Seventy seven sources are analysed in this section and organised according to the above described thematic classification. Figure 1 describes the selection process.
Migrants’ health status
The literature reviewed on health status was organized into the following focus areas: communicable and non-communicable diseases; mental health in adult refugees and migrants; children’s health status.
Communicable and non-communicable diseases
Migrants’ health status is influenced by the hardships of the migration process which negatively affects the physical health status of migrants. This was shown in a French study (6) that demonstrated how migrants’ health status tended to deteriorate with duration of stay which may be due to discrimination; poor employment conditions; differences in access and use of healthcare services. The study suggested that “migrant health deficit effect” (in comparison with natives), is less pronounced for second-generation migrants (people born in France to foreign-born parents). Similarly, an Austrian study showed that the population of migrant origins suffers to a greater extent than the resident population from heart disease, allergies, digestive and urogenital and dermatological problems and emphasizes the link between migrants’ health conditions and the stressful situations they face in both the workplace and the community at large (7). Another study comparing European countries also suggested that migrants are more vulnerable to communicable diseases, occupational diseases, poor mental health, injuries, diabetes mellitus, and maternal and child health problems (8). Two studies focusing on vulnerable migrants living in open centres in Malta (9) and in detention centres in Greece and Malta (10) showed that the prevalence of HIV, tuberculosis and non-communicable diseases (e.g. hypertension and diabetes) is higher among the non-European migrant population. However, it is difficult to compare across countries, as studies focused on specific health conditions and ethnic groups. For example, of the studies included in this review, four focused on specific conditions: ophthalmic disease (11); HIV (12); tuberculosis (13), skin diseases gynaecological concerns and other unattended health-related problems (14–18).
To conclude, data on migrants’ physical health status are insufficient on the basis of the literature reviewed. Some migrants might be at particular risk of non-communicable diseases arising from obesity and insufficient physical activity due to patterns of disease in countries of origin, disadvantageous living conditions, precarious employment and trauma.
Mental health in adult refugees and migrants
The articles that were reviewed show that refugees and migrants tend to have higher prevalence of mental distress compared to non-refugees in Europe. Ten of the papers that were reviewed focus on the mental health of migrants, mostly refugees. A German study found an association between depressive symptoms and migration status in the older migrant populations (19). A more recent study described the mental health condition of asylum seekers who passed through Médecins sans Frontières clinics in Sicily between October 2014 and December 2015 and, when invited, presented themselves for mental health screening (20). Of the 385 who were screened, most were young men who had left their home countries in West Africa more than a year prior to arrival. The most common mental health conditions were post-traumatic stress disorder (31%) and depression (20%). Most of the potentially traumatic events were reported to have been experienced in the home country (60%) and during the journey (89%), but the trauma of being a refugee was also reported, with activity deprivation, worries about people who were left behind, loneliness and fears of being sent back (20).
Another study found a connection between psychosis and a background as an irregular migrant (21). Similarly, an Italian report underlined that although empirical data and scientific research on the topic of migrants’ mental health is still rare, practitioners and sector operators have experienced the increase in requests for psychiatric care from migrants who have lived traumatic situations, social marginalization, lack of social support and are therefore at higher risk of post-traumatic stress disorders (22). The same Italian study highlighted how structural barriers impede the effective transfer of patients to further care facilities. High levels of stress in detention centres are linked to the reporting of non-specific physical symptoms (9) as a form of somatization of psychosocial stress suggesting underlying mental disorders.
Not only previous traumatic experience influences mental health but also duration of stay, as suggested by a study conducted by the Jesuit Refugee Service (JRS) in 2010. This study stated that 80% of Asylum Seekers interviewed reported a deterioration in their mental health since their arrival in the detention centre. From a population of around 500 detainees, 74 individuals required in-patient psychiatric care (23). A project conducted in Malta by Aditus and a UN agency underlined mental health problems affecting a large proportion of the refugee community, including post-traumatic stress disorder, depression, anxiety, psychosis, paranoia and self-harm; feelings of isolation and loneliness were also mentioned by refugees as major concerns to service providers (24) Reported symptoms such as stress, anxiety disorders, panic attacks, and other psychiatric problems were said to be the most common symptoms in some camps more than in others (21).
There seems to be a growing interest in the mental health condition of migrants, even though the studies that look at this issue seem to focus mostly on refugees— for whom there is a presumption that mental health problems arise from uncertain migration status.
Children’s health status
Five studies focused specifically on children’s health status. A French study showed that children born in a hepatitis A endemic area have a significantly higher prevalence of hepatitis A seropositivity compared to children born in France, possibly as a result of exposure during overseas trips to visit family or of family members visiting from the endemic areas, implying an urgent need to vaccinate children (25). Another study in France underlined the lack of clinical practice recommendations for the care of unaccompanied refugee minors as causing significant disparities depending on the department or region to which the young person arrived. The most frequently diagnosed serious conditions were digestive parasites, schistosomiasis, filariasis, hepatitis B and iron deficiency and the failures of care implied the need for standard care to be defined (26).
Vaccination status and dental issues as well as Latent Tubercolosis Infection (LTBI), anaemia, low serum ferritin, eosinophilia, and protective antibodies among migrants were discussed in a Greek study of child migrants (27). Reports of hypothermia after arrival by sea and mental health challenges associated with the experience of violence, separation from family, insecurity, inadequate housing, trafficking, and sexual exploitation were also recorded (28).
Oral health was also discussed in a study of 12-year-old migrants in Austria that showed the prevalence of caries among children born to migrants was 42% higher compared with children with no migrant background. Children with a migrant background were more affected by gingivitis (gum inflammation) and less likely to seek orthodontic treatment or counselling compared to other twelve-year-olds. The report underlined how better use of group prophylaxis and individual healthcare prevention would be a means of reducing unequal distribution of health risk (29).
Generally, our review found that references describing child migrants’ health status are limited, country specific and focus on specific illnesses, making it difficult to draw comparisons and commonalities across countries or to determine the health status of children with migrant background within each country.
Social determinants of health
In the WHO definition, the social determinants of health “are the condition in which people are born, grow live, work and age” and bear the major responsibility for differences in health status. As it affects health status, we decided to include the literature looking at social determinants of health in this review. The majority of studies (7) in this review looking at social determinants of health were conducted in France (6,30–35) and three in Malta (9,36,37). According to a systematic literature review, the link between socio demographic conditions and health is stronger for migrants than for the native population (6). In France, studies reported on the increased health risks for homeless migrants (34), including chronic diseases. A hospital polyclinic in Paris used overwhelmingly by migrants was surveyed and, although their average duration of stay in the country was 12 years, about half of the sample were undocumented and a quarter had no health insurance. Vulnerable migrants in France (including minors, women, and people with disability) were found to have poor self-rated health and poor living conditions as well as being exposed to violence. A study focused on the health effects of violence (38), showed that 84% of 128 women migrants consulting a ‘Médecins du Monde’ clinic in Paris had faced violence, whether verbal, physical or sexual.
Prevalence of having experienced violence and insecurity was higher for people living in public emergency accommodation and those who were homeless than for those living in camps or in someone else’s accommodation according to people’s declaration (30). Migrants and especially women migrants from sub-Saharan Africa in France in 2012-2013 faced precarious administrative and social conditions, associated with poor health outcomes (33). The same study showed that compared to women, men’s diagnosis occurred after a longer delay following arrival in France and occurred more frequently during an active phase of the disease. An ethnographic study from 2015 showed that the availability of accommodation for migrants was positively linked to migrant access to healthcare (33) .
Discrimination against migrants’ access to employment or healthcare was shown to be a pressing issue in another French study. Discrimination due to a migrant’s country of origin is shown to have consequences for health status not just for immigrants who are newly arrived, but throughout their life course (32).
In a study from Malta the social and economic environment of migrants, the harsh living conditions in open centres and detention homes, have been shown to lead to negative health outcomes (9). Other factors such as limited access to paid work was raised as a concern in the literature that was reviewed. Reference was made to particular sub-Saharan African asylum seekers who seemed especially vulnerable to exploitation and abuse (36). Over 2,000 immigrants in Malta, living in open centres were assessed between August 2010 to June 2011 and the following factors were found to be detrimental to health outcomes: the environment in detention homes including exposure to cold, a lack of space and overcrowding, a lack of activity, poor diet and high levels of stress; together with a lack of systematic and/or preventive medical care and a lack of treatment for infections and diseases. Furthermore, the report emphasizes how the detention context poses additional significant challenges for asylum seekers and migrants with chronic medical conditions, disabilities or mental health problems.
Although these results emphasize the need for stable accommodation available regardless of the migrant’s legal status as a key means of promoting increased health equality for migrants, the studies only reflect findings from France and to some extent Malta, making it difficult to generalise.
Access to healthcare
Evidence of migrants’ access to healthcare is scant. Access to healthcare for refugees, asylum seekers and migrants varies across European countries in terms of regulation and laws (39). Even when legal accessibility is available, differences and inequalities still exist in accessing healthcare (40–43).
Organisational and administrative issues were highlighted as barriers to access healthcare for migrants in studies from Italy and Greece (43). A European report (2016) suggests that there is a lack of institutionalized procedures for taking care of unaccompanied minors leading to frequent breaks in the continuity of care (21).
Undocumented migrants’ access to healthcare is especially problematic (44). Two qualitative studies (21,45) and a narrative review (46) focused on undocumented adult migrants and refugees in different European countries, health needs and access to health services and concluded that healthcare services are underused by undocumented migrants, since these migrants tend to be unaware of their entitlement, and when they receive care, it tends to be inadequate.
Marques (2012) reviewed countries in regard to access to healthcare for undocumented migrants and refugees showing a multi-faceted picture. Even though access to healthcare may be granted by law, as in France, other barriers such as lack of knowledge, administrative requirements, language difficulties, and fear of being reported, as well as discriminatory practices and refusal of care are mentioned as obstacles to accessing care (47).
In the section below, we review communication and information issues and particular factors affecting access to healthcare for migrant women.
Access to maternal health services
Evidence on maternal healthcare focused mainly on specific issues such as female genital circumcision (FGC) (48), the delayed use of maternal health services by certain groups of migrants (49), and inequalities in pregnancy and childbirth (50). FGC was investigated together with prenatal care in refugee women from Syria, Somalia, Libya, Eritrea, Ethiopia, and the Ivory Coast in Malta (48). Obstacles identified in access to healthcare included language barriers, not only within the healthcare setting, but also in using transport to reach healthcare services (48).
Insufficient interpreters and lack of cultural mediators, communication and information barriers were mentioned in two studies (48,50). These obstacles led to women missing important appointments, required medical tests remaining incomplete and women feeling uncomfortable (48). Existing inequalities in childbirth outcomes for migrant women in Europe were evident, and underlined the lack of evidence for planning improved care and access to care (50).
Communication and information issues
Evidence showed a heterogeneous situation in European countries concerning health literacy between migrants and non-migrants (51). A number of studies highlighted under-addressed cultural and communication issues described below (52–55) between migrants and healthcare providers leading to poor health service provision for migrants, governance problems and incoherent distribution of power and responsibility for the provision of healthcare between different actors as reported by an Italian study (56).
A German comparative study looked at migrants from several European countries and demonstrated that migrants make more use of first-aid stations; show predictable communication and understanding difficulties and have different views about health and illness compared to ‘non-migrants’; the results were suggestive of barriers to the use of regular healthcare services among migrants (57).
Two studies showed that lack of information regarding available care options and language barriers were among the factors contributing to migrants’ health vulnerability (58,59). A lack of knowledge concerning specific diseases such as HIV and AIDS and other sexually transmitted diseases was reported by a quantitative study of 600 migrants from “third countries” in Cyprus (59). Factors such as “high cost, lacking awareness of the healthcare system, culturally insensitive services, different perceptions of illness and stigma, as well as limited language skills” were highlighted in a Finnish study among various groups of migrants (Russians, Somalis and Kurds) and were shown to contribute to an increasing perception of unmet needs (60).
A multi-method study in Austria focusing on migrants from Turkey and former Yugoslavia, compared various groups of migrants in terms of their previous experiences with healthcare, showed that different groups of migrants had the same level of health literacy as the general population (61). On the other hand, 455 adult refugees speaking Arabic, Dari, Somali or English were surveyed in Sweden showing that the majority of these refugees had inadequate or limited health literacy, both functional and comprehensive. The study recommended that levels of health literacy should be taken into consideration in activities addressing migrants (62). Another study in Spain also recommended action research as a way to tackle poor health among migrants (63).
Concerning the perceptions of migrants’ own health and unmet health needs, an Italian study among migrants in Spain and Italy shows that perceptions of unmet healthcare needs have increased from 2007 to 2012 among the migrant population in Italy (51). By contrast, in Spain 2012, the native population’s perception of unmet needs also increased.
Migrants’ healthcare use
Under this category we included studies dealing specifically with migrants’ patterns of use of healthcare services. Most of the studies of healthcare use tend to homogenise migrants and compare/oppose them to non-migrants who are also homogenised— e.g. (57,64,65). These studies often highlighted the increased use of emergency room (ER) or acute care provision by migrants compared to non-migrants and the increased likelihood of visiting ER during unsocial hours as well as increased use of obstetrical and gynaecological services among migrant women (57,64,65). At the same time, migrants, especially certain vulnerable groups such as first generation migrant women, are shown to use preventive screening and preventative services less than non-migrants (8,66).
Similarly, a Spanish study with healthcare providers showed a perception that emergency service is the main access route for migrants and reported failures in the continuity of care for immigrant patients. Variations existed, however, among migrants depending on both their country of origin and the level of social integration (67).
A study of how migrants in Greece made use of the healthcare available to them, showed that compared with non-migrant patients, hospitalization rate was lower for chronic conditions but higher for accident-related diagnoses, treatments for infectious disease, and medical conditions related to depression or alcohol use (including: TB, gastritis/gastroenteritis, hepatitis, pneumonia, alcohol-related conditions, poisoning, and allergy) (65).
A study of the utilization of hospital services by the patient’s country of origin in Aragona, Spain showed that foreigners tend to use the public hospital less than the native population. However, this observation is inconclusive since the variation in prevalence of different diseases in immigrants’ countries of origin meant that the reason for using hospitals services varied by country of birth of the immigrants (68).
A review of mainly survey-based evidence of healthcare providers on the use of healthcare services among migrants showed no difference in the use of medical services by migrants compared to the native population. However, differences exist in the use of specialist care where migrants use of this type of care less (69).
A study in Vienna investigated the reasons for a reduced use of professional healthcare services even when needed, focusing on older migrants from Turkey, former Yugoslavia (Bosnia, Serbia), Poland and Iran (70). The study evaluated the relevance of different reasons, from primary structural reasons (poverty, marginalization, discrimination), to a lack of knowledge about the care system, to insufficient ‘transcultural competences’ of the healthcare stuff. The solutions suggested aim at strengthening the “orientation towards the principles of openness, diversity and individuality” of the city of Vienna by recruiting people with migration experience/background as well as transcultural competencies.
Our review found that studies of healthcare use tend to offer simplified pictures of migrants versus locals, where both groups are taken as homogeneous. Such simplification makes it hard to reach a conclusion about the reasons behind the differences in healthcare use — whether socio-economic circumstances, health status, or the system’s lack of transparency and openness to diversity.
Challenges to healthcare provision in transfer countries
Understanding the challenges of providing care for new migrants has had a particular focus in countries such as Greece and Spain that are entry points for arrivals to Europe. The challenge that the refugee crisis posed to national health services in transfer countries was said to have received inadequate media coverage and to be too marginal in public debate (71).
The studies underline the needs of caregivers in transfer countries, in terms of psychological support; additional financial and human resources; training courses. They underline the limited availability of diagnostic equipment, mental care services and an integrated provision of care for new migrants that allows them to easily access different services, including translation and cultural mediation.
A Greek study on “caregivers working in contemporary refugee hotspots” found that caregivers suffer from psychological stresses and sleep disturbances as well as post-traumatic stress syndrome (7% PTSD) (72). Organisational issues faced by healthcare providers in these countries included problems of internal and external communication and coordination, cultural and language differences, inadequate funding, inadequate human resources to treat an overwhelming volume of refugees. Greece in particular was noted as one of the countries dealing with sheer numbers of refugees (73). Other challenges faced by healthcare providers working in the front line in Greece included the limited availability of on-site diagnostic tests, electricity, and running water in camps (74).
A comparative study underlined the challenges faced by Greece, Italy and Slovenia. The study reported on insufficient training courses in transcultural competencies for health and social care professionals in Italy; staff shortages on the islands, lack of interpreters in emergency care departments, and a lack of suitable accommodation for vulnerable populations in Greece. In Slovenia the lack of funding to treat chronic non-communicable diseases was emphasised. In all three countries poor coordination between participating organisations, for example with regards to supplying food and clothing to reception and accommodation centres, was blamed for the gap between demand and supply of goods and services (75).
An increase in migrants’ requests for hospitalization and psychiatric care and deficiencies in the services that should provide mental care was reported by an Italian study (22). In particular, the report referred to how traumatic and tragic experiences (including torture) and post- migration living difficulties contribute to post-traumatic stress disorder (PTSD). Although some special initiatives to address PTSD exist (the Protection System for Refugees and Asylum Seekers for example), the increased demand for support has proven difficult for the Italian State (22). Serious deficiencies in the availability of cultural mediators and of expertise in migrant mental health, combined with the increased demand, placed a severe strain on the Italian provision of mental health services for migrants (76).
The availability and organisation of health assistance for migrants, refugees and asylum seekers through civil society organisations varies across European member states. The already mentioned qualitative report comparing Italy, Greece and Slovenia (74) shows that the services are centrally administered in Greece and Slovenia compared to Italy’s regional organisation. Healthcare services for migrants, refugees and asylum seekers in Italy have been provided mainly by health professionals appointed by the ministry of health while in Greece, non-voluntary organisations (NGOs) have been playing a big part in providing healthcare. Slovenia has state-appointed health professionals undertaking the work alongside NGOs (75). The creation of a Refugees’ Health Unit in Greece offered the opportunity for healthcare providers working with a translator or cultural mediator (77). In Spain, an Intercultural Mediation Programme for women mostly treated reproductive problems among Latin American women. The programme provided information, education and facilitated access to reproductive health services (78). These last two examples suggest that integrated provision of care, whereby migrants can access a range of services, together with translation and cultural mediation as appropriate may represent a form of good practice.
According to the sources overviewed, transfer countries appear to face specific problems in the provision of healthcare for migrants and refugees, to a higher degree. Lack of money and of trained and stable human resources, organisational malfunctioning and poor coordination among the actors are all mentioned as factors hindering the provision of healthcare for migrants and refugees.