Journal of Immigrant and Minority Health

, Volume 21, Issue 2, pp 401–413 | Cite as

Migrant Healthcare Guidelines: A Systematic Quality Assessment

  • Eric Nwachukwu AgbataEmail author
  • Paulina Fuentes Padilla
  • Ifeoma Nwando Agbata
  • Laura Hidalgo Armas
  • Ivan Solà
  • Kevin Pottie
  • Pablo Alonso-Coello
Review Paper


Significant international and cross-border migration has led to a growing availability of migrant healthcare guidelines (MHGs), which we systematically reviewed for quality. PubMed, MEDLINE, CINHAL, PsychINFO and guideline developer/guideline databases were searched for MHGs published 2006–2016. Three independent reviewers assessed eligible MHGs using the Appraisal of Guidelines, Research and Evaluation II instrument (AGREE II). MHGs were identified as high quality if they had a score of ≥ 60% in at least three of the six domains, including “rigour of development”, and overall quality was assessed on a seven-point Likert scale. We included 32 MHGs. Overall agreement between reviewers was very good. Mean scores for each AGREE II domain were as follows: 85 ± 19.0% for “scope and purpose”; 51 ± 30.5% for “stakeholder involvement”; 34 ± 31.9% for “rigour of development”; 86 ± 7.3% for “clarity of presentation”; 40 ± 23.6% for “applicability”; and 27 ± 38.5% for “editorial independence”. Nine and six MHGs were deemed “recommended” or “recommended with modifications”, respectively, and 17 were “not recommended”. Our review of MHGs has highlighted critical deficiencies in rigour of development, applicability, editorial independence and stakeholder involvement that point to the need for improvements in future MHGs.


Migrant health Refugee health Practice guidelines AGREE II tool Quality assessment 



EA is a doctoral candidate for the PhD in Methodology of Biomedical Research and Public Health (Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine), Universidad Autònoma de Barcelona, Barcelona, Spain. Also, we acknowledge Ailish M J Maher, a medical writer/editor for providing important edits to the writing ad presentation of the manuscript to improve clarity.

Author Contributions

EA and PAC contributed to the conceptualization, design and conduct of the study. EA, IS and PF contributed to the search strategy design, searching and screening. EA and IA performed data extraction with input from PF. EA, IA and LH evaluated the MHGs using the AGREE II tool. EA performed data analysis with input from PF and PAC. EA, IS, PF and PAC interpreted the data. EA wrote the initial draft of the manuscript, which was then added to and edited in subsequent iterations with PAC, PF, KP. All authors reviewed and approved the final manuscript.


There was no specific funding support for this study. PAC received support via a Miguel Servet investigator Contract from the Instituto de Salud Carlos III (CPII15/0034).

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no competing interests.

Supplementary material

10903_2018_759_MOESM1_ESM.docx (27 kb)
Supplementary material 1 (DOCX 26 KB)
10903_2018_759_MOESM2_ESM.docx (13 kb)
Supplementary material 2 (DOCX 12 KB)


  1. 1.
    Suphanchaimat R, Kantamaturapoj K, Putthasri W, Prakongsai P. Challenges in the provision of healthcare services for migrants: a systematic review through providers’ lens. BMC Health Serv Res. 2015;15:390.CrossRefGoogle Scholar
  2. 2.
    Zimmerman C, Kiss L, Hossain M. Migration and health: a framework for 21st century policy-making. PLoS Med. 2011;8(5):e1001034.CrossRefGoogle Scholar
  3. 3.
    Centre HPS. Infectious disease assessment for migrants ireland health services executive; 2015. p. 77.Google Scholar
  4. 4.
    ECDC. Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA: technical report. Technical Report Stockholm; 2014.Google Scholar
  5. 5.
    Kontunen K, Rijks B, Motus N, Iodice J, Schultz C, Mosca D. Ensuring health equity of marginalized populations: experiences from mainstreaming the health of migrants. Health Promot Int. 2014;29(Suppl 1):i121–9.CrossRefGoogle Scholar
  6. 6.
    Organization WH. Health of migrants: the way forward. Report of a global consultation, Madrid, Spain, 3–5 March, 2010. World Health Organization. 2010.Google Scholar
  7. 7.
    Migration I of International migration, health and human rights. Office of the High Commissioner for Human Rights and the International Organization for Migration. 2013.Google Scholar
  8. 8.
    Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. The Lancet.381(9873):1235–45.Google Scholar
  9. 9.
    Núñez RTLI., Arjona DR, Alcazo TL, Navarrete M. Health policies of national and regional level for the immigrant population in Spain. Gaceta Sanitaria. 2010;24(2):115-e1.Google Scholar
  10. 10.
    Scott P. Black African asylum seekers’ experiences of health care access in an eastern German state. Int J Migr Health Soc Care. 2014;10(3):134–47.CrossRefGoogle Scholar
  11. 11.
    Biswas D, Kristiansen M, Krasnik A, Norredam M. Access to healthcare and alternative health-seeking strategies among undocumented migrants in Denmark. BMC Public Health. 2011;11(1):560.CrossRefGoogle Scholar
  12. 12.
    Choi S, Davis C, Cummings S, Van Regenmorter C, Barnett M. Understanding service needs and service utilization among older Kurdish refugees and immigrants in the USA. Int Soc Work. 2015;58(1):63–74.CrossRefGoogle Scholar
  13. 13.
    Gullberg F, Wihlborg M. Nurses’ experiences of encountering undocumented migrants in Swedish emergency healthcare. Int J Migr Health Soc Care. 2014;10(3):148–58.CrossRefGoogle Scholar
  14. 14.
    Loos J, Manirankunda L, Hendrickx K, Remmen R, Nöstlinger C. HIV testing in primary care: feasibility and acceptability of provider initiated HIV testing and counseling for sub-Saharan African migrants. AIDS Educ Prev. 2014;26(1):81–93.CrossRefGoogle Scholar
  15. 15.
    Jensen NK, Norredam M, Draebel T, Bogic M, Priebe S, Krasnik A. Providing medical care for undocumented migrants in Denmark: what are the challenges for health professionals? BMC Health Serv Res. 2011;11(1):154.CrossRefGoogle Scholar
  16. 16.
    Kredo T, Bernhardsson S, Machingaidze S, Young T, Louw Q, Ochodo E, et al. Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care. 2016;28(1):122–8.CrossRefGoogle Scholar
  17. 17.
    Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006;21(Suppl 2):S14–20.Google Scholar
  18. 18.
    Ernstzen DV, Louw QA, Hillier SL. Clinical practice guidelines for the management of chronic musculoskeletal pain in primary healthcare: a systematic review. Implement Sci. 2017;12(1):1.CrossRefGoogle Scholar
  19. 19.
    Colbeck M, Lockwood C, Peters M, Fulbrook P, McCabe D. The effect of evidence-based, treatment-oriented, clinical practice guidelines on improving patient care outcomes: a systematic review protocol. JBI Database Syst Rev Implement Rep. 2016;14(6):42–51.CrossRefGoogle Scholar
  20. 20.
    Leach MJ, Segal L. Are clinical practical guidelines (CPGs) useful for health services and health workforce planning? A critique of diabetes CPGs. Diabet Med. 2010;27(5):570–7.CrossRefGoogle Scholar
  21. 21.
    Jiang M, Guan WJ, Fang ZF, Xie YQ, Xie JX, Chen H, et al. A critical review of the quality of cough clinical practice guidelines. Chest. 2016;150(4):777–88.CrossRefGoogle Scholar
  22. 22.
    Bahtsevani C, Uden G, Willman A. Outcomes of evidence-based clinical practice guidelines: a systematic review. Int J Technol Assess Health Care. 2004;20(4):427–33.CrossRefGoogle Scholar
  23. 23.
    Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–30.CrossRefGoogle Scholar
  24. 24.
    Michie S, Lester K. Words matter: increasing the implementation of clinical guidelines. Qual Saf Health Care. 2005;14(5):367–70.CrossRefGoogle Scholar
  25. 25.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. Development of the AGREE II, part 2: assessment of validity of items and tools to support application. Can Med Assoc J. 2010;182(10):E472–8.CrossRefGoogle Scholar
  26. 26.
    Armstrong JJ, Goldfarb AM, Instrum RS, MacDermid JC. Improvement evident but still necessary in clinical practice guideline quality: a systematic review. J Clin Epidemiol. 2017;81:13–21.CrossRefGoogle Scholar
  27. 27.
    Alonso-Coello P, Irfan A, Solà I, Gich I, Delgado-Noguera M, Rigau D, et al. The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care. 2010;19(6):e58-e.Google Scholar
  28. 28.
    Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med. 2012;172(21):1628–33.CrossRefGoogle Scholar
  29. 29.
    Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting, and evaluation in health care. Prev Med. 2010;51(5):421–4.CrossRefGoogle Scholar
  30. 30.
    Ríos E, Serón P, Lanas F, Bonfill X, Quigley EM, Alonso-Coello P. Evaluation of the quality of clinical practice guidelines for the management of esophageal or gastric variceal bleeding. Eur J Gastroenterol Hepatol. 2014;26(4):422–31.CrossRefGoogle Scholar
  31. 31.
    AGREE Enterprise Website: AGREE Enterprise Website. 2013. Accessed 02 Sept 2016.
  32. 32.
    McMaster AGREE II score calculator Excel spreadsheet.: Canadian Partnership Against Cancer Corporation. Accessed 02 Sept 2016.
  33. 33.
    Terrace L. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care. 2003;12:18–23.CrossRefGoogle Scholar
  34. 34.
    Brosseau L, Rahman P, Poitras S, Toupin-April K, Paterson G, Smith C, et al. A systematic critical appraisal of non-pharmacological management of rheumatoid arthritis with appraisal of guidelines for research and evaluation II. PLoS ONE. 2014;9(5):e95369.CrossRefGoogle Scholar
  35. 35.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.CrossRefGoogle Scholar
  36. 36.
    Centre for Disease Control and Prevention. Guidelines for evaluating and updating immunizations during the domestic medical examination for newly arrived refugees. 2015. Accessed 05 July 2016.
  37. 37.
    Centre for Disease Control and Prevention. Guidelines for mental health screening during the domestic medical examination for newly arrived refugees. 2015. Accessed 05 July 2016.
  38. 38.
    Centre for Disease Control and Prevention. Guidelines for overseas presumptive treatment of strongyloidiasis, schistosomiasis, and soil-transmitted helminth infections. 2013. Accessed 05 July 2016.
  39. 39.
    Overseas refugee health guidelines: Malaria: centre for disease control and prevention. 2012 [cited Division of Global Migration and Quarantine (DGMQ) and Office of Refugee Resettlement (ORR) Health Work Group.
  40. 40.
    Centre for disease control and prevention. Guidelines for screening for tuberculosis infection and disease during the domestic medical examination for newly arrived refugees. 2012. Accessed 05 July 2016.
  41. 41.
    Screening for Hepatitis During the Domestic Medical Examination for Newly Arrived Refugees. Online/United states Centers for Disease Control and Prevention; National Center for Emerging and Zoonotic Infectious Diseases. 2014.Google Scholar
  42. 42.
    Centre for Disease Control and Prevention. Screening for sexually transmitted diseases during the domestic medical examination for newly arrived refugees. 2014 (updated 28 Feb 2017).
  43. 43.
    Centers for Disease Control and Prevention. Lead screening during the domestic medical examination for newly arrived refugees. 2013. Accessed 05 July 2016.
  44. 44.
    Office of Refugee Resettlement (ORR) Health Work Group; Centre for Disease Control and Prevention. Intestinal parasite guidelines for domestic medical examination for newly arrived refugees. 2013.
  45. 45.
    Screening for HIV Infection During the Refugee Domestic Medical Examination. Online-United States of America: Centre for Disease Control and Prevention (CDC), and the Office of Refugee Resettlement (ORR) Health Work Group. 2012.Google Scholar
  46. 46.
    Centre for Disease Control and Prevention. Guidelines for evaluation of the nutritional status and growth in refugee children during the domestic medical screening examination. Office of Refugee Resettlement (ORR) Health Work Group. 2012.Google Scholar
  47. 47.
    Centre for Disease Control and Prevention. Guidelines and discussion of the history and physical examination. 2012. Accessed 05 July 2016.
  48. 48.
    Committee on Infectious Disease. Recommendations for administering hepatitis A vaccine to contacts of international adoptees. Pediatrics. 2011;128(4):803–4.CrossRefGoogle Scholar
  49. 49.
    Centers for Disease Control and Prevention. Domestic refugee health guidelines: Malaria. 2012. Accessed 05 July 2016.
  50. 50.
    World Health Organization. Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. 2015. Report No.: 978 92 4 154905 9 Contract No.: 166.Google Scholar
  51. 51.
    Getahun H, Matteelli A, Abubakar I, Aziz MA, Baddeley A, Barreira D, et al. Management of latent Mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries. Eur Respir J. 2015;46:ERJ-01245-2015.CrossRefGoogle Scholar
  52. 52.
    WHO. Systematic screening for active tuberculosis: principles and recommendations. World Health Organization. 2013.Google Scholar
  53. 53.
    European Centre for Disease Prevention and Control. Guidance on tuberculosis control in vulnerable and hard-to-reach populations. Stockholm: European Centre for Disease Prevention and Control; 2016.Google Scholar
  54. 54.
    Van Hest N, Aldridge R, De Vries G, Sandgren A, Hauer B, Hayward A, et al. Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement. Euro Surveill. 2014. Google Scholar
  55. 55.
    Bhugra D, Gupta S, Schouler-Ocak M, Graeff-Calliess I, Deakin N, Qureshi A, et al. EPA guidance mental health care of migrants. Eur Psychiatry. 2014;29(2):107–15.CrossRefGoogle Scholar
  56. 56.
    Dara M, De Colombani P, Petrova-Benedict R, Centis R, Zellweger J-P, Sandgren A, et al. Minimum package for cross-border TB control and care in the WHO European region: a Wolfheze consensus statement. Eur Respir J. 2012;40(5):1081–90.CrossRefGoogle Scholar
  57. 57.
    Bichler KH, Savatovsky I, Naber KG, Bischop MC, Bjerklund-Johansen TE, Botto H, et al. EAU guidelines for the management of urogenital schistosomiasis. Eur Urol. 2006;49(6):998–1003.CrossRefGoogle Scholar
  58. 58.
    Homer C, Oats J. Clinical practice guidelines antenatal care—Module II. Canberra: Australian Government Department of Health; 2014.Google Scholar
  59. 59.
    Chaves NJPG., Biggs BA, Thambiran A, Smith M, Williams J, Gardiner J, Davis JS. Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds. Australia: Australasian Society for Infectious Diseases Inc. 2016.Google Scholar
  60. 60.
    Johnston V. Screening guidelines for the initial health assessment of newly arrived refugees in the Northern Territory. Centre for Disease Control - Northen Territory Government 2012.Google Scholar
  61. 61.
    Krause V. Policy recommendation: latent tuberculosis infection screening and treatment in children in immigration detention. Commun Dis Intell Q Rep. 2015;39(4):E597–8.Google Scholar
  62. 62.
    Checkley AM, Chiodini PL, Dockrell DH, Bates I, Thwaites GE, Booth HL, et al. Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management. J Infect. 2010;60(1):1–20.CrossRefGoogle Scholar
  63. 63.
    Association BH. UK national guidelines for HIV testing. Health. 2008.Google Scholar
  64. 64.
    MacFarlane ADOR-dBM, Nurse D. Guideline for Communication in Cross-Cultural General Practice Consultations Ireland; 2012. Report No.: 0263-2136.Google Scholar
  65. 65.
    Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. Can Med Assoc J. 2011;183(12):E824–925.CrossRefGoogle Scholar
  66. 66.
    Almasio PL, Babudieri S, Barbarini G, Brunetto M, Conte D, Dentico P, et al. Recommendations for the prevention, diagnosis, and treatment of chronic hepatitis B and C in special population groups (migrants, intravenous drug users and prison inmates). Dig Liver Dis. 2011;43(8):589–95.CrossRefGoogle Scholar
  67. 67.
    Birken SA, Ellis SD, Walker JS, DiMartino LD, Check DK, Gerstel AA, et al. Guidelines for the use of survivorship care plans: a systematic quality appraisal using the AGREE II instrument. Implement Sci. 2015;10:63.CrossRefGoogle Scholar
  68. 68.
    Deng Y, Luo L, Hu Y, Fang K, Liu J. Clinical practice guidelines for the management of neuropathic pain: a systematic review. BMC Anesthesiol. 2016;16(1):12.CrossRefGoogle Scholar
  69. 69.
    Vernooij RW, Sanabria AJ, Sola I, Alonso-Coello P, Martinez Garcia L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014;9:3.CrossRefGoogle Scholar
  70. 70.
    Al-Ansary LA, Tricco AC, Adi Y, Bawazeer G, Perrier L, Al-Ghonaim M, et al. A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of hypertension. PLoS ONE. 2013;8(1):e53744.CrossRefGoogle Scholar
  71. 71.
    Polus S, Lerberg P, Vogel J, Watananirun K, Souza JP, Mathai M, et al. Appraisal of WHO guidelines in maternal health using the AGREE II assessment tool. PLoS ONE. 2012;7(8):e38891.CrossRefGoogle Scholar
  72. 72.
    Appraisal of guidelines for research & evaluation II - AGREE Next Steps Consortium [Internet]. The agree research trust. 2009.Google Scholar
  73. 73.
    Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;5(2):e007047.CrossRefGoogle Scholar
  74. 74.
    Bindslev JB, Schroll J, Gotzsche PC, Lundh A. Underreporting of conflicts of interest in clinical practice guidelines: cross sectional study. BMC Med Ethics. 2013;14:19.CrossRefGoogle Scholar
  75. 75.
    Schunemann HJ, Wiercioch W, Etxeandia I, Falavigna M, Santesso N, Mustafa R, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. Cmaj. 2014;186(3):E123–42.CrossRefGoogle Scholar
  76. 76.
    National Institute for H, Care E. NICE Process and Methods Guides. The Guidelines Manual. London: National Institute for Health and Care Excellence (NICE) unless otherwise stated. All rights reserved. 2012Google Scholar
  77. 77.
    Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer’s handbook. In: Scotland HI, editor. Edinburgh: Healthcare Improvement Scotland. 2014.Google Scholar
  78. 78.
    GIN-McMaster guideline development checklist. Ontario: McMaster University. 2014.
  79. 79.
    Eikermann M, Holzmann N, Siering U, Rüther A. Tools for assessing the content of guidelines are needed to enable their effective use—A systematic comparison. BMC Res Notes. 2014;7(1):853.CrossRefGoogle Scholar
  80. 80.
    Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383 – 94.CrossRefGoogle Scholar
  81. 81.
    Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Chichester: Wiley. 2011.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Faculty of Health and Psychology, Master of Public Health (MPH) programmeUniversity of RoehamptonLondonUK
  2. 2.Methodology of Biomedical Research and Public Health, Department of Paediatrics, Obstetrics, Gynaecology and Preventive MedicineUniversitat Autònoma de BarcelonaBarcelonaSpain
  3. 3.Iberoamerican Cochrane CentreBarcelonaSpain
  4. 4.Faculty of Medicine and DentistryUniversidad de AntofagastaAntofagastaChile
  5. 5.The Wicklow Mental Health ServiceNewcastle HospitalGreystonesIreland
  6. 6.Biomedical Research InstituteSant Pau (IIB Sant Pau)BarcelonaSpain
  7. 7.CIBER Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
  8. 8.Biomedical Research InstituteSant Pau (IIB Sant Pau)BarcelonaSpain
  9. 9.Centre for Global Health Institute of Population HealthUniversity of OttawaOttawaCanada
  10. 10.C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada

Personalised recommendations