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Health assessments of asylum seekers within the Swedish healthcare system: a study of the interface between control and care, and how structure and procedures may influence access and coverage
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Folkhälsomyndigheten.ORCID iD: 0000-0003-1217-0106
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Despite lack of evidence, there is a common notion that diseases are brought along with migrants, and thus a threat to people in the host country. In Sweden asylum seekers are to be offered a health assessment (HA), but national statistics show that the coverage is less than 50%. It has been assumed that asylum seekers do not want to attend, but this research data instead indicate structural barriers.

Objectives: To explore to what extent the Swedish healthcare system provides optimal conditions for asylum seekers to access the HA and how the HA could meet their own perceived health needs, as well as society’s demand on detecting contagious diseases, from a public health perspective.

Methods: This research project adopted a mixed method approach. A quantitative cross-sectional design was applied where different questionnaires were used, targeting administrators and healthcare professionals as well as former asylum seekers. In addition a qualitative, interpretative and descriptive research approach was applied, guided by grounded theory. Individual interviews were carried out among former asylum seekers.

Results: This research revealed that there is no coherent national system for the HAs on asylum seekers in Sweden. The structures, organizations, procedures and outcomes vary significantly between the 21 counties, and the reasons for the low coverage seemed multifold. The former asylum seekers stated feelings of ambiguity and mistrust due to lack of information on the purpose of the HA and how it might influence their asylum application. Poor communication was identified as one of several barriers to access healthcare. The attitude was positive to the HA as such, but it was considered to be just a communicable disease control, without focus on their own perceived health needs, thus an imbalance between control and care.

Conclusions: Although being an important contribution, the HA does not suffice to fulfill the right to health of asylum seekers, due to shortcomings regarding accessibility and acceptability of the information, procedures and services that it includes.

Abstract [sv]

Bakgrund: Trots avsaknad av fakta så finns en föreställning om att migranter för med sig sjukdomar som utgör ett hot för personer i värdlandet. I Sverige ska asylsökande erbjudas en hälsoundersökning (HU), men nationell statistik visar på en genomförandegrad av mindre än 50 procent. Det har antagits att asylsökande inte vill delta, men resultat från denna forskning indikerar istället på strukturella hinder.

Syfte: Att utforska i vilken utsträckning det svenska hälsosystemet erbjuder optimala förutsättningar till asylsökande att få tillgång till en HU och hur HU kan möta den asylsökandes upplevda hälsobehov, liksom kravet på att upptäcka smittsamma sjukdomar, utifrån ett folkhälsoperspektiv.

Metod: I detta forskningsprojekt har olika forskningsmetoder använts. En kvantitativ tvärsnittsdesign tillämpades där olika frågeformulär användes till administratörer och vårdpersonal samt till före detta asylsökande. Vidare användes en kvalitativ design med tolkande och beskrivande forskningsansats enligt ”grounded theory”. Individuella intervjuer genomfördes bland före detta asylsökande.

Resultat: Forskningsresultaten visar på avsaknad av ett sammanhängande nationellt system för genomförande av HU av asylsökande i Sverige. Struktur, rutiner, uppföljning och resultat varierar avsevärt mellan de 21 landstingen, och skälen till den låga genomförandegraden förefaller vara mångsidig. Deltagarna uttryckte ambivalens och misstro eftersom de saknade information om syftet med HU och hur resultatet skulle kunna påverka deras asylansökan. Bristfällig kommunikation visade sig vara ett av flera hinder för att ta del av vård. Att bli erbjuden en HU uppfattades positivt, men fokus sades bara var på smittsamma sjukdomar och inte på den ohälsa man själv upplevde. Således fanns en obalans mellan kontroll av smittor och upplevda vårdbehov.

Slutsatser: Även om HU ansågs betydelsefull, visar resultaten på att den inte påtagligt bidrar till att förverkliga asylsökandes rätt till hälsa, på grund av hinder och bristande tillgänglighet och acceptans av information och genomförandet av HU.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 75
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2033
Keywords [en]
Public health, migration, asylum seekers, health system, health assessment, control and care, Sweden
Keywords [sv]
Folkhälsa, migration, asylsökande, hälsosystem, hälsoundersökning, kontroll och vård, Sverige
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-158778ISBN: 978-91-7855-067-8 (print)OAI: oai:DiVA.org:umu-158778DiVA, id: diva2:1314337
Public defence
2019-06-03, Sal E04, NUS, Umeå universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2019-05-13 Created: 2019-05-08 Last updated: 2019-05-10Bibliographically approved
List of papers
1. Structural and procedural barriers to health assessment for asylum seekers and other migrants - an explorative survey in Sweden
Open this publication in new window or tab >>Structural and procedural barriers to health assessment for asylum seekers and other migrants - an explorative survey in Sweden
2018 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 1, article id 813Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Health assessments (HAs) for newly arrived asylum seekers have become a regular practice in most EU countries, but what is performed, how they are organized, and whether it is mandatory or not to attend varies between countries. Swedish national statistics have shown that only about 45% of asylum seekers attend the optional HA offered upon their arrival in Sweden. There are significant variations among Sweden's 21 counties, ranging from 20 to 90%. The reasons for the low attendance have not yet been fully explored, though there are indications of structural weaknesses within the healthcare system. This study aimed to identify variations in policies and implementation of HAs targeting asylum seekers and other migrants. The study analyzes the structure and processes in different Swedish counties and discusses how this might influence the coverage.

METHODS: This research project had an exploratory quantitative descriptive design applying a cross-sectional survey based on two structured questionnaires. Descriptive statistics were performed to summarize the data.

RESULTS: The number of healthcare centers in each county that carried out HAs on asylum seekers varied independently of the size of the county. Variations in regard to structure, organization, processes, and performance monitoring of the HA process also appeared diverse, and these were in some cases also reported differently by administrators and healthcare professionals in the same county. Most commonly, the HAs were carried out in ordinary health centers, though some counties presented alternative solutions on how to organize the HAs.

CONCLUSIONS: There seems to be no coherent national system for carrying out HAs on asylum seekers in Sweden. The structure, organization, processes, and outcomes vary between the counties, and the reasons for the low coverage of HAs appear to be multifaceted.

Keywords
Asylum seekers, Health assessment, Health system, Migrants, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-154116 (URN)10.1186/s12913-018-3588-6 (DOI)000448123200001 ()30352595 (PubMedID)
Available from: 2018-12-12 Created: 2018-12-12 Last updated: 2019-05-09Bibliographically approved
2. A state of limbo - in transition between two contexts: health assessments upon arrival in Sweden as perceived by former Eritrean asylum seekers
Open this publication in new window or tab >>A state of limbo - in transition between two contexts: health assessments upon arrival in Sweden as perceived by former Eritrean asylum seekers
2015 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 43, no 5, p. 548-558Article in journal (Refereed) Published
Abstract [en]

Background: National statistics have shown that only about 40% of asylum seekers actually attend the optional health assessment offered upon their arrival in Sweden, but the reasons for this have not been fully explored. Health assessments for newly arrived asylum seekers have become a regular practice in most EU countries, but what is performed, how it is organized and whether it is mandatory or not varies between countries. Aim: The aim of the study was to explore and improve our understanding of how former asylum seekers from Eritrea perceived and experienced the health assessment during their asylum-seeking process. Methods: We used a qualitative research approach guided by grounded theory. Semi-structured interviews were conducted with 11 former asylum seekers from Eritrea. Data were analysed based on constant comparative analysis. Findings: The asylum seekers expressed feelings of ambiguity and mistrust and felt that they were seen only as objects by the Swedish healthcare system during their asylum-seeking process. Poor communication and inability to overcome language and cultural barriers seemed to be the most important findings in the narratives. The core category was defined as ‘A state of limbo – in transition between two contexts’. Conclusions: There are reasons to believe that these issues with communication negatively affected both the quality of the health assessment and the number of asylum seekers attending the health assessment. Improved communication by the authorities towards the asylum seekers is, therefore, of vital importance.

Keywords
Asylum seekers, migration, migrant health, health assessments, grounded theory
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-107085 (URN)10.1177/1403494815576786 (DOI)000357581300015 ()25902741 (PubMedID)
Available from: 2015-09-23 Created: 2015-08-18 Last updated: 2019-05-09Bibliographically approved
3. Health Assessment and the Right to Health in Sweden: Asylum Seekers' Perspectives
Open this publication in new window or tab >>Health Assessment and the Right to Health in Sweden: Asylum Seekers' Perspectives
2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 9, article id e0161842Article in journal (Refereed) Published
Abstract [en]

Background Swedish law entitles asylum seekers to a voluntary health assessment and to "health care that cannot be postponed". The last expression suggests, however, restrictions on the entitlement, and what it may or may not include remains ultimately a decision for health professionals in the specific case. Indeed, the health assessment constitutes the sole active effort from Swedish authorities to fulfill this right. This study was therefore aimed at assessing how the information, procedures and services related to the health assessment are accessible and acceptable to fulfill the right to health of asylum seekers, from their own perspective. Methods The study has a cross-sectional design. A questionnaire was administrated in 16 language schools for immigrants, in four counties of Sweden. Three hundred eighty-six individuals fulfilled the inclusion criteria. The frequency of their answers was tabulated to estimate how the information, procedures and services related to the health assessment correspond to the criteria for accessibility and acceptability regarding the right to health. Findings Forty-eight (12.4%) respondents did not undergo the health assessment. Thirty-one of them did not even receive the invitation letter. They said they lost the opportunity to know their health status, to obtain treatment for or advice about their health problems. Additionally, 55.2% of those who attended the health assessment indicated that their needs were overlooked, particularly when these were of a psychological nature. Two in three participants also considered the health assessment to be a communicable disease control, rather than an effort to take care of their health needs. Nevertheless, the respondents had a positive attitude towards the health assessment as such. Conclusions Although being an important contribution, the health assessment does not suffice to fulfill the right to health of asylum seekers because there are shortcomings regarding the accessibility and acceptability of the information, procedures and services that it includes.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-126498 (URN)10.1371/journal.pone.0161842 (DOI)000382877800021 ()
Available from: 2016-10-27 Created: 2016-10-10 Last updated: 2019-05-09Bibliographically approved

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