Qualification programmes for immigrant health professionals: A systematic review

Background Immigrant health professionals are a particularly vulnerable group in a host country’s labour market, as they face several barriers when re-entering their occupations. International studies indicate that early interventions can increase the employability of immigrants. Qualification programmes are one of these early interventions that can support the re-integration of these health professionals into the labour market. The purpose of this review is to identify international qualification programmes for immigrant health professionals, analyse their content and evaluate their effectiveness. Methods Six international databases (PubMed, Web of Science, CINAHL, PsychInfo, EBSCO and ProQuest Social Sciences) were systematically searched. The search terms were identified using the PICOS-framework. The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were screened independently by two authors and discussed. Studies included in the final synthesis were assessed with the Mixed Methods Appraisal Tool (MMAT) and Kirkpatrick’s Training Evaluation Model. Results Out of 10,371 findings, 31 articles were included in the final synthesis. The majority of them were addressed to international health care professionals and doctors. Two of them were addressed to refugee doctors. Three types of programme elements were identified: teaching, clinical practise and social support. The programmes’ length ranged from 2 days to up to 2.5 years. Despite recommendations in its favour, pre- and post-programme support was scarce. Results also indicate a lack of transparency and quality in terms of evaluation. Effectiveness was mostly observed in the area of language improvement and an increase in self-confidence. Conclusion This review points out the lack of systematically evaluated qualification programmes for immigrant health professionals. Programme providers should focus on implementing programmes for all health professionals as well as for underrepresented groups, such as refugees. In order to generate best practises it is necessary to evaluate these programmes. This requires the development of appropriate instruments when working with immigrant population in the context of educational programmes.


Introduction
Over the past few years, the number of immigrants and refugees has increased worldwide [1]. In 2017 the number of international migrants reached 258 million, up from 220 million in 2010 and 173 million in 2000 [2]. Among those immigrants and refugees are skilled health professionals. As the global health care workforce is facing a shortage [3], several host countries health care systems focus on employing foreign-trained health professionals. However, the (re-)integration of immigrant and refugee health professionals is connected with multiple barriers. Good knowledge of the host country's official language [4] and the technical workplace-related language [5] are the first and foremost requirements for starting the (re-) integration process. As the professional standards for working in health professions differ between countries [6], additional training is required [7]. Due to a lack of supporting structures [5], this requirement is not easy to fulfil. Another barrier for immigrant health professionals is the unfamiliarity with the host country's health care system, procedures and standards [8]. These barriers may lead to deskilling [9], loss of self-confidence [10] and high levels of frustration [11]. The experience of racial discrimination [10] and structural inequality [7] in the host country's environment also hinder the integration process. Refugees experience additional barriers, as their access to labour market may be restricted [12], depending on the host countries legal framework. Furthermore, they must often go through a difficult recognition process [10] and/-or they may not be able to provide official documents [6].
In order to address these barriers and prepare immigrants for work, qualification programmes are strongly recommended [12,13]. However, there is a broad range of programmes and designs. Some programmes have focused on the exchange between local employees and international health professionals in order to increase reflection on workplace differences, which have resulted in better workplace adjustments [14]. Other programmes, like the project "Placing Refugee doctors in Medical Employment" (PRIME) [15], have focused on clinical practise. PRIME facilitated a supervised training post for 25 refugee doctors. After participation in the project, 15 participants gained a job and were able to work again. Due to the increasing numbers of refugees in the past few years [16], several host countries have also decided to implement programmes. One such recent programme is hosted through a collaboration between the World Health Organization (WHO) in Turkey and the Ministry of Health in Turkey [17]. Whereas the Ministry of Health passed a law that allowed Syrian health professionals to work in Turkey, the WHO implemented a 7-week adaption training programme to prepare them for practise [17]. However, the outcomes of this programme have not yet been evaluated. There are also more extensive programmes expanding their design and integrating their programmes into residency trainings [18,19] and/or combining them with courses on language and intercultural skills [20,21]. Depending on the content, participation in such programmes has resulted in higher chances of passing national examinations [22][23][24][25][26][27] that are required in order to work. Nevertheless, reviews on the effectiveness of qualification programmes for international medical graduates and health professionals criticise the methodological quality of the performed evaluations [28][29][30]. Furthermore, the examples of the programmes above show that the content of the programmes is diverse. Thus, in order to help educational providers design, implement and evaluate their programmes, this review aims at systematically identifying and analysing the content and effectiveness of evidence-based international qualification programmes for the labour market integration of immigrants in all health professions.

Methods
This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, [31]; S4 Table).

Search strategy
The search was conducted via six international and interdisciplinary electronic databases during August 2017 and updated in September 2019 to include studies published during/after August 2017. The databases were PubMed, Web of Science, CINAHL, PsychInfo, EBSCO and ProQuest Social Sciences. No time limit was set and studies in English and German were included. The search terms were identified using the PICOS-framework [32] and adapted to each database. In order to identify programmes in the context of health care the PICOS-criteria comparison was replaced with context [33]. For each of the PICOS-criteria (P: immigrant health professionals, I: qualification programme, C: health care, O: evaluation, S: primary and secondary articles) synonyms were collected and reviewed by the co-authors´group. The synonyms were then built into a search string according to each of the databases' rules and requirements (S1 File). Search terms were double-checked with MeSh terms. If a MeSh term did not cover any of the synonyms, it was added separately to the string. Search protocols documented the used search string, the dates, the database syntax requirements and the total number of articles found in the databases.

Study selection
Title and abstract screening. During the first stage of title and abstract screening the inclusion criteria (Table 1) were simplified.
The articles found in the databases were exported to a reference management system in order to remove all duplicates and then exported for screening.
At the first stage of screening, the articles had to fit into the population and intervention of interest. The first 200 abstracts were screened and crosschecked by the first and second authors, reaching an interrater reliability of K = 0.7. The first author screened all abstracts for inclusion and exclusion criteria, whereas the second author screened one quarter of all of the retrieved references.
For the full-text (second stage) screening, the following inclusion criteria were applied according to the PICOS-tool: Population: Due to a lack of evidence-based programmes for refugees, the search was extended to qualification programmes for immigrants as well as international and overseas trained health professionals from all health professions. To be included, these groups must have had personal migration experiences. Descendants of immigrants were excluded. Henceforth the term immigrant will be used for the target population as it reflects this shared experience of personal migration of a variety of groups. The second part of population referred to occupational groups and health professions. Besides generic synonyms like medical or professional personnel every health care profession according to the international labour organisation [34] was used as a term in order to ensure that no health care profession would be excluded.
Intervention: Intervention was defined as programmes that aimed to prepare the population to work in health professions. Occupation-specific educational programmes and programmes focusing on the recognition and licensing of the population were also included. Language courses were only included if they focused specifically on medical and health professional language. If the population group in the programme was already licensed or even working in their professions, the programmes were excluded because a successful labour market integration was presumed in these cases.
Context: The context of the intervention was labour market integration into health care and health context. Health care was defined in a very broad sense, not only including professions with contact to patients, but also those working with machines in primary, secondary or tertiary health care. Professions such as social workers or teachers were excluded.
Outcome: The intervention needed to be qualitatively or quantitatively evaluated. It was of crucial importance that evaluation methods were transparently described. Furthermore, the intervention and the sample had to exceed two days and two participants.
Study Design: Articles in German or English with primary and secondary data that were conducted in a qualitative or quantitative manner were considered for this review. Commentaries, newspaper articles, and policy papers were excluded.
Additionally, records identified from two reviews [28,29] on qualification programmes for international medical graduates (IMG) were included into the screening process. Table 1. Screening criteria for studies (S1 Table).

First stage of screening
Population immigrant health professionals, refugee health professionals, international, foreign and overseas trained health professionals Intervention programmes that aimed to prepare the population for working in health professions Second stage of screening

Population
The full text screening was conducted independently by the first and second authors. Regular meetings between the authors were held to discuss differences. After the screening process, data from the studies were transferred into an extraction sheet and crosschecked by members of the research group. Data extraction related to several categories such as study design, information regarding the target group and the sample, information referring to the intervention, statistical analysis, evaluation methods, qualitative and quantitative results and key conclusions. The studies were assessed with the Mixed Methods Appraisal Tool (MMAT) [35] and Kirkpatrick's Training Evaluation Model [36]. Kirkpatrick's Model assesses the scope of the evaluation performed in the programmes on four levels (Level 1: Reaction, Level 2: Learning, Level 3: Behaviour, Level 4: Results). The MMAT assesses the overall methodological quality of the studies according to four quality criteria, depending on the study design. According to these four quality criteria studies can be ranked from 25% to a maximum of 100%. All articles were independently assessed by the first and second authors and critically discussed to ensure consensus. Two raters reached an interrater reliability of K = 0.8 for the MMAT and K = 1 for Kirkpatrick´s Training Evaluation Model. Throughout the screening and assessment process, regular meetings between the authors ensured critical reflection on possible disagreements and the reaching of a consensus.

Study selection
Out of initially 8,507 findings, more than 7,000 had to be removed as they did not match the inclusion criteria for the first stage but often focused on the health of refugees and their treatment as patients. Through the update in September 2019, an additional 1,864 publications were found. 171 articles were included in the final full-text screening. 140 articles had to be excluded, mostly because they were not evaluated, did not offer any kind of programme or did not focus on health professionals. Eventually, 31 articles were included in the final analysis (Fig 1) and synthesised descriptively.

Study characteristics
The general characteristics as well as information related to structural aspects of the studies, content and evaluation are summarised in Table 2. Almost all of these studies (n = 28) were conducted in an English-speaking country. Two were conducted in Israel and one in Germany. They were mostly published in the 2000s (n = 14) and 2010s (n = 14). The majority of the programmes were addressed to international health care professionals (n = 25). Four studies used the terms migrant or immigrant health professionals, whereas two studies explicitly addressed refugees. Most of the programmes were designed for doctors (n = 22). Six studies were designed for nurses, two were open to all health care professions, and one was designed for physiotherapists.

Clinical practise
Clinical practise relates to any kind of clinical engagement-whether as an observer, an intern or as an employee. Clinical practise was supported by a mentor or a supervisor and emphasised as an important aspect of a programme. The role of the supervisor was emphasised by participants in one study [37] on the following terms: the supervisor should not only be a contact person to answer questions about clinical practise, but their role in the studies was also to give feedback, support, and promote participants´skills and commitment. Results in one study explicitly reported on the lack of cultural competences of the supervisors, which resulted in the discouragement of the participants [37]. Two programmes solely offered clinical practise for three months [40,48]. In terms of payment, one programme explicitly acknowledged the unpaid work of the participants during the clinical practise [40].

Social support
Other elements of the programmes included peer support [45], the establishment of a network, especially with local staff [38], discussion and reflection with and between local staff [14], case management [38], counselling [19,26,41,45], social support [52] and group activities [27]. Pre-post practicum ITER (S1) and prepost English language assessment (S1 and S2 Qualification programmes for immigrant health professionals

Outcomes
The outcomes of the interventions can be divided into three categories: the improvement of (i.) professional skills, (ii.) formal skills and (iii.) language skills. Within the first category of improving professional skills (n = 20), participants reported on gaining knowledge about the health care system and becoming familiarised with the system and the procedures. Studies also indicated an increase in self-confidence amongst the participants and observed significant improvements in terms of communication skills (p<0.001, [21]), emotional resilience (p<0.001, [39]) and perceptual acuity (p<0.03, [39]), coping with patients and peers (p<0.000, [41]), judgemental skills (p<0.046, [41]), defining and explaining clinical problems (p<0.02, [43]), script writing (p<0.05, [52]) and on In-training evaluation reports (p<0.001, [54]). The second category (n = 13) refers to formal resources, such as getting jobs, passing national exams and establishing professional networks. Three studies proved higher chances of passing the national examinations through their programmes [22,26,27], whereas one study could not find any significant differences following programme completion [18].
The third category refers to outcomes only on the language skills level (n = 10). This includes improvement in language, consultation and communication skills. Apart from the significant changes in communication and writing skills that were reported in the first category, one programme explicitly focused on audio and video performance of the participants. They showed significant improvement in language skills (p<0.005, [44]), such as speaking, listening, comprehension and nonverbal communication.

Quality assessment of the programmes
The majority of the studies (n = 17) evaluated on only one level of Kirkpatrick's training evaluation model (Table 3): eight studies evaluated only on the level of reaction, 3 studies on the level of learning, none on the level of behaviour and 5 on the level of results in terms of passing rates of examinations or getting jobs. All the other studies (n = 14) evaluated outcomes on two or more levels of Kirkpatrick's training evaluation model. The mean MMAT score (Table 3) for qualitative (n = 4) and quantitative descriptive studies (n = 3) was 75%, for quantitative randomised studies (N = 13) it was 50% and for mixed methods studies (n = 11) between 25% (n = 7) and 50% (n = 6). Table 3. Quality assessment (S3 Table).

Qualitative
Quantitative descriptive

Discussion
This review aimed to identify evidence-based qualification programmes for immigrant health professionals and analyse their effectiveness. Previous research on the effectiveness of labour market programmes for all immigrants in Europe suggests that only wage subsidies positively influence the unemployment of immigrants [56]. However, as highly skilled professionals tend to remain in jobs which they are overqualified for, the question of how to successfully support their re-integration into labour markets arises. Research on IMGs´transition indicates that qualification programmes surely play a role in the adjustment of IMGs and state that ongoing support is crucial for the success of such [28]. Nevertheless, research to date was unable to determine the effectiveness of programmes, as they lacked systematic evaluations. Hence, this review focused only on evidence-based programmes that transparently named evaluation methods. However, after becoming familiarised with the studies and assessing their quality, it became apparent that the risk of bias in the included studies was high and/or in many cases not sufficiently reflected upon. Additionally, due to a lack of reporting in the included studies, there may be a risk of incomplete or missing data in this review especially referring to the programmes design and content. In the context of programme design and content, it is important to reflect on the social context of the programmes. National examinations, licensing procedures and other requirements may influence the purpose of the programmes and correspond to national requirements. However, in this study no country-specific patterns could be identified. Therefore, results on programme design, content and effectiveness can help educational providers design, implement and evaluate their programmes so that several aspects may be replicated in further studies.

Programme design
Only one programme [38] in this review explicitly offered advice to participants about their career strategy before starting the qualification programme, although providing assistance for participants prior to the programme is recommended [12]. This may not only be helpful in terms of establishing individual career plans [12] but also in reducing barriers for participation, such as financial issues [38]. Regarding the core elements of the programmes, three components were identified: Teaching, clinical practise and elements of social support. These elements were either provided in combination or separately depending on the intervention aim. As language competencies are the first requirement for a successful labour market integration, it is not surprising that language and communication-including aspects of doctorpatient relationship, cultural issues and teamwork-seem to be the most important topic in the curriculum. However, it is surprising that only ten programmes aimed to prepare participants for examinations, even though passing national exams is a formal requirement on the path of labour market integration for health professionals [13]. This rare focus on exam preparations may be explained by the fact that a certain language proficiency is required in order to pass the exams, which is why programme providers focus primarily on language skills. As mentioned above, studies in this review mostly reported successful outcomes. When it comes to clinical practise, one study reported challenges between participants and supervisors who lacked cultural competencies [37], whereas in another study participants emphasized support from peers of the same cultural background as being helpful [45]. This underlines the role of local employees and health care providers who can function as facilitators. They can contribute to the success of labour market integration through a cultural competent attitude that supports the integration of immigrant health professionals [28]. It is also consistent with the claim that organisations need to promote an interculturally aware and sensitive atmosphere in order to give immigrant health professionals a sense of being accepted [28]. Furthermore, local supervisors, mentors or buddies can become trustworthy go-to persons in situations of doubt and provide the opportunity to try out tasks in a safe environment [28]. In addition, it can be assumed that they serve as the initial network in the clinical environment that may influence the target populations' career in terms of long-term sustainability. One limitation about the programmes was that it remained unclear whether there was any support for participants following successful completion of the programme and whether long-term networks were established via these programmes that could increase the cultural and social capital of participants and contribute to the outcomes identified in the second category of formal resources. The appropriate length of a programme could not be determined due to a lack of reporting in the studies. Although there is no evidence on how long it takes health professionals to adapt to their new environment [57], results indicate that most providers prefer a programme of three to four months in duration. This duration is in line with recommendations given by the European Union for the labour market integration of refugees, stating that programmes with a duration of more than one year delay the transition to employment [12].
In general, the concepts of all reviewed programmes revealed a deficit-oriented view based on the assumption that immigrants come from countries with differing standards that need to be adapted to those of the host country by means of these programmes. However, at the same time these professionals bring competencies and work experience, which are often not valued in the host country [11]. Similarly, previously gained competencies were not made visible in the programmes and thus not explicitly acknowledged. But with regard to the reported stress factors such as deskilling and high levels of frustration, as well as with regard to the outcomes that reported an increase in self-confidence, it appears that more positive affirmation and visible empowerment is needed in order to positively influence labour market integration [58]. Offering social support contributes to addressing this need. Nonetheless, to go even further, programme providers and organisations are responsible for creating an appreciative and empowering working and learning environment [28] in order to prevent immigrant health professionals from feeling like second-rate employees [59].

Programme effectiveness
Approximately a quarter of the over 170 studies had to be excluded from this review in the second screening phase due to a lack of transparency in terms of evaluation methods. Based on the included studies, a general trend was observed in three different outcome dimensions: the improvement of (i.) professional skills (ii.) language skills and (iii.) the acquisition of formal qualifications. Although the sorting of the outcomes into these three dimensions should be interpreted with caution, as they are intertwined, they had an increase of self-confidence among the participants and their familiarisation with the health care system in common. As the loss of self-confidence and deskilling are reported stress factors for immigrants, it can be assumed that such programmes are at least helpful in counteracting these stress factors. However, in what way they contribute to a long-term successful labour market integration and how well immigrant health professionals adjust to their new working environment cannot be determined with certainty. Although a certain lack of evaluation methods and significant outcomes is consistent with previous research in this field [28][29][30], it raises the question about the appropriateness of the existing evaluation methods for the target group, as the instruments used to date in this field of research have limited or untested validity and reliability [60], and selfdeveloped questionnaires are unreliable [61]. This may be one explanation for the poor quality of the studies assessed. Another reason for the poor assessment is the appropriateness of the MMAT tool in this context. If missing information from the studies was not traceable, studies received lower scoring rates due to information resources but not necessarily due to a poor methodological quality. Another challenge in applying this tool was selection bias for quantitative non-randomised studies. When working with immigrant health professionals, providers may not always be able to randomly choose participants. So during quality assessment, we were generally unable to definitively answer the question referring to selection bias, thus certain studies were rated poorly. Also, in most of the programmes there was no control group, which always led to one question (MMAT Item 3) remaining unanswered, thus resulting in assessment indicating poor methodological quality. The same applies to mixed method studies, where generally question three on appropriateness of reflection upon triangulation methods could not be answered as the term "appropriate" in its item is not clearly defined. Nevertheless, through quality assessment it can be concluded that there is a lack of systematically evaluated programmes without a high risk of bias. One possible explanation for this may be that programme providers' primary focus is not to conduct a scientific research but to promote the hands-on re-integration of immigrant health professionals. Despite this, in this review studies were only included if they were evaluated and published. Due to a lack of resources, we excluded grey literature. However, a number of qualification programmes are delivered by governments or non-governmental organisations who do not publish in scientific journals.
Thus, it should be noted that more programmes for the labour market integration exist that are helpful in some ways but have not been evaluated or published yet.
Despite the above listed challenges, a broad range of programmes was able to be identified. At the same time major blind spots in the field of qualification programmes became apparent. Out of the 31 included programmes, two were addressed to refugees-more precisely they were addressed to refugee doctors as part of a larger National Health Service (NHS) initiative aiming at getting refugee doctors back to work. This reveals a threefold gap in this field of research: (1) a lack of programmes for refugee health professionals (2) a lack of programmes for all health professionals (3) a lack of programmes that are systematically evaluated. The first gap refers to a general lack of programmes for refugees. This may be due to the fact that the latest included programme in this review dates back to 2016. The numbers of refugees increased between 2012 and 2015 [16] and raised humanitarian issues prior to issues of labour market integration [62]. Nevertheless, considering their labour market integration, there is evidence that refugees are confronted with more barriers than immigrants, due to their sudden flight and legal restrictions [6,13]. These barriers may particularly affect refugee women, as they have poorer labour market outcomes [12]. Therefore, programme providers should consider the specific barriers for women and refugees in order to ensure an equitable access to labour market [7,63]. The second gap refers to a lack of programmes that are supportive to all health professionals, although there is evidence that transition needs of doctors and nurses are similar and that exchange between professions is fruitful in terms of acculturation [28]. As skilled labour shortage does not only apply to doctors but also to other professions [3], programme providers should consider partly opening up programmes to involve all health care professions, instead of focusing on doctors. The third gap refers to a lack of programmes that are systematically evaluated. Consequently, the development of appropriate instruments for working with immigrant population in the context of qualification programmes should be promoted by future researchers.

Strengths and limitations
The major strength of this review is the focus on a large group-not only international medical graduates but also immigrants and refugees and the consideration of their special needs. Furthermore, international programmes for all health professionals were included and interdisciplinary databases were used to consider programmes from all fields. Since there was no time limit set and due to the use of broad search terms, we were able to systematically analyse the content and the outcomes of the programmes. The analysis was also supported through quality assessment and the continuous reflection between the co-authors in order to ensure high quality of the findings. Nevertheless, there is a certain risk of bias in this review in terms of the population. Due to a lack of programmes for refugees, the search was extended to immigrant and international health professionals, although due to their flight and the circumstances of their flight, refugees may face even more or different challenges than international health professionals [6]. Another limitation of this review is that only studies in German and English were included in the analysis, and studies published in other languages are missing. Correspondingly, in this review there is only a representation of programmes conducted in the Global North, despite the fact that ten of the twenty largest destination countries for migrants worldwide are located in countries of the Global South [2].

Conclusion
This study summarises evidence-based qualification programmes for immigrant health professionals and analyses their content and outcomes. Courses on communication, medical standards and cultural aspects were frequently offered. Depending on the aim of the intervention they were combined with clinical practise or elements of social support. Effectiveness was mostly observed in the area of language improvement and in an increase of self-confidence. Nevertheless, the quality assessment of the studies pointed out a lack of transparency in terms of evaluation methods. Results also indicate a lack of evaluated programmes for all health professionals and refugees. Thus, educational providers should focus on implementing crossoccupational programmes, considering the special needs of subgroups, such as refugees, and evaluate their programmes in order to generate best practises.