Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees

PLOS ONE RESEARCH ARTICLE Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees Daniela Georges ID1☯*, Isabella Buber-Ennser2☯, Bernhard Rengs2☯, Judith Kohlenberger ID3☯, Gabriele Doblhammer1,4☯ a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Georges D, Buber-Ennser I, Rengs B, Kohlenberger J, Doblhammer G (2021) Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees. PLoS ONE 16(4): e0250821. https://doi.org/10.1371/ journal.pone.0250821 Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA Received: March 9, 2020 Accepted: April 15, 2021 Published: April 28, 2021 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0250821 Copyright: © 2021 Georges et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 Department of Sociology and Demography, University of Rostock, Rostock, Germany, 2 Vienna Institute of Demography (OeAW), Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Vienna, Austria, 3 Institute for Social Policy, Vienna University of Economics and Business, Vienna, Austria, 4 German Center for Neurodegenerative Diseases, Bonn, Germany ☯ These authors contributed equally to this work. * Abstract In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the nonmigrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health. Data Availability Statement: The data underlying this study are owned by third party sources and can be accessed following the the information in PLOS ONE | https://doi.org/10.1371/journal.pone.0250821 April 28, 2021 1 / 22 PLOS ONE the Materials and methods section. The German Socio-Economic Panel (GSOEP) data contain potentially sensitive information and due to legal restrictions by the German data protection law, GSOEP data from this study are only available upon request. The scientific use file of the German Socio-Economic Panel (GSOEP) is made available for scientific research by the German Institute for Economic Research (DIW) at doi: 10.5684/soep. iab-bamf-soep-mig.2016. The use of anonymized GSOEP data is subject to strict standards in the data provision and are reserved exclusively for research use. GSOEP data are available free of charge as scientific use files after requesting a data distribution contract. The form is available online: https://www.diw.de/documents/ dokumentenarchiv/17/diw_01.c.88926.de/soep_ application_contract.pdf. For further information the GSOEP hotline at either or +49 30 89789-292 can be contacted. The ReHIS data are made available upon registration for scientific research by the Austrian Social Science Data Archive (AUSSDA) at doi:10.11587/7LX1BD. The anonymous IDs of the respondents selected for the current study are provided upon request. Funding: This work was supported by the Austrian Federal Ministry of Education, Science and Research; the Austrian Federal Ministry of Labour, Social Affairs, Health and Consumer Protection; the Fonds Soziales Wien (FSW); Common Health Goals of the “Rahmen-Pharmavertrag”, a cooperation between the Austrian pharmaceutical industry and the Austrian social insurance [grant number 99901007700; initials of author who received the award: JK]. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Health determinants of Syrian, Afghan, and Iraqi refugees in Germany and Austria Introduction In recent years, Europe has been the destination of large inflows of refuge-seeking individuals, with more than 4.6 million individuals arriving in the EU-28 countries over a five-year period [1]. Large shares of these asylum seekers came from Syria, Afghanistan, and Iraq. To date, the political, societal, and scientific discourses on this wave of refugees have focused mainly on its effects on the economies and welfare systems of the receiving countries in Europe [2–5], while less attention has been paid to refugees’ health and their access to health services [6–13]. While a number of studies have examined the mental and physical health of refugees in large refugee camps and in low-income countries [14–17], the health of refugees in high- or mediumincome country contexts remains under-researched [9–11, 13]. The previous studies that have examined this topic have found that compared to the health status of the total population, AS&R in Germany have better physical but worse mental health [18], while male AS&R in Austria have better self-rated health [19]. This research gap has important consequences, as health is an individual’s most (...truncated)