Overview
The majority of AS come from countries that are experiencing war, conflict or other abuse of human rights. Additionally, these countries of origin are less likely to have good access to health care, safe drinking water, accommodation, food supply and education. Such countries have a limited capacity to treat those with acute health concerns and chronic diseases or to provide immunisation. Additionally, AS may spend many weeks or months travelling to try and reach a safe place. During their journey they are likely to have stayed in overcrowded camps with very poor hygiene, lack of sanitation and exposure to disease.11 AS will probably have found it very difficult to meet their basic needs during times of persecution in their home country and during their journey to the UK.
The diagram below summarises the factors influencing the health of migrants12; many stakeholders also emphasised the significant impact of the asylum process itself.
Figure 5: Factors influencing the health of migrants (adapted from PHE 2018) (12)
In Southampton and Portsmouth most AS receive accommodation and basic living support13. However, meeting basic needs remains very difficult even for supported AS and it is virtually impossible for other vulnerable migrants (such as failed AS who are no longer in receipt of Home Office support). Many stakeholders in this assessment mentioned Maslow’s hierarchy of need (see Figure 6) where the needs at the bottom of the pyramid (i.e. physiological needs such as water and food) must be satisfied before other needs (such as self-esteem) are met14. For instance, several healthcare professionals spoke about the difficulties in meeting the healthcare needs of vulnerable migrants when they cannot offer them accommodation through Section 117 (see Appendix for further information). This hierarchy of need may explain the tendency of some AS to drop in and out of treatment or therapy, which is an issue mentioned by several different healthcare professionals during this assessment.
Figure 6: Maslow's Hierarchy of Needs (14)
The following themes emerged from the stakeholder consultation and from the relevant literature; they are divided broadly into physical health, mental health and access to services. It is, however, important to note that AS are not a homogenous group (they encompass significant diversity of ethnicity, faith, language, culture, politics, education and socio-economic backgrounds) and, therefore, their needs will be individual just like the rest of the population.
Physical Health
Some stakeholders referred to the ‘healthy migrant effect’ meaning that it is often the younger and healthier people who attempt and succeed to move to a new country15. This is often the case for economic migrants whereas AS, although often young men, are particularly vulnerable to certain health conditions because of their experiences either before, during or after migration1 16.
The following physical health issues were identified in this assessment.
Maternal health
Concerns over poorer maternal outcomes for AS and vulnerable migrants were mentioned by several of the healthcare professionals consulted in this assessment. There is evidence from across Europe that 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 parity5. A systematic review found that pregnant AS in the UK have considerable unmet needs17. In 2007 12% of all maternal deaths in the UK were refugees and AS, despite these groups making up just 0.3% of the population in the United Kingdom at that time18.
Sexual health
Studies have highlighted the sexual and reproductive health needs of AS and vulnerable migrants, with high levels of sexual gender-based violence being reported along with limited access to contraception19.
Several stakeholders mentioned the cultural sensitivities of sexual health needs and services for AS; particularly in relation to accessing contraception and uptake of cervical screening.
Female Genital Mutilation (FGM)20 was also mentioned as a significant issue by several stakeholders. For some AS, the threat of FGM to their daughters is the very reason for their asylum claim. Health and care professionals consulted in this assessment appeared to be well aware of their safeguarding responsibilities regarding FGM but did mention the challenge of raising this sensitive issue with patients.
Chronic disease
Although AS are often younger than the general population, ethnic differences in disease susceptibility can mean that some are more at risk of certain long term conditions21. Several AS who took part in the focus groups described positive experiences of managing their conditions, such as diabetes, in primary care since arriving in Southampton or Portsmouth.
Stakeholders described how chronic disease in AS can also stem from their traumatic experiences; for instance, stress responses during the journey can increase the risk of heart disease and diabetes. Additionally, exposure to noxious chemicals and shrapnel can lead to long-term co-morbidities such as chronic mobility problems.
Communicable disease
Most AS originate from low- and middle-income countries, where there is a generally higher prevalence of infectious diseases such as Hepatitis B, Tuberculosis and HIV than in the UK.22 Additionally, the risk of contracting infectious diseases may be increased by poor living conditions before and after migration23. Vaccinations are often incomplete and AS are unlikely to have records to demonstrate their vaccination status24. Infectious diseases and issues around vaccination were a particular concern raised by the stakeholders involved in caring for UASC.
Other physical ill health and injuries
Stakeholders mentioned physical health issues caused by experiences of conflict or torture, such as amputations or shrapnel being embedded inside the body. Impacts of the journey itself were also mentioned, including hypothermia from travelling in refrigerated lorries and malnutrition.
Mental Health
Throughout the stakeholder consultation, mental health was consistently mentioned by professionals as a key area of need for AS in Southampton and Portsmouth. Mental health was also talked about by AS themselves but they tended not to describe it in these terms instead talking about their symptoms. The mental health issues most frequently mentioned were anxiety, depression and Post Traumatic Stress Disorder (PTSD); comorbidity with physical health problems was also common.
PTSD is the most common mental health diagnosis in refugees who seek treatment (K.Young, personal communication, 13/09/2019). AS have often experienced multiple traumatic events involving repeated, and prolonged exposures to threat and violence which puts them at much greater risk of ‘complex PTSD’25. This is characterised by high levels of dissociation, nightmares and flashbacks plus some complex PTSD sufferers experience ‘psychotic-like’ symptoms (e.g. hearing the voice of a torturer commenting on events in the here and now.)
One AS in the focus groups hinted at the trauma he had been through and the impact of this on his mental health:-
“Many bad things happened to me...I’m 30 years old so I need to do something for my life and for my future....the problem in my head...think, think too much”.
Studies have shown that prevalence of clinically significant symptoms of depression, anxiety and risk for post-traumatic stress disorder are significantly higher among AS compared to the general population of the host country26. Fazel et alestimated that 9% of adult refugees may suffer with post-traumatic stress disorder, which is approximately 10 times that of an age-matched American population27, whilst other studies indicate rates of PTSD and depression are 14-15 times higher in refugees then the host population (K.Young, personal communication, 13/09/2019).
Difficulties with anxiety, loneliness, grief, anger, self-harm and insomnia are also widely documented in refugee populations and suicide rates have been found to be higher than in host populations28 29. In addition, there is an acknowledged interaction between the psychological well-being of refugees and the physical disabilities/chronic health conditions that they may experience as a consequence of war and torture (K.Young, personal communication, 13/09/2019).
One GP practice in Southampton has analysed the results of a special health check done on 55 of their patients who are refugees; they found that 25% of these refugee patients had evidence of PTSD and 25% had depression30. This compares with a prevalence of 4.4% in the general population of the UK31. Belz et al (2017) report high levels of comorbidity of PTSD and depression among distressed refugees at a reception centre in Germany; 94% of patients who had PTSD also had depression32.
Stress continues for AS even after arrival in a host country through loss of social networks, shifting societal roles and integration issues19. Additionally, local stakeholders reported the impact on mental health of the asylum process itself; one voluntary sector employee described ‘points of crisis’ happening all the way through the process. Although the evidence is limited, an extended asylum procedure appears to be associated with increased psychiatric disorder5.
In the focus groups, AS spoke about the impact of the asylum process on mental wellbeing, particularly because of the uncertainties and the lack of purpose each day from not being able to work:-
“I try to find things to keep my head running....if you allow the process to get to you then every one of us is going to be mentally cracked down at the end of the day....the process is very hostile, it’s very mean, so if you can’t find things to do to keep you running and then get tired at the end of the day so you fall asleep...everyone is going to have mental issues if we just sit down like this”
Sleep disturbances are common amongst AS. In a study of a clinical sample of refugees attending a specialized centre in the Denmark, almost all reported sleep disturbances and recurrent nightmares33. One focus group participant in Southampton explained that:-
“sometimes the stress makes you forget everything....and you can’t sleep....you may even forget your phone....you just forget everything....sometimes this comes for 4-5 days and I just lay on my bed and can’t sleep and just thinking like this and I don't know where it has come from...”
It is clear from the available literature and from the stakeholder consultation that distinguishing between mental and physical problems is particularly complex amongst the AS population. Some literature describes this as ‘somatisation’ (i.e. presentation of mental health problems in the form of physical symptoms) which is reportedly higher in refugees from non-Western countries than the general Western population34. However, other sources and some local stakeholders describe physical pain as a result of mental health issues, particularly from experience of trauma35. This complex presentation of symptoms makes investigation difficult and costly. Inaccurate diagnoses may occur and AS may feel that they are not being listened to or believed.
Generally, people with poorer mental health experience higher rates of adverse outcomes such as poverty and social exclusion which can lead to substance misuse and incarceration36. Several stakeholders mentioned a concern that AS in Southampton and Portsmouth were more likely to become involved in criminal activity if their mental health issues were not addressed.
Children’s Health
With unprecedented numbers of UASC in Portsmouth, identifying the health needs of young AS is particularly important.Often the issues for UASC are the same as for adults, with stakeholders specifically mentioning communicable disease, sexual health and mental wellbeing.
Figure 7: Risk factors for mental illness in UASC (37)
Local professionals working with AS children were concerned about communicable diseases; in particular, the uncertainty around vaccination status as well as cultural reasons for parents not consenting to immunisations such as HPV. However, as with adults, the over-whelming concern was for the mental health of these young people; the diagram in Figure 7 shows the risk factors for mental illness in UASC. The Kent UASC HNA provides a comprehensive review of the literature on the health needs of these young people37.
Accessing Health Services
The evidence from this assessment suggests that, generally, AS in Southampton and Portsmouth are able to register with a GP and navigate the healthcare system reasonably well. Participants in the focus groups mentioned that information is provided when they initially arrive at their accommodation to direct them to local services including primary care. However, in the focus groups, several AS mentioned that negative experiences of accessing healthcare have driven them to avoid seeking professional support and instead accessing care through other means. For instance, one participant said:-
“personally for me I do not enjoy going to the GP or the hospital....I don’t go any more...I just go to Savers to buy painkillers or whatever...”
And another commented how one person’s bad experience could dissuade other AS from accessing healthcare:-
“most people in the migrant community they talk to each other...so they would be like ‘oh my god...don’t go to hospital’...”
Below is a summary of the barriers to accessing healthcare that were identified in the stakeholder consultation and from the published literature.
Waiting for appointments
Several participants in the focus groups mentioned the time taken for getting an appointment. Some stakeholders have suggested that dissatisfaction around this is shared by the UK population generally whilst others said that it may reflect differences in accessing healthcare in countries of origin (for instance, AS may be used to waiting in a queue to see a doctor that day rather than having to make an appointment for several days’ time).
One consequence of this was that some AS said that they felt they had to over-emphasise the significance of their health issue in order to get a quicker appointment:-
“sometimes we have to show, for example, that our pain is really killing us, for example, and then we get a short appointment”
This clearly can result in a difficult dynamic between clinician and AS as well as exacerbating any issue of AS feeling they are not being believed.
Language
Language, as a barrier to meeting AS health needs, was raised repeatedly across all types of stakeholders and in the published literature19,38. For instance, several stakeholders mentioned that healthcare services, such as primary care and IAPT, often have telephone triage as the standard pathway which is a significant barrier for a non-English speaker.
In accordance with national guidance39, the use of family or friends as interpreters was not favoured by stakeholders because of issues of confidentiality and safeguarding.
While various interpreter services are available to healthcare professionals in Southampton and Portsmouth, several issues were identified with these. For instance, less common languages or dialects can be difficult to source an interpreter for and sometimes interpreters do not turn up on time.
A recent survey of GP trainees in neighbouring Dorset revealed that they lacked knowledge regarding migrant health needs and rights to care. They also lacked experience and confidence in caring for this patient group with language mentioned as the biggest perceived challenge.38
Cultural differences
In addition to language, other cultural differences were mentioned by many stakeholders as barriers to accessing healthcare. A recent systematic review into the challenges in providing healthcare services to AS and refugees, identified cultural understanding as an issue. Studies in the review identified issues such as using different terms to refer to health conditions, unfamiliar concepts (such as preventive care) and unreasonably high expectations of health services amongst AS. Additionally, differences in cultural values such as gender roles, decision-making, social taboos and time-orientation were mentioned as challenges.19
Some healthcare professionals consulted in this assessment described different perceptions of risk between AS and the general UK population; for instance, a minor respiratory illness may be perceived as likely to be life threatening by someone from a country where childhood mortality from pneumonia is common.
Dignity and respect
Several participants in the focus groups mentioned that they had at times felt they were treated without dignity or respect when accessing healthcare services in Southampton and Portsmouth. In relation to her experience of maternity care, one AS stated:-
”sometimes they fail to recognise that you are a member of the human species”
Many participants mentioned that they felt messages about their health could have been communicated to them in a better way.
Ease of access and cost of healthcare
Many of the stakeholders mentioned uncertainty about AS eligibility for healthcare. During the stakeholder consultation, healthcare professionals frequently sought clarification about charging for services, particularly for failed AS. The AS themselves talked about the stress that results from being presented with a bill for healthcare.
“I don’t know if I have to pay for it or if it is free for us...I don’t have any other problems apart from that”
AS also described the confusion and stress of paying for non-prescription drugs and several questioned why their GP told them to buy drugs, such as painkillers, rather than giving them a prescription which would have been free.
The ‘hostile environment’ policy40, which has resulted in AS being asked to prove their entitlement to healthcare before receiving treatment, was mentioned by several stakeholders and the AS themselves. This was felt to be hugely inappropriate, to cause considerable stress, and sometimes to exacerbate ill health.
The distance to hospital and the associated cost of getting there was a significant barrier for many AS.
“I got referred to one of them and I didn’t know where it was....I went to St Marys and I was told I was not on the system....eventually when I found out where it was...it was like an hours walk”.