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date: 15 December 2017

Health Status of Refugees and Asylum Seekers in Europe

Summary and Keywords

The health status of refugees and asylum seekers varies significantly across the European region. Differences are attributed to the political nature of the legal categories of “asylum seeker” and “refugee”; the wide disparities in national health services; and the diversity in individual characteristics of this population including age, gender, socioeconomic background, country of origin, ethnicity, language proficiency, migration trajectory, and legal status. Refugees are considered to be at risk of being or becoming relatively “unhealthy migrants” compared to those migrating on the basis of economic motives, who are characterized by the “healthy migrant effect.” Refugees and asylum seekers are at risk to the drivers of declining health associated with settlement such as poor diet and housing. Restricted access to health care whether from legal, economic, cultural, or language barriers is another likely cause of declining health status. There is also evidence to suggest that the “embodiment” of the experience of exclusion and marginalization that refugee and asylum seekers face in countries of resettlement significantly drives decrements in the health status of this population.

Keywords: refugee, asylum seeker, health status, Europe, integration

Introduction

Migrants who are refugees and/or are seeking asylum—whether currently or intending to do so at some point in the future—are a group whose definition is politically and administratively sensitive. The identities reflected in the terminology of “asylum seeker” and “refugee” are heterogeneous, dynamic, and regularly contested, not least because they have important political implications, including around access to health care (Zetter, 1991). The globalization of migration (mixed migration flows, transnational social transformations) has seen government interests bearing down on the categorization of who qualifies as a refugee and who has the right to seek asylum. Western European governments’ interests in fractioning out undeserving “labour migrants” from so-called genuine refugees during the Mediterranean refugee crisis of 20151 heightened the political salience of these categorizations. A shift in the process of labeling refugees has been informed by the interests of the nation-state in controlling in-migration (Zetter, 2007) rather than, for instance, the interests of migrants in gaining access to appropriate and equitable health care.

The term “forced migration” (covering internally and internationally displaced people) emphasizes the health vulnerabilities involved with weak protection and poor access to service provision (Ager, 2014). While refugees are formally owed protection by the country of asylum under international convention and these obligations formally grant access to health services, in practice, these rights may be routinely denied. The state is the key duty bearer with regard to the health needs of forced migrants in countries of reception, whereas natural disasters and conflicts usually imply an international humanitarian response within the sending and transit context. Delays in refugees and asylum seekers receiving care may reflect local implementation rather than problematic national policies of provision (Ager, 2014). For refugees who do not or cannot declare themselves to the statutory authority, fear of detection may prevent them from seeking access to health services.

The rights of migrants to seek asylum vary across Europe. Certain countries refuse specific groups defined by country of origin or ethnic group to claim asylum. Furthermore, the political will to support refugees, including in providing appropriate health services, varies with some governments notably disengaged. The politically contentious and labile nature of “refugee” and “asylum seeker” as legal and administrative categories adversely impacts people’s ability and will to access health services. Migrants’ legal status is regularly contested, including the right to claim asylum and, furthermore, individuals move between categories, for instance a refugee may become a labor migrant and then an undocumented migrant, and often these changes occur without the migrant’s cognizance. Given the uncertainty in distinguishing between refugees and asylum seekers, it is not surprising that there is little research that systematically seeks differences in disease prevalence between them (Gerritsen et al., 2006). Refugees and asylum seekers are not disaggregated in this article, except where expressly stated.

Refugee and Asylum Seeker Health Status and Access to Health Care

Formal access to health care for refugees and asylum seekers varies across the countries of Europe; however little research has been undertaken that focuses on whether asylum seekers and refugees suffer worse health than other sections of the population. The available research suggests that refugees have poorer health status but there are significant differences among and between refugees, not least between nationalities, legal status route, and education (van den Heuevel, 1998; Wangdahl, Lytsy, Martensson, & Westerling, 2014). For example, no overall difference in self-reported use of health services was found between refugees and asylum seekers in The Netherlands. However, disaggregating by country of origin did show significant patterns, with refugees and asylum seekers from Somalia reporting less contact with a general practitioner, and less use of mental health services and of medication than those from Afghanistan and Iran (Gerritsen et al., 2006).

Assumed Poor Health and Barriers to Accessing Care

The main health problems affecting asylum seekers and refugees (malnutrition, mental distress, infectious diseases) are attributed to living in refugee camps or to making perilous journeys over long distances (Clinton-Davis & Fassil, 1992). However, the majority of research that addresses refugee health status assumes from the outset that asylum seekers and refugees have worse mental and physical health compared to other sections of the population. Problems identified as affecting refugees and asylum seekers include tuberculosis; HIV/AIDS; hepatitis A and B; parasitic diseases; nonspecific body pains and mental distress, particularly depression and Post-Traumatic Stress Disorder, due to traumatic experiences, including torture. Furthermore, it is assumed that refugees and asylum seekers encounter specific “barriers” to accessing health care.

The following barriers are identified as hindering health care access for asylum seekers and refugees with negative effects for health status (UN High Commissioner for Refugees (UNHCR), 2007; World Health Organization, 2010):

  • Legal

  • Language and the provision of interpreting services

  • Cultural

  • Lack of knowledge of the health system

  • The connection between health and immigration policy and practice

  • Financial

  • Bureaucracy

  • Confusion about entitlement

  • Recentness of arrival

Influences on the capacity of a health system to make health care available to refugees and asylum seekers include the size of the migrant population in a local area, the number of refugees, the proximity to a frontier to Europe or another frontier that people wish to cross, the development of health infrastructure, and the state capacity to fund health care for the general population (Mladovsky, Ingleby, & Rechel, 2012; UN High Commissioner for Refugees (UNHCR), 2007; World Health Organization, 2010).

Even with a system that has the capacity to provide health care and an individual’s legal entitlement to care, access is not guaranteed. While program refugees who are formally resettled may fare better, there are a number of impediments for refugees and asylum seekers (IOM, 2009). A lack of language provision, cultural competency, and clear guidance on entitlements conspire with bureaucratic barriers to impede access (Collantes, 2010; Joshi et al., 2013). Where asylum seekers and refugees are entitled to care, it is much easier to access that care through a so-called Beveridge system (such as the United Kingdom and most of Scandinavia) where facilities are state owned and no fees or limited, set fees are charged, compared to the Bismark model (such as Germany, France, Belgium, The Netherlands), which is based on social insurance. RegiGovernment Legislation and Policystration for social insurance is particularly problematic for new arrivals and those with uncertain legal status, which prevents timely access to appropriate health care and therefore risks damaging health status (Collantes, 2010).

Refugees and asylum seekers in Europe have no particular exposure to infectious agents, except through an association with poverty (Jakab, 2017). Nonetheless, barriers to accessing care for acute conditions and infectious disease can have a short-term and detrimental effect on health status. Less evident is the effect of a lack of access to preventative and occupational health services, as well as advice and health promotion, which is rarely addressed in research with refugees and asylum seekers. While the ill effects of non-communicable disease and chronic conditions manifest themselves slowly, the damage to health status is nonetheless important, both for the individual affected and for the planning of services (WHO, 2015b).

Assessing Health Care via Primary Services

Primary care is where referral to a wide range of services tends to take place and so is key to both health care access and to improved health status among refugees and asylum seekers. Refugees’ access to primary health care in resettlement countries has been measurably improved by employing multidisciplinary staff, interpreters and bilingual staff, having no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers (Joshi et al., 2013). Refugees’ health status was improved through increased access to general practice across a range of resettlement countries by means of practical support for patients to register, make appointments, attend services, and through the use of interpreters to ensure clear explanations about unfamiliar clinical processes and treatments, as well as timely management (Cheng, Drillich, & Schattner, 2015).

A range of factors, including those in wider society beyond the medical system may influence the health status of refugees and asylum seekers. By using refugee children’s receipt of drug therapy as a marker for access to primary health care, refugee children were shown to be more likely to receive prescribed medicines and less likely to receive “over the counter” medicines compared with British children (Alkahtani et al., 2014). Refugees and asylum seekers may have different expectations of health care provision that do not necessarily coincide with those of local care providers (O’Donnell, Higgins, Chauhan, & Mullen, 2007).

Linguistic and cultural translation including health advocacy for individual asylum seekers and refugees is important for facilitating access to primary and other care and therefore crucial to asylum seekers’ and refugees’ health status (Fatahi, Nordholm, Mattsson, & Hellström, 2010; Novak-Zezula, Schulze, Karl-Trummer, Krajic, & Pelikan, 2005; Ochieng, 2013). Good clinical communication in terms of adequate language concordance is significantly associated with higher reporting of past experience of traumatic events and of severe psychological symptoms by asylum seekers in Geneva. By contrast, inadequate language concordance is associated with decreased symptom reporting and fewer referrals to psychological and secondary care (Bischoff et al., 2003). Increased cultural awareness and sensitivity facilitates communication, management, and compliance in cross-cultural consultations (Ochieng, 2013; Papadopoulos, Lees, Lay, & Gebrehiwot, 2004). However, research consistently highlights that professional interpretation is not routinely provided, especially in emergency consultations and where small numbers of a range of linguistic groups are being treated such that family members, including children, are regularly relied upon, despite well-rehearsed ethical dilemmas (Bischoff, 2006).

Calls for “culturally competent services” or “cultural sensitivity” (Burnett & Peel, 2001; Joshi et al., 2013; Ochieng, 2013) are common in health care research focusing on asylum seekers and refugees to improve health outcomes, but discussion of what this might mean in concrete terms is rarer (Bhatia & Wallace, 2007; O’Donnell et al., 2008). “Cultural competence” has been defined as comprising a trusting relationship (Feldman, 2006; Helberg-Proctor, Meershoek, Krumeich, & Horstman, 2015) and the ability to explain the host country’s system of health care (Suurmond, Seeleman, Rupp, Goosen, & Stronks, 2010). A broader conceptualization of cultural competence includes knowledge of the political situation in the country of origin, knowledge of how refugee status influences health, specific knowledge with regard to diseases common in the countries of origin, awareness of the juridical context, and specific skills in asking delicate questions about traumatic events (Suurmond et al., 2013). However, where a clinical setting treats people from dozens of different linguistic group and national origins, having such a comprehensive grasp of each background and current context may be an unreasonable expectation (Phillimore, 2015).

Calls for health systems to incorporate the needs of migrants at a range of levels, including finance, policy, planning, commissioning, provision, implementation, and evaluation, suggest that health services can become “migrant sensitive” (Fortier, 2010). Such systems-based approaches could help to avoid blaming migrants’ for their “special” needs, which are seen as differing from those of the general population.

Government Legislation and Policy

Government legislation and policies of access for different categories of asylum seeker and refugee differ across Europe, particularly with regard to screening (Norredam, Mygind, & Krasnik, 2006). Even where policies for accessibility exist, practice often depends on the individual healthcare professional (Hargreaves, Holmes, & Friedland, 1999). Denying failed asylum seekers access to free secondary care and the proposed extension of this denial to non-urgent primary care in the United Kingdom have been termed unethical and found to put greater pressure on already overburdened emergency services (Hargreaves et al., 1999; Williams, 2004). In Sweden “care that cannot wait” as well as acute care is covered for asylum seekers, but the interpretation of the types of care that cannot wait is left to the individual clinician.

Dispersal policies and forced internal movement of asylum seekers have been associated with increased rates of temporary GP registration (Hargreaves et al., 1999; Jones & Gill, 1998) and migrants’ necessarily limited understanding of the health system (Redman, Reay, Jones, & Roberts, 2011). In Ireland, the relocation of asylum seekers caused anxiety and stress for practitioners and asylum seekers alike, with insufficient time to plan and prepare appropriate primary care such that new arrivals were seen to put a significant strain on services (Pieper, Clerkin, & MacFarlane, 2011). Relocation means that refugees and asylum seekers arrive in places where appropriate services have not been developed, potentially impeding access due to a lack of interpreters or refugee community support groups (Bronstein & Montgomery, 2011; Creighton, Sethi, Edwards, & Miller, 2004; Hogan, 1999). Non-governmental organizations have established clinics for vulnerable migrants who have difficulty accessing primary care, but their ability to provide continuity of care, refer to secondary care, and use local resources are all uncertain (Hardy, 2006).

The coordination of different service providers to respond to the social needs of refugees and asylum seekers, ensuring that services are affordable, appropriate, and acceptable through case management by specialist workers (Joshi et al., 2013) is crucial to promoting good health, but unusual in practice. Despite a wider emphasis on patient and public involvement in health care provision, few studies offer refugees’ perspectives (Bischoff et al., 2003; McCrone et al., 2005) on services, let alone explore their own conception of what constitutes “good health” (Papadopoulos et al., 2004).

Although research tends to assume that asylum seekers and refugees have specific and elevated health needs, there is no systematic evidence to show this and the existing evidence is often inappropriately generalized to other settings and other groups. There is a presumption that particular barriers exist that prevent the uptake of health care services, implying that access is the only problem, rather than a wider issue of the configuration of services. Primary health care as the access point for referral to other services makes this a crucial site for appropriate linguistic and cultural interpretation. Such interpretation needs to take into account the configuration of the local health care system and providers’ expectations as well as the expectations and skills of migrants seeking care.

A longitudinal multiple case study highlighted how “taken for granted” communication created a barrier to understanding with a strong influence on health outcomes for refugees and asylum seekers such that staff self-awareness was said to be of “paramount importance” (Briscoe & Lavende, 2009). To promote more effective communication and service utilization, Shim proposes a concept of cultural health capital (2010), to indicate a combination of cultural skills, communication competencies, behaviors, and interactional styles that have to be developed by both patient and professional. Health systems often operate under the assumption that refugees and asylum seekers have these skills (Briscoe & Lavende, 2009; Phillimore, 2015), regardless of evidence to the contrary.

The Mediterranean “Refugee Crisis”

In 2015, Europe experienced a shift in the magnitude and nature of migration due to unrest in the Middle East, particularly Syria. In light of these changes the World Health Organization prepared a common framework for coordinated action on refugee and migrant health entitled “Stepping Up Action on Refugee and Migrant Health” (WHO, 2015). In addition to reiterating previous calls for “migrant sensitive” health systems this document also states that migrants and refugees do not pose an additional health security threat to host communities; appropriate immunization programs for refugees, asylum seekers, and other migrants should be ensured and systems should be set in place for health data and records to be made easily available, as appropriate, as an individual moves within and beyond Europe. This document was supplemented by a “Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region” in 2016, which provides the framework for a national and international response to the health needs of refugees and migrant populations. The strategy refers to countries of transit and destination addressing both short- and long-term public health aspects (WHO, 2016).

Refugee and Asylum Seekers’ Understanding of Health and Expectations of Health Care

Refugees’ ideas about health care depend on their personal characteristics, particularly their level of educational attainment (Zepinic, Bogic, & Priebe, 2012). For example, in Norway Tamil refugees’ conceptions of pain were such that they could not find appropriate care that suited their needs due to the particular structure of the welfare and health services (Grønseth, 2011; Papadopoulos et al., 2004). Ethiopian refugees in the United Kingdom reported that happiness was a prerequisite for and also an indication of healthiness (Papadopoulos et al., 2004), and Somalis in Sweden reported conceptions of health as deeply connected to experiences of life in exile (Svenberg, Skott, & Lepp, 2011). Where refugees experience poverty and social isolation, neither happiness nor health may be achievable in their own terms. Qualitative evidence indicates complex understandings of health and describes the pathways through which asylum seekers and refugees try to solve health problems (Bhatia & Wallace, 2007) thereby foregrounding their agency and ingenuity.

Refugees and asylum seekers have complex conceptualizations of health and its connection with the context of wider life, both before and after migration. The socioeconomic and legal context of people’s lives is not well researched and there is emergent evidence that legal barriers to accessing services and structural effects marginalize and isolate those seeking asylum. The simplistic focus on “barriers” to health care implies a failure of the refugees to overcome impediments, rather than a limitation of the health care system itself in the specifics of its design or the role of health care providers’ expectations.

The evidence regarding the health status and access to services of refugees and asylum seekers is fragmentary and presumes their extra health care needs and poor health status. Specific illnesses and conditions among refugees and asylum seekers have not attracted much research interest, particularly non-communicable diseases and occupational health. Refugees and asylum seekers’ maternal health and mental health are exceptions to this rule, with a greater concentration of research that is reviewed in the next two sections.

Maternal Health

Unlike other areas of research, studies focusing on access to and service uptake of maternal health care for asylum seekers and refugees, examines outcomes as well as behaviors, perceptions and understandings.

Immigrant women have a higher risk of low birth weight, preterm delivery, perinatal mortality, and congenital malformations, even after adjustment for age at delivery and parity. Crucially, the risk of poor birth outcomes has been clearly and significantly reduced in countries with a strong integration policy (Belgium, Denmark, Netherlands, Norway, and Sweden), judged on the basis of an analysis of naturalization rates (Bollini, Pampallona, Wanner, & Kupelnick, 2009). Although this research does not disaggregate by migration status, it indicates that refugee and asylum seeking women may be disadvantaged across these outcomes. An inquiry in the United Kingdom highlighted that 12% of all maternal deaths were refugees and asylum seekers, despite these making up just 0.3% of the population in the United Kingdom at that time (Phillimore, 2015).

Research is inconclusive regarding the effect of migrant status on birth outcomes. One study suggests that immigrant women have consistently poorer perinatal health than non-immigrant women (Gagnon, Zimbeck, & Zeitlin, 2009). While not disaggregating between asylum seekers and refugees from other categories of migrant, Asian, North African and sub-Saharan African migrants are considered to be at greater risk of feto-infant mortality and Asian and sub-Saharan African migrants were at greater risk of preterm birth.

There is no evidence that sub-Saharan African women who have been resettled in “developed countries” are “at high risk of pregnancy complication, based on concurrent disease and unusual medical conditions.” Rather language and communication difficulties, limited economic resources (more relevant in countries without free health care), limited health understanding and limited knowledge of services, all compounded by unsympathetic service providers have been highlighted as influential (Carolan, 2010). Research has indicated that language and communication problems, inequalities due to combinations of legal status and the associated restrictions in rights and entitlements, a lack of understanding of the health system, isolation, and discrimination are all relevant to understanding pregnant migrant women’s perspectives (Phillimore, 2015).

Structures of entitlement in the receiving country, rather than women’s behavior or experiences were found to be most relevant when determining birth outcomes. For example, migrant women in Ireland were impeded from attending antenatal care due to a lack of language support; travel; childcare; an accompanying partner or friend; and/or due to their own poor health, exhaustion, and stress (Kennedy & Murphy-Lawless, 2003). Differences were found between “program refugees” from Kosovo and those who had sought asylum upon arrival in Ireland. The widespread reporting of the war in Kosovo meant that these refugees were seen as victims, thereby escaping from a sense of disapproval, while benefiting from secure accommodation, autonomy over their lives in relation to privacy and provision of their own food. Furthermore, program refugee women had individual access to translators and were accompanied to all antenatal and hospital visits, often by taxi, at the expense of the state. These provisions went some way to mitigating the anxiety and uncertainty common to all the refugee and asylum seeking women studied. This highlights the need to disaggregate not only between refugees and asylum seekers, but also the different routes to becoming a refugee as significant to health outcomes.

Postpartum depression may affect up to 42% of migrant women, compared to 10–15% of native-born women, an elevated risk attributed to stressful life events and a lack of social support and “cultural factors,” described as specific practices offering strong postnatal nurturing whose absence led to social isolation (Collins, Zimmerman, & Howard, 2011). Asylum seeking women may hesitate in disclosing symptoms associated with psychological problems for fear of jeopardizing their asylum application (McLeish, 2005, quoted in Collins et al., 2011).

A retrospective analysis of 271 immigrant women with confirmed refugee status who delivered in the National Maternity Hospital in Dublin between June 1999 and May 2000 found no differences in the gestational age at delivery, incidence of caesarean section and birth weight compared with the wider hospital population but three times the number of perinatal deaths (Lalchandani, MacQuillan, & Sheil, 2001). Seven patients (3%) tested positive for Human Immunodeficiency Virus (HIV) and two (0.8%) were diagnosed with active tuberculosis with the majority (80%) living in emergency accommodation, suggesting this population had a combination of obstetric, medical, and social problems that adversely affected their health status.

Somali Women’s Maternal and Other Health

Somali-born women’s maternal health and, in particular, the role of female circumcision, has featured in a disproportionately large number of research papers that have arguably skewed the public health agenda for refugee women in Northern Europe. The largest national study to address Somali women’s use of maternity health services utilized a retrospective, case-controlled comparison of 523 Swedish-born women with 262 Somali-born women. Somali-born women were found to book later, to make fewer visits for antenatal care, were more likely to have anemia, and a few had “very serious health conditions.” Perinatal mortality and small-for-date infants were more prevalent among the Somali-born women (Råssjö et al., 2013).

However, a meta-analysis of routinely collected data from six countries (Australia, Belgium, Canada, Finland, Norway, and Sweden) found Somali-born women were less likely to have preterm infants; or to have infants of low birth weight compared to non-immigrant women. By contrast, the analysis of 10,431 Somali-born women and 2,168,891 non-immigrant women found that Somali-born women were more likely to have caesarean sections and stillbirths (Small et al., 2008). These disparities are not readily explained but nonetheless point to problems within the provision of maternity care.

A comprehensive review of the policies on Female Genital Cutting (FGC, also known as Female Genital Mutilation FGM) throughout European Union member states concludes that the training of health professionals is crucial together with “community education” and “culturally sensitive health services” (Powell, Leye, Jayakody, Mwangi-Powell, & Morison, 2004). The review assumes FGM is a crucial consideration for women’s gynecological and obstetric health, citing long-term complications, including recurrent urinary tract infections and problems with menstruation, sexual intercourse, pregnancy, and childbirth.

However, there has been no conclusive evidence to support the conclusion that there is a relationship between female circumcision and perinatal death (Essen, 2002). Obstructed or prolonged labor, caused by scar tissues from circumcision did not have any impact on the number of perinatal deaths, suggesting that other factors contribute to perinatal death among circumcised women. Swedish research suggests that the most common factors for perinatal death were delay in seeking health care; refusal of caesarean sections; insufficient surveillance of intrauterine growth restriction; inadequate medication, misinterpretation of cardiography, poor interpersonal miscommunication (Essen et al., 2002); and the underreporting of sexual violence (Byrskog, Olsson, Essen, & Allvin, 2015).

Language and communication difficulties are regularly highlighted as problematic with regard to pregnant Somali women’s health status across different settings, including the provision of care for women seeking asylum in Switzerland (Kurth, Jaeger, Zemp, Tschudin, & Bischoff, 2010) and the United Kingdom (Bulman & McCourt, 2002; Davies & Bath, 2001; Phillimore, 2015). Byrskog and colleagues (2015) examined antenatal-care midwives working with Somali women who may have encountered sexual violence. Language skills were found to be critical for Somali-born women to understand their rights and access support in the Swedish health care system. An acute fear around misinterpretation and compromised confidentiality limited the usefulness of interpreters and led to Somali women’s perception that they were denied information due to punitive attitudes and health professionals’ prejudiced views. Eritrean women expressed fear that health care professionals would disapprove of FGM (Lundberg & Gerezgiher, 2008), which, together with a lack of support in Sweden, led to feelings of isolation and loneliness compared to previous countries of residence where new mothers were well supported by friends and family. Another Swedish study demonstrates low reliability of self-reported forms of FGM with implications for research, interventions, and health care (Litorp, Franck, & Almroth, 2008).

A focus on gender rather than cultural difference showed how Somali parents experience difficulties adapting to Swedish models of parenthood, indicating the influence of receiving countries’ ideals surrounding parenthood for refugees’ and asylum seekers’ health and well-being. Communication and language barriers were the main concern. This study also included the importance of Somalia’s oral culture, which is not recognized in the other literature that addresses communication barriers (Wiklund, Aden, Högberg, Wikman, & Dahlgren, 2000).

Somali women’s maternity care (and particularly the impact of FGM) receives disproportionate attention in research that does not always disaggregate between different types of migrant. Strong integration policies seem to reduce immigrant women’s health risk, but poor outcomes are not uniformly elevated among refugees and asylum seekers, including those who had experienced FGM. Legal status, including the refugee route, was important for determining the resources that women had available. Communication and language are regularly indicated as important, including staff assumptions about refugee and asylum seeking women. The focus on FGM and on Somali women’s maternity care, particularly in Nordic countries, is anomalous, fails to reflect the needs of the wider group of refugees, and does not always account for women’s own health priorities. The disproportionate resources devoted to researching FGC or FGM contributes to the construction of Somali women as the epitome of vulnerable refugees in need of special care. Arguably this focus has more to do with health care practitioners’ anxieties than the women themselves.

Mental Health

The mental health of refugees and asylum seekers has gained particular focus in research on the health status of this population in Europe. Mental health care provided by national and international organizations has been criticized for the application of Western psychiatric categories in ways that ignore the social, political, and economic factors that influence refugees’ experience (Summerfield, 2001; Watters, 2001) and a tendency to identify external stressors rooted in pre-resettlement experiences (Watters, 2001, 2002; Watters & Ingleby, 2004). The portrayal of refugees as “passive victims” of mental health problems ignores their resilience to withstand significant stresses (Eastmond, 1998; Muecke, 1992). Research has begun to address refugees’ post-flight environments (Blight, Ekblad, Persson, & Ekberg, 2006; Craig, Jajua, & Warfa, 2009; Silove, Steel, & Watters, 2000) and to account for refugees’ own experiences and expressed needs addressing the broader social policy context rather than specific mental health provision (Watters, 2001).

In Southern and Eastern European countries, there are no specialist mental health services (Watters, 2002), while in countries where asylum seekers are held in accommodation centers services may be delivered outside mainstream health care (Germany and The Netherlands). In countries with dispersal policies (such as the United Kingdom), there are challenges in terms of access to, and appropriateness of, mainstream services (Watters & Ingleby, 2004).

An extended asylum procedure is associated with increased psychiatric disorder, but the evidence is patchy and limited. A national community-based study used random sampling to compare two groups of Iraqi asylum seekers who had resided in The Netherlands for fewer than six months and for more than two years (Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004). Overall prevalence of psychiatric disorders was higher in the second group, as were the prevalence rates of anxiety, depressive, somatoform disorders, and post-traumatic stress disorder (PTSD). Logistic regression of all relevant risk factors, showed extended duration of asylum procedure to be an important risk factor for psychiatric problems. Asylum seekers have been found to have higher rates of attempted suicide when compared to other sectors of the resident population. In Denmark, suicidal reactions were associated with long waiting times (more than 20 months) and rejection of the asylum application (Robjant, Hassan, & Katona, 2009).

The experience of detention also influences the health status of refugees and asylum seekers. A systematic review of mental health outcomes for adult, child, and adolescent immigration detainees found that anxiety, depression and PTSD, self-harm, and suicidal ideation were commonly reported, with time in detention positively associated with severity of distress and longitudinal results showing the persistence of the negative impact of detention (Robjant et al., 2009). Limited data suggests that compared to the U.K. prison population, there are higher levels of self-harm and suicide among detained asylum seekers, which is also higher than that among asylum seekers in the community (Cohen, 2008).

The diagnosis and treatment that refugees and asylum seekers receive for mental health problems varies across Europe and by country, making any assessment regarding the prevalence of problems highly problematic. For example a cross-sectional study of 43,403 refugees compared with Swedish-born residents demonstrated refugees to have much lower rates of dispensed psychotropic drugs (Brendler-Lindqvist, Norredam, & Hjern, 2014). While the rate increased with longer duration of residence, highly divergent rates of dispensed drugs by nationality pertained nonetheless, where refugees from Afghanistan were four times more likely to received antidepressants than those from the Horn of Africa. Refugees may have psychiatric disorders but are not necessarily receiving treatment. For example, Gernaat and colleagues (2002) found the prevalence of psychiatric disorders among adult Afghan refugees to be significantly higher than among the general population of The Netherlands, yet only 4% of them were receiving psychiatric treatment.

Research addressing adult refugees in the European Union and other Western countries found deficiencies in the identification and treatment of trauma, arguing that screening is often used to reduce threats to public health or to mitigate potential impacts on health services rather than to enhance the individual’s health (Blight, Ekblad, Lindencrona, & Shahnavaz, 2009). Craig, Mac Jajua, and Warfa (2009) suggest that the difference in reported rates of refugees’ mental health problems across countries reflects variations in how easily migrants from different countries can integrate with the host population and find employment. When asylum seekers and refugees were disaggregated, one Irish study found that asylum seekers have a higher level of self-reported PTSD and depression/anxiety symptoms compared to refugees, with asylum seekers using GP services more often, but not mental health services (Toar, O’Brien, & Fahey 2009).

Prevalence of Mental Health Problems in Refugee and Asylum Seeking Populations

Despite the fragmentary evidence base, mental disorders are clearly a significant issue for refugees and asylum seekers and attempts have been made to establish prevalence rates. A systematic review of 20 psychiatric surveys based on selected refugee populations gathered results for 6,743 adults from seven countries and five surveys of 260 refugee children from three countries identified a probable 10-fold increase in PTSD prevalence (Fazel et al., 2012). Among studies of children, a prevalence of 11% was identified for PTSD, with 9% diagnosed for adults. Four percent of adults were diagnosed with generalized anxiety disorder and 5% with major depression. These rates are lower than those reported in some studies. Over three years (Lie, 2002) followed 240 settled refugees in Norway and found severe and chronic mental health problems that were associated with previous trauma, unemployment, and unresolved family reunion in Norway. A meta-analysis showed a higher prevalence of mental distress among refugees compared with that of non-refugees (Porter & Haslam, 2005) with PTSD and common mental disorders the most common mental health problems among refugees (Fazel, Wheeler, & Danesh, 2005).

A random sample of adult refugees and asylum seekers from Afghanistan, Iran, and Somalia in The Netherlands found half of the respondents suffering from more than one chronic condition. More asylum seekers than refugees had PTSD symptoms and depression. Respondents from Afghanistan and Iran had a higher risk of PTSD and depression. Other risk factors included female gender, older age, experience of traumatic events, less social support, and more post-migration stress (Gerritsen et al., 2006).

The impact of torture and past trauma on the current mental health of refugees has begun to be explored. Hermansson, Timpka, and Thyberg (2003) examined the long-term impact of torture on 44 war-wounded refugees in Sweden: 22 had suffered torture and 22 had not. No significant differences in mental health between the two groups were found. The strongest associations with poorer mental health were higher education in the tortured group and unemployment in the non-tortured group. However, these associations did not hold for a group of tortured and non-tortured new arrivals to Denmark (Masmas et al., 2008). Among asylum seekers that were newly arrived in Denmark from 33 different countries in Denmark, those who had suffered torture were two to three times as likely to have mental health problems when compared to those who had not been tortured. Five to 10% of asylum seekers who had not been tortured, compared to 30–40% of torture survivors suffered depression and anxiety (Masmas et al., 2008).

A number of longitudinal studies have been undertaken to explore the relationship between mental health and prolonged exposure to new resettlement environments. Roth and Ekblad (2006) studied symptoms of depression in a sample of adults mass-evacuated from Kosovo, using a prospective design with a baseline study and follow-ups at three months and six months in Sweden, with an additional follow-up after one and one-half years in both Sweden and Kosovo. Depression scores increased and those who remained in Sweden became significantly more depressed than those who were repatriated.

Refugees’ mental distress decades after resettlement point to risk factors that are attributed to new environments (Gorst-Unsworth & Goldenberg, 1998; Hauff & Vaglum, 1997; Porter & Haslam, 2005). Stressors in the post-migration environment are part of the wider social determinants of health including poverty, racism, acculturation stress, language problems, and loss of family and friends (Blight et al., 2009). Other stressors are related to legal asylum procedure, dispersal policies, detention, family separation, exclusion from work, and life under threat of deportation and detention. Lindencrona, Ekblad, and Hauff (2008) identified four dimensions of resettlement stress among Middle Eastern refugees who had been granted permanent residency in Sweden including social and economic strain, alienation, discrimination and status loss, and violence and threats in Sweden.

Structural conditions in receiving societies have been shown to have adverse consequences for refugees’ mental well-being. Warfa and colleagues (2012) suggest that access to labor markets for refugees may promote opportunities for better integration and mental well-being. In The Netherlands starting up or intensifying existing drug use in the asylum system is related to boredom, depression, and feelings of helplessness, which may be particularly acute in countries where asylum seekers are not allowed to work (Dupont, Kaplan, Verbraeck, Braam, & van de Wijngaart, 2005).

The mental health needs of children should not be treated as a simple extension of adult refugee and asylum seekers’ needs. Exposure to violence prior to migration is the most common risk factor for children and adolescents who are forcibly displaced to high-income countries (Fazel, Reed, Panter-Brick, & Stein, 2012). Other risks include being female, unaccompanied, a perception of discrimination, exposure to post-migration violence, several changes of residence in host country, parental exposure to violence, poor financial support, single parenthood, and parental psychiatric problems. Stable settlement and social support in the receiving country have the most positive effect on the child’s psychological functioning, with self-reported positive school experience and same ethnic-origin foster care also protective factors.

Young refugees have been found to have a high prevalence of anxiety, sleep disturbance, and depressed mood on arrival, with severity reducing over time in exile (Montgomery, 2011). School participation, friends, language proficiency, and mother’s education predicted fewer long-term psychological problems. Refugee children from former Yugoslavian countries showed a range of stress-related reactions including eating disorders, separation fears, and withdrawal or aggression (Ajduković & Ajduković, 1993). Children exhibited a significantly higher incidence of stress reactions if their mothers also had difficulty coping with the stress of displacement, with children in collective shelters at greater health risk than their peers housed with host families. Mothers’ emotional well-being predicted that of the children and current life circumstances in the receiving country were of equal or greater importance than previous exposure to organized violence (Almqvist & Broberg, 1999). For refugee children living in London with at least one parent, PTSD was significantly associated with pre-migration experience whereas higher depression scores were associated with insecure asylum status and severe financial difficulties (Heptinstall, Sethna, & Taylor, 2004).

Unaccompanied asylum seeking children are at a higher risk of mental illness than those who have one or more parents. Following 582 unaccompanied minors over 12 months, Bean, Eurelings-Bontekoe, and Spinhoven (2007) found severe and stable self-reported psychological distress. Unaccompanied minors are often treated solely as “refugees” rather than taking account of their psychological characteristics as children (Derluyn & Broekaert, 2008). Refugee adolescents separated from both parents experienced the highest number of traumatic events and were more likely to develop severe mental health problems when compared to accompanied refugee adolescents (Derluyn & Broekaert, 2008; Sourander, 1998). Analysis of all admissions in 2001 at the Child and Adolescent Psychiatry emergency unit in Malmö, Sweden, found that unaccompanied refugee minors were overrepresented in inpatient psychiatric care (Ramel, Taljemark, Lindgren, & Johansson, 2015).

In summary, referrals for mental disorders have been positively associated with length of stay in asylum centers across all categories of psychiatric illness and for a majority of national groups of asylum seekers (Hallas, Hansen, Stæhr, Munk-Andersen, & Jorgensen, 2007; Steel et al., 2006). There is little accurate information about the prevalence of illicit drug and alcohol abuse and substance dependency among refugee populations, even though refugees are at a greater risk of exposure to relevant risk factors such as being concentrated in poorer areas of cities and high rates of unemployment (although this work has been undertaken for “migrants” in general; see Bhugra, 2004; Lindert, Schouler-Ocak, Heinz, & Priebe, 2008). Similarly, more accurate data collection regarding rates of self-harm, mental disorder, and suicide in asylum seeking and refugee populations is called for (Cohen, 2008). There is little literature that addresses disability, although one study suggests that Bosnian refugees in Croatia who reported symptoms of depression and PTSD were associated with an increased risk for disability independent of the effects of age, trauma, and health status (Mollica, McInnes, Sarajlić, Sarajlić, & Massagli, 1999).

Evidence suggests higher rates of mental illness among refugees, particularly those who have experienced an extended process of asylum seeking that has involved detention, social isolation, and poverty. While post-traumatic stress disorder, depression, and anxiety rates seem to be linked with trauma before migration, the evidence is neither systematic nor consistent. The conditions of life post-migration are also important, with social integration and socioeconomic security key protective factors against mental health problems. Refugees’ exposure to severe traumatic events is given as an explanation for higher prevalence of mental disorder, yet research has shown that the resettlement processes is also an important influence. The range of refugee and asylum seeker access to mental health services reflects European variation in the organization of general practice, within and between nations. It may also reflect a lack of national, European, or international strategy in the health care management of refugees.

Conclusion

The migration and health literature is extensive but the heterogeneity of study designs and variation in the ways that different types of migrant groups are sampled limits the conclusions that can be drawn. Consolidating and harmonizing health datasets would go some way to closing this gap in data (Norredam, Mygind, & Krasnik 2006). Although access to health has been widely addressed, health outcomes and health status are not widely addressed in the literature beyond birth outcomes and measures of mental distress. There is limited evidence that is multidisciplinary and incorporates micro- and macro-level indicators (Ruiz-Casares, Rousseau, Derluyn, Watters, & Crépeau, 2010).

There is a need to disaggregate more systematically between and among asylum seekers and refugees. For example, data should compare different nationalities of refugees and routes to settlement including those who entered the host country through formal resettlement programs or through gaining asylum in country. There is little comprehensive and systematic research on the health effects of detention including pregnancy and birth (Newall, Phillimore, & Sharpe, 2012), and few longitudinal studies.

Limited literature investigates refugee and asylum seeking children and adults’ own perspectives with regard to their health status (Bollini et al., 2009; Carolan, 2010). Evidence on the post-migration context of asylum seekers and refugees is limited, with an emphasis put on the effects of trauma prior to flight. The culture of the country of exile and the organization of its health system is rarely scrutinized in research.

Despite these limitations, there are some areas where health penalties are consistently found, including symptoms of post-traumatic stress and perinatal outcomes but the evidence is neither consistent nor generalizable. However, it seems clear that legal and structural impediments as well as uncertainties in communication, expectation, and entitlement are all detrimental to refugee and asylum seekers’ access to good quality health care. Undoubtedly, the largest improvement in asylum seeker and refugee health would be gained by the removal of all legal impediments to access (Norredam et al., 2006).

Research generally focuses on barriers to access and while that is important, there is little focus on resilience and problem solving by refugees and asylum seekers and also by their service providers. While there has been significant research on mental and maternal care, this has not usually addressed migrants’ own priorities and where it does, these are sometimes at odds with those of professionals. The tendency has been to assume that asylum seekers and refugees should adapt to the models of health care professionals in the receiving country. A more radical proposition would be to reorganize the provision of care to meet refugee and asylum seekers’ needs. Doing so might also benefit other population groups, including those who are highly mobile, those who do not share health care professionals’ expectations, and/or are unable to assert their own needs effectively.

Acknowledgments

Many thanks to Jenny Phillimore and Dave Newall, co-authors of the WHO Health Europe Network report on which this article is based and to the PHAME team at WHO Regional Office for Europe.

Further Reading

Ager, A. (2014). Health and forced migration. In E. Fiddian-Qasmiyeh, G. Loescher, K. Long, & N. Sigona (Eds.), The Oxford handbook of refugee and forced migration studies. Oxford: Oxford University Press.Find this resource:

Agyemang, C., Goosen, S., Anujuo, K., & Ogedegbe, G. (2012). Relationship between post-traumatic stress disorder and diabetes among 105,180 asylum seekers in the Netherlands. European Journal of Public Health, 22(5), 658–662.Find this resource:

Kurth, E., Jaeger, F. N., Zemp, E., Tschudin, S., & Bischoff, A. (2010). Reproductive health care for asylum-seeking women—a challenge for health professionals. BMC Public Health, 10(November), 659.Find this resource:

Norredam, M., Mygind, A., & Krasnik, A. (2006). Access to health care for asylum seekers in the European Union—a comparative study of country policies. European Journal of Public Health, 16(3), 285–289.Find this resource:

Papadopoulos, I., Lees, S., Lay, M., & Gebrehiwot, A. (2004). Ethiopian refugees in the U.K.: Migration, adaptation and settlement experiences and their relevance to health. Ethnicity & Health, 9(1), 55–73.Find this resource:

Thomas, F. (2016). Handbook of migration and health. Cheltenham, U.K.: Edward Elgar.Find this resource:

World Health Organization. (2010). How health systems can address health inequities linked to migration and ethnicity. Copenhagen, Denmark: WHO Regional Office for Europe. Available at http://www.euro.who.int/en/health-topics/health-determinants/social-determinants/publications/2010/how-health-systems-can-address-health-inequities-linked-to-migration-and-ethnicity.Find this resource:

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Notes:

(1.) Sometimes termed the “crisis of solidarity and of racism” to emphasize the failure of host populations’ response.