The gap between entitlement and access to healthcare: An analysis of “candidacy” in the help-seeking trajectories of asylum seekers in Montreal

Experiences of Providers and Immigrants/Refugees with Health Care: A Meta-Synthesis of the Latin American Context

INTRODUCTION

The experiences of providers and immigrants/refugees related to healthcare in the Latin American context have not yet been aggregated. This study aimed to synthesize the qualitative evidence on this theme.

METHOD

A systematic review of qualitative evidence with meta-synthesis. After identification, eligible studies were evaluated for methodological quality, and information was systematically analyzed.

RESULTS

The sample comprised 26 articles. The meta-theme shows that the experiences of providers and immigrants/refugees are determined by multilevel factors. In a macro-context, these factors involve the vulnerabilities of immigrants/refugees and the healthcare system/model, and in a closer context, they involve the lack of professional training in cultural skills and communication; language barriers; and prejudice/xenophobia. Within healthcare, the relationship is mostly conflictual, asymmetric, and unable to solve problems, leading to negative repercussions for both.

CONCLUSIONS

Managers involved in developing public policies and providers must consider improving the interrelationship between healthcare services and the migrant population.

Distanciation as a technology of control in the UK hostile environment

This article considers how distanciation, understood as the active production of different forms of distance as a method of control, is used to manage people racialised and criminalised as migrants within the UK's hostile environment. Analysing different policies introduced under the hostile environment agenda, as well as the more recent New Plan for Immigration, we argue distanciation is a key tactic that shapes these policies and their implementation as well as offers us insight into changing forms of governing migration. Drawing on the analysis of a wide range of policy documents, the paper attends to different forms of distanciation used as a method of control within the UK's wider hostile environment and then presents the results of a case-study of how distanciation is mobilised within the English National Health Service, under the Migrant and Visitor Cost Recovery Programme in particular, which was introduced in 2014 to ensure the NHS receives 'a fair contribution' from people racialised as migrants. Addressing different forms of distanciation such as - spatial, legal and emotional - we argue that the lens of distance can offer insights into how detachment - increasing distance between different agents in immigration law and border enforcement is an intentional design to control empathy, solidarity and resistance. Tracing ways these forms of distanciation are designed into legislative and administrative measures helps us better understand how hostile environment policies work as well as locating agencies and possibilities of resistance within different spaces, agents and subjects of bordering.

Conceptualizing access to community-based supports from the perspectives of people living with young onset dementia, family members and providers

People living with young onset dementia and their families have significant support needs, but experience difficulties accessing services. This study explored the process of accessing community-based services drawing on semi-structured interviews with people living with dementia, family members and providers in Winnipeg, Canada. Data analysis involved a combination of inductive coding and theoretical analysis using the candidacy framework as a conceptual lens. Forced to navigate services that do not recognize people with young onset dementia as a user group, participants experienced ongoing barriers that generated continuous work and stress for families. Access was constrained by information resources geared towards older adults and restrictive eligibility criteria that constructed people with young onset dementia as "not impaired enough" or "too impaired". At the organizational level, fragmentation and underrepresentation of young onset dementia diminished access. Our findings underscore the need for continuous, coordinated supports alongside broader representation of young onset dementia within research, policy, and practice. We conclude with a discussion of how the candidacy theory could be extended to account for the social and political status of user groups.

Barriers adult refugees face to community health and patient engagement: a systematic review

Meeting the health needs of refugee populations and increasing access to healthcare remains a challenge for healthcare systems globally. As such, community health and patient engagement are increasingly recommended strategies to address health-related issues among refugees. This systematic review aims to identify the reported barriers that adult refugees encounter with community health and patient engagement. Data sources included MEDLINE, Embase, APA PsycINFO, CINAHL, and Core Collection (Web of Science), yielding 1156 records. After removing duplicates and two levels of screening, 18 studies were selected for qualitative analysis. The barriers were conceptualised as cultural norms, pre-departure history, education, language proficiency, stigma, racism, social support, and multi-factorial barriers. These barriers can be addressed to improve rapport with refugees and the quality of community health and patient engagement initiatives.

Refugee healthcare needs and barriers to accessing healthcare services in New Zealand: a qualitative phenomenological approach

Background

Refuges and asylum seekers have specific healthcare needs; however there has been insufficient attention and effort to address these needs globally. Furthermore, effective communication between healthcare providers and refugees remains poor, further widening the imbalanced power dynamics. The aim of this research project was to examine refugee healthcare needs and current barriers to accessing healthcare services in New Zealand, and to propose solutions by exploring the perceptions, attitudes, beliefs, and opinions of key stakeholders regarding refugee healthcare needs within the scaffold of health and social care systems.

Methods

We conducted semi-structured interviews between September and December 2018 with 18 purposively selected refugee service provider stakeholders in New Zealand using an interview guide that addressed healthcare needs, existing barriers to access healthcare services, and perceived future healthcare delivery solutions.

Results

Thematic analysis of emergent themes of this study indicated the need for a national framework of inclusion, mandating cultural safety training of frontline personnel, improving access to interpreters and cultural mediators, and establishing the role of patient navigators. Barriers to accessing health services included entrenched social health determinants such as housing scarcity and disenfranchised community environments; refugee health-seeking behaviour and poor health literacy; along with existing social support networks. We propose that healthcare delivery should focus on capacity building of existing services, including co-design processes with refugees and asylum seekers and increasing funding for refugee-specific health service via the implementation of an overarching national strategy.

Conclusion

Based on the findings of this study, refugee organisations and their frontline personnel should seek to address the deficiencies identified in order to provide equitable, timely and culturally-accessible healthcare services for refugees in New Zealand and in comparable countries.

Qualitative study of candidacy and access to secondary mental health services during the COVID-19 pandemic

Candidacy, a construct describing how people's eligibility for care is negotiated between themselves and services, has received limited attention in the context of mental health care. In addition, candidacy research has only rarely studied the views of carers and health professionals. In this article, we use concepts relating to candidacy to enable a theoretically informed examination of experiences of access to secondary mental health services during the first wave of the COVID-19 pandemic in England. We report a qualitative study of the views and experiences of service users, carers, and healthcare professionals. Analysis of 65 in-depth interviews was based on the constant comparative method. We found that wide-ranging service changes designed to address the imperatives of the pandemic were highly consequential for people's candidacy. Macro-level changes, including increased emphasis on crisis and risk management and adapted risk assessment systems, produced effects that went far beyond restrictions in the availability of services: they profoundly re-structured service users' identification of their own candidacy, including perceptions of what counted as a problem worthy of attention and whether they as individuals needed, deserved, and were entitled to care. Services became less permeable, such that finding a point of entry to those services that remained open required more work of service users and carers. Healthcare professionals were routinely confronted by complex decisions and ethical dilemmas about provision of care, and their implicit judgements about access may have important implications for equity. Many of the challenges of access exposed by the pandemic related to pre-existing resource deficits and institutional weaknesses in care for people living with mental health difficulties. Overall, these findings affirm the value of the construct of candidacy for explaining access to mental healthcare, but also enable deepened understanding of the specific features of candidacy, offering enduring learning and implications for policy and practice.

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Candidacy is a framework for understanding influences on access to healthcare.

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We studied access to mental healthcare services during the COVID-19 pandemic.

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Candidacy was profoundly affected by service changes.

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Understandings of entitlement and thresholds for access were reconfigured.

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The value of the candidacy framework for mental health contexts is affirmed.

Service User and Service Provider Perceptions of Enablers and Barriers for Refugee and Asylum-Seeking Women Accessing and Engaging with Perinatal Mental Health Care Services in the WHO European Region: A Scoping Review Protocol

There is a need to understand the specific perinatal mental health care needs of migrant subgroups who often have differing health care needs and specific barriers to accessing and engaging with health care services. It is important to have evidence about the WHO European context given the rising numbers of refugees and asylum seekers in the region. The aim of this scoping review is to map the factors that enable and prevent access and engagement of refugee and asylum-seeking women with perinatal mental health care services in the WHO European Region, from the perspectives of service providers and service users. The database search will include PsycINFO, Cochrane, Web of Science, MEDLINE, EMBASE, CINAHL complete, Scopus, Academic Search Complete, and Maternity and Infant Care (OVID). Search results will be exported to an online tool that provides a platform to help manage the review process, including title, abstract, and full-text screening and voting by reviewers independently. Data concerning access and engagement with health care services will be mapped on to the candidacy framework. Systematically searching evidence within the WHO European region and examining this evidence through the candidacy lens will help develop a more comprehensive and a deeper conceptual understanding of the barriers and levers of access and engagement with perinatal mental health care services, whilst identifying gaps in existing evidence. Exploring factors that influence access and engagement for refugee and asylum-seeking women from the perspective of key stakeholders in the service provision and/or service utilisation of perinatal mental health care services will add a more comprehensive understanding of the recursive relationship between service provision and use.

Unmasking legislative constraints: An institutional ethnography of linkage and engagement in HIV healthcare for African, Caribbean, and Black people in Ontario, Canada

The Human Immunodeficiency Virus (HIV) epidemic significantly impacts African, Caribbean, and Black (ACB) immigrants in Canada. Health scholarship has revealed striking injustices within Canada's public healthcare system that restrict access to healthcare and violate the human rights of ACB immigrants living with HIV who are marginalized. We conducted an institutional ethnography to comprehensively understand how HIV healthcare in Ontario is organized and experienced by ACB immigrants, focusing on unjust and discriminatory legislative frameworks and institutional practices regulating access to publicly funded healthcare resources and services. We interviewed 20 ACB immigrants and 15 healthcare workers, including specialists, primary care providers, immigration physicians, and social workers. We found a disjuncture between the organization of HIV healthcare in Ontario and how ACB immigrants experienced access to care. We uncovered how immigration, public health and healthcare laws and related institutional practices intersect to produce structural violence which create barriers and missed opportunities to timely linkage and engagement in HIV healthcare. Black immigrants' accounts revealed that they underwent mandatory HIV under the Immigration Medical Examination policy (IME) without providing informed consent and receiving pre and post-test counselling. Furthermore, Black immigrants did not receive referrals and were not adequately linked to care following HIV diagnosis. Troubling encounters with immigration and public health state agents and healthcare legislative barriers including difficulty finding a physician, the 3-month waiting period under the Ontario Health Insurance Plan (OHIP), long wait times, lack of drug coverage, and stigma, discrimination, and anti-Black racism shaped and affected Black people's linkage and engagement in HIV care. We elucidate how the legislative and structural organization of healthcare regulated and constrained health service access for ACB immigrants living with HIV, including their ability to "achieve" HIV undetectability.

Policies and initiatives/programs that promote health and self-care in asylum seekers living in high income countries: a narrative review

Purpose

This paper aims to identify health-care entitlements that exist for asylum seekers with chronic non-communicable disease (CNCD) that promote their health and self-care, and to explore health policies, initiatives and programmes with the potential to foster self-care in this populace.

Design/methodology/approach

Narrative review of literature conducted by searching EMBASE, CINAHL, WEB OF SCIENCE and PSYCINFO databases for articles published from 2010 to 2021. Included articles focussed on policies, programmes or initiatives with the potential to promote health in adult asylum seekers residing in high-income countries. Studies inclusive of other migrant groups such as undocumented migrants and those with mental health conditions were excluded. Eleven studies fitting the inclusion criteria were assessed against the study objectives.

Findings

Free access to health-care services and pharmaceutical products, free access to food banks and supermarket model food banks, English and cooking lessons, community integration training sessions and culturally competent health-care workers were found to promote health and self-care. There is little research on self-care and health promotion in adult asylum seekers with CNCD. CNCDs represent high burden of disease in asylum seekers but have a low priority in reported research.

Originality/value

This narrative review is the first to explicitly focus on asylum seekers in high-income countries with CNCD, excluding mental health conditions, and to explore initiatives, programmes and policies that enhance health promotion to facilitate self-care in this populace.

Beyond biopolitics: the importance of the later work of Foucault to understand care practices of healthcare workers caring for undocumented migrants

Background

Undocumented migrants experience multiple institutional and legal barriers when trying to access healthcare services. Due to such limitations, healthcare workers often experience ethical dilemmas when caring for undocumented migrants. This article aims to understand how individual healthcare workers who regularly take care of undocumented migrants deal with these dilemmas in practice. So far, the role of healthcare workers in this context has mainly been theorized through the lens of biopolitics, conceiving of healthcare workers as merely obedient instruments of humanitarian government or gatekeeping.

Methods

Based on semi-structured, in-depth interviews and ethnographic observations with healthcare workers in Belgium, we explore how they ascribe meaning, reflect upon and give shape to care practices in relation to undocumented migrants. We use Foucault’s later work on care of the self to interpret the accounts given by the healthcare workers.

Results

Healthcare workers in clinical roles exercise a certain degree of freedom in relation to the existing limitations to healthcare access of undocumented migrants. They developed techniques such as purposefully being inattentive to the undocumented status of the migrants. They also try to master their affective responses and transform their bodily attitude towards undocumented patients. They perform practical mental exercises to remind themselves of their role or position in the wider healthcare system and about their commitment to treat all patients equally. These techniques and exercises are inspired by colleagues who function as role models, inspiring them to relate in an ethical way to limitations in healthcare access. The developed care practices sometimes reproduce, sometimes transform the legal and institutional limitations to care for undocumented migrants.

Conclusions

The findings nuance the biopolitical analysis regarding the role of healthcare workers in healthcare delivery to undocumented migrants that has been dominant so far. Theoretically this article provides a reconceptualization of healthcare ethics as care of the self, an ethical practice that is somewhat independent of the traditional professional ethics.

Trial Registration Medical ethics committee UZ Jette, Brussels, Belgium – Registration date: 18/05/2016 – Registration number: B.U.N. 143201628279.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00726-z.

Canadian Health Personnel Attitudes Toward Refugee Claimants' Entitlement to Health Care

Health care personnel attitudes toward refugee claimant entitlement to health care are influenced by multilevel factors including institutional and societal culture. Although individual attitudes may be modified through training, macro- and meso-issues require system-level interventions. This paper analyzes the role of individual-, institutional-, and city-level factors in shaping attitudes toward refugee claimants' access to health care among Canadian health care personnel. A total of 4207 health care personnel in 16 institutions located in Montreal and Toronto completed an online survey on attitudes regarding health care access for refugee claimants. We used multilevel logistic regression analysis to identify individual-, institutional-, and city-level predictors of endorsing access to care. Participants who had prior contact with refugee claimants had greater odds of endorsing access to care than those who did not (OR 1.13; 95% CI 1.05, 1.21). Attitudes varied with occupation: social workers had the highest probability of endorsing equal access to health care (.83; 95% CI .77, .89) followed by physicians (.77; 95% CI .71, .82). An estimated 7.97% of the individual variation in endorsement of equal access to health care was attributable to differences between institutions, but this association was no longer statistically significant after adjusting for city residence. Results indicate that the contexts in which health care professionals live and work are important when understanding opinions on access to health care for vulnerable populations. They suggest that institutional interventions promoting a collective mission to care for vulnerable populations may improve access to health care for precarious status migrants.

Implementation of an intersectoral outreach and community nursing care intervention with refugees in Quebec: A protocol study

AIM

To establish and assess an intersectoral local network focused on the roles of registered nurses and primary healthcare nurse practitioners to ensure the continuity of care and service pathways for refugees in Quebec.

DESIGN

Developmental evaluation with a mixed methodology.

METHODS

The qualitative component will include: (1) a document review; (2) observations of participants during meetings of different governance structures; (3) semi-structured interviews with key actors (n = 40; 20/neighbourhood interventions); and (4) focus groups with end users of the services (refugees) (n = 4; 6 to 8 participants per group). The quantitative component will be based on: (1) a data sheet on health and social interventions for refugees users filled in by registered nurses, primary healthcare nurse practitioners and physicians and (2) data analysis of the clinical-administrative database since 2012. This study received funding in June 2019 and Research Ethics Committee approval was granted in July 2020.

DISCUSSION

In Quebec, refugee vulnerability is exacerbated by the lack of integration of existing resources and the lack of access to care and continuity of services. To address these issues, an integrated local network for refugees must be developed. Additionally, we will explore the role of registered nurses and their collaboration with primary healthcare nurse practitioners.

IMPACT

This study will provide recommendations on how to optimize the scopes of practice of registered nurses and primary healthcare nurse practitioners, adapt care and services and develop a local intersectoral network to better meet the complex needs of refugees. It will evaluate the use and the appreciation of new services for targeted populations (neighbourhoods and refugees) and aim to improve the accessibility, continuity and user experience of all health services for those populations.

Digital mediation of candidacy in maternity care: Managing boundaries between physiology and pathology

This paper brings together scholarship across sociology, media and communication, and human computer interaction to explore the intersection of digital health and the maternity care system. We draw on data (including interviews, focus groups, observations, and analyses of digital media content) from 19 studies involving over 400 women to explore women's experiences of using different forms of digital support such as the Internet, mobile technologies (apps and text messaging), social media, and remote monitoring devices in their reproductive journeys. We use a best fit approach to analysis, mapping our findings to the candidacy framework and notions of trajectory work to understand how women engage in digital health practices to negotiate boundaries between physiology and pathology and to enter dialogue with maternity services during conception, pregnancy and the postnatal period. We propose an integrated revised conceptual framework which explicates intersections between digital and care practices, and micro-level negotiations between women and professionals in the maternal health context. Our revised framework retains the dimensions of candidacy, but it introduces a precursor to the identification of candidacy in the form of 'understanding normality'. It identifies distinct forms of digital work (e.g. information work, navigation work, machine work) which operate across the candidacy dimensions that women (and partners at times) engage in to negotiate legitimacy when entering into encounters with the maternity care system. Operating conditions (norms around expert motherhood; neoliberal discourses around health optimisation, risk and responsibilisation) provide a broader macro-level context, influencing the micro-level dialogic processes between women and healthcare professionals. Our synthesis highlights digital mediation as a useful filter to understand care systems, distribution of lay/professional responsibilities, relational practices and the (dis)enablement of candidacy.

Racism, healthcare access and health equity for people seeking asylum

People seeking asylum are at risk of receiving poorer quality healthcare due, in part, to racist and discriminatory attitudes, behaviours and policies in the health system. Despite fleeing war and conflict; exposure to torture and traumatic events and living with uncertainty; people seeking asylum are at high-risk of experiencing long-term poor physical and mental health outcomes in their host country. This article aims to raise awareness and bring attention to some common issues people seeking asylum face when seeking healthcare in high-income countries where the health system is dominated by a Western biomedical view of health. Clinical case scenarios are used to highlight instances of racist healthcare policies and practices that create and maintain ongoing health disparities; limited access to culturally and linguistically appropriate health services, and lack of trauma-informed approaches to care. Nurses and midwives can play an important role in countering racism in healthcare settings; by identifying and calling out discriminatory practice and modelling tolerance, respect and empathy in daily practice. We present recommendations for individuals, organisations and governments that can inform changes to policies and practices that will reduce racism and improve health equity for people seeking asylum.

Primary Care and Access to Mental Health Consultations among Immigrants and Nonimmigrants with Mood or Anxiety Disorders: Soins de première ligne et accès aux consultations en santé mentale chez les immigrants et les non-immigrants souffrant de troubles de l'humeur ou anxieux

OBJECTIVE

To examine the association between usual place of primary care and mental health consultation among those with self-reported mood or anxiety disorders. We also describe access to mental health services among people who are recent immigrants, longer-term immigrants, and nonimmigrants and determine whether the association with place of primary care differs by immigration group.

METHODS

We used data from the Canadian Community Health Survey (2015 to 2016) to identify a representative sample of individuals with self-reported mood or anxiety disorders. We used logistic regression, with models stratified by immigration group (recent, longer-term, nonimmigrant), to examine the association between usual place of primary care and receiving a mental health consultation in the previous 12 months.

RESULTS

Higher percentages of recent and longer-term immigrants see a doctor in solo practice, and a higher percentage of recent immigrants use walk-in clinics as a usual place of care. Compared with people whose usual place of care was a community health center or interdisciplinary team, adjusted odds of a mental health consultation were significantly lower for people whose usual place of care was a solo practice doctor's office (AOR = 0.71; 95% CI, 0.62 to 0.82), a walk-in clinic (AOR = 0.75; 95% CI, 0.66 to 0.85), outpatient clinic/other place (AOR = 0.72 95% CI, 0.59 to 0.88), and lowest among people reporting no usual place other than the emergency room (AOR = 0.59; 95% CI, 0.51 to 0.67). Differences in access to mental health consultations by usual place of primary care were greatest among immigrants, especially recent immigrants.

CONCLUSIONS

People with mood or anxiety disorders who have access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Expanded access to team-based primary health care may help reduce barriers to mental health services, especially among immigrants.

Access to health care among racialised immigrants to Canada in later life: a theoretical and empirical synthesis

Evidence that immigrants tend to be underserved by the health-care system in the hosting country is well documented. While the impacts of im/migration on health-care utilisation patterns have been addressed to some extent in the existing literature, the conventional approach tends to homogenise the experience of racialised and White immigrants, and the intersecting power axes of racialisation, immigration and old age have been largely overlooked. This paper aims to consolidate three macro theories of health/behaviours, including Bronfenbrenner's ecological theory, the World Health Organization's paradigm of social determinants of health and Andersen's Behavioral Model of Health Service Use, to develop and validate an integrated multilevel framework of health-care access tailored for racialised older immigrants. Guided by this framework, a narrative review of 35 Canadian studies was conducted. Findings reveal that racial minority immigrants’ vulnerability in accessing health services are intrinsically linked to a complex interplay between racial-nativity status with numerous markers of power differences. These multilevel parameters range from socio-economic challenges, cross-cultural differences, labour and capital adequacy in the health sector, organisational accessibility and sensitivity, inter-sectoral policies, to societal values and ideology as forms of oppression. This review suggests that, counteracting a prevailing discourse of personal and cultural barriers to care, the multilevel framework is useful to inform upstream structural solutions to address power imbalances and to empower racialised immigrants in later life.

Reducing health inequities for asylum seekers with chronic non-communicable diseases: Australian context

Asylum seekers are susceptible to chronic non-communicable diseases pre- and post-arrival due to poor living conditions, unhealthy lifestyles and restrictive and poor access to health services. Despite their need for constant and continuous health care access due to poor health, they face healthcare services access restrictions dependent on their visa conditions in Australia. Some visas only allow access to hospital services with restrictions on primary health services access such as GPs and free or discounted pharmaceutical products. In comparison, disadvantaged host populations have access to free/discounted pharmaceutical products and unrestricted access to primary and secondary health care. Ten professionals who constantly engage with asylum seekers in three large asylum seeker centres in Melbourne were interviewed either face-to-face or over the phone. The interviews were essential to understand how health inequities may be addressed for asylum seekers. Interviews were audio-recorded, transcribed verbatim and analysed using a thematic analysis framework. Their recommendations, based mainly on their experience and evaluation of programs, were: (1) cultural competence training; (2) use of interpreters; (3) free access to health services and medications; (4) use of English learning to promote health literacy and community integration; (5) robust chronic non-communicable diseases screening; and (6) health promotion and accessible food programs.

"It's a life you're playing with": A qualitative study on experiences of NHS maternity services among undocumented migrant women in England

BACKGROUND

Undocumented migrant women experience complex barriers to maternity services, are less likely to receive the recommended level of maternity care, and have poorer obstetric outcomes than non-migrant women. There are concerns increasing restrictions on entitlement to health services have a detrimental impact on access to services and obstetric outcomes, particularly among undocumented migrant women. The study aimed to investigate the experiences of undocumented migrant women who have been pregnant in England, and factors affecting access to care and health outcomes.

METHODS

We conducted in-depth semi-structured interviews June-December 2017 with a purposive sample of migrant women born outside the UK (aged>18) who had experiences of pregnancy and undocumented status (without permission to reside) in the UK, recruited through Doctors of the World (DOTW) UK. Interpreting services were used on request. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval: Imperial College London Research Ethics Committee (ICREC reference: 17IC3924).

RESULTS

Semi-structured interviews were conducted with 20 participants, 10 of whom had their first antenatal appointment after the national target of 13 weeks, and nine of whom reported complications. Themes defining women's experiences of pregnancy included: restricted agency, intersecting stressors, and an ongoing cycle of precarity, defined by legal status, social isolation, and economic status.

CONCLUSIONS

This study provides new evidence of women's experiences of pregnancy in the UK in the context of increasingly restrictive health policies including charging and data sharing. Six recommendations are made to ensure the UK and other migrant receiving countries work towards reducing inequalities and achieving national and global targets for maternal and child health and universal health coverage.

Does Facilitated and Early Access to the Healthcare System Improve Refugees’ Health Outcomes? Evidence from a Natural Experiment in Germany

Because of their often-dramatic, life-threatening flight patterns and resulting pronounced health disparities, many refugees have a great need for medical treatment after arrival to their host countries. In Germany, refugees whose asylum application is not approved or whose duration of stay has not yet exceeded 15 months must request doctor visits, with a considerable amount of bureaucracy, from the local responsible authority. Since 2016, however, several federal states and municipalities in Germany have introduced electronic health cards ( eHCs) which give refugees immediate and unbureaucratic access to the healthcare system. We examine whether being eligible for eHCs because of this policy change had an effect on multidimensional health indicators for refugees in Germany. For empirical identification, we take advantage of variation in policy adoption across German regions and over time. Relying on the IAB-BAMF-SOEP Survey of Refugees, we find that being eligible for eHCs because of the policy change improved the mental well-being and subjective health assessment of recently arrived refugees, while having no impact on physical health status. These results can be traced back to the moderating effect of facilitated healthcare access on post-migration stress, which is known to affect primarily psychological well-being. Moreover, facilitated healthcare access appears to alleviate potential language and cultural barriers faced by refugees with low health literacy (measured by the ability to read or write in the origin-country language). Altogether, the article illustrates how structural and institutional constraints may shape individual health outcomes of adult refugees.

The Impact of Pre- and Postarrival Mechanisms on Self-rated Health and Life Satisfaction Among Refugees in Germany

In this study, we focus on the evolution of refugees' well-being in the first years after their arrival in Germany. In contrast to other immigrants (e.g., labor migrants), refugees experience higher risks of unexpected and traumatic events and insecurity before and during their migration and face various legal and structural barriers in the receiving country. We contribute to the existing literature by exploring from a dynamic perspective possible pre- and postarrival determinants of refugees' life satisfaction and self-rated health upon arrival in Germany and the development of their life satisfaction and self-rated health in the process of becoming established. Applying linear regression and panel models with recent longitudinal data from the IAB-BAMF-SOEP Survey of Refugees in Germany, we find significant effects of prearrival factors, such as traumatic experiences and the complexity of migration, on both life satisfaction and self-rated health at the time of the first interview. Regarding postarrival factors, our results suggest that improvement in language proficiency and labor market status significantly shape refugees' life satisfaction and self-rated health. The time-dynamic analyses reveal substantial improvements in life satisfaction upon the approval of refugee status and the transition from shared housing to private accommodations. However, we find no improvements in self-rated health due to legal status but rather deterioration effects due to long-term residence in shared housing.

Barriers to Accessing and Negotiating Mental Health Services in Asylum Seeking and Refugee Populations: The Application of the Candidacy Framework

This review brought together research investigating barriers asylum seekers and refugees (AS&R) face in accessing and negotiating mental health (MH) services. The candidacy framework (CF) was used as synthesizing argument to conceptualize barriers to services (Dixon-Woods et al. in BMC Med Res Methodol 6:35, 2006). Five databases were systematically searched. Twenty-three studies were included and analyzed using the CF. The seven stages of the framework were differentiated into two broader processes-access and negotiation of services. Comparatively more data was available on barriers to access than negotiation of services. The Identification of Candidacy (access) and Appearances at Services (negotiation) were the most widely discussed stages in terms of barriers to MH care. The stage that was least discussed was Adjudications (negotiation). The CF is useful to understand inter-related barriers to MH care experienced by AS&R. A holistic approach is needed to overcome these barriers together with further research investigating understudied areas of candidacy.

Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation

BACKGROUND

In Europe, the number of children born by non-Western immigrant women is rising and these women have an increased risk of negative pregnancy and birth outcomes, compared to the host populations. Several individual and system barriers are associated with immigrant women's access to maternity care. Scientific evaluations of interventions to enhance the health of immigrant women in the maternity setting are lacking, and there is a need for further development of the evidence base on how health care system initiatives may mitigate ethnic inequities in reproductive health. In Denmark, the MAMAACT intervention was developed to improve midwives' as well as non-Western immigrant women's response to pregnancy complications and to promote midwives' intercultural communication and cultural competence. The intervention included a training course for midwives as well as a leaflet and a mobile application. This study focuses on the significance of the antenatal care context surrounding the implementation of the MAMAACT intervention (Id. No: SUND-2018-01).

OBJECTIVES

To explore the main organisational barriers, which impacted the intended mechanisms of the MAMAACT intervention in Danish antenatal care.

DESIGN

A qualitative study design was used for data collection and analysis.

SETTING

Midwifery visits at ten antenatal facilities affiliated to five Danish maternity wards formed the setting of the study.

PARTICIPANTS AND METHODS

Data consisted of nine focus group interviews with midwives (n = 27), twenty-one in-depth interviews with non-Western immigrant women, forty observations of midwifery visits, and informal conversations with midwives at antenatal care facilities (50 h). Data were initially analysed using systematic text condensation. The candidacy framework was applied for further interpretation of data.

RESULTS

Analysis of data revealed three main categories: 'Permeability of antenatal care services', 'The interpreter as an aid to candidacy´, and 'Local conditions influencing the production of candidacy'.

CONCLUSIONS

Several organisational barriers impacted the intended mechanisms of the MAMAACT intervention. Major barriers were incomplete antenatal records, insufficient referrals to specialist care, inadequate interpreter assistance, and lack of local time resources for initiating a needs-based dialogue with the women. Immigrant targeted interventions must be understood as events within complex systems, and training midwives in intercultural communication and cultural competence cannot alone improve system responses to pregnancy complications among immigrant women. Changes in the legal, social, and political context of the health care system are needed to support organisational readiness for the MAMAACT intervention.

A need-based, multi-level, cross-sectoral framework to explain variations in satisfaction of care needs among people living with dementia

BACKGROUND

Provision of care and support for people with dementia and family carers is complex, given variation in how dementia manifests, progresses and affects people, co-morbidities associated with ageing, as well as individual preferences, needs, and circumstances. The traditional service-led approach, where individual needs are assessed against current service provision, has been recognised as unfit to meet such complexity. As a result, people with dementia and family members often fail to receive adequate support, with needs remaining unmet. Current research lacks a conceptual framework for explaining variation in satisfaction of care needs. This work develops a conceptual framework mapped onto the care delivery process to explain variations in whether, when and why care needs of people with dementia are met and to expose individual-, service-, system-level factors that enable or hinder needs satisfaction.

METHODS

Data collected through 24 in-depth interviews and two focus groups (10 participants) with people with dementia and family carers living in the North East of England (UK) were analysed thematically to develop a typology of care needs. The need most frequently reported for people with dementia (i.e. for support to go out and about) was analysed using themes stemming from the conceptual framework which combined candidacy and discrepancy theories.

RESULTS

The operationalisation of the framework showed that satisfaction of the need to go out was first determined at the point of service access, affected by issues about navigation, adjudication, permeability, users' resistance to offers, users' appearance, and systems-level operating conditions, and, subsequently, at the point of service use, when factors related to service structure and care process determined (dis)satisfaction with service and, hence, further contributed to met or unmet need.

CONCLUSION

The conceptual framework pinpoints causes of variations in satisfaction of care needs which can be addressed when designing interventions and service improvements.

The NHS visitor and migrant cost recovery programme - a threat to health?

BACKGROUND

In April 2014 the UK government launched the 'NHS Visitor and Migrant Cost Recovery Programme Implementation Plan' which set out a series of policy changes to recoup costs from 'chargeable' (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced.

METHODS

There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP.

RESULTS

We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001).

CONCLUSION

Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

The relational dimensions of pharmaceutical care: Experience from caring for HIV-infected asylum seekers in Montréal

By describing the experience from dispensing antiretroviral drugs to asylum seekers infected with HIV in Montreal we argue for the relational dimensions of pharmaceutical care. Between 2010 and 2016, the Government of Canada changed the medical coverage for refugees and asylum seekers, leading to some uncertainty about what types of care were reimbursable for each migrant status. In Quebec, despite the compensatory coverage provided by the provincial medical insurance board (Régie d'assurance maladie du Québec, or RAMQ), this uncertainty led to a breakdown in patient followup in some establishments. The McGill University Health Centre's Chronic Viral Illness Service (CVIS) was nevertheless able to maintain continuity of care for refugees and asylum seekers living with HIV. This article looks more specifically at the pharmaceutical care provided during this period and, more particularly, at the convergence of the technical and relational dimensions. The methodology used was a qualitative case study, which made it possible to explore pharmaceutical care, by conducting qualitative interviews (n = 16). Semistructured interviews were conducted with patients and various professionals from the CVIS, including pharmacists. The cultural, administrative, and political dimensions of pharmaceutical care described here appear very important for overall patient care. Further reflection on the importance of relational dimensions of pharmaceutical care and the place and value of pharmaceutical care in the advancement of patient care is required.

"We Cannot Let Them Die": Undocumented Immigrants and Media Framing of Health Deservingness in the United States

Based on a systematic qualitative analysis of articles published by The New York Times (2009-2017), this article presents the main media frames that support the access to government-sponsored health care by undocumented immigrants, just before and after passage of the U.S. Affordable Care Act in 2010. Under the umbrella of "selective inclusion," this study highlights a "compassionate frame" that conveys sympathy toward severely ill, undocumented immigrants. This approach is reinforced by a "cost-control" frame that underlines the economic benefits of providing health care to the undocumented immigrant population in the United States. Supported by both humane and market-based approaches, these frames make a compelling case for the inclusion of particular groups into the U.S. health care safety net. Ultimately, these findings contribute to our understanding of the media framing of undocumented immigrants' right to health care on the basis of deservingness.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

“Healthcare as a refuge”: building a culture of care in Montreal for refugees and asylum-seekers living with HIV

Purpose

Between 2012 and 2016, the Government of Canada modified health insurance for refugees and asylum seekers. In Quebec, this resulted in refusals of care and uncertainties about publicly reimbursed services, despite guaranteed coverage for people with this status under the provincial plan. The Chronic Viral Illness Service (CVIS) at the McGill University Health Centre in Montreal continued to provide care to refugees and asylum seekers living with HIV. The purpose of this paper is to explain how and why challenges brought by this policy change could be overcome.

Design/methodology/approach

A qualitative case study was conducted using interviews with patients and staff members, observation sessions and a review of media, documents and articles. A discussion group validated the interpretation of preliminary results.

Findings

The CVIS provides patient-centered care through a multidisciplinary team. It collectively responds to medical, social and legal issues specific to refugees. Its organizational culture and expertise explain the sustained provision of care. The team’s empathetic view of patients, anchored in the service’s history, care for men who have sex with men and commitment to human rights, is key. A culture of care developed over time thanks to the commitment of exemplary figures. Because they countered the team’s values, changes in refugee healthcare coverage strengthened the service’s culture of care. However, the healthcare system reform launched in 2014 in Quebec is perceived as jeopardizing the culture of care, as it makes, refugee and asylum-seeker patients a non-lucrative venture for providers.

Originality/value

This research analyzes the origin of sustained provision of care to refugees and asylum seekers living with HIV through the lens of culture of care. It considers the historical and political contexts in which this culture developed.

Mental health needs and services for migrants: an overview for primary care providers

BACKGROUND

The objective of this article is to present an overview of the burden, spectrum of diseases and risk factors for mental illness among subgroups of migrants, namely, immigrants, refugees and individuals with precarious legal status. This expert review summarises some of the implications for primary care services in migrant receiving countries in the global North.

METHODS

A broad literature review was conducted on the epidemiology of mental health disorders in migrants and the available evidence on mental health services for this population focusing on key issues for primary care practitioners in high-income countries.

RESULTS

Although most migrants are resilient, migration is associated with an over-representation of mental disorder in specific subpopulations. There is a general consensus that stress-related disorders are more prevalent among refugee populations of all ages compared to the general population. Relative to refugees, migrants with precarious legal status may be at even higher risk of depression and anxiety disorders. Persistence and severity of psychiatric disorders among migrant populations can be attributed to a combination of factors including severity of trauma exposures during the migration process. Exposure to stressors after resettlement, such as poverty and limited social support, also impacts mental illness. Services for migrants are affected by restricted accessibility and should address cultural and linguistic barriers to and issues in the larger social environment that impact psychosocial functioning.

CONCLUSION

There is substantial burden of mental illness among some migrant populations. Primary care providers seeking to assist individuals need to be cognizant of language barriers to and challenges of working with interpreters as well as sensitive to cultural and social contexts within the diagnosis and service delivery process. In addition, best practices in screening migrants and providing intervention services for mental disorders need to be sensitive to where individuals and families are in the resettlement trajectory.

Climate change, migration and health systems resilience: Need for interdisciplinary research

Climate change is one of today's major challenges, and among the causes of population movement and international migration. Climate migrants impact health systems and how their ability to respond and adapt to their needs and patterns.  To date, the resilience of health systems in the context of climate change has barely been explored. The purpose of this article is to show the importance of studying the relationship between climate change, migration, and the resilience of health systems from an interdisciplinary perspective. Resilience is an old concept, notably in the field of psychology, and is increasingly applied to the study of health systems. Yet, no research has analysed the resilience of health systems in the context of climate change. While universal health coverage is a major international goal, little research to date focused on the existing links between climate, migration, health systems and resilience. We propose an interdisciplinary approach relying on the concept of health system resilience to study adaptive and transformative strategies to articulate climate change, migration and health systems.

Climate change, migration and health systems resilience: Need for interdisciplinary research

Climate change is one of today's major challenges, among the causes of population movements and international migration. Climate migrants impact health systems and how they respond and adapt to their needs and patterns. But to date, the resilience of health systems in the context of climate change has been little explored. The purpose of this article is to show the importance of studying, from an interdisciplinary perspective, the relationships between climate change, migration, and the resilience of health systems. Resilience is an old concept, notably in the field of psychology, and is increasingly applied to the study of health systems. Yet, no research has analysed the resilience of health systems in the context of climate change. While universal health coverage is a major international goal, little research has to date focused on the existing links between climate, migration, health systems and resilience. We propose an interdisciplinary approach relying on the concept of health system resilience to study adaptive and transformative strategies to articulate climate change, migration and health systems.