Study design
This was a retrospective, descriptive study using routinely collected program data.
Study setting
Serbia is a central country of transit along the so-called Western Balkan migration route. Despite the attempted closure of the corridor, via establishment of physical barriers across international borders, the Balkan route continues to be used by migrants attempting to reach the European Union. It is estimated that over 70,000 migrants entered Serbia in 2018 and 2019 [11, 12]. Although, this represents a decrease in entries compared to the peak of the migrant crisis in 2015, migrants reported longer stays in Serbia in 2018 and 2019 as border closures impeded their journey.
MSF core activities in Serbia
MSF operates its core activities from a fixed location in Belgrade. It runs an outpatient clinic that provides primary health care services (diagnosis, treatment) and mental health support to new arrivals, undocumented migrants in transit, migrants transiting from government-run asylum and reception centers to borders, those who do not receive adequate care in centers and those who live outside of the officially established system.
In addition to this, MSF works in outreach with a medical mobile clinic and non-medical capacities (distribution of non-food items -NFIs, shelter) that are used to respond to the needs of populations congregating in informal areas, including the areas close to the borders of neighboring states. This activity is carried out by a small-scale team engaging from Belgrade when needed.
Provision of social care by MSF
Apart from medical and mental health services, the outpatient clinic also provides social protection and case management services. In 2018, a social worker was added to the team to identify the social needs, in particular protection needs, of highly vulnerable patients, directly support or refer them to external social services actors and follow the progress of their situation. The social worker also facilitated and advocated for access to legal aid, social and health services, accommodation, while providing information about the available sources of support.
Specifically, MSF social services focused on delivering social-related activities, liaising with legal, administrative, medical and non-medical actors, in order to ease patient’s situation, maximize adherence to treatment, reach therapeutic goals and improve psychosocial condition.
Figure 1 outlines the patient flow through social care services at the clinic. The most common referral pathway is via staff at the MSF clinic who identify social needs and refer patients who present for medical or mental health care. Additionally, patients can self-refer or can be referred by another NGO, Commissariat for refugees and migrants or state centers for social work. After consultation, the social worker can refer the child to one or more services such as housing, protection and legal support. The organizations presented as referral end-points in Fig. 1, provided guardianship and integration services for unaccompanied children (state Centre for Social Work, Jesuit Relief Services integration house for vulnerable refugees etc.), protection, administrative assistance including registration for new arrivals (police), protection and accommodation (Serbian Commissariat for Refugees and Migrants), legal assistance, protection, access to essential services, transportation to transit-reception and asylum centers around the country (Praxis, Info park, Belgrade Center for Human Rights, Atina etc.), resettlement and assisted voluntary return services (UNHCR and IOM). Referral pathways between different actors were often two directional as cooperation was key for complex case management.
Study population
Study population included all children, UMC and AMC, who attended the MSF outpatient clinic in Belgrade, from January 2018 through January 2019.
“Migrant is someone who changes his or her country of usual residence, irrespective of the reason for migration or legal status” as per the International Organization for Migration [4]. Migrant children do not fall under a unique definition, however it is recognized that they may travel accompanied by parents, other adults or alone [4]. Accompaniment status of children was self-reported by the child at the time of the consultation. UMC reported traveling alone and AMC with their family members of caregivers.
Data sources, collection and variables
Medical data was collected and directly entered into a database using the People on the move (POM) application. All data entered through POM application was stored in an electronic, online database. POM was an application developed by IBM, with technical inputs from MSF and donated to MSF Italy to support the response to the migration crisis in 2016. When the use of application was discontinued by the medical team, it was replaced by KoBo toolbox, an open source, free software for data collection, developed by Harvard humanitarian initiative in March 2019 [13]. The variables collected in POM and KoBo for medical patients included information on demographic characteristics of patients (sex, age, country of origin), vulnerabilities (unaccompanied minors, children under 5, disabilities, mental health condition, chronic physical illness, victims of human trafficking), main reason of consultation (disorders categorized generally by different organ systems), previous stay in the camp and access to health services along the migration route (yes/no), experience of trauma along the journey (list of traumatic events), trip duration (in months), outcome of treatment (no referral, referral accepted by patient, referral refused by patient).
The mental health consultation data and social work database were generated in excel file tables. Mental health data was collected via structured interview, conducted by a mental health professional (clinical psychologist or psycho-therapist). Due to dominant transit context and difficult follow up, no recognized assessment tools were used. Symptoms such as agitation, disturbance, uneasiness were recognized and oftentimes self-reported. Collected data was demographic (sex, age, country of origin), data on vulnerabilities (unaccompanied minor, moderate to severe mental illness, victim of sexual and gender-based violence, survivor of torture, no vulnerability), place of residence (asylum or transit-reception center, Belgrade streets/squats, private accommodation etc.) experience of trauma along the journey (list of traumatic events), trip duration (in months), major category of symptoms (symptoms of anxiety, depression, adjustment, psychosomatic symptoms, PTSD, behavioral problems etc.), sexual and gender-based violence (pre migration, peri-migration, pre and peri migration), torture (pre migration, peri-migration, pre and peri migration), referral to mental health services (MSF MD or nurse, other NGO, self-referral, friend or family, identification after group session), referral to psychiatrist (yes/no).
The social worker also conducted a structured interview and collected demographic data (sex, age, country of origin), data on vulnerability (unaccompanied minor) and case type (social protection with medical and/or mental health care), date of arrival to Serbia and leaving the country of origin, administrative status (registered, without legal administrative status), previous and current place of residence, referred by whom to social worker (MSF MD, mental health specialist, MSF cultural mediator). Also, all requests to the social worker were categorized as administrative, legal assistance, referral to a state social worker, accommodation (shelter, safe accommodation, special institution/hospital), protection from violence, UNHCR resettlement, IOM voluntary return, non-food items and food, health services, accompaniment. It was noted if the assistance was provided successfully or not and finally if further referral was needed, what was the case status (open, closed), the reason of closing the case (beneficiary left the country, lost to follow up, referral to another actor, other).
Doctors and other medical team members (nurses, cultural mediators) were trained to recognize if the patient needed mental health or social worker assistance. Access to these databases was granted only to psychologists and social worker, who collected and entered all data on a password protected laptop.
Data analysis
Data collected from POM, mental health and social work databases during the study period was imported in MS Excel 2010 version. Variables used for research were summarized using descriptive statistics, frequencies and proportions. The Chi-square test was used to assess the significant difference between the UMC and AMC populations in the category of medical conditions (main reasons for consultation). All analyses were completed using STATA version 11 (Stata Corp. LLC, Texas, USA).
Ethics
This research fulfilled the exemption criteria set by the Médecins Sans Frontières Ethics Review Board for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Medical Director, Operational Centre Brussels, Médecins Sans Frontières. In addition, approval was officially granted by the Ethics board of the National Institute of Public health of Serbia.