Background
During the immigrant crisis (15th September 2015 – 8th March 2016) 650 thousands of migrants passed through Croatia [
1]. Slovenia as one of the transit countries counted more than 62000 migrant transits in January 2016 [
2]. The increased number of migrants and diversity of population put pressure on health systems in Europe, especially in the provision of accessible, equitable and good quality health services [
3,
4].
Countries like Norway, Sweden and many other final destinations for asylum seekers had been dealing with problems regarding the provision of quality healthcare for several years before the actual migration flows. Studies conducted between general practitioners [
5‐
7] showed achievement of mutual understanding with migrant patients required additional efforts by health workers. They mostly had to undertake an individual approach (each patient is treated as a unique or
sui generis case), because of the differences in their characteristics, educational level, urban or rural upbringing etc. When mutual understanding was poor, cultural differences played a central part. A Norwegian study [
8] found that information about the organisation of the healthcare system and its accessibility is an important factor [
9]. A study by Priebe et al. [
3] underlined the importance of organisational flexibility, good service of interpreters, and the implementation of educational programmes for health workers. A study in the United Kingdom emphasized difficulties in access to health care for those refugees who don’t have support from their family and friends. Professional interpreters may be helpful when the language barriers appear, but on the other hand they can reduce the confidentiality between a patient and a healthcare worker [
10]. Numerous studies highlight that professional interpreters are more likely to bridge the gaps between healthcare workers and migrants and/or other non-English-speaking patients [
5,
11]. Confidentiality and trust are particularly important in the cases when patients (mostly female) are victims of physical, sexual, and emotional violence. The problem also occurs when professional interpreters as less respectful (e.g. religion of the patient), less friendly, less concerned for the patient as a person, and less likely to make the patient comfortable. In these cases healthcare workers’ role could be contra productive for the development of trust and a genuine relationship between the health worker and migrant patient [
12].
Several studies highlight problems in healthcare provision for migrants [
3‐
8,
10]. However, all these studies focused on migrants that had already decided to stay in the country involved or had at least been living there for more than six months. With the sealing of Hungary’s borders in September 2015, increasing numbers of migrants arrived in Croatia and Slovenia from Serbia. Transit and reception centres began to be established at multiple entries, transit and exit points. Emergency shelters, establishments of collective shelters in existing buildings or in tents and adaptation of buildings and sites were established to allow basic services and facilities to be provided in areas of transit [
13]. Living conditions in transit camps, where they often spend months and even years, often fall well short of basic humanitarian standards because of poor sanitation, overcrowding, and insecurity [
14]. Available facilities at these crossing points were put to temporary use as registration points and accommodation, but conditions were very basic, providing only protection against the elements, food distribution and emergency medical services [
13]. Croatia, Slovenia and other transit countries on the Balkan route had to take a completely innovative approach to provide good healthcare for migrants, because they were passing through and staying in one place for only a couple of hours. The migration flow through Croatia and Slovenia was enormous. The number of migrants who were accepted and provided in some centres significantly exceeded the planned number and their capabilities [
15].
Illegal border crossings, cold weather (November and December 2015), lack of resources in reception centres etc., further complicated the situation. Acute medical care was provided for migrants who needed help, especially vulnerable groups. Responding quickly and efficiently to the arrival of large groups of people from abroad requires effective coordination and collaboration between and within countries as well as between sectors. A good response to the challenges faced by migrant groups requires good preparedness. High-quality care for refugee and migrant groups cannot be ensured by health systems alone [
16]. The experience of improvised primary care settings as globalised and culturally neutral unites in order to ease the connectivity between patients and health workers in the transit zones were reported from the border site [
17].
This study examined the views and experiences of healthcare professionals on the health care of migrants at border camps during the migrant crisis. We conducted interviews directly after mass movements, when the media warned of many health risks both of migrants and of local residents. Previous studies emphasize the problems of the daily provision of adequate health care to migrants in clinics in primary care. Little is known about health care provision in temporary border camps with different circumstances and large group of migrants. We thought that we would find poor quality health care and bad responses due to chaotic conditions. We wanted to explore the experiences of healthcare professionals and organization of health care in the border camp, main weaknesses at providing health care and the relationship between migrants and health care professionals. The idea of the research was created when researchers DRP and MŽ visited the camp on the field (Šentilj). Researchers’ preconceptions were that may be too stressful for participants to talk about some events. Some were also emotionally disturbed and affected. Researchers’ methods of opening up and focusing on interviewees’ interaction were to establish trust, respect and openness for participants. In order to achieve this, the participants voluntarily chose if they wanted to talk about their experiences with working with migrants and the interviews took place at their home environment. In a relaxed conversation in their environment and our understanding of working in a very hard conditions the interviewees could freely responded to descriptive questions. We allowed enough time and encouragement to describe their experiences supported with examples. The interviewees shared with us their experiences, disappointments and surprises. The authors decided to focus only on health care providers in border camps because of their experiences and perspectives to contribute to the knowledge on the topic and obtain many useful information about migrants health care provision in border camps. Our primary interest was to identify the problems faced by primary health workers at border camps in order to prepare suggestions on how to prepare health care in future waves of massive border crossings.
Results
Seventeen categories, 72 codes with a total frequency of 523 were identified. Four themes referring to Croatian and Slovenian health workers experiences with health service provision for migrants on Schengen border were formed. We named themes depending on the content they illustrate.
Organization of health services on the ground
The first theme includes three categories related to the organization of health services on the ground: country specifics; organization of work in (transit) migrant camps; and working conditions (e.g. organization of work, handling equipment and logistics etc.).
Interviewed health workers have exposed some country specifics addressing the migrant crisis. Those specifics were related to Slovenia’s and Croatia’s unwillingness for the wave of migrants with the consequent impact on the health service provisions. The unwillingness of the countries refers to the number of migrants who were accepted in some border centers and significantly exceeded the planned number and its capabilities. In that context some of the health workers have emphasized chaotic situation (in some of the migrant camps). They mentioned the problem of the number of migrants (the trains with migrants were not predicted), the size of migrant camps, lack of human resources and basic human necessities.
This is directly connected with the organization of work and working conditions in migrant camps. Different health workers had different experiences. Some of them had witnessed good organization of work without problems with necessary equipment and logistics, while others mentioned inadequate organization and problems with medical equipment and other supplies. There were differences in the opinions of doctors and nurses regarding the organization. Despite experienced health professionals, they all found themselves in such conditions of work for the first time. The quotations below show that there were differences in positions.
My impression is the camp as a whole functioned perfectly and was very well organized, all services. I would say everything was perfect, as far as possible (HW6, Slavonski Brod, Bjeliš);
In the camp health care was not adequately provided. There was something but definitely not enough for routine care standard for refugees, as we know it today (HW2, Opatovac, Slavonski Brod).
Problem areas
Four problem areas were identified: communication (language barriers); migrants’ social deprivation and traumatic occurrences; negative attitudes among health workers and migrants; and cultural differences. Those categories are broad and comprehensive, and they include different problems we recognized though coding interviews.
Probably the biggest and most common were communication problems. Data obtained in some of the previous studies (e.g. 3) indicated that the language barrier is the biggest obstacle for comprehensive health service provision for migrants. Our study showed that making a diagnosis, due to language difficulties, was real challenge for health workers. The latter was in permanent stress due to incomplete communication and possible wrong diagnosis or misidentified treatment of migrants that needed health service provisions.
Some interviewees outlined translators while others used different techniques to communicate with migrants. Present translators were mostly volunteers, i.e. health workers did not have a translator as an integral part of their medical team. In that context some interviewees engaged:
Google translate and tried to pronounce some Arabic words (HW6, SlavonskiBrod, Bjeliš).
other have tried to improvise and use:
Arms and legs to explain something (HW10, SlavonskiBrod).
An additional problem was migrants’ social deprivation and traumatic occurrences. Those people came from war zones and besides medical problems they survived different war situations, which resulted in social deprivation and traumatic occurrences. Migrants were therefore suspicious and introverted. Majority of interviewed health workers outlined the importance of the psychological (moral) support, understanding, and a sense of security and acceptance. Most common diseases, injuries and other problems were: malnutrition, injured foot, diarrhoea and vomiting, respiratory infections and colds. For the majority of refugees medical treatment was less important which is best illustrated by the statement of one of the interviewees:
Migrants are mainly healthy, but exhausted (HW6, SlavonskiBrod, Bjeliš).
Most interviewees expected migrants to be sicker than it turned out later. Most migrants were young and healthy and were capable to make long and hard way and because of that exhaustion was the most frequent problem. Children and young families were also not very ill at all. Healthcare professionals described cases of more serious ill elderly people with chronic illnesses and pregnant women. The results of social deprivation and trauma experiences were negative attitudes among health workers and migrants. The latter did not want to be separated from the group; they mostly rejected hospitalization and more detailed medical examination because of fear. Partly this could be also explained through cultural differences. Majority of migrants were Muslims from socially deprived parts of Syria, Afghanistan and Iraq. According to their cultural heritage those people sometimes have different understanding of illness and treatment, which was also mentioned by some health professionals. Some of the interviewees emphasized issues about privacy, family ties and ethical dilemmas (should they stay in the camp or should they go further; should they leave their children in a hospital etc.). All of this further hampered the work of health workers at the ground.
Positive experiences
The third theme also includes four categories. The first category inside the third theme we have called positive attitudes among health workers and migrants. It is followed by philanthropy, medical oath and human ethics, and cultural awareness of health workers.
All of the interviewed health workers emphasized at least one positive attitude about migrants. They were friendly and grateful for the help. This has affected health workers to be even more philanthropic:
To do their job in accordance with a medical oath and human ethic (HW2, Opatovac, Slavonski Brod).
Cultural awareness of health workers was reported as an important element for successful actions. In that case Croatian and Slovenian medical profession deserve compliments for culturally sensitive service during the migrant crisis.
Some health workers exposed that the only problem was lack of human resources. In that context migrant crisis – from the medical point of view – was the result of inappropriate organization and disinterestedness of national governments to solve the problem more seriously, which was shown in the following statement:
I was frightened of the organization, where will we get enough people to work with the refugees (HW9, Vrhnika).
Interviewed health workers have shown readiness to re-engage in similar campaigns, which additionally highlights positive experiences with the (mostly) humanitarian crisis.
Social dimension of the migrant crisis
Our fourth theme is reserved for a social dimension of the migrant crisis. This theme includes two categories (lack of food and other necessities; fear and uncertainty) that best exemplify the essence of the migrant crisis.
Beside organizational chaos, lack of human resources and inadequate working conditions in migrant camps, health workers have also emphasized the social dimension of a humanitarian crisis. According to some authors the current migrant crisis in Europe is a test of European values. In other words, the current migrant crisis in Europe “will truly prove if Europe can live up to its founding principles of human dignity, solidarity, freedom, democracy and equality” [
32]. Migrants were concerned about how their problems would be solved and what would happen to them. Health care professionals observed their anxiety and thinking about the need for psychological support. Basically all interviewed health workers expressed sympathy with migrants:
The soul hurts them, they really needed someone to treat them as human beings (HW1, Vrhnika).
Concerns were where people go, what to expect from the future, and do they have real chances for integration in the final host country.
Based on concerns how migrants will cope with an uncertain future in a foreign country, we can say that health workers had multiple functions on the ground. Besides their medical profession they were also psychologists, social workers and philanthropists. Such positions of health workers provide them an ability to understand all dimensions of the crisis, humanitarian crisis. They tried to draw attention to the permanent shortage of food and other basic necessities (infant foods, hygiene gadgets, blankets, tents etc.). They also tried to talk about migrants’ fears and uncertain future. In that context moral support was most important.
As potential measures to mitigate the migrant crisis, interviewed health workers also made some suggestions. Based on their experience in working on the ground they suggested it is necessary to introduce a permanent emergency services, and provide permanent health care for all migrants, no matter where they are located. More sophisticated proposals were focused on the inclusion of international organizations – concretely:
Organization Magna, which is an international organization for pediatric health (HW10, Slavonski Brod).
Conclusions
Findings revealed some information that may be seen as useful tips for all health care workers and policy makers who face migrant crisis and participate in health service provision for migrants and other refugees. It is necessary to provide more permanent accessible professional interpreters. Irrespective of the circumstances, and the scope of any humanitarian crisis, health workers should be aware that successful overcoming of language barriers and the observance of cultural differences are key factors for successful treatment of migrants. A useful set of skills for health care providers includes compassion, susceptibility for social deprivation and traumatic experiences of those people. It is necessary to provide more health professionals and multidisciplinary treatment, cooperation with psychologists, psychiatrists and social workers. More than professional health care migrants need to feel health workers’ humanity and willingness to help them. However, health workers should be mindful that providing assistance during crisis takes place in special working conditions with shortages of everything: adequate facilities for patients’ treatment and other medical equipment; human resources; food and other necessities; translators other actors involved in the social care of migrants (e.g. administrators; representatives of state authorities (police, army, social workers) etc.). The government could consider a better organization, an increasing number of migrant centres that would reduce overcrowding and improve the conditions for providing adequate medical care for migrants.
Our findings extend the findings from previous studies and make some contribution to the literature in the field. Our study contributes to important information in the research gap regarding the main obstacles to providing health care for migrants only in transit centres during the migration crisis, which is a real challenge for individual countries when the migration centres become overcrowded.
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