Discussion
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 60 % 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.
Authors’ contributions
FKNK conceived of the study, carried out the interviews, analyzed data and drafted the manuscript. AKH and CA participated in the design of the study and data analysis, and helped to draft the manuscript. AN participated in the coordination of the study and data collection. BMA participated in the study design, analyzed data and helped to draft the manuscript. All authors read and approved the final manuscript.
FKNK: MD, MPH, DrPH and has also worked as trained medical interpreter in Sweden. AKH, MD, DrPH, professor in Public Health.
AN, PhD, Head of the Public Health Center for the Norrbotten County council.
CA, MD, PhD, professor in Infectious Diseases.
BMA, PhD in Sociology, professor in International Health.