Digital solutions for migrant and refugee health: a framework for analysis and action

Abstract

Digital technologies can help support the health of migrants and refugees and facilitate research on their health issues. However, ethical concerns include security and confidentiality of information; informed consent; how to engage migrants in designing, implementing and researching digital tools; inequitable access to mobile devices and the internet; and access to health services for early intervention and follow-up. Digital technical solutions do not necessarily overcome problems that are political, social, or economic. There are major deficits with regard to (1) reliable data on the health needs of migrants and mobile populations and on how they can use digital tools to support their health; (2) evidence on effectiveness of solutions; and (3) a broad framework to guide future work. This article provides a wide socio-technical perspective, as a framework for analysis and developing coherent agendas across global-to-local spaces, with particular attention to the European region.

Full text

Digital solutions for migrant and refugee health: a framework
for analysis and action
Stephen A. Matlin,
a
,
∗
Johanna Hanefeld,
b
Ana Corte-Real,
c
Paulo Rupino da Cunha,
d
Thea de Gruchy,
e
Karima Noorali Manji,
f
Gina Netto,
g
Tiago Nunes,
c
˙
Ilke S
¸anlıer,
h
Amirhossein Takian,
i
Muhammad Hamid Zaman,
j
and Luciano Saso
k
a
Institute of Global Health Innovation, Imperial College London, London, UK
b
Centre for International Health Protection (ZIG), Robert Koch Institute, Nordufer 20, Berlin, 13353, Germany
c
University of Coimbra, Clinical and Academic Centre of Coimbra, Faculty of Coimbra, Coimbra, Portugal
d
Department of Informatics Engineering, University of Coimbra, CISUC, Coimbra, Portugal
e
African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
f
Charité Center for Global Health (CCGH), Charité Universitätsmedizin Berlin, Germany
g
The Institute of Place, Environment and Society, Heriot Watt University, Edinburgh, UK
h
Migration and Development Research Center (MIGCU), Çukurova University, Sarıçam/Adana, Turkey
i
Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences (TUMS), Iran
j
Departments of Biomedical Engineering and International Health, Center on Forced Displacement, Boston University, Boston, MA, USA
k
Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy
Summary
Digital technologies can help support the health of migrants and refugees and facilitate research on their health
issues. However, ethical concerns include security and confidentiality of information; informed consent; how to
engage migrants in designing, implementing and researching digital tools; inequitable access to mobile devices and
the internet; and access to health services for early intervention and follow-up. Digital technical solutions do not
necessarily overcome problems that are political, social, or economic. There are major deficits with regard to (1)
reliable data on the health needs of migrants and mobile populations and on how they can use digital tools to support
their health; (2) evidence on effectiveness of solutions; and (3) a broad framework to guide future work. This article
provides a wide socio-technical perspective, as a framework for analysis and developing coherent agendas across
global-to-local spaces, with particular attention to the European region.
Copyright © 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Keywords: Migrant and refugee health; Digital health; mHealth; Telehealth; Telemedicine; Ethics; Privacy; Security;
Equity
Introduction
An increasing array of health applications is being
found for digital technologies, including in communi-
cation, information storage and retrieval, diagnosis,
booking of medical appointments, prescribing and re-
ferrals, research, and the management of health services
and systems.
1,2
This trend was considerably boosted by
the COVID-19 pandemic,
3,4
as well as by recent advances
in applications of artificial intelligence (AI) in health-
care.
5
Compared to traditional face to face health ser-
vices, potential benefits to refugees and migrants,
including those on the move, encompass increased ac-
cess to health information, services, and professionals
and to their own health records, as well as faster and
more accurate diagnosis and more timely and effective
treatment that is more patient-centred, patient-empow-
ering, and aligned with integrated systems of care.
6,7
For
migrants, refugees and other people moving (Panel 1),
there are additional potential benefits for individuals
and groups who may have very limited access to tradi-
tional in-person health services, including in Europe,
8,9
for enhancing the self-reliance and resilience of refu-
gees,
10
as emphasised in the Global Compact on Refu-
gees,
11
and explored in the Expert Meetings on Digital
Solutions for Migrant and Refugee Health in 2021.
12
Compared to non-digital health services, digital health
technologies can also enhance health literacy and sup-
port individuals who may fear being stigmatised
through targeted interventions, for instance, women
who are experiencing Post-Traumatic Stress Disorder
(PTSD).
13
Migrants, refugees, and others on the move such as
displaced persons may have poorer health outcomes
than the general populations in countries of transit and
*Corresponding author.
E-mail addresses: s.matlin@imperial.ac.uk (S.A. Matlin), hanefeldJ@
rki.de (J. Hanefeld), atgoncalves@fmed.uc.pt (A. Corte-Real), rupino@
dei.uc.pt (P.R. da Cunha), theadegruchy@gmail.com (T. de Gruchy),
karima.n.manji@gmail.com (K.N. Manji), G.Netto@hw.ac.uk (G.
Netto), tiago.nunes@fmed.uc.pt (T. Nunes), isanlier@cu.edu.tr (˙
I.
S
¸anlıer), takian@tums.ac.ir (A. Takian), zaman@bu.edu (M.H. Zaman),
luciano.saso@uniroma1.it (L. Saso).
The Lancet Regional
Health - Europe
2025;50: 101190
Published Online xxx
https://doi.org/10.
1016/j.lanepe.2024.
101190
www.thelancet.com Vol 50 March, 2025 1
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destination, including in Europe.
8,20–24
Discriminatory
policies that limit or deny access to health services are
embedded in global, regional, and national instruments
and are compounded by discriminatory practices and
attitudes encountered within services and by fear of
detention or expulsion resulting from accessing
services.
25–27
There is growing interest in adapting digital
tools to assist migrants, refugees, and others on the
move such as displaced persons.
28,29
However, digital
tools can also exacerbate existing vulnerabilities experi-
enced by migrants and refugees due to increasingly
tighter border controls across Europe, a phenomenon
which has led to the region being referred to by analysts
as ‘Fortress Europe’and to the use of dangerous routes,
often resulting in fatalities.
30
These populations are
often rendered vulnerable as a result of xenophobia and
discrimination and, in some cases, cross-national sys-
tems, such as the Common European Asylum System,
and hostile policy landscapes that limit their access to
services, including timely healthcare.
31,32
It is worth
highlighting that digital tools should not be viewed as a
panacea for countering inhumane treatment institu-
tionalised in the European border regimes
33
and in rules
causing marginalisation or exclusion from health ser-
vices, either nationally or regionally, which have been
described
34,35
as ‘necropolitics’. While it has been argued
that digital health could reduce inequality and increase
universal health coverage,
36
in practice migrants, refu-
gees, and those seeking asylum are generally excluded
from the “leave no-one behind”principle proclaimed in
Agenda 2030 and the goal of “universal”health
coverage
37,38
and encounter many hurdles to taking
advantage of digital solutions as discussed in this article.
Furthermore, in considering the use of digital tech-
nologies to improve access to services, it is important to
be cognisant of the gendered digital divide in access to
these technologies, in addition to their cost, and the use
of these digital technologies by States for surveillance
and migration control. Reliance on digital technologies
to reach these populations may, therefore, further
exclude the most vulnerable and expose individuals and
communities to the risks associated with increased
surveillance, including detention, deportation and
discrimination.
39
Ethical issues and questions regarding the use of
digital tools in migrant and refugee health are discussed
in Panel 2. Practical concerns have also been high-
lighted, including issues related to confidentiality, pri-
vacy, security, misappropriation and misuse of personal
data,
40,41
and limitations to access for patients who lack
the necessary means, hardware, connectivity, language,
culture or skills to use digital tools in the way that they
are being imagined.
10,42,43
Moreover, the incorporation of
skewed data sets into digital applications may lead to
distortions in their use and to perpetuation of existing
biases and inequalities.
44
The actual benefits and dis-
advantages associated with each digital application
consequently depend, among other factors, on where,
how and by whom it is designed and used. More
fundamentally, the development of these tools should be
undertaken as part of the process of decolonising the
digital rights field through more collaborative ap-
proaches, as is currently being undertaken by European
Digital Rights, a network defending rights and freedoms
online.
45
In practical terms, the development of privacy-
enhancing technologies which are compliant with the
General Data Protection Regulation (GDPR) and a hu-
man rights approach can play an important role in
safeguarding the rights of migrants and refugees,
including those whose residential status is uncertain
and who are at risk of deportation.
46
Understanding the
background factors relating to access and use of mobile
communications and the internet in general
47
is there-
fore crucial to assessing the balance of potential health
benefits and harms for each individual, including for
migrants and refugees and others who are on the move.
The Minoritised Ethnic People’s Code of Practice for
Equitable Digital Services (ME-CoP) has been provided
to guide decision making about the purpose of digital
services, their design, delivery, and use of people’s data,
including but not limited to, race and ethnicity infor-
mation. Through seven principles,
46
it recommends how
the design of digital services can help safeguard against
Panel 1:Migrants, refugees, and other people on the move.
In this article, ‘migrant’refers to those who have crossed an international border,
although we are aware that some of the issues raised here may also apply to
internal migrants and/or internally displaced persons.
14
Migrants include people moving with or without documentation such as personal
identity papers and documents confirming rights to visit or reside in the place in
which they are currently located.
Arefugee was defined in the 1967 Protocol of the 1951 Refugee Convention
15
as a
person who, “owing to a well-founded fear of persecution for reasons of race,
religion, nationality, membership of a particular social group or political
opinions, is outside the country of his nationality and is unable or, owing to
such fear, is unwilling to avail himself of the protection of that country”. The
1984 Cartagena Declaration extended this to include persons who flee their
country “because their lives, security or freedom have been threatened by
generalised violence, foreign aggression, internal conflicts, massive violations of
human rights or other circumstances which have seriously disturbed public
order”.
16
Refugees are afforded special protection and entitlements by
international agreements.
17
An asylum-seeker is a person who seeks safety from persecution or serious harm in
a country other than his or her own and awaits a decision on the application for
refugee status under relevant international and national instruments. A person who
is denied asylum must leave the country where they have applied and may be
expelled.
18
Adisplaced person is one who has been forced or obliged to flee or to leave her/his
home or place of habitual residence, in particular as a result of or in order to avoid
the effects of armed conflict, situations of generalised violence, violations of human
rights or natural or human-made disasters.
19
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2 www.thelancet.com Vol 50 March, 2025

Panel 2:Ethical concerns and considerations.
Background
The growing opportunities for accessing health information and services afforded by digital interventions need to be considered in the light of the multiple
vulnerabilities that may apply to migrants and refugees in different circumstances. For people involved in setting policy, regulating practice, andin
offering, operating or using digital approaches, it is therefore vital to take account of ethical concerns, above all operating on the ethical nonmaleficence
principle of ‘do no harm’,
48
set against the normative background of the UN’s Universal Declaration of Human Rights
49
and Sustainable Development Goals
(SDGs)
50
and relevant regional instruments such as the European Convention on Human Rights and its subsequent protocols.
51
Onarheim et al.
52
have set out the importance and value of an ethical approach to migration health policy, practice and research, with benefits that include
(1) highlighting the inherent normative questions and trade-offs at stake in migration health; (2) assisting decision makers in deciding what is the ethically
justifiable thing to do; (3) ensuring that migrants’interests are considered by using ethical frameworks and technical guidance to set normative and
practical standards for decision makers facing ethical questions; and (4) responding to the need for greater transparency and accountability in decision
making, as well as meaningful participation of migrant groups. Onarheim et al. list a range of ethical issues that need to be considered when dealing with
migration health in general, raising questions for health workers, policy makers, data managers and researchers, as well as for international migrants
themselves. They also point to the availability of methods to identify ethical issues, frameworks for systematising information and suggesting ethically
acceptable solutions, and guidance on procedural concerns and legitimate decision-making processes.
In this article, we focus on the dimension of ethical issues relating in particular to the adoption of digital approaches for migrant and refugee health.
Focussing on data protection in migrant and refugee health,
53
the Migration Data Portal of the International Organization for Migration (IOM), discusses
ethical concerns over confidentiality, privacy, security, and misappropriation and misuse of personal data. Providing technical guidance on the collection
and integration of data on refugee and migrant health,
54
the WHO Regional Office for Europe stresses the urgent need for integration of migration health
data into every national health information system in order to support the inclusion of refugees and migrants, which became apparent in the COVID-19
pandemic. Bozorgmehr et al.,
55
while calling for such data to be collected systematically, highlight the importance of attention to safeguarding privacy
while combining data from multiple sources, ensuring survey methods take account of the groups’diversity, and the need to engage migrants and
refugees in decisions about their own health data. UNHCR cites digital risks, including from online censorship to cyber threats, data protection risks,
disinformation and privacy harms, which demand increased attention and action as ‘connectivity as aid’is mainstreamed as an essential form of
humanitarian assistance.
56
Particular attention has focused on the recent expansion in the use of big data and AI, and it has been suggested that AI provides a test case for rights and
that use of AI in decision-making raises ethical questions of fairness and due process.
57
Floridi and Cowls
58
have synthesised ethical concerns regarding uses
of AI into an overarching framework of five core principles, relating to beneficence, non-maleficence, autonomy, justice, and explicability. Guillen and
Teodoro
59
stress the need to embed AI ethical principles into the design, development, and deployment stages of AI predictive tools for migration
management. Taki et al.
60
argue that research on novel healthcare technologies aiming to benefit forcibly displaced persons such as refugees, who are at an
increased risk of physical and mental health conditions, can be conducted under an ethical framework. They observe that, in the areas of omics and digital
technology, attention is required to access and connectivity barriers, privacy concerns, guarantee of anonymity and inclusion. To improve the accessibility
of clinical research on novel technologies, they emphasise to value of community-based participatory research.
Questions to consider
To assist in ensuring a broad coverage of ethical issues in the design and operation of digital approaches to migrant and refugee health, we have
assembled a list of questions that should be considered. These cut across the concerns identified above, related to areas that include privacy,
confidentiality, security, inclusivity, misappropriation and misuse of personal data, respect for rights and freedom of choice. The list of questions has been
grouped under three headings and framed in a way that points to practical approaches for adoption.
Data protection
•Does use of the app or platform expose the participant/patient to potential surveillance risks? Is it possible to create a firewall between the app or
platform and immigration and police services?
•What data is being collected by the app and/or platform in the background? Who is collecting it? And what will be done with it now and what might be
done with it in future?
•If there is a data breach, could the information collected expose the participant/patient to identification and/or risk? Are there ways to minimise this?
•What identifying information will be collected? Is it possible to collect less?
•How and where will the data be stored and de-identified/anonymized? Who will have access to it? When will the data be destroyed?
•What safeguards are in place to ensure that data shared via the app or platform is not misappropriated or misused by those who currently have access to
it and those who may have access in the future if the app or platform is sold?
•Is the app or platform sufficiently secure so that if another person uses or steals the participant/patient’s device, they will not have access to the
information? Is it easy for the participant/patient to delete the app or their interaction with the service or research from their device?
Informed consent
•How does the target population use mobile devices and apps? What are the security concerns regarding the use of these? Are they aware of other risks
associated with sharing personal information through apps and on mobile devices?
•Has due attention been paid to ensuring that processes of informed consent have considered the most commonly used languages of potential users?
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some of the inequities minoritised ethnic people expe-
rience in access, outcomes, and their experiences of
services. The principles have been co-created with
minoritised ethnic community members as experts by
experience, and also stakeholders and representatives
from across healthcare, third sector, social housing,
design consultancy, public sector, local authorities, UK
regulators, and the data science community.
Evidently, there is a need for policies, strategies, and
tailored tools to maximise the benefits while safe-
guarding the individuals and for more research to un-
derstand the advantages and risks. Research related to
these issues may itself be facilitated by the use of digital
tools, but again with need to consider both users and
subjects in relation to benefits and risks and having
regard to both ethical and practical factors.
As noted by Mancini et al., the realm of digital
migration studies has been fragmented and lacking an
analytical focus,
61
while the importance of a combined
socio-technical perspective has been emphasised.
62
The
variations in circumstances that are significant for migrant
and refugee individuals and groups include their locations,
with important factors including laws and practices that
relate to the opportunities and constraints they experience
in accessing health and digital connectivity. In the Euro-
pean region, countries in general have high levels of health
service coverage and of digital connectivity nationally,
63,64
as
well as inter-country reciprocal agreements providing
cross-border health coverage and supporting digital
roaming. Migrants and refugees may nevertheless find
their access to these services severely constrained,
65
espe-
cially when having unclear resident status.
This Perspective article draws on the expertise of a
number of researchers with extensive personal experience
of working with migrants and refugees (including some
from the Global South and, in some cases, having expe-
rienced migration themselves), combined with an exten-
sive search of the literature. The origins of this article in a
World Health Summit Expert Meeting, its development
and the methods employed are set out in Panel 3.
The article summarises key opportunities and chal-
lenges in the use of digital technologies for the health of
migrants and refugees. These opportunities include
wide accessibility of digital tools through mobile phones
among people on the move, the continued increase in
digital literacy, the possibility of developing context
appropriate solutions (e.g., apps) with smaller in-
vestments (compared to non-digital solutions) and
accessibility and protection of medical records that
otherwise can be lost in the chaos of migration, to name
a few. There are important ethical and technical chal-
lenges that are also discussed in this paper. This intro-
ductory section has contextualised the research against a
global background, focussing in particular on the Eu-
ropean context. We intend to use a socio-technical
perspective to offer a broad, multi-dimensional frame-
work both for analysis and for developing recommen-
dations for action across global-to-local spaces. Key
terms and ethical guidelines have been outlined. Next,
the article explores digital tools for health in the general
population followed by a discussion which pays detailed
attention to key aspects relating to the use of digital tools
for health for migrants and refugees. The article then
considers the use of digital tools in research in two re-
spects: use by migrants and refugees of digital applica-
tions for health and utility of digital applications to study
migrant and refugee health. This is followed by a dis-
cussion of issues related to equity and inclusion. Finally,
we draw together the framing of our analysis and rec-
ommendations for analysing and developing digital
tools for migrants and refugees.
Digital tools for health: general population
In the WHO Global Strategy on Digital Health,
70
the
term digital health encompasses eHealth (information
•Can the consent process outline—in a clear and concise manner—the purpose of the app or intervention and what data is being collected, including in
the background, and what risks are associated with this approach, specifically in relation to data protection?
•Are there ways through which participants/patients can request that their data be deleted or modified?
•Will changes to the app or platforms ownership and data storage approaches be clearly communicated to participants/patients until the data is deleted?
•Is information about the complaints process included? Is this information available in the languages most commonly used locally?
Exclusion and inclusion criteria
•Does the use of the app or platform exclude certain groups of people, specifically due to their gender, age, documentation status or financial situation?
How will this affect the results of the research or the impact of the service?
•What additional barriers to access care or participate in research may the use of an app, platform and/or mobile device create? Are there other
approaches being simultaneously employed to ensure that those who cannot or do not want to use the app, platform or device are not excluded
from the research or unable to access services?
•Are there ways to circumvent potential participants/patients’initial discomfort or scepticism regarding the app or platform, for example, through an in-
person initiation?
•In research involving digital solutions for migrant health, does the research design, conduct and analysis and reporting involve meaningful migrant
participation at every possible stage and have the research processes and tools been assessed to ensure that benefit to the migrants and protection
of their privacy and security are prioritised?
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and communication technologies for health),
71
mHealth
(medical and public health practice supported by mobile
devices),
72
and other uses of digital technologies for
health such as the Internet of Things (IoT), advanced
computing, big data analytics, artificial intelligence (AI),
robotics, telehealth, telemedicine, and personalised
medicine. The Global Strategy notes that “digital health
should be an integral part of health priorities and benefit
people in a way that is ethical, safe, secure, reliable,
equitable, and sustainable. It should be developed with
principles of transparency, accessibility, scalability,
replicability, interoperability, privacy, security, and
confidentiality”.
The 2023 State of Digital Health report
73
shows
extremely variable progress towards the goals of the
Global Strategy
70
across WHO regions. The report as-
sesses most countries at the western side of the WHO
European region to be at a mature phase (Phase 5) of
development in digital health, while some at the eastern
side of the region are at a lower phase (Phase 4). The
report calls for more action on equity and inclusion,
strengthening workforce skills, the development and
implementation of architectures and standards that
promote interoperability between digital health in-
terventions to support the continuum of care, and more
investment in infrastructure and services.
While a wide range of potential benefits of digital
tools have been proposed for health providers and pa-
tients, there have also been a number of concerns
expressed, including about the need for AI ethics and
governance to keep pace with the rapid technical
advances being observed.
74,75
Cummins and Schuller
76
pointed to challenges they considered crucial to over-
come to ensure that digital health systems meet the
guiding principle of being “for all anywhere and at any
time”. Five groups of challenges were highlighted: (1)
societal (regulatory and legislation factors, perceived
lack of commercial sector accountability, complexity of
the multinational nature of the digital health market
operating within a multitude of different health sys-
tems, varying levels of digital and health literacy in the
general population, especially in the elderly, data
ownership, and other ethical concerns); (2) ethical (role
of consumer technology companies in collecting, stor-
ing, and analysing health data); (3) increasingly con-
nected health solutions (patient safety, security and
privacy concerns in transferring data from the point of
collection, such as IoT devices, to remote servers and
the degree to which patients and research subjects un-
derstand how their data is being processed and by
whom); (4) role of AI (safety, explainability, and fairness,
lack of standards for verification and validation); and (5)
potential of genomics (uses of and sharing of informa-
tion derived from genetic profiling).
In addition, we must recognise the xenophobia and
continued poor treatment of refugees and migrants at
the European borders
77,78
as well as within countries.
25
Digital health solutions—no matter how precise or ac-
curate in identifying the cause or the symptoms, or
providing a guideline for care—would be impotent in an
environment that degrades humans and disregards their
basic human rights. There have been several studies to
Panel 3:Background and methods.
Background
The World Health Summit (WHS) Academic Alliance (formerly known as the M8 Alliance of Academic Health Centers, Universities and National Academies)
has organised World Health Summit annual meetings since 2009.
66
These meetings bring together policy-makers and people working in international and
non-governmental agencies and academia, with the goals of agenda-setting for global health improvement and development of science-based solutions
to global health challenges. Since 2015, the Alliance has put migrant and refugee health on the agenda of the annual Summit meetings and since 2017, led
by Sapienza University of Rome, has held Expert Meetings, either in Rome or online, attended by participants from around the world, on migrant and
refugee health.
67
An online meeting in 2021, co-organised by Sapienza University of Rome and the London School of Hygiene and Tropical Medicine,
68,69
discussed the subject of digital solutions for migrant and refugee health. Subsequently, the presenters in this meeting agreed to collaborate to develop a
broad-ranging overview of digital solutions for migrant and refugee health, combining knowledge from their own on-going work in the field with the
growing body of literature on digital aspects of health and placing this in the evolving technological, social and political contexts of particular relevance in
the European region.
Literature search strategy and selection criteria
Co-authors contributed to the identification of themes and topics, through the discussions in the original Expert meeting and subsequent exchanges as
they contributed text to the draughting, with incorporation of results from their own ongoing work and from the emerging literature. To complement
and extend the literature presented by the co-authors which informed the initiation of this article, a search was implemented across Google, Google
Scholar, PubMed, Scopus, ScienceDirect, and open-access documents from pertinent organisations, including the International Organisation for Migration,
World Health Organization (WHO), and European Commission. Combinations of terms relating to digital technology in general and specific forms (e.g.,
eHealth, mHealth, telemedicine) were combined with ‘health’and the terms migrant, refugee, asylum seeker or displaced person. Additionally, to refine the
scope and consider factors such as regional and ethical dimensions, keywords such as “Europe”“European”and “ethics”were incorporated. The final
reference list was curated based on the relevance and quality of the studies regarding the topics within the extensive scope of the review, as well as priority
for papers published in the last five years and papers concerning the European region.
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date, demonstrating how, at the borders of the EU,
migrants and refugees are treated with a disregard to
their humanity, and the power dynamic between border
guards and migrants results in ill-treatment and
exploitation.
79–81
Digital interventions—and cross border
partnership between countries—therefore must not
operate in a vacuum where technical interventions are
disconnected from ground realities of violation of hu-
man rights and must include equity in digital rights as a
central feature.
82
Digital tools for health: migrants and refugees
Framinghealthinbroadercontexts
For migrants and refugees, the totality of events, expe-
riences and circumstances leading to their current sit-
uation may include diverse stresses and traumas along
their migration pathway.
20,22
Multiple, complementary
perspectives are therefore necessary. Interwoven with
the potential benefits, risks and challenges of digital
health in relation to the general population categorised
by Cummins and Schuller,
76
there are additional human
factors that need to be considered with regard to the use
of digital tools to support the health and health-seeking
behaviours of migrants and refugees, including per-
sonal and societal factors and vulnerabilities. A broad
framework for analysis was developed earlier to examine
gaps in migrant and refugee health (Fig. 1).
83
The
constellation of dimensions and multiple factors rele-
vant to the use of digital tools for migrant and refugee
health is illustrated in Fig. 1.
This model represents the health of migrants and
refugees as being at the centre of concentric spheres of
influence, most immediately involving human factors
(personal and social factors and vulnerabilities). A
further sphere of influence (see WHO Global Strategy
70
)
involves technological factors, with important re-
quirements including the need for digital solutions to be
accessible, confidential, ethical, secure, and portable.
This space in which migrant and refugee health resides
is subject to many further influences, which the model
combines into three complementary perspectives
considered to be of particular significance, grouped in
three dimensions as follows:
•Structural factors:
Deficits have been observed in all aspects of struc-
tural factors that are embedded in states and sys-
tems, including rights, governance, policies,
practices, equity and social justice, that affect the
health of migrants and refugees
27,83
and have been
highlighted in discussions of the WHO Global Ac-
tion Plan.
84–86
Migrants and refugees are often
‘exceptionalised’by governments,
87
despite commit-
ments to rights for all and to ‘leave no-one
behind’.
88–91
The concept of ‘structural vulnerability’
has been presented in relation to the challenges of
clinical care and healthcare advocacy for migrants,
aiding consideration of how specific social, economic
and political hierarchies and policies produce and
pattern poor health.
92
There has been criticism of
interoperability, biometrics, and identity manage-
ment in the EU, including concerns for the lack of
equity built into in these structural arrangements
which become entangled with security politics
93–96
and demand participation by groups concerned
with digital rights.
97
•Health determinants:
The Dahlgren-Whitehead model of health de-
terminants incorporates a range of biological,
behavioural, sociocultural, economic, and ecological.
Factors that are contained in the core categories, or
pillars, of nutrition, lifestyle, environment, and ge-
netics, with medical care as a fifth pillar to support
them.
98
Further extension of this model has come
from understanding the importance of individual
experience of events as a contributory factor to good
health or ill-health.
99
In this context, the experience
of migration itself is recognised as a significant
determinant of health, with contributary factors
coming from the individual’s experiences, before,
during and after the migration process.
24,100
As an
example, a systematic review found that restrictive
entry and integration policies are linked to poor
migrant health outcomes in high-income countries
and it was noted that efforts to improve the health of
migrants would benefit from adopting a Health in
All Policies perspective.
101
•Human security:
Defined
102
as “freedom from want and fear and
freedom to live in dignity”, the concept of human
security incorporates threats to security in health,
food, environmental, economic, personal, commu-
nity, and political domains. It has been adopted by
the UN as the basis for an integrated approach for
the realisation of Agenda 2030.
103
Further, digital
inclusion and digital technologies have also been
recognised as determinants of health.
104,105
In the context of digital solutions for the health of
migrants and refugees, the involvement of these com-
ponents of Fig. 1 is exemplified in the sections below. In
this multi-dimensional, multi-factor perspective, the
health of an individual migrant or refugee emerges from
dynamic, complex, interacting ecosystems
106
that alter
with spatial and temporal factors. Analysis and formula-
tion of policy and strategy need to incorporate system-
level understanding and systems and spatial thinking if
they are to avoid the pitfalls of siloed approaches.
107–109
Mobile technology and connectivity: availability,
access, affordability, and rights
The capacity of those who are in the process of
migrating or experiencing displacement to access and
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use mobile devices and the internet can be crucial fac-
tors contributing to their survival and wellbeing.
110
The
multifunctional mobile phone enables many opportu-
nities, including maintaining contact with family and
friends, obtaining information related to security
threats, facilitating travel, access to food, water, shelter,
and work, providing channels for remittances, and
seeking health assistance.
28,62,111–113
For many refugees,
internet and mobile connectivity have a level of impor-
tance similar to basic needs such as water, food, and
energy,
114–116
in this sense bridging the dimensions of
health determinants, human security and structural
factors such as human rights (Fig. 1).
Migrants moving through regular channels and able
to have a residential address and financial resources will
often see the establishment of a mobile phone account
at their new location as one of their immediate prior-
ities. For those who have migrated irregularly, arranging
mobile access may be one of their greatest concerns,
whether or not health issues are an immediate prob-
lem.
117
In some circumstances, possession of a mobile
phone is so important that it may be the subject of
barter, extortion, blackmail or physical conflict.
61
The
UN High Commissioner for Refugees (UNHCR) as-
serts
118
that displaced populations and communities that
host them have the right, and the choice, to be part of a
connected society, with access to technology that enables
them to build better futures.
For some migrants and refugees, including in
Europe, barriers to their mobile phone usage may
include confiscation (whether legal or not) by author-
ities.
119,120
In addition, studies have noted that internet
infrastructure can be unreliable, incapable of handling a
high volume or deliberately denied, thereby creating a
substantial challenge for communities on the move to
access information, health and other essential services
that rely on robust communication.
121
Other constraints
include difficulties accessing devices that have the ca-
pacity to operate the applications and features needed
and receive security updates, lack of a power supply,
costs and documentation requirements associated with
SIM cards,
56
access to charging points,
122
and lack of the
required documentation to register for a mobile money
account
111
and an underlying income problem often
linked to restrictions on rights to move and work.
123
Effort and resources are needed to ensure that mobile
ecosystems mature equitably and inclusively.
111,114,124
Reception conditions in Europe often lack adequate
access to the internet and WiFi, which becomes espe-
cially critical during health emergencies, such as the
COVID-19 pandemic. During such times, access—or
rather the lack of access—to the internet has emerged as
Fig. 1: Dimensions and factors relevant to the use of digital tools for migrant and refugee health.
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a significant barrier for refugees and asylum seekers in
seeking health information and maintaining commu-
nication with individuals and organisations. As services
and information rapidly shifted to the digital realm, the
digital divide exacerbated existing vulnerabilities. For
instance, refugees faced challenges in accessing essen-
tial health information, social services, and even basic
daily needs, such as ordering food or sanitary supplies
while under quarantine. This digital gap has been
highlighted in various reports
125–127
from multiple
countries. In Germany, for example, research has
shown that the lack of digital infrastructure in reception
centres left many refugees unable to access crucial
health information, particularly during the pandemic.
128
Similarly, in Greece, a study found that the limited
availability of internet and WiFi in refugee camps
severely restricted the ability of refugees to access online
health services and essential daily needs.
129
Moreover, in
Italy, the lack of affordable mobile data plans for refu-
gees has been cited as a significant barrier to accessing
online platforms for health information and social
services.
130
The failure to provide adequate digital infrastructure
not only hampers access to health information but also
impedes the fulfilment of basic social and humanitarian
needs.
121
For instance, during quarantine periods, the
inability to order food or access sanitary products online
left many refugees in precarious situations. Addressing
these infrastructural deficiencies is therefore crucial, as
they serve as barriers to essential health information
and the fulfilment of basic needs, ultimately impacting
the well-being and integration of refugees.
Adopting a patient-centric approach, in which a pa-
tient is the owner of their data and may allow hospitals
and health professionals access to their data,
131
implies
that the patient has access linguistically to the data owned
and requires, in the case of migrants, the potential for
multilingual operation of the data.
132
At the present time,
automated machine translation—especially in specialised
technical areas like health and medicine—is not suffi-
ciently advanced to be reliable without human participa-
tion in verification and editing.
133,134
Digital inclusion of refugees has been framed by
humanitarian agencies as a fundamental human right
and essential tool to promote access to education, health
care, social connections, income, and skills develop-
ment.
135
Lack of access by migrants to Internet and
WiFi, including in reception conditions and during
health emergencies, represents a loss of digital rights
and barrier to accessing essential services.
121
Recent
critical literature highlights significant concerns
regarding digital rights and the healthcare of migrants
and refugees, particularly around issues of privacy,
consent, and data security on one hand and rights of
access on the other. For instance, the increasing use of
digital technologies in humanitarian contexts can lead to
unintended consequences, such as the surveillance and
profiling of vulnerable populations, which can exacer-
bate existing inequalities and discrimination.
135–137
Lato-
nero
138
has discussed the ethical implications of digital
data collection in refugee populations, emphasising the
need for strict data protection measures to prevent
misuse by both state and non-state actors. Gillespie
et al.
139
explored the tension between the potential ben-
efits of digital health tools and the risks associated with
digital exclusion, surveillance, and the erosion of privacy
rights for migrants and refugees. Digital exclusion pre-
vents access to health information and services has been
reported for migrants seeking asylum, for example in
the UK.
121,140
These critical perspectives highlight the
need for improvements in policy and practice, under-
scoring the importance of adopting a rights-based
approach
141
to the development and deployment of dig-
ital health solutions, ensuring that the rights and dignity
of migrants and refugees are upheld. They point to the
need to make digital approaches for the health of mi-
grants and refugees ‘safe and beneficial by design and in
operation’.
Opportunities and risks
For the migrant, opportunity and vulnerability to risk
are associated with digital and mobile technologies in
ways that vary with time and place along the migration
pathway,
62,142–144
constituting an infrastructure
145
for
‘digital passages’. These have been described
138
as
“sociotechnical spaces of flows in which refugees,
smugglers, governments, and corporations interact with
each other and with new technologies.”
A scoping review
146
of digital health interventions for
ethnic or cultural minority and migrant populations,
published in 2023, found that about two thirds were
developed for communities in the USA and the
remainder aimed at communities spread across Europe,
Asia, Africa, and Australia. The review noted that
addressing this unequal distribution in the future is
important as population diversity and heterogeneity are
significant factors. Moreover, the studies included
focused showed a general tendency to prioritise the
development of digital health interventions for people
with a settled legal status over those with a precarious or
unclear immigration status. The technologies that were
most widely used included mhealth interventions (35%),
websites and informational videos (23%), text messages
(14%), and telehealth (14%). Most applications were
aimed at illness self-management, followed by consul-
tations and prevention, with the main health issues
addressed being mental health and wellbeing (23%),
pregnancy and postpartum (17%), and overall lifestyle
habits (15%).
In a commentary on using digital health technolo-
gies as a possible solution for improving accessibility to
essential healthcare services or mitigating the health
consequences in migrants when conventional service
approaches are unavailable, Hou et al.
147
observed that
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there remains an unrealised opportunity for in-
vestments in digital health to address migrants’health
needs. They noted that, while digitalised health offers
the hope of providing cost-effective, mobile health ser-
vices that can help to overcome structural barriers to
achieving the highest possible health level in migrants, a
number of changes are necessary. These relate to rein-
forcing production and synthesis of evidence through
research, fostering collaborations across national and
local multi-stakeholders, and empowering migrants.
However, in the case of migrants, refugees, and
asylum-seekers the growing opportunities for digital
interventions to benefit health must be weighed against
the potential disadvantages and risks, which can vary
substantially with the locations and circumstances of
each individual and connect with the recognition of
migration as a determinant of health, with personal
security and human rights (Fig. 1). An area of particular
concern that poses a substantial threat that may apply to
large numbers of individuals relates to European border
regimes, which have become increasingly dehuman-
ising in recent years and failed to respect human rights
in their treatment of those seeking refuge and
asylum.
148–150
The Council of Europe Commissioner for
Human Rights has highlighted four areas for urgent
action to end the human rights violations taking place at
Europe’s borders and that relate to pushbacks involving
the summary return of refugees, asylum seekers, and
migrants by states without the observance of the
necessary human rights safeguards. These areas involve
the need for member states to re-focus on the imple-
mentation, in good faith, of their human rights obliga-
tions, in particular those set out in the European
Convention on Human Rights; to enhance transparency
of border control activities, in particular through
strengthening independent monitoring to prevent and
identify violations, as well as bolstering mechanisms to
ensure accountability when such violations occur; and to
acknowledge pushbacks as a pan-European problem
requiring collective action by all member states; and for
parliamentarians to mobilise to stand up against push-
backs, including by holding their governments to ac-
count and by preventing the adoption of laws or policies
that are not human rights compliant.
81
Both analogue and digital information is used by
police and border guards seeking to identify and exclude
refugees and asylum-seekers even before their cases have
been properly examined. Because of the ease with which
it can be obtained, amassed, searched and exchanged,
digitalised data is of particular concern.
151
The possession
of a mobile phone, generally regarded as a vital resource
for a migrant (see section "Mobile technology and
connectivity: availability, access, affordability, and
rights") can also increase the person’s vulnerability, for
example, to surveillance.
152,153
A digital infrastructure for
movement can easily be leveraged for surveillance and
control. Fear of detention and deportation may deter
migrants and refugees from seeking health care in a
timely manner and this adds significant further risk to
their health.
154,155
Reports that in some countries,
including in Europe, immigration authorities extract
mobile phone data in order to identify migrants who may
be undocumented or to ascertain whether asylum seekers
are “lying”reinforces these fears.
156–158
In a scoping review of studies on the role of mobile
phones on refugees’experience, Mancini et al.
61
re-
ported that mobile phones have sometimes become a
form of currency, to be bought and sold, exchanged and
bartered, fought over and gifted. Obtaining new SIM
cards can present risks of exploitation, exposure or be-
ing tracked.
159
Digital technology, especially social media
networks, also provide mechanisms to circulate evi-
dence of the suffering experienced by refugees on social
media platforms—serving as a ‘digital witnesses’which
may help to address human rights abuses, but may also
be a risk to the lives of those holding or transmitting the
information. Thus, ensuring that individuals can
remain invisible when they so wish is imperative.
62
Positive associations have been observed between
technology-enabled social connections and overall well-
being, including in the areas of mental health and
facilitation of information relating to health and health
care,
160
while negative aspects of the use of digital media
include technology-facilitated domestic violence against
immigrant and refugee women.
A UNHCR report
56
identified a number of digital
risks, including online censorship, cyber threats, data
protection risks, disinformation, and privacy harms.
These risks demand increased attention and action while
“connectivity-as-aid”
118
is mainstreamed as an essential
form of humanitarian assistance. The report
56
noted
research showing that, despite awareness of the issues,
connected refugees often feel powerless to do much
about online threats and digital risks to their security and
privacy online, while policy environments related to
telecommunications access, such as SIM registration re-
quirements, may introduce risks to vulnerable users.
In more than 100 countries, including the Member
States of the European Union (EU), the right to privacy
or private life enshrined in the Universal Declaration of
Human Rights is expressed, among other ways, by the
operation of data protection laws that aim to preserve
the confidentiality of personal data,
161
including the
GDPR in the EU. However, for migrants and refugees,
being able to keep information confidential, to have a
private life and to be secure from harm, detention or
expulsion may be very difficult in practice.
162
The diffi-
culties may be further compounded by factors such as
gender and age. Mobile phones offer a secure way to
connect with family, friends and helpers through
encrypted media such as WhatsApp, but the use of the
phone may entail risks that the user may be tracked,
plans for movement intercepted or phone lists used to
identify contacts of interest to criminals or
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authorities.
61,135,163
The risks, as well as opportunities,
have increased in recent years
5
with the growing use of
AI tools by migrants (e.g., employing ChatGPT) and by
government authorities (e.g., using AI pattern recogni-
tion capacities).
Digital literacy and the connected migrant
With the growing use of smartphones and social media
such as Facebook and WhatsApp around the world,
including across most emerging economies,
164
the
important contribution that digital health literacy can
make to helping to limit inequalities from expanding
has been highlighted.
104,165
Among other factors, this
requires a digitally literate health workforce,
166,167
having
competencies
104
in four areas:
•Functional: the ability to successfully read and write
about health using technological devices;
•Communicative: the ability to control, adapt, and
collaborate communication about health with others
in online social environments;
•Critical: the ability to evaluate the relevance, trust-
worthiness, and risks of sharing and receiving
health-related information through the digital
ecosystem (e.g., the Internet); and
•Translational: the ability to apply health-related in-
formation from the digital ecosystem (e.g., the
Internet) in different contexts.
The importance of digital literacy for the ‘connected
migrant’has also been emphasised.
168,169
Refugees in
particular settings have been characterised as subject to
a digital divide, digital exclusion or being ‘digitally
unprepared’.
121,170–172
Reports also highlight the wide
spectrum of capacities and skills in digital literacy
observed in practice and the requirement for better
alignment between needs and provisions to mitigate
concerns that access to technology can potentially exac-
erbate inequalities within refugee communities,
including along the lines of proficiency in the dominant
languages used at the local level.
10,62,110,173–175
A 2021 state-
of-the-art review
160
of digital skills in refugee integration,
spanning the major resettlement regions (North Amer-
ica, Western Europe, Oceania), highlighted, among
other aspects, the systematic overlooking of the per-
spectives and preferences of refugees in the develop-
ment of digital apps to assist integration, as well as
neglecting variations in, and the need for training in,
digital skills to navigate and judge capably the reliability
of internet resources.
Digital health literacy is a critical component in
addressing health inequalities, particularly as digital
tools become increasingly integral to accessing health-
care and health information. However, it is important to
recognise that digital health literacy is one of many
factors that contribute to health outcomes. Health in-
equalities are influenced by a complex interplay of
determinants, including socioeconomic status, educa-
tion, cultural barriers, and access to healthcare services.
While digital health literacy can empower individuals to
better navigate digital health environments and make
informed health decisions, it should not be seen as a
“super determinant”
165
that can independently mitigate
all health disparities. Rather, it is a valuable piece of a
larger puzzle (c.f. Fig. 1) that requires a comprehensive,
multi-faceted approach. Ensuring equitable access to
digital tools, alongside improving general health liter-
acy, enhancing socioeconomic conditions, and
addressing systemic barriers, is crucial to effectively
reduce health inequalities.
Digital identity
Lack of official documents establishing identity can limit
a person’s access to resources, services and socio-
economic participation. It is estimated that there are
680,000 stateless persons currently residing in Europe,
often lacking basic documents such as a birth certificate,
identity card or passport.
176
Establishing a digital identity
may be an alternative, but it has been argued that the
technologies and processes involved in digital identity
will not provide easy solutions in the migration and
refugee context, while they introduce a new socio-
technical layer that may exacerbate existing biases,
discrimination, or power imbalances that are among the
structural factors influencing migrant and refugee
health (Fig. 1).
177
Case studies in Italy reported in 2019
observed that migrants exchanged identity data for re-
sources without meaningful consent, while privacy,
informed consent, and data protection were compro-
mised throughout the process of migrant and refugee
identification. Moreover, there were systemic bureau-
cratic biases that would likely impede the fair develop-
ment and integration of digital identity systems. A
stronger evidence base and appropriate safeguards were
priorities, without which new digital identity systems
were likely to amplify risks and harms in the lives of
vulnerable and marginalised populations.
Digital identities and biometric data, such as fin-
gerprints and iris scans, are increasingly employed to
ensure migrants and refugees can access essential ser-
vices and claim their rights. While these measures are
vital for legal identification and service provision, they
pose significant risks, including heightened surveil-
lance, privacy violations, and potential abuses by state
and private actors.
178,179
Unlike the general population,
migrants are often subject to mandatory biometric
registration, leading to disproportionate surveillance
and control justified under security or administrative
needs. Additionally, when private companies manage
these systems, there is a risk of commercial profiling
and exploitation, further complicating the balance be-
tween securing rights and protecting individual privacy.
These challenges highlight the need for robust data
protection, informed consent, and transparent
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governance to ensure that identification measures do
not compromise the rights and freedoms of vulnerable
populations.
The concept of the “smart refugee”, characterised by
self-monitoring, agility, entrepreneurship, and resil-
ience,
113
reflects an individualising rhetoric that aligns
with neoliberal ideals of self-sufficiency and market-
ability. However, this narrative can obscure the broader
structural and political contexts that shape refugees’
lives, reducing complex social realities to simplistic
notions of individual capability and responsibility. Van
Dyk and Haubner
180
critique this framework as symp-
tomatic of a “community capitalism”that, paradoxically,
emerges even as neoliberalism faces its own crises and
pivots away from extreme individualism towards more
collective approaches. Furthermore, Brunnett
181
argues
that the focus on individualised medicine often neglects
the social determinants of health and the political power
dynamics that influence access to care and health out-
comes, particularly for marginalised populations such as
refugees. Integrating these critical perspectives high-
lights the need to move beyond reductionist narratives
of the “smart refugee”and towards a more compre-
hensive understanding of how systemic inequalities and
power relations impact health and well-being.
Apps for health
There has been a growing number and range of uses of
smartphones and apps for health applications, both by
health professionals and patients
182,183
and the field has
been extensively covered in systematic reviews.
184–191
In
this section we focus on uses for the health of migrants
and refugees. These have broadly fallen into two,
sometimes overlapping, areas: (1) provision of health
information and service gateways for those not able to
access other local services
192
and (2) provision of assis-
tance to facilitate access, communication, and
integration.
193
One advantage of digital health interventions is that
they can be deployed rapidly in conditions where phys-
ical access may be limited, as was demonstrated during
the COVID-19 pandemic in the provision of an mHealth
application to increase access to preventive maternal and
child health services for Syrian refugees in Turkey.
194
However, digital communication, in itself, can be a
paradoxical factor in relation to health, as was seen
during the COVID-19 pandemic, either amplifying
existing inequalities in access to health care for many
migrants (as was seen in a UK study,
195
attributed to a
lack of digital literacy and access to technology, com-
pounded by language barriers) or reducing psychologi-
cal distress but increasing health-related risk perception
(as was seen in a study
196
of refugees in Italy). Further-
more, a lack of empathy perceived by migrants or ref-
ugees in interactions with healthcare providers can lead
to misunderstandings, especially in cases with limited
language skills and/or health literacy, which may be
exacerbated by remote interactions or use of AI
tools.
197,198
Many migrants and refugees experience psychologi-
cal problems, including as a result of stresses and
traumas before, during and after migration, feelings of
loneliness and isolation from family and friends, anxiety
about their own and their family’s situation and fear of
being detained or deported.
199,200
Communication diffi-
culties often act as barriers for migrants and refugees
seeking help with mental health issues.
201
A systematic
rapid review
202
highlighted the strong need for language
support (with remote language facilities, including
multilingual electronic systems, being options to
consider) and development of cultural competence in
mental health services. A systematic review of electronic
tools for bridging language gaps concluded that there
was need for rigorous evaluation of their acceptability,
efficacy, and actual use.
203
A 2023 systematic review by Abtahi et al.
13
of how
digital interventions are implemented to address the
mental health and well-being of international migrants
found few studies that involved delivery of the inter-
vention rather than use of technology in the research
process. The reports included in the review showed
evidence of benefit in interventions for depression, ef-
forts to increase mental health literacy, targeted health
promotion, the aiding of social connections, and the
alleviation of Post-Traumatic Stress Disorder (PTSD).
As in other literature,
204
the review by Abtahi et al. noted
that the stigma associated with mental health problems
can be a barrier to seeking treatment and that digital
interventions may allow a person to receive mental
health services with more privacy, without the knowl-
edge of their family, friends, and community. However,
the results of the two RCT studies examining stigma
included in the review were mixed, with Kiropoulos
et al.
205
finding lower personal stigma scores in the
Internet-based intervention group for depression than
the control group, while the study by Nickerson et al.
206
of an online stigma reduction intervention specifically
designed for refugees (‘Tell Your Story’) reported no
significant effects for self-stigma for PTSD. A 2024
integrative literature review
207
of digital mental health
interventions for the mental health care of refugees and
asylum seekers reported a few more recent studies that
suggested benefit in overcoming shame, but overall
concluded that further research is needed to confirm
effectiveness.
A study of Arabic-language digital interventions for
depression in German routine health care found them
acceptable, but adoption of the digital interventions re-
mains a challenge and requires facilitation and
tailoring.
208
Examination of ‘Step-by-Step’, a digital psy-
chological intervention for refugees in Egypt, Germany,
and Sweden, identified diverse factors that influenced
scalability of the intervention in each country.
209
The
complexity of interrelated factors and actors involved
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pointed to the need for multi-stakeholder collaboration,
including the involvement of end-users, being essential
for integrating novel e-mental health interventions for
refugees into routine services. Rafftree
210
has explored
how digital approaches and interventions could be
incorporated safely and feasibly into the different layers
of mental health and psychosocial support services for
displaced and stateless adolescents.
With the market proliferating for mental health apps
that are designed to help refugees manage symptoms of
PTSD and other mental health issues, Abdelrahman
211
has noted that these apps are part of a larger
endeavour to create the ‘smart’refugee who is self-
monitoring, agile, entrepreneurial and resilient in the
face of adversity, However, she cautioned that these
apps are harvesting, storing and selling information on
refugee trauma and experience of loss, grief and
suffering as marketable commodities. As such,
ensuring that firewalls are put in place to protect data
shared through these apps from being shared with
immigration or law enforcement agencies, as well as
from the private sector, is imperative if access to
healthcare is predicated on use of these apps.
212
Exam-
ining digital technology to address chronic illnesses in
moving populations, Osae-Larbi
213
identified the need
for the strategic development and adoption of ‘realisti-
cally smart’phones. These would be affordable and
designed to have, in addition to the basic features of a
mobile phone, capacity for wireless internet connection;
a built-in or affixed sensor for measuring multiple vital
health information; and a core set of approved medical
and health apps preinstalled.
Health records and uses of blockchain
Migrants and refugees may face difficulties in obtaining
appropriate and timely diagnosis and treatment due to
absence of health records, pointing to the need for
creating electronic health records.
214
As indicated by a
systematic review,
215
electronic health records that are
portable and that can be accessed from any location by
those authorised may be efficient and effective tools for
registering, monitoring and improving the health of
migrants and refugees, with potential to address some
of the challenges that they face in accessing health care.
The importance of user-centred design in the creation of
such tools has been emphasised.
216
Blockchain (BC) technology, which involves tamper-
evident and tamper-resistant digital ledgers,
217
is increas-
ingly used in fields where data security and confidentiality
are important.
218
It is generally claimed to be robustly
secure with regard to cybersecurity, data privacy and the
IoT.
219–222
Furthermore, BC is claimed to enhance users’
control over the data generated using web applications,
since it prevents enterprises providing network applica-
tions from privately storing user interaction data.
223
However, concerns have been raised about the se-
curity and privacy-related challenges derived from BC’s
complexity, scalability, lack of standardisation, and di-
versity of protocols,
224–226
and about whether use of BC is
compliant with EU data protection law.
227
Examining the
feasibility of new humanitarian applications for block-
chain, Connolly et al.
228
surveyed current theoretical and
practical work on how BC can be used to help protect
the human rights of migrants and refugees, primarily
through creation of digital identities. In a critical ex-
amination of cases, they found BC can be useful in
empowering vulnerable individuals, but there are also
potential human rights risks, such as the infringement
of privacy and discrimination, and it is recommended
that adequate safeguards should be in place to ensure
that BC initiatives meet their true purposes of protecting
the most vulnerable groups. Dimitropoulos
229
critically
examined the adoption of BC by international organi-
zations, including those in the humanitarian sector,
raising questions about the legitimacy of use per se of
digital distributed ledgers, and the risk that, while giving
someone a digital identity, a very robust, hard-to-change
record is created that collects everyone’s data. High-
lighting the importance of accountability of public po-
wer, Dimitropoulos called for a new social contract for
blockchain to ensure that its use by international orga-
nisations and all public institutions supports the goal
that no one is left behind in the digital era, both in terms
of means of subsistence, as well as basic political rights.
Self-sovereign identity (SSI)—user-controlled, decen-
tralised forms of digital identification—is closely linked
with the distributed ledger technology and is proposed
as a tool to empower marginalised groups, including
refugees. Some advocates claim that SSI removes the
need for powerful, centralised state and corporate
structures by giving individuals control and ownership
of their identity information,
230
which is a vital asset in
contexts of migration circumstances where an in-
dividual’s identity documents become lost or inacces-
sible. Cheesman
231
has challenged these claims, arguing
that the reality of competing factors related to four is-
sues (the neutrality of the technology, the capacities of
refugees, global governance and the nation state, and
new economic models for digital identity) act to desta-
bilise SSI’s potential as a tool of refugee empowerment
rather than state or corporate control.
Applications of BC in health
232–240
include preserving
and exchanging patient data through hospitals, diag-
nostic laboratories, pharmacy firms, and physicians;
contributing to identifying severe and dangerous med-
ical mistakes; improving the performance, security, and
transparency of sharing medical data in the health care
system; enhancing the analysis of medical records; and
responding to the COVID-19 pandemic. A number of
features claimed for BC technology are of particular
relevance to migrants and refugees.
228,241–244
These
include the core requirements (Fig. 1) for digital health
to take account of personal and societal factors and
vulnerabilities while being accessible, confidential,
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12 www.thelancet.com Vol 50 March, 2025

ethical, secure, and portable. To date, the main uses of
blockchain in support of migrant and refugee health
have been in addressing lack of personal identification
and unavailability of health records.
242,243,245,246
In the context of this evolving picture of the use of
BC to provide security, confidentiality, and privacy in
personal data records, Panel 4 presents a discussion of
the employment of BC for health records and the po-
tential benefits and challenges for their application to
the health of migrants and refugees, with a focus on the
European Region.
Artificial intelligence
Applications of AI in the health field are increasing
273
and present both opportunities and risks for migrants
and refugees. The potential benefits for the health of
migrants and refugees, include the ability to identify
and proactively target migrant groups which may be
particularly vulnerable to certain illnesses. For instance,
African and Caribbean men are at higher risk of con-
tracting prostate cancer and may benefit from access to
screening tests, thus supporting expanded access to
services. Such efforts need to be considered alongside
the risks of use of AI to identify, trace, and monitor
individuals, as well as the perpetuation of existing biases
and discriminatory processes that become embedded in
the algorithms and data sets incorporated in the AI.
274
Research
Research relating to digital solutions for migrant and
refugee health has two main aspects. One relates to
investigations about the use of digital applications by
migrants and refugees for their own health needs. The
other concerns investigations of the value of the use of
digital applications by researchers as a means to gather
data on migrant and refugee health. There is growing
interest in such research, including in cross-cutting
opportunities afforded by advancing technologies and
in the methodological and ethical challenges particular
to research in this field.
275–277
A cross-cutting theme re-
flected in the literature is the need for inclusion of mi-
grants, refugees and displaced persons—those who may
otherwise be invisible to or be harmed by traditional
research tools and methods—in the whole research
process, based on clear ethical criteria.
60
While quantitative studies offer important data on
migration and refugee health, incorporating qualitative
research methods rooted in humanities and social sci-
ences, including ethnographic studies, is crucial for
capturing the complex and sensitive nature of refugee
experiences.
97,143,146
Ethnographic research, such as that
described in Fresh Fruit, Broken Bodies,
278
provides a
deep understanding of the social, cultural, and eco-
nomic factors that shape migrant lives and health out-
comes. This type of research allows for a more nuanced
exploration of the lived experiences of refugees and
migrants, often revealing systemic inequalities and
barriers to accessing healthcare that quantitative
methods alone might overlook.
Moreover, qualitative studies like those conducted by
Willen
279
on unauthorised migrants’experiences of
healthcare in Tel Aviv and Khosravi
280
on undocumented
migrants in Sweden further underscore the importance
of ethnographic approaches in highlighting the everyday
realities and struggles of migrant populations. These
studies illustrate how qualitative methods can capture
the voices and perspectives of migrants, providing a
richer context for understanding their health needs and
challenges.
281
In addition to ethnographic studies, participatory
research approaches are needed in refugee and
migration-related research, aiming not only to enhance
the validity of the research by incorporating the per-
spectives of the participants but also to contribute to
empowerment of the participants and their commu-
nities and providing them with a platform to share their
stories. Such approaches actively involve refugees and
migrants in the research process, ensuring that the
findings are more relevant and reflective of their lived
experiences. Recent examples of participatory research
include storytelling and arts-based activities, which have
been used to explore migrants’experiences of integra-
tion and well-being and support adjustment
282
and the
Photovoice initiative with Syrian refugees in Lebanon
which allowed participants to document their daily lives
and health challenges through photography, with self-
reports from some participants highlighting changes
in posttraumatic stress, anxiety, and somatic symptoms
over the course of programming.
283
With the aim of promoting health equity for mar-
ginalised groups, a continuum of approaches to partic-
ipatory health research (PHR) have been developed,
with a list of more than 25 ranging in type from
academic-driven research to equitable shared decision
making between academic and community partners.
284
This plethora of approaches has raised questions
including what constitutes PHR, how to evaluate the
impact and added value of PHR, how to adapt PHR to
specific areas of application, and what clarifications are
important in ethical questions in PHR.
285
Rustage
et al.
286
highlight that two fundamental principles of
participatory research that underpin the ability for
stakeholders to effectively co-operate and share power
are those of inclusivity and democracy, encapsulated in
the questions, “has the research included the in-
dividuals the research would otherwise be about, and
have these individuals, during their inclusion, had in-
fluence or power over research decisions on par with the
research professionals?”
In the first systematic review to robustly measure the
application of participatory approaches and principles to
health intervention research for migrants, Rustage et al.
note that there are varied interpretations as to how to
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Panel 4:Blockchain insights: transforming health records in Europe.
The European Health Data Space emphasises the efficiency of health systems during a crisis, individual ownership of data, access, and the global impact of
data reuse.
247
Its objective is to overcome shortcomings in communication, interoperability, security, privacy, and data quality
247
caused by European
countries’fragmentation of standards and specifications.
5,242
By 2025, the Member States, except for Denmark and Romania, will be required to implement
electronic health records (EHR) in a standardised format (EHRxF),
248,249
including information on medicines and health data (Myhealth@EU).
250
Similarly, in
2022 the OECD also addressed the implementation of EHRs through cohesive regulation and governance, referencing Denmark and Finland.
251
Globally,
EHRs must promote functional, structural, and semantic interoperability, mitigating data heterogeneity.
242,252,253
Additionally, quality, record certification
and access to data are contemplated and mandatory in the Europe standards.
247
In centralised systems, the transfer of information between two entities is overseen by a third-party organisation, which validates and completes the
transaction.
254
Implementing European data protection regulation standards in closed domains, protected with firewalls and intrusion detection systems, is
possible through centralised management.
254
However, the applicability of this model is questionable, given the growing volume of data.
255
Additionally,
there are interoperability challenges due to the incompatibility of the information systems, particularly in the cases of Germany, Spain, and Italy.
253
In a
decentralised network, several entities communicate and coordinate with each other to maintain a coherent system for the users.
254
The design challenge
resides in managing the replicas, ensuring consistency of all the copies of data distributed across several parties, and dealing with security, transparency,
fault tolerance and management, scalability, and load balancing.
256
An example of a decentralised network that can be used to manage health records is blockchain (BC) technology.
257
This is a distributed ledger technology
used in domains where trust is a fundamental concern.
242,244,256–258
A block is defined as a set of data or a collection of records. Once a block is full, another
block is created and added to the network as part of a chain through a mining or validation process. The information is replicated through a distributed
network of peers and, once written, cannot be modified. New records can be added after peer validation using a consensus algorithm.
257
BC chronologically
records information in a tamper-resistant data record, transacted or broadcasted across a network of peers or users.
258,259
This allows any legitimate user or
node to participate in the network and read and write in its ledger. A consortium BC creates a decentralised environment, a collaborative ecosystem, where
no third party controls the transaction and the data.
257
The data is shared and available to all nodes, which makes the system transparent. The
immutability and transparency of the blocks constituting the ledger enable tamper-proofness and traceability of the data source.
257
From an individual
entity perspective, security is achieved by assigning a unique identity associated with their account and restricting access to personal records exclusively to
the user.
242,260
The veracity of data held also depends in part on the protection it receives from external attackers, and preventing unauthorised access is
contingent upon the network’s privacy features.
261
This protection is closely linked to the network’s privacy model.
242,256,261
While applications of blockchain
technology are growing rapidly, there is are significant skills gaps,
262–264
including in relation to the need to develop capacity of health workers and patients
to access and use health records appropriately, skills of professionals to critically assess applications in areas such as migrant and refugee health, and lack of
experts, investment, and infrastructure.
BC is associated with EHR in a distributed workflow that is consented, authorised, and regulated. This safeguards medico-legal issues and the
implementation requirements of a health data management network.
243,244
BC can be employed in inter-organisational workflows as a disruptive
technology with the potential to enhance the accessibility and reliability of the information, facilitate data sharing, and provide users with the ability to
input and review information in real-time, particularly in the context of identity, health, law, or academic records.
244
In 2021, the Expert Meetings on
Digital Solutions for Migrant and Refugee Health explored the potential of blockchain technology.
265,266
The potential of BC to address the issues of
migrants and refugees was introduced in Estonia
260,267
and subsequently it has been considered for restructuring cross-border flows, scaling diasporas, and
globalising identity data.
242–244,256,258–260,265,266
A secure and verifiable blockchain-based or self-sovereign identity integrated into certified platforms would
provide migrants and refugees access to cross-transactional records.
242,267,268
Estonia provides an example of the introduction of BC technology and its
applications across a range of e-government functions. Since 2007, Estonia has been at the vanguard of rethinking the security of personal data, utilising
BC in a hybrid public-private digital signature model
269
and making available a public key infrastructure card which gives access to EHR on the Guardtime
platform.
267
This has helped reduce the economic and social vulnerability of the migrant population in Estonia by including them in e-Residency which
provides access to Estonian e-services and can be used in online environments for personal identification and digital signing,
270
affording e-Residents
digital identity
271
and access to secure financial transactions.
Due to its considerable importance, BC has been the subject of conceptual and empirical investigation, including ad hoc implementations by companies
and other organisations in recent years.
243,256
Regarding interoperability solutions, blockchain networks have been identified as a key component in the
design of database architecture for research platform pilot projects, particularly from a bottom-up perspective, focussing on the homeless population.
243
Besides technological progress, the digitalisation of healthcare is also shaped by regulation, particularly the GDPR
244
in the EU. Following the 2019
pandemic crisis, it was necessary to analyse the regulatory framework.
272
In 2021, the European Council proposed the creation of a cross-sectoral legislative
framework on the collection, access, storage, use, and re-use of healthcare data, addressing specific challenges and compliance with European values, with
an emphasis on maintaining a complete history of medical data, the development of personalised medicine, and the quality of healthcare.
247
The
transparency of civil and medical data is a highly sensitive issue in the different jurisdictional scenarios within Europe.
55
The potential for conflict between
the GDPR and the immutability of BC can be mitigated by a number of means, including the review of existing laws and regulations, the implementation
of compliance mechanisms, the utilisation of hybrid network architectures and governance frameworks for privacy assessments, and the pursuit of a
balance between the rights of the individual and the impact on the community.
244
This can be achieved by anonymisation or by following ethical
guidelines and standards (e.g., transparent policies on secure and responsible storage) in accordance with leges artis, theoretical concepts, and basic moral
principles adapted to the new challenges of the digital age. Integrating compliance mechanisms, auditing processes, and privacy-enhancing technologies in
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14 www.thelancet.com Vol 50 March, 2025

apply participatory approaches. For example, they found
instances of active participation of migrants, proxy
participation and indirect participation in the 28 studies
selected for review (only a handful of which involved a
digital tool as an integral component, such as a video or
social media message), and while all the studies
involved non-academic stakeholders in at least one stage
of the research, only two showed evidence of active
participation of migrants across all research stages. The
authors conclude that participatory approaches to
developing health interventions for migrants are insuf-
ficiently applied and reported and that the application of
approaches does not fully embody core principles of
participatory research, particularly relating to providing
decision-making power to individuals ultimately
affected by the research. They recommend that those
wishing to engage in participatory research must
consider the approach they take and critically analyse
whether it is sufficient to achieve high-quality partici-
pation, not just high-quality research. They also
emphasise the crucial need for introduction of guide-
lines for reporting of participatory research methods, as
a prerequisite to explore the overall impact of partici-
patory research, which currently remains inadequately
understood. The International Collaboration for Partic-
ipatory Health Research working group on migration
has presented a position statement
287
addressing op-
portunities, challenges and ways forward in relation to
migrant health. They note that, for each research
context, it is essential to gauge the ‘optimal’level and
type of participation that is most likely to leverage mi-
grants’empowerment.
A framework for refugee and migrant health research
in the WHO European Region has been provided by the
WHO Regional Office for Europe.
288
The framework
discusses three interrelated dynamics in research prac-
tice, namely research prioritisation, study samples and
research design, offering recommendations to consider
for each. It emphasises the value of involving refugees
and migrants in research and research agendas and the
need to develop an ecosystem that will support and sus-
tain participatory, interdisciplinary, transdisciplinary, and
inter-sectoral projects.
Participation of migrants and refugees themselves is
a core requirement for block chain. As a cross-cutting
digital tool, blockchain affords opportunity for a range
of applications that can benefit migrants and refugees
including in healthcare, financial matters and oversight
of programmes such as for asylum and migrant inte-
gration and the exposure of human rights abuses. As
Ardittis observed, “Although not a panacea, blockchain
could offer major cost-efficiency, transparency and
accountability benefits for future migration and asylum
programmes”.
289
Given the sensitivity of data security
and confidentiality, it is important that the risks atten-
dant on adoption of BC are carefully considered in every
case, including for data collection and management in
both service programmes and research, with primacy
always being given to the interests of the subjects
through their participation.
Research on use by migrants and refugees of digital
applications for health
Data on the health status and needs of migrants and
refugees at population levels is generally sparse and
more is required. The World Bank’s Handbook
290
offers
guidance to support Member States in the collection,
tabulation, analysis, dissemination and use of migration
data, to contribute directly to monitoring the imple-
mentation of the SDGs. The Handbook highlights that
the 2030 Agenda to “leave no one behind”has signifi-
cant implications for data collection, since policy makers
need to identify and address all under-served groups, so
that data must be disaggregated by migratory status,
including in the health field. Potential innovative, big
data sources of migration data are indicated, including
mobile phones, online tools and platforms such as social
media or online payment services, and digital sensors
and metres such as satellite imagery. The Handbook
advocates a multisectoral approach to health, with policy
responses addressing the underlying social de-
terminants of migrants’health (as illustrated in Fig. 1)
and the barriers that prevent migrants from accessing
quality health care services.
Social media platforms and other digital in-
terventions can enhance uptake of health prevention
and promotion services among migrants and refugees,
such as health information services, vaccinations, and
health check-ups, as demonstrated by evidence relating
to the COVID-19 pandemic period.
291–296
This is an area
where research could help advance understanding of the
factors involved and provide more evidence on effec-
tiveness of such interventions.
A National Academy of Medicine report in 2019
emphasised that, while technology has the potential to
support individuals across the mental healthcare con-
tinuum and is already being extensively used, it raises a
complex web of ethical dilemmas.
297
While the report
did not specifically refer to migrants and refugees, its
focus on ethical factors in the areas of privacy, rights,
trust, and transparency, make the findings of particular
relevance to these groups. To address the concerns
the context of BC use can be a pivotal strategy, capitalising on privacy-enhancing technologies such as encryption or pseudonymisation. The combination
of BC with off-chain storage to store or delete sensitive data can be employed to store hashes of that data, which serve as “fingerprints”attesting to the
integrity of the data off-chain. It would be prudent to consider the implementation of governance frameworks with a view to ensuring compliance with
data protection legislation and the mitigation of potential privacy risks.
244,256
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identified, the report called for a number of actions from
decision-makers and other stakeholders, including
creating a governance structure to support the broad and
ethical use of new technology in mental healthcare,
developing regulation grounded in human rights law,
embedding responsible practice into new technology
designs and adopting a “test and learn”approach in
implementing technology-led mental healthcare services
in ways that allow continual assessment and improve-
ment and that flag unintended consequences quickly.
A rapid review
298
of digital health applications in
mental health care for immigrants and refugees found
that satisfaction and positive attitudes were generally
reported by participants. However, there was generally
poor implementation and reporting of the ethical
standards of the digital health application studied. A
systematic review
299
of the literature on smartphone-
delivered mental health care interventions for refugees
also noted that participants were mostly satisfied, but
levels of provision fell far short of the needs. Among
other findings, the review identified room for improve-
ment in the efficacy and effectiveness of smartphone-
delivered interventions and in data safety, as well as
the need for more knowledge about effective treatment
elements and the barriers that hamper wider use in
refugee populations. To achieve high acceptance and
utilisation among refugees, the review recommended
developing culturally and contextually adapted in-
terventions with high attractiveness and trustworthi-
ness, as well as intervention approaches that are as
diverse as possible to address the heterogeneity of the
target population.
Technology-based interventions allowing support
and treatment for mental health to be provided to ref-
ugees offer a number of advantages, including the op-
portunity to deliver help rapidly and remotely to difficult
locations, and the possibility to use digital innovation to
deliver interventions while reducing reliance on spe-
cialists.
300
However, to be successful, the need was also
emphasised for digital interventions to be in line with
the capacity and motivations of the target audience,
focussing attention on the vital importance of user-
centred design in developing digital interventions.
Research on utility of digital applications to study
migrant and refugee health
Innovations in digital technologies offer increasing op-
portunities to conduct research with migrants and ref-
ugees, including research related to their health and
health-seeking behaviour.
301–303
Digital devices and apps
may provide opportunities to overcome some of the
myriad methodological challenges of primary data
gathering in challenging settings for example, where
research participants are on the move or may be put at
risk by exposure through research methods that force
them to be visible, where there are cultural and lin-
guistic differences, and where participants may be
retraumatized by face-to-face research methods. Missing
or incomplete sampling frames are also a challenge that
may be assisted by digital devices and apps, but much
more attention is needed to understand the benefits and
limitations of these approaches.
304,305
The growing use by migrants and refugees of
smartphones and social media
306,307
has encouraged
exploration of the use of social media platforms as
digital research tools.
308,309
A scoping review examined
published health research that uses WhatsApp as a data
collection tool that offers opportunities to maintain
contact and participation across time and place and that
can interface with online platforms that allow for the
automatic administration of surveys.
310
The papers
reviewed largely used WhatsApp to send hyperlinks to
online surveys, or to deliver and evaluate either an
intervention designed for healthcare users or a
communication programme for healthcare providers.
Notable findings included a lack of attention in publi-
cations to the experiences of research participants while
interacting with the WhatsApp interface, to the impact
of the studies, or to research ethics, including protecting
participants’privacy. Recommendations for researchers
included the need to systematically and clearly docu-
ment and discuss their use of the application when
presenting their research, pay greater attention to data
privacy and security through selecting and recording
only necessary information and encrypting the recorded
data so that it is only available to the researchers,
removing identifying information, saving the data on
secure servers, and making greater efforts to ensure that
participants understand the terms of the research and
are provided with information, relating to the specifics
of the research project and how they can seek and access
support should it be required.
There has been success with research that has used
WhatsApp to understand the intersections between
migration, mobility, health and gender in South Af-
rica
311
and conduct the first survey with migrants and
refugees from sexual and gender minorities in South
Africa.
312
This research points to the potential of What-
sApp as a research tool, whilst highlighting the need for
researchers to proactively engage with the ethical im-
plications of this work as it takes place outside of a well-
established framework for ethical research.
However, there have been increasing concerns
expressed about data protection and the lack of security
of global social media platforms, including
WhatsApp.
313–315
A complaint that WhatsApp Ireland
Limited was forcing users to accept its processing of
their data if they wished to continue using the service
was upheld.
316
WhatsApp’s compulsory privacy policy is
not uniform globally, but incorporates its right to collect
a wide range of personal identity and location data.
317
An
independent review into the use of WhatsApp and other
instant messaging applications within the police service
in the UK
318
identified risks of non-compliance with data
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protection legislation and of data breaches and disclo-
sure as being areas of real concern and recommended
the development of guidance on when the app could be
used in police work. In the light of these wide-ranging
concerns, researchers wishing to use social media plat-
forms need to ensure they have up-to-date information
on security and privacy risks when contemplating the
use of the platforms in their studies. It should be
required that this information is presented as part of an
application for approval of the research.
Equity and inclusion
Many factors, including gender, age, ethnicity, cultural
background, migration status and language skills, as
well as digital literacy, influence opportunities and ca-
pacities to take advantage of digital tools and services,
including those related to health.
319,320
While overall use
of mobile phones and the internet in Europe is high,
there is a significant difference between usage rates for
men and women, with a gender gap of 6–8% being re-
ported. Usage rates are much lower in many low- and
middle-income countries and gender gaps higher,
321
and
these gaps may contribute to lower overall and gender-
related gaps in digital access and use in migrant pop-
ulations in Europe.
322
Ethnicity is also a significant factor
in the health inequalities seen in and between host and
migrant populations. Such inequalities may be exacer-
bated or potentially alleviated by digital health care, as
has been discussed in the UK.
323,324
Such factors present
a compelling argument for taking an intersectional
approach to examining access and use of digitalised
health services, which considers not only the impact of
social identities, but also geography. The absence of
attention to many areas of diversity, including aspects
such as disability and LGBQTI, in the digital space has
been highlighted,
325–327
and movements initiated towards
decolonising digital rights.
45,328,329
Verovic
330
has stressed
the importance of a multidimensional perspective on
diversity in the migration context, both in terms of
moving beyond the ethnic group as either the unit of
analysis or sole object of study and by appreciating the
coalescence of factors which condition people’s lives. An
intersectional approach illuminates health disparities
and the underlying structures that create and maintain
disparities. The use of intersectionality theory
331,332
to
consider the ways in which experiences of racism
interact with sexism and other systems of oppression in
individuals’experiences of health sciences is still new,
for instance in the UK.
333
However the use of the theory
in health sciences is growing
97,334,335
and is currently
being extended to investigation into the use of digital-
ised health services in the UK.
323
Sabik
336
has provided
an intersectionality toolbox as a resource for teaching
and applying an intersectional lens in public health.
Inclusion is also an important factor in the process of
developing apps and digital services to support the
health of migrants and refugees. A 2023 Scoping Review
looked at digital health interventions developed for
ethnic or cultural minority and migrant populations, the
health problems they address, their effectiveness at the
individual level and the degree of target population
participation during development. About half did not
involve the target population in development and only a
minority involved them consistently, while the increased
involvement of the target population in the development
of digital health tools led to a greater acceptance of their
use.
146
Bozorgmehr et al.
55
have commented that coverage of
migrant and refugee data is incomplete and of insuffi-
cient quality in European health information systems.
To create healthcare policies and practices that are truly
inclusive of migrants and refugees, they have proposed
four approaches, involving (1) strategies that ensure that
data is collected, analysed and disseminated systemati-
cally; (2) methods to safeguard privacy while combining
data from multiple sources; (3) enabling survey methods
that take account of the groups’diversity; and (4)
engaging migrants and refugees in decisions about their
own health data. In support of the last approach
Quyoum and Wong
44
have argued that the use of co-
design methods can strengthen capacity amongst
racialised communities and stakeholders to articulate
where inequities are occurring, increase understanding
of how to counter harm, and co-create solutions to
ensure that digital services are equitable and responsible
by design. The involvement of refugees in the develop-
ment of applications through transdisciplinary research
is also illustrated through two studies building on evi-
dence generated from qualitative research and partici-
patory approaches in the same project from a social
science and human computer interaction approach,
respectively.
12,45
Elements of this collaboration which
may be regarded as good practice include early consul-
tation with a refugee-led organisation in determining
the focus of the study; financing the organisation to
engage with the research; pre-workshop meetings with
participants to build trust and rapport; the inclusion of
trusted community workers in the facilitation of the
workshops; exercising gender and linguistic sensitivity
throughout the process; feeding back the results to
participants, to validate the research findings and iden-
tify ways forward; and participation in the planning of
dissemination activities. The authors argue that these
collaborative processes not only enabled them to build
up trust and rapport with key individuals within the
refugee community, but also contributed to the devel-
opment of more ethically developed and effective digital
tools.
337
In another example of good practice, the Hera
app, developed as a social enterprise model to ensure
sustainability, bridges the gap between Syrian women
refugee women and the care they and their children
need, by allowing the user to carry their medical records
with them on their smartphone. The app sends
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reminders when immunisations or check-ups are
needed, and also contains relevant emergency infor-
mation, such as the location of the nearest hospital.
338
Framing analysis and action
As noted in the UN’s roadmap for digital cooperation,
339
“digital technology does not exist in a vacuum—it has
many sociotechnical facets that have enormous potential
for positive change, but can also reinforce and magnify
existing fault lines and worsen economic and other in-
equalities”. Digital tools are not a panacea. The technical
and equity problems generally associated with digital
technology, including access, identity, security, confi-
dentiality of information, risks of abuse, exploitation
and fraud, also apply to and may be magnified for mi-
grants and refugees. They may change the balance of
opportunities and risks each individual faces in seeking
solutions to their daily challenges, including in health.
Digital tools provide technical solutions: they do not
necessarily overcome problems that are political, social,
or economic and that originate beyond the technical
sphere (Fig. 1), although they may be able to help. For
example, they may facilitate access to information, but
do not replace the need for health workers to acquire
cultural competence as an essential tool
340
in their
engagement with migrants and refugees.
Hou et al.
147
have observed that “addressing the
intersecting challenges of migration and healthcare
service accessibility demands a holistic approach that
calls for both feasible solutions and policy supporting
the implementation of solutions”. While much attention
has been focused on how digital approaches can
potentially assist with challenges of accessibility to
health information and treatment,
341,342
as discussed in
this article, relatively little has been given to the implicit
assumption that improving accessibility when conven-
tional service approaches are unavailable will lead to
improved clinical outcomes. Hou et al.
147
also observed
that migrating affects healthcare service accessibility,
continuity, quality, and equity through the diverse and
complex needs of migrants generated depending on
geographic conditions, pre-existing health issues, expo-
sure to new health risks through migration and settle-
ment, food security, mental health, livelihood, and other
non-health factors which result in health vulnerabilities,
including but not limited to gender, age, ethnicity, and
religion. All of these factors mediate the extent to which
accessibility translates into improved clinical outcomes,
with digital health approaches able to facilitate, cost
effectively, better recognition of health problems and
potential solutions by both patients and health pro-
viders. But they do not to overcome structural and social
factors in the provision and uptake of treatment. Re-
views of the use of digital approaches for migrant and
refugee health highlight the lack of evidence on clinical
outcomes, including lack of data on the magnitude of
inequalities in infection risk, disease outcomes, conse-
quences of pandemic measures or explanations of un-
derlying mechanisms.
343
Available evidence on the effectiveness of digital
approaches in producing improved clinical outcomes is
mixed. For example, one of the areas most studied has
been in mental health. A randomised controlled trial of
a WHO-guided digital health intervention for depres-
sion in Syrian refugees in Lebanon was effective in
reducing depression in displaced people,
344
and a
scoping review on the impact of digital technology on
the well-being of older immigrants and refugees
concluded that use of digital technology benefited the
well-being and quality of life of older immigrants and
refugees, including helping them cope with migration-
induced stress.
320
However, a systematic review of
technology-based mental health interventions in mini-
mising mental health symptoms among immigrants,
asylum seekers or refugees found scant evidence that
the use of digital interventions, such as mobile-based
therapies, video conferencing, and digital platforms,
was associated with a statistically significant reduction
in depressive and anxious symptoms.
345
Implications
include that health service providers and researchers
need to gather more evidence on the effectiveness of
digital interventions and acquire greater training them-
selves in the use of digital technologies for health. Im-
plications for policy makers and service planners
include the need to provide channels and mechanisms
through which migrants can acquire greater under-
standing of the opportunities and risks associated with
digital solutions and enhance their skills in using digital
approaches.
Set in the context of the SDGs, the UN Road Map for
Digital Cooperation has the goal of ensuring that every
person has safe and affordable access to the Internet by
2030, including meaningful use of digitally enabled
services, taking a people-centred approach that leaves no
one behind.
339,346
The Road Map
339
stresses the vital
importance of digital inclusion, requiring better metrics
and greater attention to the situation of people on the
move, including migrants and other vulnerable com-
munities who are often absent from digital cooperation
discussions and face additional challenges in achieving
connectivity.
In September 2024, the UN Summit of the Future
included a digital technology track leading to a Global
Digital Compact, billed as the first comprehensive global
framework for digital cooperation and AI governance,
which was issued as an Annex to the Summit’s Pact for
the Future, along with a Declaration on Future Gener-
ations.
347
The Global Digital Compact espouses
numerous principles and commitments of direct rele-
vance to migrants and refugees, including closing all
digital divides between and within countries, recognis-
ing the need to identify and mitigate risks of new
technologies, having the goal of an inclusive, open,
Personal View
18 www.thelancet.com Vol 50 March, 2025

sustainable, fair, safe and secure digital future “for all”,
fostering an inclusive, open, safe and secure digital
space that respects, protects and promotes human
rights, promoting digital accessibility for all and sup-
porting linguistic and cultural diversity in the digital
space, committing to connect all persons to the internet,
including the needs of people in vulnerable situations
and those in underserved, rural and remote areas in the
development and implementation of national and local
digital connectivity strategies, and expanding inclusion
in and benefits from the digital economy “for all”.
However, the Compact makes only one direct reference
to migrants, in paragraph 13 committing to “develop
and undertake national digital inclusion surveys with
data disaggregated by income, sex, age, race, ethnicity,
migration status, disability and geographical location
and other characteristics relevant in national contexts, to
identify learning gaps and inform priorities in specific
contexts”. This focus on identifying migration status
rather than dealing with any other aspect of migration
may not be understood as congruent with the procla-
mation of rights and benefits for all permeating the rest
of the text. It is now important that organisations con-
cerned with migrants and refugees work for the inter-
pretation and implementation of the Compact in ways
that support and benefit their rights, welfare and health.
Development of actions flowing from the Global
Digital Compact will also need to be set in the context of
other global instruments that affect migrants, refugees
and displaced persons—in particular, the Global
Compact on Refugees
11
and the Global Compact for
Safe, Orderly and Regular Migration.
348
It will be
important to avoid the historical tendency
24
to create
policy sector silos and ensure that policy-making related
to digital aspects of migrants, refuges and health is
coherent with human rights and humanitarian aims, as
well as the SDG principles. Similar considerations of
policy coherence and the avoidance of structural barriers
apply at all global-to-national levels.
124,349
In the European
context, implications include the need for coherent
policy and action among the major agencies, including
the European Union and WHO Regional Office for
Europe, and the integration of migrant and refugee data
in health information systems in Europe.
55
The EU’s
Pact on Migration and Asylum, agreed in May 2024, is a
set of new rules for managing migration and estab-
lishing a common asylum system at EU level. It in-
cludes the Eurodac asylum and migration database. The
Eurodac Regulation
350
turns the existing database into a
fully-fledged asylum and migration database, “ensuring
clear identification of everyone who enters the EU as an
asylum seeker or an irregular migrant”.
351
The 2024
Regulation also sets the conditions under which re-
quests for the comparison of biometric or alphanumeric
data with Eurodac data for the purpose of preventing,
detecting, or investigating terrorist offences or other
serious criminal offences should be allowed.
The Migration Policy Institute Europe
352
has
emphasised the need for policymakers, civil servants,
and others involved in digitalisation efforts to judi-
ciously steer their adoption of the Pact, including by
developing appropriate governance frameworks to
regulate aspects such as data protection, oversight, and
accountability, and creating a strategic vision for the use
of new technologies in migration and asylum systems.
Eurodac is an EU-wide information system that pri-
marily processes the fingerprints of asylum seekers and
irregular migrants apprehended in connection with
their irregular border crossing and irregular staying. Its
aim is to track secondary movement in the EU by
obliging Member States to collect the fingerprints of
every asylum seeker over the age of 14 when they apply
for international protection. Eurodac fingerprinting does
not determine the identity of a person per se, though it
does contribute to their identification. Over time, the
purposes for which Eurodac is used have been expanded
and more categories of personal data added, including
facial image, lowering the fingerprinting age to six years,
increase in the retention of irregular border crossers’
data from 18 months to 5 years and possibility of
transfers of Eurodac data for return purposes.
353
Critical
analysis
354
has demonstrated that Eurodac is progres-
sively being transformed from an information system of
limited aims and capacities into a support tool for a
range of EU policies on asylum, resettlement and
irregular migration. Use of blockchain can help to
strengthen the security and confidentiality of data held
and limit access to those authorised, although access
may be extended to others (nodes) officially mandated as
a result of policy changes. Challenges, where appro-
priate, need to be made through political, legal, and
human rights channels. In an alternative vision for
digital technologies that support migrant and refugee
health, it has been proposed
242
that, with regard to forced
migration, BC technology could support creation of a
global data space in situations of humanitarian catas-
trophe in an emergency context. Anchored in the se-
curity, privacy, and medico-legal regulation of medical
data, this could improve communication, overcome
gaps in medical data sharing, and empower inter-
organisational services or workflows anywhere in the
world.
It is evident that addressing the health of migrants
and refugees through digital technologies and services
needs to be framed in a multi-dimensional context that
includes considerations of (1) the entire digital space as
it operates globally-to-locally and the extent to which this
is accessible and affords opportunities and risks to the
users; (2) the rights of migrants and refugees; (3) the
health systems and services with which they are able to
engage; and (4) personal factors and circumstances of
each person. All of these factors are dynamic, evolving
and interacting in parallel. Thus, action aiming to in-
crease the benefits and decrease the risks of digital
Personal View
www.thelancet.com Vol 50 March, 2025 19

Addressed to Recommendations
Users/research subjects/
participants
and their representatives
Active participation
Individuals and representatives of groups and communities with personal experience of migrating and asylum-seeking should actively engage with those
developing and implementing policy, technologies, and services in the public, private and not-for-profit sectors concerned with digital solutions for their
health, in order to:
•From their experiences of the realities of migration, highlight the ways that digital rights and health rights, both of which are aspects of defined human
rights, are not being respected in current practice relating to digital technologies and their applications to migrants and refugees, and apply their
knowledge and experience to encourage and facilitate improvement.
•Encourage efforts to make digital approaches for their health ‘safe and beneficial by design and in operation’.
•Participate directly and actively in all stages of the development, roll-out and evaluation of digital solutions for migrant and refugee health.
Policy makers Rights and equity as paramount principles
Having adopted global, regional and national instruments respecting human rights and equity, governments should avoid inconsistency in the application
of the principles these instruments contain, especially in the case of migrants and refugees, who are often ‘exceptionalised’despite commitments to ‘leave
no-one behind’. Taking rights and equity as paramount principles in promoting and enabling digital solutions for migrant and refugee health requires:
•Ending practices that dehumanise migrants and refugees in all aspects of their treatment, including in the control of borders and in the denial of services
that are the basis of fundamental human rights.
•Encouraging efforts, through policies, programmes and investments, to make digital approaches for their health ‘safe and beneficial by design and in
operation’.
•Paying particular attention to instituting regulatory mechanisms to ensure the security, confidentiality and privacy of digital data, which is necessary for
the benefit of the whole population, including migrants.
Technology developers/
providers/operators
Accessibility
The device, app, platform or digital intervention should be designed to be as accessible as possible, being mindful of restrictions the potential user may face
in access to the hardware, software and connectivity and barriers that may occur due to factors such as language, cultural differences and social situations.
Data security
Design of the device, app, platform or digital intervention should try to minimise if not eliminate exposure of the user to potential identity or surveillance
risks. Where possible, it should create a firewall protecting the app or platform from misappropriation of data on the user.
Careful consideration should be given to:
•What identifying information will be collected and whether it is possible to collect less.
•What other data is being collected by the app and/or platform in the background, who is collecting it and what will be done with it presently and later.
•If there is a data breach, could the information collected expose the participant/patient to identification and/or risk; and, if so, what ways can be used to
minimise this.
•How and where the data will be stored and de-identified/anonymized, who will have access to it and when the data will be destroyed.
•What safeguards are in place to ensure that data shared via the app or platform is not misappropriated or misused by those who currently have access to
it and those who may have access in the future if the app or platform is sold or passed on to a third party.
•Whether the app or platform is sufficiently secure so that if another person uses or steals the participant/patient’s device, they will not have access to the
information and it is easy for the participant/patient to delete the app or their interaction with the service or research from their device?
Digital health service
providers
Informed consent
When involvement of migrants and refugees in digital services for health requires consent, the provider should ensure that the purpose of the service and
the process for and nature of the consent are clearly explained to, and understood by, the user, where necessary in the user’s own language; that the user
does not feel under pressure to give consent; and that risks associated with taking part in the service, are explained and understood, including risks to health
and to the privacy and security of the person’s data and identity.
Inclusion
The provider should ensure that use of the app, platform or digital service is inclusive of the full diversity of the intended population and will not exclude
certain groups of people due to, for example, factors such as age, disability, documentation status, ethnicity, financial circumstances, gender or LGBQTI
status.
Humanitarian assistance
provider
States, international agencies, nongovernmental organizations and local community groups providing assistance to migrants, refugees, asylum seekers, and
displaced persons need to be aware of the risks as well as the benefits. In minimising risks associated with adoption of digital tools and services, they need
to pay attention to inclusion factors, access barriers, challenges in ensuring informed consent and risks to privacy, confidentiality and security that may
ensue from the participation of individuals in diverse and sometimes very precarious circumstances, as discussed above.
Researchers, research funders,
ethics review committees,
academic institutions
Ethics, diversity, inclusion
Those supporting, designing, approving, and conducting research on digital approaches to the health of migrants and refugees should ensure that:
•The research applies ethical principles that are fully adapted to the needs, vulnerabilities and diverse situations experienced by the individ uals, with
detailed consideration being given to the ethical questions related to data protection, informed consent and exclusion and inclusion criteria listed in Panel
2in this article.
•They adopt participatory research that involves migrants and refugees in all possible stages of the research process, assessing the ‘optimal’level and type
of participation that is most likely to ensure benefit to them and leverage their empowerment. The participatory approach selected should ensure that the
research design, conduct, analysis and reporting involve meaningful migrant participation at every possible stage; and that priority is given, in deciding
the nature of the research processes and the digital tools employed, to ensuring both benefit to the subjects and protection of their privacy and security.
•Effort is made to include the full diversity of the intended population, with attention given to factors that may exclude some people and result both in
fostering health inequalities and in created skewed data that can perpetuate inequalities and misconceptions.
•Concerted effort is directed to developing an ecosystem that will support and sustain participatory, interdisciplinary, transdisciplinary, and inter-sectoral
projects.
Table 1: Recommendations regarding digital solutions for migrant and refugee health.
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health approaches for migrants and refugees needs to
take a comprehensive systems approach, in which the
net outcome for the individual emerges as a property of
the whole system and cannot be identified only by
considering one aspect (e.g., a health need or a tailored
digital app) in isolation from others (e.g., security, fi-
nances, social or cultural factors). Such a multi-
dimensional approach can also help to ensure that the
use of digital technologies and services for the health of
migrants and refugees is aligned with the overall aim of
the SDGs to “leave no-one behind”and specific goals
including SDGs 3 (good health and wellbeing), 5
(gender equality), 10 (reduced inequalities), 16 (peace,
justice and strong institutions), and 17 (partnerships for
the goals).
To summarise key points in this article and provide
the basis for advancing the effective, safe and equitable
use of digital solutions for migrant and refugee health,
we present in Table 1, a number of commendations
aimed at the spectrum of actors involved.
Contributors
SAM and JH conceptualised the manuscript. SAM, JH, and KNM wrote
the original draft of the manuscript. All authors contributed to the
identification of references, development of the text and reviewed and
edited the manuscript. SAM finalised the manuscript and con-
ceptualised and constructed the Figure.
Declaration of interests
We declare no competing interests.
Acknowledgements
We thank the World Health Summit M8 Alliance Expert Group on
Migrant and Refugee Health and London School of Hygiene and
Tropical Medicine for organizing an expert meeting on 19 April 2021,
which initiated the collaboration that led to the writing of this article.
MHZ is a commissioner for the CHH–Lancet Commission on
Health, Conflict, and Forced Displacement. The Protecting Minority
Ethnic Communities Online (PRIME) project which has informed
the co-authorship of this paper by GN is supported by the Engi-
neering and Physical Sciences Research Council grant number EP/
W032333/1.
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