Asylum seekers, refugees, and the politics of access to health care: a UK perspective

Navigating challenges and workarounds: A qualitative study of healthcare and support workers' perceptions on providing care to people seeking sanctuary

BACKGROUND

Healthcare and support workers play a pivotal role in delivering quality services and support to people seeking sanctuary who have experienced poor physical and mental health linked to previous trauma, relocation and loss of freedoms. However, they often encounter various challenges in their daily work, ranging from communication barriers to resource constraints. This qualitative study seeks to delve into the perspectives of healthcare and support workers' experience of workarounds, employed to overcome barriers to providing care.

AIM

This study aims to describe healthcare providers', practitioners' and health and third sector support workers' views on barriers and workarounds to providing care for people seeking sanctuary, to inform policy and practice.

DESIGN

A qualitative study was carried out using semi-structured telephone interviews.

SETTING

This study focused on primary, secondary, community and specialist National Health Service (NHS) support services for people seeking sanctuary in Wales, United Kingdom (2018).

METHOD

We interviewed 32 healthcare providers, practitioners and support workers employed by primary care and third sector organisations. Our approach involved obtaining verbal informed consent before digitally recording and transcribing all interviews. To analyse the data, we used the Four Levels of Change for Improving Quality model as a guiding framework for interpretation.

RESULTS

Our study findings reveal that certain respondents expressed challenges in meeting the needs of people seeking sanctuary; notably, their experience of delivering care differed by care settings. Specifically, those involved in providing specialist NHS care believed that there was room for improvement. Mainstream primary, secondary and community health practitioners faced limitations due to resource constraints and lacked tailored information to address the unique circumstances and needs of sanctuary seekers. To address these gaps, workarounds emerged at both individual and local levels (team/departmental and organisational level). These included establishing informal communication channels between providers, fostering cross service collaboration to fill gaps and adapting existing services to enhance accessibility.

CONCLUSION

Understanding healthcare providers', practitioners' and support workers' perspectives offers invaluable insights into ways to enhance healthcare delivery to sanctuary seekers. Acknowledging challenges and harnessing innovative workarounds can foster a more effective and compassionate service for this vulnerable population.

PATIENT OR PUBLIC CONTRIBUTION

The HEAR study actively involved public contributors in the design, delivery and dissemination of the research. Two public contributors (S. M. and G. R.) who had personal experience of seeking asylum served as study co-applicants. They played pivotal roles in shaping the research by participating in its development and securing funding. Alongside other co-applicants, S. M. and G. R. formed the Research Management Group, overseeing study delivery. Their contributions extended to strategic decision-making and specific feedback at critical junctures, including participant recruitment, data collection, analysis and reporting. Additionally, S. M. and G. R. were instrumental in recruiting and supporting a team of peer researchers, enhancing respondent participation among people seeking sanctuary. To facilitate effective public involvement, we provided named contacts for support (A. K. and R. F.), research training, honoraria, reimbursement of expenses and accessible information in line with best practice.

It is time to think about refugees' mental health: The case of Dzaleka Refugee Camp - Malawi

Refugees are individuals who live outside of their country and are at increased risk of mental health problems. Even though many papers assessed Refugees' mental health, few intended to evaluate in remote areas, such as refugee camps. On this study we assessed 102 individuals who lives in the Dzaleka Refugee Camp - Malawi. We found 78% of individuals with probable depression, 53% with thoughts about death, 25.5% with suicidal plans, and 15% reporting having attempted suicide in the 12 months prior to the assessment. This data points out to an urgent political mobilization to promote mental health to this vulnerable population.

Qualitative study on mental health and well-being of Syrian refugees and their coping mechanisms towards integration in the UK

OBJECTIVE

This study aimed to explore the mental well-being of Syrian refugees and identify their coping mechanisms and pathways towards integration into new communities.

DESIGN

Qualitative study using in-depth semi-structured interviews.

SETTING AND PARTICIPANTS

Adult Syrian refugees (>18 years old) currently residing in South East of England.

RESULTS

12 participants (3 women and 9 men) took part in the study, all were born in Syria and the majority (n=9) were over 45 years of age. Our findings show that Syrian refugees face constant challenges as they try to integrate into a new society. Loss of and separation from loved ones as well as the nostalgia for the homeland were often cited as a source of psychological distress that created an overwhelming sense of sadness. Participants reported that they struggled for connectedness due to cultural difference and the problematic nature of rapidly formed migrant communities in their new setting. They believed in 'being their own doctor' and turning to faith, ritual and nature for healing and comfort. Taboo and stigma around mental health and language barriers were cited as barriers to accessing mental healthcare services.

CONCLUSION

Past experiences and present challenges frame Syrian refugees' sense of well-being, impact use of healthcare and risk future mental health problems. It is hoped that this study will act as a catalyst for further research on this vulnerable group to promote integration, community support and culturally sensitive mental health services.

"East" in Europe-Health Dimension through the Lens of the UK Daily Mail and Statistical Facts

The study concerns the relationship between health and geopolitics in the United Kingdom (UK). To demonstrate this relationship, we examined the subject and tone of articles published in the popular media (on the example of tabloid the Daily Mail) in 2006–2020 concerning health and medical care, and the health and health care practice of Eastern European immigrants belonging to and not belonging to the European Union (EU). There was an increase in media criticism of the behaviour of immigrants in the years 2014–2017, in the period around the referendum in favour of the UK leaving the EU (Brexit). Attention was drawn to the media’s use of a Belief in a Zero-Sum Game (BZSG) narrative at that time. On both sides, “hosts” and the “guests”, a progressive anomy process was observed, degrading the behaviour of individuals and social groups.

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.

COVID-19 Highlighting Inequalities in Access to Healthcare in England: A Case Study of Ethnic Minority and Migrant Women

Our commentary aims to show that the COVID-19 pandemic has amplified existing barriers to healthcare in England for ethnic minority and migrant women. We expose how the pandemic has affected the allocation of healthcare resources leading to the prioritisation of COVID-19 patients and suspending the equal access to healthcare services approach. We argue that we must look beyond this disruption in provision by examining existing barriers to access that have been amplified by the pandemic in order to understand the poorer health outcomes for women in ethnic minority and migrant communities. The reflection focuses on racialised medical perceptions, gendered cultural norms including information barriers and stigma, and specific legal barriers.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context

OBJECTIVE

Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice.

DESIGN

Systematic review and meta-synthesis of published findings from qualitative studies.

DATA SOURCES

Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched.

ELIGIBILITY CRITERIA

Studies employing qualitative methods published in English.

SETTINGS

EDs in high-income countries.

PARTICIPANTS

ECPs included doctors, nurses and paramedics.

TOPIC OF ENQUIRY

Staff views on migrant care in ED settings.

DATA EXTRACTION AND SYNTHESIS

Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice.

RESULTS

Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants.

CONCLUSION

ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

Supporting access to healthcare for refugees and migrants in European countries under particular migratory pressure

BACKGROUND

In 2015 the increased migratory pressure in Europe posed additional challenges for healthcare providers. The aim of this study was to inform the development of a "Resource Package" to support European Union (EU) member states in improving access to healthcare for refugees, asylum seekers and other migrants.

METHODS

A mixed method approach was adopted: i) interviews and focus groups were carried out to gather up-to-date information on the challenges the different healthcare providers were facing related to the refugee crisis; ii) to complement the results of the FGs, a literature review was conducted to collect available evidence on barriers and solutions related to access to healthcare for refugees and migrants.

RESULTS

The different actors providing healthcare for refugees and migrants faced challenges related to the phases of the migration trajectory: arrival, transit and destination. These challenges impacted on the accessibility of healthcare services due to legislative, financial and administrative barriers; lack of interpretation and cultural mediation services; lack of reliable information on the illness and health history of migrant patients; lack of knowledge of entitlements and available services; lack of organisation and coordination between services. These barriers proved particularly problematic for access to specific services: mental health, sexual and reproductive care, child & adolescent care and victim of violence care.

CONCLUSIONS

The findings of this study show that solutions that are aimed only at responding to emergencies often lead to fragmented and chaotic interventions, devolving attention from the need to develop structural changes in the EU health systems.

Severe disseminated tuberculosis in HIV-negative refugees

In high-income countries, the presentation of tuberculosis is changing, primarily because of migration, and understanding the specific health needs of susceptible populations is becoming increasingly important. Although disseminated tuberculosis is well documented in HIV-positive patients, the disease is poorly described and less expected in HIV-negative individuals. In this Grand Round, we report eight HIV-negative refugees, who presented with extensively disseminated tuberculosis. We discuss the multifactorial causes, such as deprivations during long journeys, precarious living conditions, and the experience of violence, which might add to nutritional factors and chronic disorders, eventually resulting in a state of predisposition to immune deficiency. We also show that disseminated tuberculosis is often difficult to diagnose when pulmonary symptoms are absent. Communication difficulties between refugees and health-care workers are another major hurdle, and every effort should be made to get a valid patient history. This medical history is crucial to guide imaging and other diagnostic procedures to establish a definite diagnosis, which should be confirmed by a positive tuberculosis culture. Because many of these patients are at risk for multidrug-resistant tuberculosis, drug susceptibility testing is imperative to guide therapy. In the absence of treatment guidelines for this entity, clinicians can determine treatment duration according to recommendations provided for extrapulmonary tuberculosis and affected organs. Paradoxical expansion of tuberculous lesions during therapy should be treated with corticosteroids. In many cases, treatment duration must be individualised and might even exceed 12 months.

"If you can, change this system" -Pregnant asylum seekers' perceptions on social determinants and material circumstances affecting their health whilst living in state-provided accommodation in Germany - a prospective, qualitative case study

Background

Pregnant women and new mothers seeking asylum are highly vulnerable and have special needs, yet there is dearth of research related to this group in Germany. This paper reports on material circumstances and behavioural factors as social determinants of asylum seekers’ health during pregnancy and early motherhood. The study aim was to gain in-depth insights into these women’s experiences and perceived needs with a focus on material circumstances whilst living in state-provided accommodation in one federal state in Southern Germany.

Methods

A qualitative, prospective approach was taken with individual semi-structured interviews of participants during pregnancy and up to the six-week postnatal assessment, aiming at interviewing each woman twice during pregnancy and once after giving birth. Two female interviewers performed interviews assisted by female professional interpreters on the telephone. Interviews were recorded digitally and transcribed verbatim. An inductive approach was taken to perform content analysis of interview material.

Results

21 interviews were performed with nine women seeking asylum in pregnancy and early motherhood. Content analysis of women’s perceived health-related needs revealed significant health challenges due to considerable constraints in two major themes each with associated categories: a) material circumstances and b) behavioural factors. Participants’ experiences of living conditions included significant challenges in terms of housing and neighbourhood quality e.g. poor hygiene standards with fear of disease and restless sleep due to threats of violence. Consumption potential was severely limited because of a minimal living allowance. Food was a major preoccupation for all participants. Catering services in state-provided accommodation were perceived as unsatisfactory and neglecting religious practices. Institutional food provided adequate calorific intake but participants reported loss of appetite due to bland food, limited variety, little choice and unfamiliar tastes. Self-catering was prohibited further exacerbating this problem.

Conclusions

Pregnant asylum seekers and new mothers living in state-provided accommodation experienced major restrictions related to material circumstances in this study. Key results identified housing and neighbourhood quality, consumption potential and nutrition as social determinants of health which women perceived to adversely affect their health, especially during pregnancy and early motherhood.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6481-2) contains supplementary material, which is available to authorized users.

Healthcare service delivery to refugee children from the Democratic Republic of Congo living in Durban, South Africa: a caregivers' perspective

BACKGROUND

Refugees are generally considered a vulnerable population, with refugee children (newborn and young children) being particularly so. Access to healthcare for this population remains a challenge. The main purpose of this study was to explore refugee caregivers' perceptions of their children's access to quality health service delivery to their young children in Durban, South Africa.

METHODS

This study used an explanatory mixed methods design, purposively sampling 120 and 10 participants for the quantitative and qualitative phases, respectively. Participants were administered a self-developed questionnaire that assessed demographic information of participants, socioeconomic status and living standard, medical history of children, satisfaction and experiences with healthcare services and refugees' networks and social support. A semi-structured interview schedule was developed to elicit in-depth and more detailed information from the participants on the quantitative areas that were investigated. Frequencies were calculated and a χ² test was used to explore the factors associated with refugees' satisfaction of the healthcare provided and thematic analysis was used to analyse the qualitative data.

RESULTS

The majority (89%) of caregivers were women, with over 70% of them aged between 30 and 35 years. Over 74% of caregivers visited public clinics for their children's healthcare needs. The majority of caregivers (95%) were not satisfied with healthcare services delivery to their children due to the long waiting hours and the negative attitudes and discriminatory behaviours of healthcare workers, particularly in public healthcare facilities.

CONCLUSION

These findings underscore the need to address health professionals' attitudes when providing healthcare for refugees. Attitudinal change may improve the relationship between service providers and caregivers of refugee children in South Africa, which may improve the health-related outcomes in refugee children.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

Equitable tuberculosis care in the North West of England: analysis of tuberculosis cohort review data

BACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown.

METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models.

RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27–19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10–2.62). In multivariable analysis, there were no significant associations.

CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.

Exploring the infant feeding practices of immigrant women in the North West of England: a case study of asylum seekers and refugees in Liverpool and Manchester

Little is known about the infant feeding experiences of refugees residing in the UK. To enable successful health promotion for this population, such experiences must be understood. The study aimed to gain an understanding of infant feeding practices among a group of UK-based refugee mothers. Objectives were to explore mothers' perceptions and influences of infant feeding practices, to explore challenges faced by mothers in feeding their infants and to identify concerns and experiences of health care professionals with regard to caring for them. Fifteen semi-structured interviews and two focus group discussions with refugee mothers and five semi-structured interviews with health care providers were conducted in 2012. A framework approach was used to identify main themes. Overall mothers were dissatisfied with their infant feeding outcomes. A preference to exclusively breastfeed was often not achieved. Most resorted to using formula feed, perceiving that this was primarily due to a lack of support. Mothers who were positive to human immunodeficiency virus followed the UK guidelines of exclusively formula feeding for 6 months, but struggled with guilt of not being able to breastfeed. All mothers unable to exclusively breastfeed experienced a sense of loss. Lack of wider support services coupled with complex lifestyles appeared to create challenges in providing infant feeding support. The results highlight a need for an intensified response to facilitate these mothers to maintain their preferred infant feeding choices, or when required, to support them in the adoption of a new method. Using experienced refugee mothers to guide newer mothers, and integrating health and social care, would be positive starting points.

Refugee experiences of general practice in countries of resettlement: a literature review

BACKGROUND

Refugees and asylum seekers often struggle to use general practice services in resettlement countries.

AIM

To describe and analyse the literature on the experiences of refugees and asylum seekers using general practice services in countries of resettlement.

DESIGN AND SETTING

Literature review using systematic search and narrative data extraction and synthesis methodologies. International, peer-reviewed literature published in English language between 1990 and 2013.

METHOD

Embase, Ovid MEDLINE, PsycINFO, CSA Sociological Abstracts, and CINAHL databases were searched using the terms: refugee, asylum seeker, experience, perception, doctor, physician, and general practitioner. Titles, abstracts and full texts were reviewed and were critically appraised. Narrative themes describing the refugee or asylum seeker's personal experiences of general practice services were identified, coded, and analysed.

RESULTS

From 8722 papers, 85 were fully reviewed and 23 included. These represented the experiences of approximately 864 individuals using general practice services across 11 countries. Common narrative themes that emerged were: difficulties accessing general practice services, language barriers, poor doctor-patient relationships, and problems with the cultural acceptability of medical care.

CONCLUSION

The difficulties refugees and asylum seekers experience accessing and using general practice services could be addressed by providing practical support for patients to register, make appointments, and attend services, and through using interpreters. Clinicians should look beyond refugee stereotypes to focus on the needs and expectations of the individual. They should provide clear explanations about unfamiliar clinical processes and treatments while offering timely management.

Access to medicines by child refugees in the East Midlands region of England: a cross-sectional study

OBJECTIVES

To explore access to primary healthcare and drug therapy by refugee children in the East Midlands region of England.

DESIGN

Interviews with refugees with children and a control group of British parents with children.

SETTING

East Midlands region of England.

PARTICIPANTS

50 refugees with children and a control group of 50 parents with children.

MAIN OUTCOME MEASURES

Number of medicines used by children in the last month and the past 6 months. Health of parents and children. Registration with a general practitioner (GP).

RESULTS

All families in both groups were registered with a GP. There was no difference in the number of children in the two groups experiencing illnesses .In the last month, 30 refugee children received 60 medicines and 31 control children 63 medicines. In the past 6 months, 48 refugee children received 108 medicines and 43 control children 96 medicines. There was no difference between the two groups of children in relation to the likelihood of receiving any medicines in either the last month (P=0.839) or the past 6 months (p=0.81). Children in the refugee group were more likely to receive prescribed medicines for the last month (p=0.008) and the past 6 months (p<0.001). They were also less likely to receive over the counter (OTC) medicines in the past 6 months (p=0.009).

CONCLUSIONS

The refugee children in this study in the East Midlands had access to primary healthcare, medicines and a family doctor. They were more likely to receive prescribed medicines and less likely to receive OTC medicines, especially paracetamol.

Asylum seekers, violence and health: a systematic review of research in high-income host countries

We performed a systematic review of literature on violence and related health concerns among asylum seekers in high-income host countries. We extracted data from 23 peer-reviewed studies. Prevalence of torture, variably defined, was above 30% across all studies. Torture history in clinic populations correlated with hunger and posttraumatic stress disorder, although in small, nonrepresentative samples. One study observed that previous exposure to interpersonal violence interacted with longer immigration detention periods, resulting in higher depression scores. Limited evidence suggests that asylum seekers frequently experience violence and health problems, but large-scale studies are needed to inform policies and services for this vulnerable group often at the center of political debate.

Ethical and professional considerations providing medical evaluation and care to refugee asylum seekers

A significant number of asylum seekers who largely survived torture live in the United States. Asylum seekers have complex social and medical problems with significant barriers to health care access. When evaluating and providing care for survivors, health providers face important challenges regarding medical ethics and professional codes. We review ethical concerns in regard to accountability, the patient-physician relationship, and moral responsibilities to offer health care irrespective of patient legal status; competing professional responsibility toward society and the judiciary system; concerns about the consistency of asylum seekers' claims; ethical concerns surrounding involving trainees and researching within the evaluation setting; and the implication of broader societal views towards rights and social justice. We discuss contributing factors, including inadequate and insufficient provider training, varying and inadequate institutional commitment, asylum seekers' significant medical and social problems, and the broader health and social system issues. We review existing resources to address these concerns and offer suggestions.

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.

Poor uptake of primary healthcare registration among recent entrants to the UK: a retrospective cohort study

OBJECTIVES

Uptake of healthcare among migrants is a complex and controversial topic; there are multiple recognised barriers to accessing primary care. Delays in presentation to healthcare services may result in a greater burden on costly emergency care, as well as increased public health risks. This study aimed to explore some of the factors influencing registration of new entrants with general practitioners (GPs).

DESIGN

Retrospective cohort study.

SETTING

Port health screening at Heathrow and Gatwick airports, primary care.

PARTICIPANTS

252 559 new entrants to the UK, whose entry was documented by the port health tuberculosis screening processes at Heathrow and Gatwick. 191 had insufficient information for record linkage.

PRIMARY OUTCOME MEASURE

Registration with a GP practice within the UK, as measured through record linkage with the Personal Demographics Service (PDS) database.

RESULTS

Only 32.5% of 252 368 individuals were linked to the PDS, suggesting low levels of registration in the study population. Women were more likely to register than men, with a RR ratio of 1.44 (95% CI 1.41 to 1.46). Compared with those from Europe, individuals of nationalities from the Americas (0.43 (0.39 to 0.47)) and Africa (0.74 (0.69 to 0.79)) were less likely to register. Similarly, students (0.83 (0.81 to 0.85)), long-stay visitors (0.82 (0.77 to 0.87)) and asylum seekers (0.46 (0.42 to 0.51)) were less likely to register with a GP than other migrant groups.

CONCLUSIONS

Levels of registration with GPs within this selected group of new entrants, as measured through record linkage, are low. Migrant groups with the lowest proportion registered are likely to be those with the highest health needs. The UK would benefit from a targeted approach to identify the migrants least likely to register for healthcare and to promote access among both users and service providers.