This study suggests that migrants, particularly asylum seekers acknowledge the need
for health screening. However, because of the structural organization of the screening,
they see health screening not only as a benefit but rather as a requirement they have
to fulfill in order to get permission to stay in Sweden. The health screening process
reinforces the current debates and the “othering†of migrants across the EU where
they are constantly represented as a threat to the native population. Thus, the screening
process normalizes the idea that immigration is a source of danger and racialize and
construct immigrants from countries considered to pose health risks as ‘diseased others’
and a threat to the nation. In this way, health screening can be understood as a context
where various markers of difference including, race, legal status, citizenship, intersect
to restrict admission to the country, social rights and access to care. In other words,
health screening can be interpreted as a proxy for discrimination based on national
origin, which is a common aspect of racial discrimination.
This study highlights a number of issues that impact on the screening process. These
include lack of (cultural and linguistic) sensitivity and inclusiveness of the screening
service, health care staff attitudes, a focus on infectious diseases that overlook
migrants’ actual needs and the involvement of staff from the Migration Board that
contributes to the perception that the screening is a legal requirement. Finally,
the poor living conditions, delay in screening combined with restrictive entitlement
to care for asylum seekers is counterproductive as it may increase theirs and other
migrants’ vulnerability to infectious diseases and poor health, and further expose
them to discrimination. If not addressed these issues may limit the uptake of the
screening service, prevent early detection and effective management of ill health
and thereby undermine the achievement of public health goals.
This study indicates that the screening service is not easily accessible to migrants
because of structural barriers mentioned above as well as the way information about
the screening offer is conveyed for example, the use of Swedish language which has
been previously identified as a structural discrimination by health care staff who
participated in previous studies 15], 27]. This practice, in addition disregards the NBHW guidelines (that stipulate that information
about health screening should be sent in a language migrants understand), and violates
the administrative Act (Förvaltningslagen para. 8) that recommends that all public services use interpreters when dealing with people
with limited competence in Swedish 18], 20]. Moreover, new migrants might not understand the rationale for screening as they
may have symptom- driven health seeking behaviors 15], 27]. Participants in this study stressed that some migrants missed their appointment
because they could not read or understand the content of the letter and thus did not
know what to do, where to go for screening after receiving the letter or simply had
reservations about providers inviting them for screening. Lack of awareness as well
as inability to access available information on health matters and services may prevent
effective utilization and cause delay in diagnosis and treatment of ill health as
illustrated by the late diagnosis of HIV, cancers and diabetic complications commonly
reported among migrants 11], 28], 29]. Lack of cultural sensitivity, language differences, limited literacy and unfamiliarity
with the host countries’ healthcare system are well known barriers that limit migrants’
access to and use of health care, including the uptake of screening service in many
host countries 15], 28]–31].
Language and cultural differences have also been reported as serious problems in the
interaction of migrants with health care staff 15], 27], 29], 30]. Even in this study, communication problems were reported during the medical interview
despite the use of interpreters. This was said to be caused by the interpreters’ lack
of competence, professional misconduct such as breach of confidentiality as well as
the screening staff inattention to language or dialect variation while booking interpreters.
Poor interpretation can compromise symptom reporting and lead to misunderstandings
with increased risk for wrong diagnoses, inappropriate treatment and a frustrating
encounter for both clinician and patient as reported in other studies 15], 27], 32]. However, it is worth stressing that only participants who were not assisted by interpreters
during data collection talked negatively about them suggesting that those who were
dependent on interpreters were afraid of negative consequences and refrained from
criticizing them. Poor communication between migrants and health care staff might
as well reflect lack of cultural competence among providers, low health literacy among
migrants as well as differences in cultures and expectations about screening combined
with lack of information about the Swedish health care system and health-related rights,
which possibly generate a feeling of discrimination and disrespect leading to dissatisfaction
and mistrust towards medical staff 15], 27], 28], 30]. Equally important, is the use of technical terms and “medical jargon†by the screening
staff that confused migrants and could negatively affect the care 33].
Nevertheless, participants complained that the screening staff did not provide enough
information about the screening process, screened diseases or the results of blood
tests, which made them anxious as indicated in findings from a previous study that
insufficient explanation by screening staff raised anxieties about the process 21]. This stands in contrast with the NBHW guidelines on provision of information to
new migrants 18] and raises the question of whether informed consent was obtained. In a previous study
with migrant students, no association was found between undergoing screening and level
of knowledge among migrants or their attitudes towards TB, which was actually low
with negative attitudes. This led to the conclusion that health professionals missed
the screening opportunity to improve TB knowledge and to change attitudes among this
vulnerable population 34]. These findings suggest the need to assess migrants’ knowledge and understanding
of screening and screened diseases in order to address misconceptions, emphasize the
benefits of screening, decrease anxiety, improve acceptability and the image of health
services and thereby facilitate future utilization 27].
Participants also mentioned a number of issues that may be unique to asylum seekers,
including fear of the consequence of a positive test, confidentiality issues, poor
living conditions and limited access to care, which generated frustration and feeling
of discrimination and disrespect. Even though participants saw health screening as
a benefit for their health, they regarded themselves as passive recipients as they
believed it was an official requirement they had to fulfill without questioning. They
perceived undergoing screening as a way to abide by the rules, and thus feared that
a positive result could compromise their asylum application 27]. As a result, those who underwent the screening were more concerned about residency
rather than the actual benefits of health screening. Fear of legal consequences of
a positive result has been previously described as barrier to migrants’ use of screening
and HIV testing services in host countries 27], 31], 35]. This issue was exacerbated by the involvement of the staff from the Migration Board
in the screening process raising concerns about the possibility of information sharing.
Fear of links between health providers and immigration authorities has been suggested
as an important factor that may deter migrants from seeking care, compromise the development
of a trustful patient- provider relationship and limit access to and use of available
services 27]. Contrary to widely held beliefs, a previous survey of legal migrant students showed
that this issue is not limited to asylum seekers. Although all respondents had permission
to stay in Sweden, fear of deportation was the most important determinant of reluctance
to seek HIV/AIDS care 35]. Conversely, fear of legal consequences was found in a recent study to be a subsidiary
barrier for use of HIV testing service by Latino migrants in Spain. The authors attributed
this contrasting finding to the equal access that both natives and migrants (regardless
of legal status) had until recently, and warned that this situation might be reversed
by the new Spanish austerity policies regarding healthcare for migrants 36]. In other words, guaranteeing equal access to care may promote the use of available
services by migrants.
This study further stresses the role of housing and dispersal policy for asylum seekers
in impeding their access to available services including the screening service and
exacerbating their vulnerability to poor health. Participants who were housed at the
Migration Board reception centers complained about their precarious living conditions,
particularly their housing situation that they experienced as a punishment. Those
who were housed in remote areas, far from the nearest health care unit, reported facing
difficulties in accessing the screening service and health care in general due to
lack of transport, its costs or unfamiliarity with their new environment, leading
to delayed or missed appointments. These issues need further exploration to find the
best way to offer the screening service. Moreover, participants worried that their
overcrowded conditions coupled with the long waiting time for screening and test results
might increase their risk of acquiring and spreading infectious diseases and potentially
jeopardizing the effectiveness of the screening 27]. There is evidence to suggest that the poor housing conditions actually increase
the risk of transmission of infectious diseases among migrants as indicated in a report
about an outbreak of TB at an asylum seekers’ reception center in Sweden 37]. Similar issues were noted in Greece where a report from the Médecins Sans Frontières
(MSF) suggested that more than 60Â % of health problems among asylum seekers and migrants
were directly caused by or linked to the inhumane living and hygienic conditions in
detention facilities 38]. However, fear of infection reported in this study might as well express the stigma
related to screened diseases prevailing within migrant communities, which may also
partly explain the mistrust towards interpreters 21], 28], 31], 34], 35].
Participants also reported that the screening service fell short of their expectations
as it only focuses on identifying infectious diseases of public health significance
while overlooking their actual health needs. In this way, the screening policy lacked
a holistic perspective on health and was thus perceived as a discriminatory device
against their ethnicity or citizenship. Similar findings were reported in our previous
study with health care staff who described the issue as a dilemma and potential source
of conflicts 27]. Besides, the focus on infectious diseases is inconsistent with the NBHW guidelines
that emphasize not only the detection of infectious diseases of public health significance,
but also the need to identify physical and mental health problems requiring medical
attention in new migrants 18]. Lack of perceived medical benefits may negatively affect acceptance and utilization
of the screening service 28]. Meanwhile, previous reports have clearly pointed out that contrary to migrant workers,
asylum seekers and refugees are more vulnerable to mental illnesses, most screening
programs tend to focus only on infectious diseases and fail to address the disparities
in health and care needs prevailing between and within migrant groups 39], 40]. This contributes to the perception that migrants are infectious disease threats
to the host population. These laws and practices to control and prevent the spread
of communicable diseases may reinforce fear of contagion and create a hostile environment
by portraying migrants as disease vectors, and lead to their discrimination within
the health care system and the wider society 27]. Some participants reported unfriendly experiences during the medical encounters
or when they attempted to seek care corroborating findings from other studies 28], 31]. A recent study conducted in the UK suggested that discrimination from health professionals
was an important barrier to the use of screening service by migrants 31]. Moreover, screening only migrants may also create a false sense of security among
native residents that can hamper prevention efforts 41].
Furthermore, contradictory policies, such as offering health screening to asylum seekers
while restricting their entitlements to care can be counterproductive to public health
as it may delay care, increase the severity of diseases and its subsequent costs 17]. Asylum seekers who participated in this study were confused and frustrated by the
paradox of being offered health screening, but denied access to treatment for conditions
that were not perceived as immediate threats to life or public health because of their
legal status. This can intensify worries and suffering among people who are already
in a vulnerable situation. In addition, this restrictive policy is in conflict with
human rights law and the Health and Medical Care Act (1982:763), which emphasizes
equal access for all 8], 42] and represents a form of institutional discrimination that reflects an attempt to
make migration unattractive. Such conflation of public health with migration issues
raises ethical issues, creates a dilemma for health professionals 27], 42] and constitutes a serious impediment to access timely care leading to advanced disease
and significant social and health consequences 17]. Similar legislations in Australia did not only result in poor health outcomes, but
also deter refugees from undergoing health screening, which increased concerns about
the spread of communicable diseases among them, and this in turn, exacerbated their
stigmatization 43].
Finally, like in other EU countries, the screening policy mainly targets asylum seekers
and does not encompass all categories of migrants. Not including all migrants from
targeted countries may compromise the effectiveness of the screening program as evidence
suggests that migrants are more likely to be infected with HIV or TB after migration
through contacts with fellow countrymen and women 37], 44]. For instance, we could not identify any migrant worker (a growing group) or student
among participants who had been screened in this study. Even though family ties and
quota refugees can also be offered health screening under certain circumstances, only
the screening of asylum seekers and undocumented migrants is regulated by law 10], 45]. Thus, the Swedish Migration Board is required to provide information (contact details)
only about asylum seekers and is under no obligation to inform the county councils
about other categories such as family ties, quota refugees, students or labor migrants
regardless of the National Strategy to combat HIV/AIDS and other Communicable Diseases
of public health significance 46]. This ambiguity and conflict in laws also makes it difficult for health care staff
to reach all new migrants from targeted countries and may partly explain why the family
ties participants who were waiting for the invitation letter did not get it 27]. This can also be (mis)interpreted as having a residence permits removes a migrant
from the need to be screened. Furthermore, as mentioned earlier, the NBHW guidelines
are unclear as to whether the screening should be offered to all migrants from targeted
countries or some specific groups of migrants 18]. Thus, some counties choose to offer the screening to all migrants from targeted
countries, whereas others limit the offer to some subgroups depending on whether the
cost of screening will be covered by the State or not 27]. For instance, migrant workers and students are not routinely offered the screening
in most counties, whereas undocumented migrants who are not officially registered
may be hard to reach or deterred from responding to the screening offer for fear of
being reported to the migration authorities. Moreover, although asylum seekers are
one of the most vulnerable subgroups of migrants, singling them out as the only category
to be screened may expose them to social stigma and discrimination associated with
their legal status, their countries of origin and screened diseases 21], 28], 31]. This may prevent them using the screening service. From a public health perspective,
there is a need for a new way of thinking and approaching migration and health issues.
Contrary to the threat of disease approach that has been traditionally used, more
attention should be paid to the complex and multiple factors that increase the vulnerability
of migrants to poor health. Changing paradigm will not only benefits migrants, but
also the society as a whole. Future research is, thus, necessary to better understand
the role of screening in improving the health of migrants, and ultimately the health
of all.
Limitations of the study
There are a number of limitations that deserve mention. Although studies involving
human participants are context bound and, findings from this study may only apply
to the Swedish or similar contexts, our findings are congruent with findings from
other studies and provide basis for improving the screening program 21], 27], 31], 47]. Moreover, preliminary results were presented and discussed with migrants who participated
in a workshop on the health screening of new migrants organized by the National Federation
of Immigrant Women’s Associations (Riksförbundet Internationella Föreningar för Invandrarkvinnor – RIFFI), which supported our interpretation of the data. Although we used a purposive sample,
we sought a maximum diversity to reflect the wide range of countries targeted with
screening. However, undocumented migrants might have other specific barriers and were
therefore not included in this study. Even if we were unable to identify a large number
of migrants who declined screening, the issues raised in this study are likely to
affect their decisions. Further work is needed to identify the determinants of screening
uptake. The use of interpreters may have affected the results, but apart from criticism
of interpreters’ competence, we found similar views with or without interpreters across
the four settings and in feedback from migrant women during the workshop. Finally,
we had discussions throughout the study and during the analysis process, which enhanced
the interview guide, style as well as data interpretation.