Health and access to care for undocumented migrants living in the European Union: a scoping review

Literature on health and access to care of undocumented migrants in the European Union (EU) is limited and heterogeneous in focus and quality. Authors conducted a scoping review to identify the extent, nature and distribution of existing primary research (1990–2012), thus clarifying what is known, key gaps, and potential next steps.  Authors used Arksey and O’Malley’s six-stage scoping framework, with Levac, Colquhoun and O’Brien’s revisions, to review identified sources. Findings were summarized thematically: (i) physical, mental and social health issues, (ii) access and barriers to care, (iii) vulnerable groups and (iv) policy and rights.  Fifty-four sources were included of 598 identified, with 93% (50/54)  EU member states from Eastern Europe were under-represented, particularly in single-country studies. Most study designs (52%) were qualitative. Sampling descriptions were generally poor, and sampling purposeful, with only four studies using any randomization. Demographic descriptions were far from uniform and only two studies focused on undocumented children and youth. Most (80%) included findings on health-care access, with obstacles reported at primary, secondary and tertiary levels. Major access barriers included fear, lack of awareness of rights, socioeconomics. Mental disorders appeared widespread, while obstetric needs and injuries were key reasons for seeking care. Pregnant women, children and detainees appeared most vulnerable. While EU policy supports health-care access for undocumented migrants, practices remain haphazard, with studies reporting differing interpretation and implementation of rights at regional, institutional and individual levels.  This scoping review is an initial attempt to describe available primary evidence on health and access to care for undocumented migrants in the European Union. It underlines the need for more and better-quality research, increased co-operation between gatekeepers, providers, researchers and policy makers, and reduced ambiguities in health-care rights and obligations for undocumented migrants.

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title: Access to healthcare for undocumented migrants in 11 European countries
abstract: Through our national programmes we meet people in Europe who have fled extreme poverty, violent armies and police forces, conflict areas and disasters. A tiny minority of the children, women and men whom we try to support when we work in their countries end up coming here. After migration journeys which are very often long, dangerous and exhausting, many find themselves without permission to stay in the country, forced into the shadows of our towns and cities. At home, as abroad, Medecins du Monde aims to provide some support and tries to help this population protect what is often the only thing they have left--their health. With this study, we show how undocumented migrants' living conditions are harmful to their health and prevent them from building, or rebuilding, their lives. This is despite the fact that these children, women and men are in particular need of support, given what they have lived through and the migration journeys they have undertaken. Even worse, our own health systems often exclude them from healthcare. Serious health problems receive little medical follow-up, sometimes none at all. Because healthcare sometimes becomes a trap--due to the fact that people are being encouraged or required to report undocumented migrants--we urge that health policy must remain completely independent from immigration policy, respecting the obligations of health and social care.

title: Scoping studies: towards a methodological framework
abstract: This paper focuses on scoping studies, an approach to reviewing the literature which to date has received little attention in the research methods literature. We distinguish between different types of scoping studies and indicate where these stand in relation to full systematic reviews. We outline a framework for conducting a scoping study based on our recent experiences of reviewing the literature on services for carers for people with mental health problems. Where appropriate, our approach to scoping the field is contrasted with the procedures followed in systematic reviews. We emphasize how including a consultation exercise in this sort of study may enhance the results, making them more useful to policy makers, practitioners and service users. Finally, we consider the advantages and limitations of the approach and suggest that a wider debate is called for about the role of the scoping study in relation to other types of literature reviews.

title: A typology of reviews: an analysis of 14 review types and associated methodologies.
abstract: The expansion of evidence-based practice across sectors has lead to an increasing variety of review types. However, the diversity of terminology used means that the full potential of these review types may be lost amongst a confusion of indistinct and misapplied terms. The objective of this study is to provide descriptive insight into the most common types of reviews, with illustrative examples from health and health information domains.



Following scoping searches, an examination was made of the vocabulary associated with the literature of review and synthesis (literary warrant). A simple analytical framework -- Search, AppraisaL, Synthesis and Analysis (SALSA) -- was used to examine the main review types.



Fourteen review types and associated methodologies were analysed against the SALSA framework, illustrating the inputs and processes of each review type. A description of the key characteristics is given, together with perceived strengths and weaknesses. A limited number of review types are currently utilized within the health information domain.



Few review types possess prescribed and explicit methodologies and many fall short of being mutually exclusive. Notwithstanding such limitations, this typology provides a valuable reference point for those commissioning, conducting, supporting or interpreting reviews, both within health information and the wider health care domain.

title: Scoping studies: advancing the methodology
abstract: BackgroundScoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process.DiscussionWe build upon our experiences conducting three scoping studies using the Arksey and O'Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research.SummarySpecific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O'Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.

title: Paternity for Sale
abstract: Women's experiences of migration, and their relationship to a host country, vary significantly from those of migrant men simply because pregnancy is a possibility. The concept of “demographic theft” highlights popular anxieties regarding high fertility among foreigners, including undocumented migrants. This article examines pregnant undocumented women's experiences with the health care system and relationship to the state in Germany. It also provides a discussion of how a restrictive immigration climate, particular models of citizenship, and liberal family laws have resulted in unique practices surrounding paternity claims. It is based on long-term ethnographic data to highlight contradictions and ambiguities in the policy environment and utilizes the notion of stratified reproduction to bring new evidence regarding mothers' deportability and practices of paternity.

title: Illegality as risk factor: a survey of unauthorized migrant patients in a Berlin clinic.
abstract: Unauthorized migrants face health disadvantages in many receiving nations. However, few studies have explored precisely how the condition of "illegality" influences illness experiences, medical treatment, and convalescence. This article presents a case study from Germany (2004-2006 and 2008), where unauthorized migrants face limited access to health care and the threat of deportation results in avoidance of services and treatment delays. This is confounded by unique laws which essentially criminalize health care workers for aiding migrants. This article provides a snapshot of 183 patients who attended a Berlin clinic that functions as the single largest source of medical assistance for unauthorized persons in Germany. The demographic information sketches a picture of labor migrants with a mean age of approximately 29 years. More women than men presented at this clinic, a result of its ability to successfully arrange prenatal care and delivery as well as a reflection of local labor markets. The diversity of countries of origin (n=55) is surprising, underscoring the utility of using illegal status as a unifying variable to highlight migrants' shared position in the global economy and the resulting barriers to basic medical services. Patients presented with a range of illnesses typical for their age group. However, the effects of illegal status resulted in four areas of disparities: 1) limits to the overall quality and quantity of care for mothers and infants; 2) delayed presentation and difficulties accessing a regular supply of medication for patients with chronic illnesses; 3) difficulties in accessing immediate medical attention for unpredictable injuries and other acute health concerns; and 4) a lack of mental health care options for generalized stress and anxiety affecting health. In Germany, an incoherent policy environment contributes to inadequate services and treatment delays. Solutions must address these legal ambiguities, which represent a primary barrier to equity in a nation with otherwise universal health coverage.

title: Medical Humanitarianism and Physicians' Organized Efforts to Provide Aid to Unauthorized Migrants in Germany
abstract: Universal notions of a "right to health" for unauthorized migrants operate together with incongruous state and international policies. These ambivalent policies demand ethnographic attention, since they have resulted in a two-tiered system in host countries and foster short-term, improvisational remedies. Medical care for unauthorized migrants is typically left in the hands of non-governmental organizations (NGOs) and permitted under the guise of sympathy and generosity rather than anchored in policy. This paper draws upon ethnographic fieldwork in Germany to present the viewpoints of physicians engaged in medical humanitarianism and discuss the complications associated with filling access gaps through NGOs. It explores the range of motivations—political, religious, and humanitarian—that drive physicians to provide care to marginalized populations. In recent years, I argue that NGO demands upon the state have moved from requests to decriminalize medical aid to demands for compensation for the significant ...

title: Supervised preventive therapy for latent tuberculosis infection in illegal immigrants in Italy.
abstract: In a multicenter, prospective, randomized, open-label study of isoniazid-preventive therapy (IPT) for latent tuberculosis infection, illegal immigrants from countries where tuberculosis is highly endemic were enrolled at two clinical sites in Northern Italy. Of 208 eligible subjects, 82 received supervised IPT at a dose of 900 mg twice weekly for 6 mo (Regimen A), 73 received unsupervised IPT 900 mg twice weekly for 6 mo (Regimen B), and 53 received unsupervised IPT 300 mg daily for 6 mo (Regimen C). Supervised IPT was delivered at either one tuberculosis clinic or one migrant clinic. The probability of completing a 26-wk regimen was 7, 26, and 41% in Regimens A, B, and C, respectively (p < 0.005, Log- rank test calculated using Kaplan-Meier plots). The mean time to dropout was 3. 8, 6, and 6.2 wk in Regimens A, B, and C, respectively (p = 0.003 for regimen A versus either Regimens B or C). Treatment was stopped in five subjects (2.4%) because of adverse events. The rate of completion of preventive therapy for latent tuberculosis infection among illegal immigrants was low. Supervised, clinic-based administration of IPT significantly reduced adherence. Alternative strategies to implement preventive therapy in illegal immigrants are clearly required.

title: Health care provision for illegal immigrants: should public health be concerned?
abstract: European countries are becoming multicultural societies, and national health systems have progressively adapted following their political and historical  Overall, sick, immigrants with regularised administrative status are able to use health services in equal terms than people from the host country. Legal immigrants have a poorer health status and worse living conditions than the host population, and consequently, may even have a higher utilisation of health services,2 although that is not always the case.3 Ilegal immigrants are, in principle, not entitled to receive medical care from public services, except in cases of emergencies,4 but it is unclear where and how they receive medical care in cases of need. In some countries “alternative health care providers” such as non-governmental organisations (NGOs) offer medical care, often supported with public funds. But again, we do not know whether those alternative health care providers are used when they exist, and to what extent they are preferred to other providers. The objective of this study was to test whether illegal immigrants are effectively able to obtain medical treatment when ill.

Immigrants from developing countries who resided in one of the Health Areas of the Autonomous Community of Madrid (ACM) (Health Area 6), were older than 15 years of age, and had lived in Spain for more than three months were eligible to enter the study. Our research Area was selected because it had the largest share of immigrants in the ACM. The ACM host about one quarter of the immigrants of Spain, and about one fifth of them lived in our study Area. The southern …

title: European survey on undocumented migrant's access to health care
abstract: HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. European survey on undocumented migrant’s access to health care Pierre Chauvin, Isabelle Parizot, Nadège Drouot, Anne Tomasino, Nathalie Simonnot

title: Hidden violence is silent rape: sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands
abstract: Although women, young people and refugees are vulnerable to sexual and gender-based violence (SGBV) worldwide, little evidence exists concerning SGBV against refugees in Europe. Using community-based participatory research, 223 in-depth interviews were conducted with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Responses were analysed using framework analysis. The majority of the respondents were either personally victimised or knew of a close peer being victimised since their arrival in the European Union. A total of 332 experiences of SGBV were reported, mostly afflicted on them by (ex-)partners or asylum professionals. More than half of the reported violent experiences comprised sexual violence, including rape and sexual exploitation. Results suggest that refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are extremely vulnerable to violence and, specifically, to sexual violence. Future SGBV preventive measures should consist of rights-based, desirable and participatory interventions, focusing on several socio-ecological levels concurrently.

title: Access to healthcare and alternative health-seeking strategies among undocumented migrants in Denmark
abstract: BackgroundAs in many European countries, undocumented migrants in Denmark have restricted access to healthcare. The aim of this study is to describe and analyse undocumented migrants' experiences of access to healthcare, use of alternative health-seeking strategies; and ER nurses' experiences in encounters with undocumented migrants.MethodsQualitative design using semi-structured interviews and observations. The participants included ten undocumented South Asian migrants and eight ER nurses.ResultsUndocumented migrants reported difficulties accessing healthcare. The barriers to healthcare were: limited medical rights, arbitrariness in healthcare professionals' attitudes, fear of being reported to the police, poor language skills, lack of network with Danish citizens, lack of knowledge about the healthcare system and lack of knowledge about informal networks of healthcare professionals. These barriers induced alternative health-seeking strategies, such as self-medication, contacting doctors in home countries and borrowing health insurance cards from Danish citizens. ER nurses expressed willingness to treat all patients regardless of their migratory status, but also reported challenges in the encounters with undocumented migrants. The challenges for ER nurses were: language barriers, issues of false identification, insecurities about the correct standard procedures and not always being able to provide appropriate care.ConclusionsUndocumented migrants face formal and informal barriers to the Danish healthcare system, which lead to alternative health-seeking strategies that may have adverse effects on their health. This study shows the need for policies and guidelines, which in accordance with international human rights law, ensure access to healthcare for undocumented migrants and give clarity to healthcare professionals.

title: Immigration, work and health in Spain: the influence of legal status and employment contract on reported health indicators
abstract: ObjectiveTo analyze the relationship of legal status and employment conditions with health indicators in foreign-born and Spanish-born workers in Spain.MethodsCross-sectional study of 1,849 foreign-born and 509 Spanish-born workers (2008–2009, ITSAL Project). Considered employment conditions: permanent, temporary and no contract (foreign-born and Spanish-born); considered legal statuses: documented and undocumented (foreign-born). Joint relationships with self-rated health (SRH) and mental health (MH) were analyzed via logistical regression.ResultsWhen compared with male permanently contracted Spanish-born workers, worse health is seen in undocumented foreign-born, time in Spain ≤3 years (SRH aOR 2.68, 95% CI 1.09–6.56; MH aOR 2.26, 95% CI 1.15–4.42); in Spanish-born, temporary contracts (SRH aOR 2.40, 95% CI 1.04–5.53); and in foreign-born, temporary contracts, time in Spain >3 years (MH: aOR 1.96, 95% CI 1.13–3.38). In females, highest self-rated health risks are in foreign-born, temporary contracts (aOR 2.36, 95% CI 1.13–4.91) and without contracts, time in Spain >3 years (aOR 4.63, 95% CI 1.95–10.97).ConclusionsContract type is a health determinant in both foreign-born and Spanish-born workers. This study offers an uncommon exploration of undocumented migration and raises methodological issues to consider in future research.

title: Health care provision for illegal migrants: may health policy make a difference?
abstract: Illegal migrants in Europe are, generally, only entitled to emergency care and services for children and pregnant women. In 2002 legal changes in Spain made accessible medical cards and free medical care for illegal migrants in similar terms than the legal migrants or the Spanish population. We interviewed 380 migrants to assess whether there were differences on health services utilization by legal status. We did not find differences in the utilization of health services when ill between legal and illegal migrants. However, a significantly lower utilization of health services was associated with less education (RP = 0.4; 95% CI: 0.2-0.9).

title: Determinants of health care utilization by immigrants in Portugal
abstract: BackgroundThe increasing diversity of population in European Countries poses new challenges to national health systems. There is a lack of data on accessibility and use of health care services by migrants, appropriateness of the care provided, client satisfaction and problems experienced when confronting the health care system. This limits knowledge about the multiple determinants of the utilization of health services. The aim of this study was to describe the access of migrants to health care and its determinants in Portugal.MethodsThe study sample included 1513 immigrants (53% men), interviewed at the National Immigrant Support Centre, in Lisbon. Data were collected using questionnaires. The magnitude of associations between use of National Health Service and socio-demographic variables was estimated by means of odds ratios (OR) at 95% confidence intervals, calculated using logistic regression.ResultsAmong participants, 3.6% stated not knowing where to go if facing a health problem. Approximately 20% of the respondents reported that they had never used the National Health Service, men more than women. Among National Health Service users, 35.6% attended Health Centres, 12% used Hospital services, and 54.4% used both. Among the participants that ever used the health services, 22.4% reported to be unsatisfied or very unsatisfied. After adjusting for all variables, utilization of health services, among immigrant men, remained significantly associated with length of stay, legal status, and country of origin. Among immigrant women, the use of health services was significantly associated with length of stay and country of origin.ConclusionThere is a clear need to better understand how to ensure access to health care services and to deliver appropriate care to immigrants, and that special consideration must be given to recent and undocumented migrants. To increase health services use, and the uptake of prevention programs, barriers must be identified and approaches to remove them developed, through coherent and comprehensive strategies.

title: Factors associated with HIV testing among immigrants in Portugal
abstract: ObjectivesThis paper describes the uptake of HIV testing and its associated factors among a sample of immigrants in Portugal. questionnaire was completed by 1,513 immigrants at the National Immigrant Support Centre, in Lisbon. The magnitude of the association between ever been HIV tested and socio-demographic variables was estimated by means of crude and adjusted odds ratios, and their 95% confidence intervals, using logistic regression.ResultsApproximately half of the participants reported having ever been HIV tested. Age, sex, educational level, region of origin, immigration status and knowing someone infected were independently associated with the HIV test uptake. Almost 90% of participants reported knowing where to obtain support on HIV-related issues. Most declared preferring doctors to get HIV information. However, only 9.2% had sought HIV information at the National Health Service.ConclusionsOur results suggest differences between migrant groups regarding HIV testing. Adopting more innovative approaches to HIV testing could improve the efficacy of HIV prevention strategies, especially among vulnerable groups within immigrant population as male and undocumented.

title: Health care seeking among detained undocumented migrants: a cross-sectional study
abstract: BackgroundAs in many European countries, access to care is decreased for undocumented migrants in the Netherlands due to legislation. Studies on the health of undocumented migrants in Europe are scarce and focus on care-seeking migrants. Not much is known on those who do not seek care.MethodsThis cross-sectional study includes both respondents who did and did not seek care, namely undocumented migrants who have been incarcerated in a detention centre while awaiting expulsion to their country of origin. A consecutive sample of all new arrivals was studied. Data were collected through structured interviews and reviews of medical records.ResultsAmong the 224 male migrants who arrived at the detention centre between May and July 2008, 173 persons were interviewed. 122 respondents met inclusion criteria. Only half of the undocumented migrants in this study knew how to get access to medical care in the Netherlands if in need. Forty-six percent of respondents reported to have sought medical help during their stay in the Netherlands while having no health insurance (n = 57). Care was sought most frequently for injuries and dental problems. About 25% of these care seekers reported to have been denied care by a health care provider. Asian migrants were significantly less likely to seek care when compared to other ethnic groups, independent from age, chronic health problems and length of stay in the Netherlands.ConclusionThe study underlines the need for a better education of undocumented patients and providers concerning the opportunities for health care in the Netherlands. Moreover, there is a need to further clarify the reasons for the denial of care to undocumented patients, as well as the barriers to health care as perceived by undocumented migrants.

title: Immigrant women’s perceptions and experiences of health care services: Insights from a focus group study
abstract: AimThis study aimed to describe perceptions and experiences related to access and utilization of health care services of African and Brazilian immigrant women in Portugal.Subjects and methodsSix focus groups were conducted with 35 African and Brazilian women with low income and living in Lisbon, chosen through purposive sampling. Content analysis was undertaken through identification of themes and categories.ResultsAfrican and Brazilian women expressed different perceptions and patterns of use of health care services. Most participants pointed out several barriers to access and utilization of services related to legal issues, economic constraints or health professionals’ attitudes.ConclusionThese results highlight the challenges to providing health care within a multicultural setting and the need to assure the provision of integrated and comprehensive health care services. Improving access to general health care is essential in order to minimize disadvantages from vulnerable subgroups, like immigrant women. Supporting better integration into the health system may lead to improved health outcomes.

title: Illegal Aliens and Health (Care) Wants. The Cases of Sweden and the Netherlands
abstract: This thesis deals with illegal aliens in Sweden and the Netherlands with the main focus on health aspects. The three-fold aim is to investigate emergence of healthcare wants among illegal aliens, how they satisfy these wants (if they do so at all), and to explore the relation between their healthcare wants and health wants. Extensive fieldwork was conducted in both countries, including 42 interviews with illegal aliens in Sweden – and 38 in the Netherlands. In Sweden, except for a trivial exception, there are no state provisions on subsidized healthcare services to illegal aliens - while in the Netherlands, there is a state fund enabling a reimbursement for certain healthcare providers offering "medically necessary care" to this group. Subsidized care services are not restricted to a state. Activities of six private voluntary health-care initiatives (PVHIs) providing care to illegal aliens were also documented. Access to (subsidized) care actively promoted by the human rights framework (as operationalized by the UN Special Rapporteur on the Highest Attainable Standard of Health) and by the medical establishment, showed to be not necessarily sufficient in either addressing or satisfying health (care) wants of illegal aliens. More consistency is desired from different stakeholders working in this subject.

title: Health care for irregular migrants: pragmatism across Europe. A qualitative study
abstract: BackgroundHealth services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries.ResultsSemi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this.ConclusionsThe needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.

title: Mental health care for irregular migrants in Europe: Barriers and how they are overcome
abstract: BackgroundIrregular migrants (IMs) are exposed to a wide range of risk factors for developing mental health problems. However, little is known about whether and how they receive mental health care across European countries. The aims of this study were (1) to identify barriers to mental health care for IMs, and (2) to explore ways by which these barriers are overcome in practice.MethodsData from semi-structured interviews with 25 experts in the field of mental health care for IMs in the capital cities of 14 European countries were analysed using thematic analysis.ResultsExperts reported a range of barriers to mental health care for IMs. These include the absence of legal entitlements to health care in some countries or a lack of awareness of such entitlements, administrative obstacles, a shortage of culturally sensitive care, the complexity of the social needs of IMs, and their fear of being reported and deported. These barriers can be partly overcome by networks of committed professionals and supportive services. NGOs have become important initial points of contact for IMs, providing mental health care themselves or referring IMs to other suitable services. However, these services are often confronted with the ethical dilemma of either acting according to the legislation and institutional rules or providing care for humanitarian reasons, which involves the risk of acting illegally and providing care without authorisation.ConclusionsEven in countries where access to health care is legally possible for IMs, various other barriers remain. Some of these are common to all migrants, whilst others are specific for IMs. Attempts at improving mental health care for IMs should consider barriers beyond legal entitlement, including communicating information about entitlement to mental health care professionals and patients, providing culturally sensitive care and ensuring sufficient resources.

title: 'There is no love here anyway.' Sexuality, identity and HIV prevention in an African sub-culture in Amsterdam, The Netherlands.
abstract: Undocumented African immigrants in The Netherlands are persons perceived to be at high-risk for HIV infection and yet are also a group that health care providers find difficult to access. The present study explores the experiences of a sample of undocumented African immigrants living in Amsterdam and offers recommendations aimed at providing more effective prevention interventions.



Data collection occurred through interviews and focus groups with men and women aged 20-35 of both African and Dutch descent, using their interactions to explore possible communication challenges. Field notes of interviews were transcribed and analysed to identify emergent themes and patterns. A conceptual framework related to power and identity construction was adopted.



The findings of the present study show how identity is shaped and constrained by discourses around sexuality and health, as well as what participants perceived to be conflicting belief systems, as well as the Dutch socioeconomic context. The data were divided into two broad categories: challenges around Dutch prevention interventions and challenges around peer-support. Each category is structured around sub-themes, such as 'concepts used in prevention messages', 'inter-cultural tension', 'identification with the educator' and 'stigma: roots and implications'.



These findings indicate that issues of power and identity construction have great implications for the uptake of HIV prevention strategies by African immigrant groups and reveal important opportunities on which to focus prevention efforts.

title: Completion of screening for latent tuberculosis infection among immigrants
abstract: The objective of our study was to evaluate the sociodemographic factors associated with completion of screening for latent tuberculosis infection (LTBI) among undocumented immigrants in Brescia, Italy. Screening for LTBI was offered to 649 immigrants; 213 (33%) immigrants completed the first step of screening; only 44% (55/124) of individuals with a positive tuberculin skin test result started treatment for LTBI. The univariate analysis showed that being unmarried, of Senegalese nationality and being interviewed by a health-care worker with the same native language as the immigrant were significantly associated with completion of screening for LTBI. In the multiple logistic regression, being interviewed in the native language of the health-care worker (OR 2·5, 95% CI 1·3–4·8, P=0·004) and being of Senegalese origin (OR 2·3, 95% CI 1·4–3·6, P=0·0005) were independently associated with adherence to LTBI screening. Our results suggest that knowledge of the sociodemographic characteristics of immigrants, and the participation of health-care workers of the same cultural origin as the immigrant during the visits, can be an important tool to improve completion of screening for LTBI.

title: Providing medical care for undocumented migrants in Denmark: what are the challenges for health professionals?
abstract: BackgroundThe rights of undocumented migrants are frequently overlooked. Denmark has ratified several international conventions recognizing the right to health care for all human beings, but has very scanty legislation and no existing policies for providing health care to undocumented migrants. This study focuses on how health professionals navigate and how they experience providing treatment for undocumented migrants in the Danish health care system.MethodsThe study was carried out as part of an EU-project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). This presentation is based on 12 semi-structured interviews with general practitioners (9) and emergency room physicians (3) in Denmark.ResultsThe emergency room physicians express that treatment of undocumented migrants is no different from the treatment of any other person. However, care may become more complicated due to lack of previous medical records and contact persons. Contrary to this, general practitioners explain that undocumented migrants will encounter formal barriers when trying to obtain treatment. Additional problems in the treatment of undocumented migrants include language issues, financial aspects for general practitioners, concerns about how to handle the situation including possibilities of further referrals, and an uncertainty as to whether to involve the police.ConclusionsThe health professionals in our study describe that undocumented migrants experience an unequal access to primary care facilities and that great uncertainties exist amongst health professionals as how to respond in such situations. The lack of official policies concerning the right to health care for undocumented migrants continue to pass on the responsibility to health professionals and, thereby, leaves it up to the individual to decide whether treatment can be obtained or not.

title: Healthcare-seeking patterns among immigrants in Portugal.
abstract: Equity of access to health services is a major concern as it is an important precondition for positive health outcomes. However, inequities in use of health services among immigrant populations persist. Despite the increasing research in the field, patterns of healthcare seeking among immigrant populations and its associated factors are not fully understood. This study aimed to investigate healthcare-seeking patterns among immigrants in Portugal and identify factors associated with utilisation of health services. A cross-sectional study was conducted between October 2008 and May 2009 with a sample of 1,375 immigrants residing in the Lisbon region. Data were collected through a structured questionnaire applied by trained interviewers. Two stepwise logistic regressions were conducted to identify which factors were associated with utilisation of the National Health Service (NHS) and with healthcare seeking for the first time in Portugal at the Primary Health Care service, estimated by calculating odds ratios and 95% confidence intervals. Among participants, around 77% reported having used the NHS; 50% sought health-care for the first time at the Primary Health Care service and 33% at the emergency room. Lower odds of having used the NHS were associated with being male, Brazilian or eastern European compared with being African, and undocumented. Lower odds of having sought health-care for the first time at the Primary Health Care service were associated with being male and undocumented. These results suggest that further efforts are needed to tackle inequalities in access to care and promote the utilisation of health services, particularly among the more vulnerable immigrant groups. Increasing appropriate utilisation of health services, including the primary and preventive care services, may lead to better health outcomes. Immigrants' involvement and participation should be incorporated into the development of health strategies to improve access and utilisation of healthcare services.

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

title: Right of access to health care for undocumented migrants in EU: a comparative study of national policies.
abstract: The aim of this article is to characterize policies regarding the right of access to health care for undocumented migrants in the 27 Member States of the European Union and to identify the extent to which these entitlements are congruent with human rights standards.



The study is based on a questionnaire sent to experts, non-governmental organizations and authorities in the Member States between April and December 2009, as well as on available reports and official websites. Primary sources were also consulted as regards legislation.



Right of access to health care differs considerably between Member States. States can be grouped into 3 clusters: in 5 countries undocumented migrants have the right to access care that is more extensive than emergency care; in 12 countries they can only access emergency care and in 10 countries not even emergency care can be accessed. These variations are independent of the system of financing or the numbers of undocumented migrants present. Rather, they seem to relate to the intersection between practices of control of migration, the main types of undocumented migrants present and the basic norms of the welfare state-the 'moral economy' of the work society.



International obligations articulated in human rights standards are not fully met in the majority of Member States. A more complete understanding of the differing policies might be obtained by considering the relationship between the formal and informal economy, as well as the role of human rights standards within the current 'moral economy'.