Migrant and ethnic groupsArchived

Toolkit material

The mapping report on behavioural surveillance in EU/EFTA countries has shown that behavioural surveillance among migrants and ethnic minorities is a complex issue, and that overall there has been relatively little behavioural surveillance carried out amongst migrant or ethnic minority populations in Europe.

Table 1 below describes selected features of available methods for collecting behavioural data for surveillance among migrants and ethnic minorities. References of examples of good practice are given after the table.

The Table 2 proposes three best methods of reaching migrant or ethnic minority populations according to two different context.

Table 1. Selected features of available methods for collecting behavioural data among migrants and ethnic minorities


Design Advantages Disadvantages Comments

Include migrants/ethnic minorities in routine national health surveys(a)

  • Allows large sample sizes
  • Can be representative if denominator known
  • Repeatable and sustainable if health surveys are regularly conducted
  • Can be a reliable way to assess trends or to explore specific issues (e.g. access to testing)
  • Allows comparison with host country population
  • May allow comparison between sub-groups of migrants if numbers large enough
  • Survey itself is expensive. ‘Ethnic boost’ may add extra costs
  • Is unlikely to cover marginal migrant groups, those who have arrived recently or those in transit 
  • Currently, use of ‘nationality’, ‘country of birth’, ‘country of origin’ or self-defined ethnic minority status in different studies and different countries makes comparison difficult 
  • Most appropriate for established ‘ethnic minority’ or migrants communities
  • Requires preparation in ethnic minority communities to increase acceptability and response rates (explanations in media, training ethnic minority interviewers)
  • It would be helpful to ask a question about length of time in the country
Venue based (b) 
  • Easy to carry out when community members involved (involvement required for mapping and recruiting ethnic minority interviewers)
  • Good uptake reported, including for HIV testing 
  • Sample can be compared with known socio-demographic characteristics of population, with host country population, between sub-groups of migrants
  • Marginal populations can be reached
  • Can help correct biases of service-based sampling
  • Expensive (though less so than national health survey)
  • Requires climate of trust to be reliable
  • Building trust requires time  
  • May be useful for reaching newly arriving migrants (e.g. people seeking asylum, joining family members already established in the destination country, labour migrants, students,  etc) those in transit and those in irregular situations, especially if combined with network sampling
  • Active preparation, recruitment, and follow-up help increase response rates
  • Community buy-in facilitates use for community mobilisation when results available
Service-based surveys (c)    
  • Practical
  •  Can be linked with an intervention, 
  • Sampling frame exists
  • Can collect biological samples
Not representative of the whole target population
  • Suitable for behavioural surveil-lance in resource-constrained settings, or where there is provision of well used easy access services. 
  • Marginalised or stigmatised  populations may not use the services
Health service-based (c)   
  • Data easy to gather, including over long term, if relations bet-ween personnel, clients and researchers is good
  • Allows comparison with host country popula¬tion, between migrant sub-groups 
  • Can be a reliable way to assess trends
  • Especially valuable for access to care (by tracking late arrival for treatment, or disease progression) 
  • Usually clear bias towards those with health problems
  • Small sample sizes
  • May leave out the most marginal with limited or no access to health services
  • May be useful for reaching newly arriving migrants, those in transit and those in irregular situations
  • Has been used for departing migrant workers (during health exams)
  • Risk of sabotaging access to care for patients if health services are clandestine and surveillance results are poorly used by the press, although risk can be reduced by working with media and with minority communities



The table below (Table 2) proposes three best methods of reaching migrant or ethnic minority populations according to two different contexts:

  • Well established and known ethnic minority populations
  • More transient migrant populations, not very well known, and/or not easy to reach

Table 2. Best three methods to access migrants or ethnic minorities according to context 


Well-established ethnic minority populations Main indication for preference Transient migrant populations  Main indication for preference
Inclusion in routine health surveys (a)  
  • Most easily repeatable if national surveys carried out
  • Potentially most representative 
Community outreach sampling (working through migrant & community organizations, snowball) (d) Often used for unknown or very marginal sub-groups, for example to assess feasibility when no studies have yet been carried out with a particular group
Venue-based (e.g. ethnic minority neighbourhood, shops) (e) 
  • Repeatable, especially if working partnerships established with ethnic minority communities
  • Can be representative 
  • Permits creative reaching of sub-groups, including those highly stigmatized 

Health service-based (f)

  • Depending on service, may permit reaching highly marginal sub-groups otherwise difficult to reach
  • May permit obtaining representative or complete sample, for example when health tests are mandatory
  • On the other hand skews national epi if the comparison group is small and not representative (if routine HIV testing results are not available for other groups)
  • Use of any other services routinely used by migrants  (e.g. immigration) not recommended because of ethical problems potentially posed, and migrants’ lack of trust  
Health service-based (g)    
  • Easily repeatable
  • Less costly than other methods, especially if study involves only examination of clinical records
  • Allows tracking of e.g. access to care
  • Can be representative  
Internet (h)  
  • Recent studies show that migrant and mobile populations often make heavy use of internet, either with their own computers or using internet cafés.
  • Excellent means of exploring sensitive issues while maintaining anonymity



Examples (a) Routine national health surveysUK: National survey sexual attitudes and lifestyles (NATSAL). Re ‘ethnic minority boost’ to national survey see Fenton KA, Mercer CH, McManus S, Erens B, Wellings K, Macdowall W, et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability survey. Lancet 2005;365(9466):1246-55. Available at: URL: PM:15811458.

Burns, F., Fenton, K. A., Morison, L., Mercer, C., Erens, B., Field, J., Copas, A. J., Wellings, K. and Johnson, A. M. (2005). Factors associated with HIV testing among black Africans in Britain. Sexually Transmitted Infections 494-500.(b) Venue-based surveysFrance: Lydié N, Beltzer N, Fenies K, Halfen S, Lert F, Levu S. Etudes Santé, editor. Les populations africaines d'Ile de France face au VIH/sida: connaissances, attitudes, croyances et comportements. Saint-Denis: Institut national de prévention et d'éducation pour la santé (INPES); 2007.

UK: Dodds C, Hickson F, Weatherburn P, Reid D, Hammond G, Jessup K, et al. BASS Line 2007 survey: assessing the sexual HIV prevention needs of African people in England. London: Sigma Research; 2008. Available at: www.sigmaresearch.org.uk

UK: (first phase) Fenton, K. A., Chinouya, M., Davidson, O., Copas, A. and Mayisha Study Team (2002). HIV testing and high risk sexual behaviour among London's migrant African communities: a participatory research study. Sexually Transmitted Infections 241-245.(second phase of same study, this time including voluntary HIV testing with good uptake) Sadler KE, McGarrigle CA, Elam G, Ssanyu-Sseruma W, Davidson O, Nichols T, et al. Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles. Sex Transm Infect 2007;83(7):523-9. Available at: URL: PM:17932129.

Netherlands: Gras, M. J., Weide, J. F., Langendam, M. W., Coutinho, R. A. and van den Hoek, A. (1999). HIV prevalence, sexual risk behaviour and sexual mixing patterns among migrants in Amsterdam, the Netherlands. Aids 1953-1962. 

Gras, M. J., Van Benthem, B. H. B., Coutinho, R. A. and van den Hoek, A. (2001). Determinants of high-risk sexual behavior among immigrant groups in Amsterdam: Implications for interventions. Journal of Acquired Immune Deficiency Syndromes 166-172.

Netherlands: Kramer, M. A., van Veen, M. G., De Coul, E. L. M. O., Geskus, R. B., Coutinho, R. A., van de

Laar, M. J. W. and Prins, M. (2008). Migrants travelling to their country of origin: a bridge population for HIV transmission Sexually Transmitted Infections 554-555. 

van Veen, M. G., Kramer, M. A., De Coul, E. L. M. O., van Leeuwen, A. P., de Zwart, O., van de Laar, M. J. W., Coutinho, R. A. and Prins, M. (2009). Disassortative sexual mixing among migrant populations in the Netherlands: a potential for HIV/STI transmission Aids Care-Psychological and Socio-Medical Aspects of Aids/Hiv 683-691.

Examples of studies carried out in schools:UK: Coleman, L. M. and Testa, A. (2008). Sexual health knowledge, attitudes and behaviours: variations among a religiously diverse sample of young people in London, UK. Ethn. Health 55-72.

Testa, A. C. and Coleman, L. M. (2006). Accessing research participants in schools: a case study of a UK adolescent sexual health survey. Health Educ. Res. 518-526.

Netherlands: Brugman, E., Vogels, T. and van Zessen, G. (1997). Trends in sexual risk behaviour among Turkish/Moroccan adolescents in the Netherlands 1990-1995. European Journal of Public Health 418-420.

(c) Health service-based surveysSpain: Castilla,J., Sobrino,P., & del Amo,J. (2002) ‘HIV infection among people of foreign origin voluntarily tested in Spain. A comparison with national subjects’, Sexually Transmitted Infections, 78(4), 250-254.

UK:  Prost, A., Griffiths, C. J., Anderson, J., Wight, D. and Hart, G. J. (2009). Feasibility and acceptability of offering rapid HIV tests to patients registering with primary care in London (UK): a pilot study. Sex Transm. Infect 326-329.

Studies of departing migrant workers:  Croatia: Stulhofer, A. (2008). HIV related risks among Croatian migrant workers 2004-2006. AIDS Care 361-369.

Stulhofer, A., Brouillard, P., Nikolic, N. and Greiner, N. (2006). HIV/AIDS and Croatian migrant workers. Collegium Antropologicum 105-114.

(d) Community outreach samplingWas used for first studies of migration and HIV.  Examples include:McMunn, A. M., Mwanje, R., Paine, K. and Pozniak, A. L. (1998). Health service utilization in London's African migrant communities: implications for HIV prevention. AIDS Care 453-462.

Haour-Knipe, M., Fleury, F. and Dubois-Arber, F. (1999). HIV/AIDS prevention for migrants and ethnic minorities: three phases of evaluation. Soc Sci. Med. 1357-1372.

May also be used as pilot phase for larger studies:  Sadler, K. E., McGarrigle, C. A., Elam, G., Ssanyu-Sseruma, W., Othieno, G., Davidson, O., Mercey, D., Parry, J. V. and Fenton, K. A. (2006). Mayisha II: pilot of a community-based survey of sexual attitudes and lifestyles and anonymous HIV testing within African communities in London. AIDS Care 398-403. Elam, G. and Chinouya, M. Feasibility Study for Health Surveys among Black African Populations Living in the UK: Stage 2 - Diversity among Black African Communities.  2000.  UK Department of Health.

An example of use with marginal communities:Steel, J., Herlitz, C., Matthews, J., Snyder, W., Mazzaferro, K., Baum, A. and Theorell, T. (2003). Pre-migration trauma and HIV-risk behavior. Transcult. Psychiatry 91-108.

(e) Venue-basedKabakchieva, E., Vassileva, S., Kelly, J. A., Amirkhanian, Y. A., DiFranceisco, W. J., McAuliffe, T. L., Antonova, R., Mihaylova, M., Vassilev, B., Khoursine, R. and Petrova, E. (2006). HIV risk behavior patterns, predictors, and sexually transmitted disease prevalence in the social networks of young Roma (Gypsy) men in Sofia, Bulgaria. Sexually Transmitted Diseases 485-490.

Kelly, J. A., Amirkhanian, Y. A., Kabakchieva, E., Csepe, P., Seal, D. W., Antonova, R., Mihaylov, A. and Gyukits, G. (2004). Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study. AIDS Care 231-245.

Deniaud, F., Legros, P., Collignon, A., Prevot, M., Domingo, A. and Ayache, B. (2008). [Targeted screening proposed in 6 migrant worker housing units in Paris in 2005: feasibility and impact study.]. Sante Publique 547-559.

Dias, S., Goncalves, A., Luck, M. and Fernandes, M. J. (2004). [Risk of HIV/AIDS infection. Access and utilization of health services in a migrant community]. Acta Med Port 211-218.

(f) Health service based (transient migrant populations)

For especially marginal group see: Spizzichino, L., Zaccarelli, M., Rezza, G., Ippolito, G., Antinori, A. and Gattari, P. (2001). HIV infection among foreign transsexual sex workers in Rome: prevalence, behavior patterns, and seroconversion rates. Sex Transm. Dis. 405-411.

For departing migrant workers see: Stulhofer et al, references listed above.

(g) Health service based (well established ethnic minorities)See examples in table just above. In addition, numerous studies compare nationals with ethnic minority or foreign patients, for example cohort studies of people with HIV in France and Switzerland: Delpierre, C., Dray-Spira, R., Cuzin, L., Marchou, B., Massip, P., Lang, T., Lert, F. and Vespa, S. G. (2007). Correlates of late HIV diagnosis: implications for testing policy. International Journal of Std & Aids 312-317.

Dray-Spira, R., Spire, B., Heard, I. and Lert, F. (2007). Heterogeneous response to HAART across a diverse population of people living with HIV: results from the ANRS-EN12-VESPA Study. Aids S5-12.

Staehelin, C., Rickenbach, M., Low, N., Egger, M., Ledergerber, B., Hirschel, B., D'Acremont, V., Battegay, M., Wagels, T., Bernasconi, E., Kopp, C. and Furrer, H. (2003). Migrants from Sub-Saharan Africa in the Swiss HIV Cohort Study: access to antiretroviral therapy, disease progression and survival. Aids 2237-2244.

Still others examine clinical records to compare migrants and non-migrants in clinical course and stage of disease at presentation, usually in the expressed aim of assessing equity in access to HIV testing, treatment and care, and occasionally for planning of services. Examples include Fonquernie, L., Dray-Spira, R., Bamogo, E., Lert, F. and Girard, P. M. (2006). [Characteristics of newly managed HIV-infected patients: hospital Saint-Antoine, Paris 2002-2003]. Med Mal Infect 270-279.

Petruckevitch, A., del Amo J., Phillips, A. N., Johnson, A. M., Stephenson, J., Desmond, N., Hanscheid, T., Low, N., Newell, A., Obasi, A., Paine, K., Pym, A., Theodore, C. and De Cock, K. M. (1998).

(h) InternetAzough R, Poelman J, and Meijer S. Young people, sex and Islam: an investigation into Dutch young people of Moroccan and Turkish descent.  2008. Amsterdam, Soa Aids Nederland; 2008.

Dodds, C, Hickson, F, Weatherburn, P, Reid, D, Hammond, G, Jessup, K, and Adegbite, G. BASS Line 2007 survey: Assessing the sexual HIV prevention needs of African people in England.  2008.  Sigma Research.

Hickson, F, Owuor, J, Weatherburn, P, Reid, D, Hammond, G, and Jessup, K. Bass Line 2008-09: Assessing the sexual HIV prevention needs of African people in England.  2010. London, Sigma Research.

Notes(1) See MARP tool kit  for decision trees concerning most appropriate sampling and designs depending on whether migration is voluntary/forced, regular/irregular, lists are kept/not kept, services available/not available etc.

(2) RDS is applicable in populations that are socially networked and in which members of the networks are willing to recruit from among their peers (see MARP tool kit for numerous references). Its actual usefulness with migrant or ethnic minority populations needs to be evaluated.One study in Europe used it SALLEE: Sexual attitudes and lifestyles of East Europeans in London: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777871/

Behavioural surveillance toolkitArchived

The overall objective of this work is to support the development of a key set of indicators in order to ensure availability of comparable behavioural data and to support Member States to implement behavioural surveillance or surveys by preparing a user-friendly toolkit and framework (protocol) for the implementation of behavioural surveillance and second generation surveillance related to HIV and STI in Europe.