objectivity of the research [75], was realised by reflecting on our own preconceptions, bias, backgrounds, and beliefs and thus ensuring that researchers have not

influenced the findings in the process of extracting information or analysing the collected data. Yet, being conscious of all these points, and as one of the principal researchers (YSK) is a registered dentist in Eritrea and a Tigrinya speaker, we had continually to reflect on our roles in the research process and the possibility of influencing the response of participants. We embrace this professional perspective and remain as part of the research but at the same time did justice to the shared experiences of our respondents without evaluating them solely from a medical perspective. Transferability concerns how far it is possible to apply methods and findings to other similar study contexts [75]. It was reached by explicitly describing our sample, participants characteristics, methodology and study setting.

The COVID-19 pandemic and subsequent contact restrictions that were in place in Germany during the data-collection phase (March–May 2020) posed some challenges for the research. Due to that, we had to change the initially planned face-to-face into online interviews. Online communication deters the possibility of using the whole spectrum of non-verbal cues and interferes with building a robust relationship between interviewer and interviewee. We addressed that by employing follow-up and probing questions to keep respondents focused throughout and across all the interviews and discussions. We also transcribed, from the recorded video, all the verbal expressions, facial expressions, and emotional intonations of the respondents.

We highlighted a lack of back-translation of the transcripts from English back to Tigrinya as another limitation of this study. Inter-rater reliability could have been approached had another translator back translated the transcripts prior to analysis. We had insufficient funds for a second translator, however, the translations were reviewed for accuracy by both Tigrinya and English-speaking co-author (T.G.).

#### *4.2. Practical Implications*

The findings suggest that Eritrean refugees and asylum-seekers are not sufficiently well-informed about their overall oral healthcare, nor do they make enough use of oral healthcare services. Acknowledging refugees' poor oral health status and limited access globally, it is considered that dental services should be included within primary healthcare, and efforts should be made to provide comprehensive dental screening at the first point of entry into host countries.

With regards to issues related to navigating the health system and misconceptions about oral hygiene, authorities and health workers should develop and deliver oral health education, promotion, and outreach activities, to improve awareness, utilisation, and accessibility of dental services. In addition, accessible and understandable information should be provided on scientifically supported oral hygiene measures, preventative dental care, and how to access the German health system. Oral healthcare providers should also build trust with their clients by cultivating a friendly patient-provider relationship, understanding culturally sensitive information, and demonstrating intercultural competency.

Enhancing oral health literacy in the community, and appropriate dental public health strategies would probably also benefit oral health care among refugees and asylum-seekers. Policy-makers should re-define the current framework (*AsylBLG*) of eligibility criteria for asylum seekers to access dental care only for emergencies, or painful and acute conditions, and that in event involves lengthy administration procedures [32].

Finally, as oral health care of refugees is still a neglected field, we recommend further research that focuses on oral healthcare professionals' experience and perspective of dental care services.

#### **5. Conclusions**

Eritrean refugees and asylum seekers have a fairly realistic perception and understanding of oral health. However, the majority have poor dental care behaviour or practice, whilst a few have certain misconceptions of the conventional oral hygiene tools. This study uncovered that the majority of the participants were mainly concerned about the psychosocial attributes of poor oral health rather than its functional implications. Since their

arrival in Germany, the participants have been found to be influenced by the global dietary transition. This is not only a contributing factor to the rising burdens of non-communicable diseases (NCDs) worldwide [76], but is also believed to be the leading cause of their poor oral health. This study has shed light on participants' reported barriers to oral healthcare services. Along with the individual's or client's own ability barriers, communication barriers remain the main hurdle at all stages of accessing oral healthcare. That includes problems with identifying and navigating oral health services. Additionally, it interferes with initiation or building up patient-doctor relationships. It further interferes with what to do when patients arrive at the dental surgery, how to decide on payment arrangements, and whom patients should trust. To address the oral health burdens of ERNRAS, it is prudent to consider language-specific, inclusive, and culturally and professionally appropriate oral health care services. Only then the Universal Health Coverage (UHC) of the Sustainable Developmental Goals 3 (SDG 3) could be achieved.

**Author Contributions:** Conceptualization, Y.S.K., C.B., J.B.-M.; methodology, Y.S.K., C.B., S.Z., V.K., T.G.; formal analysis, Y.S.K.; writing—original draft preparation, Y.S.K.; writing—review and editing, C.B., S.Z., V.K., J.B.-M., A.J., T.G.; supervision, C.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethical Commission of the Medical Faculty of Heidelberg, Germany (protocol number: S-207/2020, 16 April 2020).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Acknowledgments:** We thankfully acknowledge for all those who provided assistance in recruiting study participants, especially Yonas Shishay and Abraham Tuemzgi. My heartfelt gratitude goes to all Eritrean refugees and asylum seekers residing in Heidelberg for their generous participation in this work. The principal author (YSK), would like to forward his sincere appreciation to Open Society Foundation (OSF) for the Civil Society Leadership Award (CSLA) and German Academic Exchange Services (DAAD) for granting him this priceless and exceptional opportunity to study Master's degree at Heidelberg Institute of Global Health.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A**

**Table A1.** Wide-ranging questions of the IDI and FGD.

### **Appendix B**

**Table A2.** Themes, sub-themes, and exemplar quotes.

**Table A2.** *Cont.*

**Table A2.** *Cont.*

#### **References**

International Journal of *Environmental Research and Public Health*

### *Review* **Dental Caries among Refugees in Europe: A Systematic Literature Review**

**Sneha Bhusari , Chiamaka Ilechukwu, Abdelrahman Elwishahy , Olaf Horstick, Volker Winkler and Khatia Antia \***

Heidelberg Institute of Global Health, Heidelberg University Hospital, 69120 Heidelberg, Germany<EMAIL_ADDRESS>(S.B<EMAIL_ADDRESS>(C.I<EMAIL_ADDRESS>(A.E<EMAIL_ADDRESS>(O.H<EMAIL_ADDRESS>(V.W.)

**\*** Correspondence<EMAIL_ADDRESS>Tel.: +49-152-2785-7798

Received: 10 November 2020; Accepted: 16 December 2020; Published: 18 December 2020

**Abstract:** Oral health is one of the most neglected aspects of refugee health. The study aimed to systematically review evidence on prevalence of dental caries and dental care services provided to refugees in Europe. Following PRISMA guidelines, we searched PubMed, Cochrane, WHOLIS, Web of Science, Medline Ovid, and Google Scholar identifying studies on dental caries among refugees in Europe after the 2015 refugee crisis. From 3160 records, fourteen studies were included in the analysis. Eight studies on oral health showed caries prevalence of between 50% and 100%, while it ranged from 3% to 65% in six general health studies. Caries prevalence was proportional to age and inversely associated with education, whereas gender and country of origin showed no significant association. Nowhere is oral health part of general health assessment on arrival and is complaint based. Primary focus on resettlement, language, cultural, and economic barriers emerged as explanatory models for limited access. Our study identified a high prevalence of caries and limited access to dental health services as main challenges. Integrating oral health check-ups may contribute in shifting towards preventive oral care. Further research is urgently needed to better understand the dental needs of refugees in Europe.

**Keywords:** caries; decay; Decayed Missing and Filled index (DMF) and dental health; refugee; asylum seeker

#### **1. Introduction**

Antonio Guterres, the Secretary-General of the United Nations, described the European situation in 2015 as "primarily a refugee crisis, not only a migration phenomenon" [1]. In 2015, the largest movement of people for 20 years was seen, with more than 3.5 million refugees in Europe [2]. The International Organization for Migration (IOM) defines a refugee as "a person who is outside the country of his nationality and is unable to avail himself of the protection of that country" [3]. During refugees' state of unrest, the most valuable assets become necessities such as clean water, food, nutrition, shelter, sanitation, and protection, while medical assessment and healthcare are neglected [4]. Moreover, refugees are faced with language barriers, unfamiliar surroundings, new laws, rules and regulations [3].

Refugees are always at a risk for innumerable issues regarding health [5]. Of all the conditions faced, necessary or emergency health issues are addressed in European countries [6]. Major areas of health focused upon include non-communicable and communicable diseases, maternal and child health, occupational health and mental health [7]. Even though oral health is a key indicator of overall health, well-being and quality of life [8], it is not part of this essential list [7]. Moreover, the exclusion of dental assessment within basic care makes refugees more vulnerable [4] and the lack of active involvement of a dentist curtails the importance of oral health [9].

Oral and or dental diseases are correlated with non-communicable diseases (NCDs) [9]. They can result in malnutrition due to alterations in diet, and phonation problems, especially in the older age group [10]. There is also higher body dissatisfaction [11] and simple acts of smiling, communicating and eating can be affected negatively [12]. Hence, oral health not only affects one's general health, but also has an impact on mental health. Dental caries is the leading oral health problem, with high prevalence, affecting a large population in the majority of the countries, including Europe [12,13]. The basic motive for seeking oral health is mainly pain based [12]. Ordinarily, oral health, and in particularly caries, is one of the most neglected aspects of health irrespective of region, culture, education or the socioeconomic status of an individual, and more so in low and middle-income countries. The overall burden is decreasing due to public health measures, but prevalence still remains high [12].

Considering war-affected regions, attention to oral health can be even worse or non-existent. Such populations suffer the most, not only with the general requirement for oral care, but also with need based (i.e., pain based) oral care, and prioritizing oral health becomes increasingly difficult for refugees as other priorities are pre-eminent [6]. In light of this situation, the prevalence of dental caries is expected to be high among refugees in general and in Europe in particular. Lack of proper education, information and awareness of oral health, lack of inclination to maintain good oral health, overall neglect of oral health and financial limitations, coupled with geographical constraints, war or devastating surroundings, migration, resettlement in foreign lands, language barriers and lack of stability have resulted in an increase in dental caries (along with other oral problems) [14]. This lack of provision is the main area of concern about, and hindrance to, obtaining health data and achieving good health care.

The aim of this study was to find out the prevalence of dental caries among refugees in the European region. The objectives were twofold: first, to synthesize the evidence of prevalence of dental caries among refugees in the European region after the 2015 crisis by evaluating the Decayed Missing and Filled index (DMF); and second, to evaluate the dental care services provided to the refugees in Europe and their needs and shortcomings

#### **2. Materials and Methods**

This study followed the reporting guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [15]. We included all types of quantitative and qualitative study. There was no restriction regarding the language, age, gender, country of origin, education, or socioeconomic status of the participants. However, we included only studies focusing on caries among refugees or asylum seekers after 2015 (the European Migrant Crisis), but not on oral conditions of periodontium or oral mucosa. We also excluded studies with the word "migration", "migrant" or "immigrant" from the search. The word 'Europe' was a broad term; therefore, we dropped the term 'Europe' during the database search and manually searched for European studies. We performed the search in English using the key words Refugee or Asylum seeker in combination with Caries, Decay, DMF or Dental Health through the following databases: PubMed, Cochrane, World Health Organization Library Information System (WHOLIS), Web of Science, Medline Ovid and Google Scholar. The search was finalized on 21st November 2020. The database searches as well as the screening procedure were run independently by the first and the second author. Conflicts were resolved upon agreement by focusing on the eligibility criteria and the aims set for this review. Removal of duplicates was carried out at a later stage. Table 1 denotes the PICO criteria used for this study.

**Table 1.** PICO and eligibility criteria for this systematic literature review.

The decayed, missed and filled index, known as the DMF index, is the measure of the prevalence of caries; it identifies the number of teeth with dental caries including its effects on an individual [16]. The DMF index has been a simple, rapid, universally accepted and widely used tool for several decades to determine coronal caries experience, since it requires a minimal inventory: natural light, plain mouth mirror and a fine probe. The calculation of DMF is performed by obtaining the number of decayed, missed and filled teeth or surfaces [17,18]. However, the DMF index does not distinguish the reason for loss of tooth (MT) [16]. We extracted information regarding Decayed teeth (DT), Missing teeth (MT), and Filled teeth (FT), and the average DMF index from the included studies to look mainly at the experience of caries, where only the DT factor was focused on.

We evaluated risk of bias using the quality assessment tool of The U.S. National Institute of Health (NIH) [19]. This provided separate assessment criteria for different types of studies under one domain. We used two groups: Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, and Quality Assessment Tool for Case Series Studies.

#### **3. Results**

Our search yielded 3160 records, 1717 from the five databases and 1443 from Google scholar for which we screened the first 200 hits per combination until no further relevant studies were found. 205 articles remained after title and abstract screening, from which twenty full texts were evaluated against the eligibility criteria. Finally, fourteen studies were included in this systematic literature review. A detailed description of the screening process can be seen in Figure 1.

From the final fourteen articles, only one was a qualitative study [20] while others were: ten cross-sectional [6,21–29], one cohort study [30] and two case reports [2,13]. All except two studies [13,28] had a comparison group. By the Quality Assessment Tool, only one was graded as 'fair' [30] while all other studies were 'good'. The main host countries were Belgium, Finland, Germany, Greece, Norway, Spain, Sweden and the UK, while refugees originated from a wide range of countries with a majority coming from Afghanistan, Iraq and Syria. Less frequently, refugees came from Asia, Africa, Europe and the Middle East as listed in Table 2.

**Table 2.** *Cont.*

Note: NS—Not specified.

**Figure 1.** Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA flow chart depicting the selection process [15].

All studies addressed information on oral or health status, four studies [6,13,29,30] focused on the healthcare needed, three studies [20,25,28] examined the treatment provided and two studies [13,30] examined necessary improvements. The study populations in three studies [24,25,29] were children, in five studies children and adults [22,26–28,30] and in four studies only adults [6,20,21,23]. All study samples consisted of more men than women. Questionnaires on both medical and travel history along with present living and medical conditions including clinical assessments were the primary sources of data in all studies except one [20], which used self-reporting as a source.

Only eight studies [6,13,20,21,23,24,27,28] had oral health as the focus while others concentrated on oral checkups along with general health assessments. The prevalence of caries was higher in the oral health focused studies as shown in Table 3. Only one study [24] reported a low prevalence of caries, which was explained by the fact that children from wealthier families had better access to oral health services in the country of origin. From the above mentioned eight studies, only five studies [6,21,23,24,27] used the DMF index as a part of their analysis, while others recorded oral issues based on complaint. Four studies [6,21,23,27] out of the five reported a very high DMF severity. These five studies also showed an expanded version of the Decayed Missing Filled Teeth (DMFT) index with individual components reported, namely Decayed Teeth (DT), Missing Teeth (MT) and Filled Teeth (FT). As seen in Tables 4–6, the DT is observed to be high for all the studies except one [23], where the author suggests the high to moderate social status of the sample population to be the reason for higher MT and FT as compared with DT. DMF is denoted as an index for permanent teeth, and dmf for deciduous teeth.

**Table 3.** DMF and Caries prevalence.

Note: GH—General health; OH—Oral health; AS—Asylum seeker; NR—Not Reported; \* For 30 Patients; <sup>a</sup> All participants were adults; <sup>b</sup> All participants were children; <sup>c</sup> Participants were children and adults. For deciduous (up to 6 years—permanent (up to 12 years) teeth respectively. SPHERE—Global movement started in 1997 to improve quality of humanitarian assistance, Humanitarian Charter and Minimum Standards in Humanitarian Response; WHO—World health organization; ICD-10—International Classification of Diseases, 10th revision; astdd—Association of State and Territorial Dental Directors; ICDAS—International Caries Detection and Assessment System; BEMA—standard of evaluation of dental services and forms within the statutory health insurance in Germany.

**Table 4.** Detailed DMF Index reported in the included (dental) studies: All participants were adults.

Note: ME—Middle East; A—Africa. **Table 5.** [24] Riatto et al., 2018.

Six studies found an association between caries and socio-demographic variables [6,21,22,24,27,30]. Age was directly correlated while education was inversely proportional to caries prevalence [30]. Caries was inversely proportional in deciduous dentition age while directly proportional to permanent dentition age [24]. All studies showed that men had a higher prevalence compared to women. No country of origin specific effects were observed [22] but Høyvik et al. [6] suggest that the differences in caries prevalence are related to the origin of the refugee population when comparing two sets of refugees from the Middle East and Africa. None of the included studies had access to the pre-arrival oral health status of the sample population.

All except four studies [13,20,22,24] showed the need for oral screening and all except five studies [2,6,22,25,30] concluded the need for a preventive focus. Freiberg et al. [28] suggested that regular check-ups have a potential to improve refugees' health literacy and raise awareness of the benefits of such preventive measures. The utilization of an existing Primary Health Center (PHC) to incorporate oral health care need was suggested in six studies [20–22,25,26,30]. Furthermore, seven studies [6,20–23,25,26] pointed to the economic burden on both the refugees and on the host

country while dealing with easily preventable oral complications. General referral systems seemed to be in place according to four studies [23,25,26,30] while two studies [13,20] directly provided necessary interventions. Specifics about utility of referral systems were not discussed in any of these studies. Six studies [6,21,24,27–29] emphasized the need for interventions. Moreover, Al-Ani et al. [27] encouraged all European migrant receiving countries to strengthen their dental capacity, as refugees' dental care needs are expected to further increase in the near future. Accessibility, cariogenic diet and poor oral hygiene were seen to be the main causes for disease pattern in all the included studies. The study of Hjern and Kling [29] argued that children are especially vulnerable, as they are affected by the caries-promoting food culture of their families. Finally, five studies [2,20,21,23,27] raised the issue of 'Health as a human right'. One [2] study stressed the importance of clinicians to carry out a dual role by providing care and advocating for dental needs. Language and cultural barriers [2,6,13,20,21,25,27,28], selection bias, mainly due to self-reporting or voluntary treatment-seeking behavior, among other reasons [6,20–23,26], lack of diagnostic tools and resources [6,13,21,22,26], small sample size [20,23,24], missed other oral health details [6,21–24,26], lack of representativeness [21,25,28] generalizability [22,25], crude methods used and insufficient data quality [27] were some of the limitations reported in the included studies.

#### *Further Results*

Our study found that refugees are at increased risk of developing oral diseases (mainly dental caries) when compared to the local populations (See Table 3). Filled Teeth were more frequent among the local populations and also among other migrants in comparison to refugees, whereas Decayed Teeth were more common among refugees (See Table 3). This clearly shows that the local population has better access to and utilization of available dental treatment. Missing Teeth were similarly distributed among all three groups (See Table 3). The authors explained this by the fact that refugees originated mainly from war-affected regions, where the priority for curative treatment is completely absent [24]. Availability of health services seems to be scarce, along with other necessities such as clean drinking water, a hygienic environment and other cleaning and sanitation products [23]. Moreover, children tend to suffer more since they are not provided with the essential oral health services and practices, which may have long-lasting negative effects [23,29].  The studies emphasized the lack of human and material resources [6,20,23,25]. A shift from curative to conservative to preventive care is highly recommended [13,20,21,23,24,26–29].

Effects of oral health on refugees' general health is an important aspect addressed by several studies; e.g., Høyvik et al. [6] state that dental problems have a substantial effect on social, physical and psychological well-being; missing teeth can be detrimental to self-confidence. Especially, reduced social and psychological well-being can delay the acceptance and amalgamation process and, therefore, lead to social isolation and mental issues resulting in increased overall health problems [23]. Other factors not directly associated, but important, such as dental fear, anxiety or post-traumatic stress disorder (PTSD), also need appropriate planning and time for treatment [2,6,13,20,26,30]. Additionally, the unavailability of orientation from the host country [21] and of proper oral care is one aspect highlighted by all studies except one [30].

Studies included in our analysis emphasize the health needs and oral health seeking behavior of refugees. Findings suggest less motivation and orientation regarding oral health care and prevention among refugees when compared to the local population [21]. Refugees' priorities tend to be more towards resettlement [6]. Additionally, studies suggest that refugees in the transition phase are provided mainly with emergency care. Refugees tend to have similar access to dental services as the local population only once their refugee status is accepted [2,20,21,25,26,28]. Language, cultural and economic barriers, social isolation, the unfamiliarity of the health care system of the host country, laws, regulations and restrictions can further limit access to needed dental care.

#### **4. Discussion**

Prevalence of caries and dental treatment needs are high among refugees and the burden is increasing with the ever-growing influx of this population. The complex process of integration entails challenges, which also puts a burden on the host country. The unavailability of oral screening at reception sites leads to missing detectable oral health problems, which should be treated as early as possible to improve treatability. Consistent with our results, other studies from the USA [31–33], Canada [34] and from Australia [35,36] show high prevalence of caries, poor oral hygiene and similar unmet treatment needs among the refugee population. Moreover, a lack of information on pre-arrival oral status makes comparison and assessment difficult.

We found that more data is available on the general health needs of refugees in Europe while data on oral health is scarce. Additionally, the lack of oral assessments and inconsistencies within insurance systems, such as lack of uniformity and harmonization in cost coverage which depends on per capita spending on health care [37], add to the barriers in achieving good oral health. As a result of these large fluctuations and the diversity of refugees, the challenges faced are not homogenous [6]. The journey, and later the waiting time to become an officially accepted refugee by the host country, exacerbate preexisting conditions [21]. This not only increases suffering, but also incurs unnecessary costs [6]. This, in turn, puts excessive pressure on the individual as well as the host country's health system [21]. Language, cultural barriers and the unfamiliarity of the health system further amplify this. The European refugee crisis is a persistent issue gripping refugees and host countries alike and brings in challenges on a daily basis. In spite of all the advancements and resources available at the disposal of European countries with a good health care system in place, inclusion and integration of refugees and asylum seekers still remains challenging [6,7,23].

Studies that primarily focused on refugee oral health examined oral hygiene practices, periodontal health, DMF of teeth and knowledge and self-perception regarding oral health. A dentist and necessary dental equipment were also available for the assessment, making it easier to detect problems. However, equipment for screening, such as dental *x*-rays, was not available which might have led to an underestimation of prevalence. Studies that focused on general health had no dentists in their study teams and dental equipment was not mentioned. Hence, only complaints about oral/teeth problems or pain were registered, which is likely to have led to an underestimated prevalence of oral problems.

Studies included in this review clearly show the substantial effect of oral health on general health and especially on mental health and well-being. Some non-migration focused studies investigated the link between oral and general health, e.g., Kitamoto et al. [38] and Patini [39] suggest an association between oral microbiota and systemic diseases.

Dental fear and anxiety are other important aspects emphasized by the included studies. Especially, children seem to be more vulnerable to pain associated with dental treatment. Some authors examine this issue and emphasize the importance of local anesthesia (LA) in achieving pain-free treatment [40]. However, according to the authors, anxiety and stress associated with local anesthetic injection makes pain-free treatment challenging [41,42].

Little emphasis has been given to oral health research among refugees in European countries during the last 25 years [6]. Further research is needed; however, based on available data, targeted interventions should be implemented [6]. Early detection of oral health conditions can be considered as the most effective way to address the complex problem of oral health. Immediate oral assessment of refugees at the point of entry or registration for consecutive dental screening [21] can prove vital [6]. Communication in the native language can also help avoid any misunderstanding and delays [21].

Consistent with our results, studies from other non-European regions suggest that targeted services will help access major oral health care challenges even with limited resources [6]. Riatto et al. [24] state that a structured assessment of the refugees' situation with respect to the amount of dental care received, economic capability, knowledge and awareness, and access to oral health care services will be needed to plan and arrange necessary services for oral health care. Canada is the only country with specific guidelines for oral services for refugees [43].

Several limitations of this systematic review should be mentioned. No language restrictions were set during the search but the search terms were in English. Due to its simplicity and popularity, we focused on the DMF index as a quantitative measure of caries prevalence. We only concentrated on the D factor of the DMF index. As MT can also be due to multiple reasons other than caries (such as trauma, periodontal issues, etc.), there can be a risk of bias. However, our search and screening procedure did not bring up other measures to quantify caries among refugees; only one study used Index of Restoration (IR) [24]. Due to the lack of comparability, we decided not to perform a formal meta-analysis. Due to unavailability of data, we could not compare pre and post-arrival oral health conditions. Lastly, the element of human error and bias cannot be neglected, which may have caused the loss of some information or a steering of the conclusions.

Despite these limitations, our study provides a comprehensive analysis of the available data on dental caries and provided oral health care among the refugee population in the European region after 2015. This systematic literature review adds to the existing literature on the specific needs and associations required for further planning. Moreover, it brings dental and oral health into focus. Concentrating on caries may help to discretely tackle a major condition, provide required treatment and precisely fulfill unmet needs for better oral health.

#### **5. Conclusions**

Our systematic literature review shows a high burden of dental caries, with increasing severity among refugees in Europe. Factors such as pre-existing poor oral health, limited access to treatment, language and cultural barriers, and lack of orientation and unfamiliarity with the host country's health care system might be major reasons and lead to low oral health-seeking behavior. Additionally, dietary behavior and changes owing to migration, low oral hygiene practices and lack of preventive measures in the host countries lead to worse oral health over time. Further research focusing on refugees in Europe is needed to better understand, plan and install preventive measures. Setting priorities now with the available data is urgently needed to improve oral health among refugees in Europe.

#### *Key Points*

**Author Contributions:** Conceptualization, K.A., V.W. and O.H.; methodology, K.A., V.W. and O.H.; formal analysis, S.B., A.E., C.I. and K.A.; resources, A.E., C.I.; writing—original draft preparation, S.B.; writing—review and editing, S.B., K.A., C.I., A.E., V.W., O.H.; visualization, S.B.; K.A.; supervision, K.A.; project administration, V.W., O.H.; funding acquisition, K.A., V.W. All authors have read and agreed to the published version of the manuscript.

**Funding:** For this systematic review no funding has been received, and no ethical approval is needed, since all relevant information is in the public domain. No research has been performed involving human participants and/or animals.

**Conflicts of Interest:** The authors have no conflict of interest to declare.

#### **References**

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### *Article* **Health Patterns among Migrant and Non-Migrant Middle- and Older-Aged Individuals in Europe—Analyses Based on Share 2004–2017**

**Nico Vonneilich 1,\*, Daniel Bremer 2, Olaf von dem Knesebeck <sup>1</sup> and Daniel Lüdecke <sup>1</sup>**

**Abstract:** Introduction: European populations are becoming older and more diverse. Little is known about the health differences between the migrant and non-migrant elderly in Europe. The aim of this paper was to analyse changes in the health patterns of middle- and older-aged migrant and non-migrant populations in Europe from 2004 to 2017, with a specific focus on differences in age and gender. We analysed changes in the health patterns of older migrants and non-migrants in European countries from 2004 to 2017. Method: Based on data from the Survey of Health, Ageing and Retirement in Europe (6 waves; 2004–2017; *n* = 233,117) we analysed three health indicators (physical functioning, depressive symptoms, and self-rated health). Logistic regression models for complex samples were calculated. Interaction terms (wave \* migrant \* gender \* age) were used to analyse gender and age differences and the change over time. Results: Middle- and older-aged migrants in Europe showed significantly higher rates of depressive symptoms, lower self-rated health, and a higher proportion of limitations on general activities compared to non-migrants. However, different time trends were observed. An increasing health gap was identified in the physical functioning of older males. Narrowing health gaps over time were observed in women. Discussion: An increasing health gap in physical functioning in men is evidence of cumulative disadvantage. In women, evidence points towards the hypothesis of aging-as-leveler. These different results highlight the need for specific interventions focused on healthy ageing in elderly migrant men.

**Keywords:** depression; self-rated health; functional limitations; older age; migrant status; health inequalities; trend analysis; Europe

#### **1. Introduction**

In the last decades, European countries have witnessed immigration flows, leading to more diverse populations in Europe [1]. The share of migrant populations in European countries is rising; over the last thirty years it rose from around 7% to about 12% in 2020, with considerable variation between countries [2].

Early research detected the health advantages of first-generation immigrants [3], who initially showed a better health status than non-migrants in host countries [4,5]. Health selection in the countries of origin, e.g., for labour immigration, and the process of migration itself, which often requires good health, played an important role in this. But the health of migrants deteriorates as they settle in host-countries [6], due to socioeconomic disadvantages, increased risks in the workplace, or even experiences of discrimination, among other factors. Migrant and non-migrant populations face different health risks in European countries over the course of their lives [7–9].

Given the ongoing population ageing and increasing longevity in many European countries [1,10], it is necessary to focus on health differences between middle- and olderaged migrant and non-migrant populations, aged 50 years and older. Studies indicate

**Citation:** Vonneilich, N.; Bremer, D.; von dem Knesebeck, O.; Lüdecke, D. Health Patterns among Migrant and Non-Migrant Middle- and Older-Aged Individuals in Europe—Analyses Based on Share 2004–2017. *Int. J. Environ. Res. Public Health* **2021**, *18*, 12047. https://doi.org/10.3390/ ijerph182212047

Academic Editor: Paul B. Tchounwou

Received: 29 September 2021 Accepted: 15 November 2021 Published: 16 November 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

poorer self-rated health, higher rates of depression, worse physical functioning, and lower life expectancy in older migrant populations [11–14]. However, most of these studies do not observe trends over time, nor do they consider variations regarding gender or age. When looking at health patterns in migrant and non-migrant elderly, a steeper rate of health decline was observed in older migrants [13].

When considering the health disparities between older migrant and non-migrant populations and their development over time, different hypotheses have been discussed: aging-as-leveler, persistent inequality, and cumulative disadvantage. The aging-as-leveler hypothesis states that health differences between population groups decrease in late life, when physical and mental limitations increase in all groups. The persistent inequality hypothesis states that, regardless of age, inequalities remain stable. And the hypothesis of cumulative disadvantage states that across the lifespan, socioeconomic disadvantages cumulate and lead to an increase in health risks and health inequalities between migrant and non-migrant elderly populations [15]. Evidence exists for the accumulation of disadvantage [13,16,17], for aging-as-leveler [18], and for persistent inequality [19], with most of the research focusing on black, Hispanic and non-Hispanic white populations in the US.

Earlier research analysing trends over time in the health of migrant and non-migrant elderly has often focused on the health of migrant and non-migrant populations in general, without specifying age or gender [13,14]. As migration background is one among other relevant factors associated with health, such as gender, age, or socioeconomic status [5,20], these factors are taken into account in the present study. Earlier studies indicated gender differences in health disparities according to migration [20–22].

Based on SHARE data, the health patterns of migrant and non-migrant middle- and older-aged individuals in different European countries were investigated. Moreover, time trends over 14 years were examined. Three health outcomes were assessed, as differences between groups might vary depending on the indicator used and in order to provide a more holistic and complex picture of health [15]: physical functioning, depression, and self-rated health (SRH). Therefore, the aim of the present trend analysis was to analyse health patterns in migrant and non-migrant middle- and older-aged individuals in Europe, focusing on individuals aged 50 years and older over a time period of 14 years, with a specific focus on gender and age differences.

#### **2. Methods**

#### *2.1. Data*

The analyses were based on data from SHARE, the Survey of Health, Ageing, and Retirement in Europe [23–28]. The sample comprised 233,117 observations from 28 European countries and Israel across 6 out of 7 waves (2004, 2006, 2010, 2013, 2015, and 2017), including Israel (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and Switzerland). Data from the third wave were excluded, since this was a retrospective SHARELIFE survey. Based on the population registers, SHARE used probability samples within the countries and included non-institutionalized adults aged 50 years or older and, if available, their partners. Further exclusion criteria were being incarcerated, moved abroad, unable to speak the language of questionnaire, deceased, hospitalized, moved to an unknown address, or not residing at the sampled address [29,30].

#### *2.2. Measures*

The health patterns were assessed using three indicators that were dichotomised for analytical reasons. Physical functioning was measured using the global activity limitation index (GALI) [31]. The goal of this index is to assess perceptions in both general and more specific populations regarding long-standing, health-related limitations in common daily activities [31]. The GALI was measured by asking: "For the past 6 months at least, to what extent have you been limited because of a health problem in activities people usually do?". Possible answers were "severely limited", "limited, but not severely" and "not limited". The first two limitations were combined for the binary variable with the categories 0 ("not limited") and 1 ("limited").

As a measure of mental health, the EURO-D was used to assess depressive symptoms [32]. The EURO-D was developed to allow the cross-country measurement and comparison of depressive symptoms. It includes 12 relevant symptoms of depression. The score ranged from 0 ("not depressed") to 12 ("very depressed"). A binary variable for "depression" was categorised as 0 ("not depressed") if the EURO-D score was lower than 4, otherwise it was categorised as 1 ("case of depression"), as proposed by the authors of the EURO-D scale [32].

The SRH was measured by asking, "Would you say your health is ... ", offering five options as potential answers ("very good", "good", "fair", "bad" and "very bad"). The variable was dichotomised, with 0 indicating "good or very good health", and 1 "less than good health".

Migrant background, age, and gender were used as the main predictors. The respondents' age and gender were recorded at each wave. The respondents were considered as migrants if they were not born in the country of data collection. Wave is a continuous variable, ranging from 1 to 7, reflecting the respective year of data collection, where "1" relates to the year 2004, while "7" stands for 2014.

The household size and educational level of the respondents were used as further covariates. Educational levels were based on the International Standard Classification of Education [33] and recoded into three levels: "low (lower/upper secondary)", "mid (post-secondary)" and "high (tertiary)".

#### *2.3. Analyses*

For each of the three dichotomised health indicators, a logistic regression model for complex samples was calculated, using quasi-binomial links to properly account for surveyweighting, disproportional sampling, and selective mortality. The country variable was used to define the strata in the survey design; hence, the regression models accounted for the fact that the respondents were clustered within different countries. Robust Horvitz– Thompson standard errors were reported [34]. Models without interaction terms were calculated first, to investigate the overall associations between the dependent variables and the predictors of interest, migration, gender and age. The interactions between wave, migration, gender, and age were analysed to explore changes over time and to stratify the results by the aforementioned variables (migration, gender, and age). Age was standardized (z-score). Predictors that vary over time, particularly age, usually exert an effect within subjects (e.g., the individual outcome level changes when a person gets older) and between subjects (e.g., outcome levels differ between younger and older people). This results in biased regression coefficients, because both the within- and between-effect are captured in *one* coefficient. This is called "heterogeneity bias" [35]. To avoid this bias, age was separated into its within- and between-component. Since differences between age groups were the main focus of interest, the between-effect of age was used in the interactions. Educational status, household size, and the within-effect of age were included as further covariates. The associations between the interaction of the focal predictors and the three indicator variables are presented as predicted probabilities. The trends for each combination of the focal predictors' categories (migrant yes/no, female/male gender, and middle/olderaged persons) are shown, resulting in figures with four panels per health indicator. Since age was a continuous variable, the values at one standard deviation below and above the average age in the sample were chosen as representative values through which to distinguish between younger and older respondents, following the suggestions from Aiken and West [36]. Thus, the figures represent model predictions as if an individual was at the age of 60 or 80, respectively. To answer the question of whether the change over time for both migrants and non-migrants and whether the comparison between these trends was statistically significant, contrast analyses and pairwise comparisons for the

predicted probabilities were conducted to test for the differences between the stratified groups. The related *p*-values are shown in the figures. All the analyses were performed using the R statistical package (R Core Team, Vienna, Austria) [37], including the packages "survey" [38], "ggeffects" [39] and "emmeans" [40].

#### **3. Results**

Our analyses were based on data from 233,117 cases (55% female, 45% male, see Table 1). Overall, 10.4% were classified as migrants (10,923 men, 13,351 women). In the sample, 39.3% of the respondents were 70 years or older. The mean age of the nonmigrants was 67.0 years and in migrants it was 66.6 years. The following significant differences between migrant and non-migrant populations were observed: the non-migrant populations were older (higher share of people aged 70 years and older) and had a higher share of lower education (45% upper secondary level or lower). Migrants across all waves under study reported a significantly higher share of GALI and a significantly higher share of poor SRH.

#### *3.1. Associations between Health Indicators, Age, Gender and Migrant Status*

In model 1 (Table 2), the regression models showed a 24% increased risk of reporting limited GALI for migrant populations, after controlling for wave, age (between and within subjects), gender, educational status, and household size. The age between and gender were not significantly associated with limited GALI. Similar results were found for depression (model 2). The migrant populations demonstrated a 19% increased risk for depressive symptoms compared to non-migrants. Model 3 demonstrates that migrants had a 28% higher chance of reporting poor SRH.

#### *3.2. Subgroup Analyses and Time Trends*

To analyse the interactions between the three focal variables (migrant background, age, and gender) with regard to three health indicators (limited GALI, depression, and poorer SRH), three logistic regressions were conducted, including several interaction terms (see Supplementary Table S1).

#### 3.2.1. Global Activity Limitation Index

Figure 1 presents the predicted probabilities of respondents who were limited in daily activities for migrant background, age, and gender over time in four line graphs (Figure 1a–d). The left-handed graphs show middle-aged males (a) and older-aged males (b). The right-handed graphs show middle-aged females (c) and older-aged females (d). When looking at the predicted probability models for GALI across the six waves, it can be observed that significantly more middle-aged migrant men reported limitations in global activities than non-migrant men, but that these differences decreased over time (Figure 1a). In terms of older males (on average 80 years of age), the trends in GALI over time contrasted significantly, as a higher proportion of migrant men reporting limitations in global activities over time was observed (Figure 1b). A significant increase in the predicted probability of GALI over time was found in the non-migrant men. In females, different trends regarding GALI over time were found. The gap between migrant and non-migrant elderly women narrowed both in the middle- and in the older-age groups (Figure 1c,d). In both age groups, GALI in non-migrant women significantly increased over time, leading to a reduction in the health gap in GALI observed in the early waves of SHARE. Generally, no significant trends were found for pairwise comparisons of trends in patterns of GALI over time between the migrant and non-migrant populations.

 waves).

**Table**

*Int. J. Environ. Res. Public Health* **2021**, *18*, 12047

**Table 2.** Logistic regression models with survey design for GALI (model 1), depression (model 2) and self-rated health (model 3) (SHARE, waves 1, 2, 4–7, *n*= 233,117); odds ratios, 95% confidence intervals (CI) and significances (*p*).

**Figure 1.** Predicted probabilities of Global Activity Limitation Index (% limited in daily activities) for migrant background, age, and gender (across six waves of SHARE); *p*-values relate to change over time for migrant and non-migrant elderly.

#### 3.2.2. Depression

Figure 2 presents the predicted probabilities of the respondents who suffered from depression on migrant background, age, and gender (Figure 2a–d).

In depression, a significant increase over time was found in non-migrant middleaged men (Figure 2a). For migrant men, a stagnation over time among the middle-aged and a decrease among the older-aged was identified, although the latter did not show a significant level (Figure 2b). A significant increase in depression over time was also

found in middle-aged non-migrant women, but not for migrant women in the same age group (Figure 2c). For middle-aged men and women alike, the gap between migrant and non-migrant populations in depression found in the early waves disappeared over time. In older-aged individuals, the likelihood of depressive symptoms increased over time, particularly in non-migrant men (Figure 2b,d). No significant trends for pairwise comparisons of patterns in depression over time between migrant and non-migrant elderly were identified.

**Figure 2.** Predicted probabilities of EURO-D (% depressed = four or more symptoms of depression) for migrant background, age and gender (across six waves of SHARE); *p*-values relate to change over time for migrant and non-migrant elderly.

#### 3.2.3. Self-Rated Health

Figure 3 presents the predicted probabilities of respondents who reported poorer SRH for the migrant and non-migrant elderly, distinguished by age and gender (Figure 3a–d).

In men, the gap in SRH between migrant and non-migrant populations increased over time (Figure 3a,b). This trend was particularly pronounced among middle-aged males, reaching significant differences in wave 4 and 5 (2010 and 2013, Figure 3a). A slightly significant increase in probability of reporting poor SRH over time was found among older-aged non-migrant men only. In women, a contrary time trend was observed (Figure 3c,d). In middle-aged females, a significant gap in wave 1 (2004), with higher risks of reporting bad SRH in migrant populations, diminished over time (Figure 3c). No significant differences and very similar amounts of poorer SRH were found in wave 7 (2017). An increase in time of poorer SRH in non-migrant middle-aged women and a decrease in migrant middle-aged women was found (Figure 3c). For older-aged women, the gap was narrowing as time trends of poor SRH were increasing in non-migrant populations (Figure 3d). This increase was more pronounced than in migrant older-aged women, leading to a decrease of the initial gap in SRH. No significant trends for pairwise comparisons in patterns of SRH over time between migrant and non-migrant elderly were identified.

**Figure 3.** Predicted probabilities of self-rated health (% less than good health) for migrant background, age, and gender (across 6 waves of SHARE; model 3.2); *p*-values relate to change over time for migrant and non-migrant elderly.

#### **4. Discussion**

#### *4.1. Summary*

Based on the trend analysis of the data from SHARE for 2004 to 2017, this study shows different health patterns between middle and older-aged migrant and non-migrant-populations. A significant health gap for migrant populations exists, with higher risks for reporting worse health outcomes in all three indicators (physical functioning, depressive symptoms, and SRH) for migrant populations. Over time, these gaps develop differently, especially when age and gender are taken into account. In women, the health gap between migrant and non-migrant elderly narrowed significantly across all three health indicators. Moreover, interestingly, there are indications for a reverse health gap, with higher risks of reporting depression in non-migrant elderly women. In men, there is evidence for widening health gaps, such as the SRH in middle-aged men and physical limitations in older-aged men. In depression, differences between migrant and non-migrant men in the all ages under study diminished over the years. The results presented need to be interpreted with caution, as the differences in time trends between migrant and non-migrant populations did not reach significant levels.

While previous studies found some evidence for deteriorating health trends over time, especially in migrant populations [13,41], the analysis revealed a more complex picture of health patterns and trends over time in the health of migrant and non-migrant elderly in Europe by considering age and gender differences (see also [5]). The results show that health differences between the migrant and non-migrant elderly change over time. There is no clear trend of deteriorating health among migrants in Europe [13]. Evidence indicates a widening of health disparities among men, while among women there is evidence indicating a reduction in these disparities.

With regard to theoretical considerations of the development of health disparities over time [15], some results point towards the hypothesis of accumulation. This is especially true for men with regard to physical limitations in older age groups and for SRH. When looking at the health trends in women, there is evidence for the hypothesis of aging-as-leveler, since the health gap between migrant and non-migrant elderly women decreased over time, especially in GALI and SRH. As other scholars have pointed out, downplaying differences among elderly migrant populations such as age or gender will likely lead to false assumptions regarding the development of health patterns [5,41]. The findings presented here underline these conclusions.