BMC Public Health 2009, 9:214 http://www.biomedcentral.com/1471-2458/9/214 Background Population based studies on adult refugees and asylum seekers living in Western countries report a high preva- lence of mental health problems, particularly symptoms suggestive of post traumatic stress disorder (PTSD), depression and anxiety [1]. Most studies are based on rel- atively small samples of patients and include people from a single country of origin [1]. Furthermore, the majority of studies focus either on refugees or on asylum seekers alone, without contrasting their health status and differ- ent health experiences. Compared to other Western countries Ireland received a relatively small number of refugees until the early 1990s. Since this time the annual number of people seeking ref- ugee status has risen substantially to a peak of over 11,000 applications in 2002 [2]. This increase has led to concerns about the health and quality of life of asylum seekers and refugees in Ireland. On an annual basis, approximately 9% of asylum seekers are granted refugee status in Ireland (2002–2007 figures [2]). While their application is being processed asylum seekers in Ireland are required to live in direct provision centres (shared hostel-type accommodation), where all their meals are provided and they receive an allowance of approximately €19 per week [3]. During this time they are legally prohibited from working, however, they are enti- tled to adult literacy and English language courses. Legal Aid and healthcare are means tested; anyone who quali- fies for a medical card (asylum seeker or refugee) is enti- tled to free healthcare, including access to a general practitioner, prescribed medications and psychology serv- ices [3]. Ireland has also been a member of the UNHCR Refugee Resettlement Program since 1998 and admits approxi- mately 140 refugees per year under this scheme (2005– 2007 figures [3]). These programme based or 'offshore ref- ugees' do not undergo the asylum process in Ireland as they are granted refugee status prior to their arrival in Ire- land and have therefore not been included in this study. Refugees and asylum seekers differ in a number of ways that may affect health status and the utilisation of health care services; for example, in terms of living arrangements, the direct provision centres and the inability to seek work may negatively impact on the health and wellbeing of asy- lum seekers. The process of seeking refugee status can take a considera- ble amount of time in Ireland, with 32% of asylum seek- ers residing in direct-provision centres for over two years [4]. The length of asylum procedure has been shown to be independently associated with an increased risk of psychi- atric disorders [5]. Previous studies report a broad range in prevalence of PTSD from 4% to 70%, and a similarly wide range of prevalence concerning depression (3% to 88%) and anxiety (2% to 80%) in refugees and asylum seekers [1]. The subsequent impact of poor mental health and its influence on health seeking behaviour and health care uti- lisation has not been previously addressed in the Irish context. The aim of this study is to provide and compare epidemi- ological data on the self-reported health status of refugees and asylum seekers using validated instruments [5,6]. We will explore any differences in health between these two groups to discover if residence status is an independent predictor of health outcomes or if it acts as a marker for other risk factors. Data will also be collected on subse- quent health care utilisation, allowing a comparison and better understanding of health and health care utilisation of refugees and asylum seekers. Methods Design, Setting and Participants We performed a cross sectional study using validated questionnaires of self-reported health status. The study sample consisted of adult asylum seekers and refugees from thirty countries including Iran (4), Iraq (7), Afghan- istan (4), Pakistan (6), Vietnam (1), Bosnia (1), Bhutan (2), Georgia (2), Kazakhstan (1), Kuwait (2), Lebanon (1), Russia (1) and a number of African countries (56). The target population of this study was asylum seekers liv- ing in two direct provision centres in Sligo and Leitrim, Ireland and refugees who were living in the same commu- nity services area. The questionnaire included questions on physical health, mental health, utilisation of health care services, pre and post migratory traumatic experi- ences and each person's socio-demographic background. Procedures Participants in this study were sent a letter and consent form, informing them about the study, the questionnaire, confidentiality, and the voluntary nature of participation. Asylum seekers were assured that participation in the study would have no influence on their asylum request. The study protocol was approved by the Research Ethical Committee of Royal College of Surgeons in Ireland. With permission from the authors, a modified version of a questionnaire developed in the Netherlands was used in this study [6]. The questionnaire was modified by the removal of sections on life-style, acculturation and social support. To minimize the risk of misunderstanding or miscommunication and to address difficulties in relation to translation or clarification on items, one of the researchers (MT) administered the questionnaire to all participants in a face to face interview and used an inter- preter when necessary to overcome any language difficul- ties. 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