Migration and access to health care
In recent years, war, conflict and violation of human rights have led to massive forced displacement, with millions of people seeking protection in other countries [
1]. During 2015–2016, Europe experienced an influx of people seeking asylum from multiple nations with Syria, Afghanistan and Iraq being the top three. [
2]. Sweden and the rest of Europe have a humanitarian responsibility for these people, to assure their safety and uphold their human rights to health and access to healthcare services [
1,
3]. According to the UN definition, a refugee is “
a person who is outside his or her home country, has a well-founded fear of persecution due to his or her race, religion, nationality, membership of a particular social group or political opinion, and is unable or unwilling to gain protection from that country, or to return there for fear of persecution” [
4]. An asylum seeker is a person who files for a refugee status in the host country and awaits a decision. Compared to refugees, asylum seekers in Sweden have not been granted a residence permit and therefore they are not included in surveillance or health information systems [
1].
International law protects the human rights of refugees and asylum seekers. The international covenant on social, economic and cultural rights is a key legal document ratified by 164 countries, including Sweden [
5]. The 1951 refugee convention states that refugees should “enjoy access to health service equivalent to that of the host country” [
4]. The Governments faces challenges in taking human rights, including right to health care into national plans, policies and strategies. Inadequate entitlement and legal restrictions to use health care services amplifies health inequalities leading to the violation of human rights of the migrants [
1,
3,
6,
7]. The absence of restrictions does not imply equity. Differences in access to health care for migrants are shaped by language barriers, sociocultural factors, and the migrants’ lack of awareness of available health services, cultural barriers and structural barriers [
6,
8]. To respond adequately to health and social care needs of refugees and asylum seekers and improve accessibility and quality of care, collaboration and intersectoral communication between authorities and actors such as, health service providers, non-governmental organizations and all levels of government (national, regional and municipal) is essential [
9,
10]. Furthermore, specific health needs of refugees and especially asylum seekers are poorly understood as high-quality data on determinants of health, health status and utilization of health services are rarely collected [
1,
6,
9,
10]. To respond to the need of refugees and asylum seekers, adequate monitoring and research can assist in acquiring relevant health information that could lay the foundation for interventions and public health initiatives aiming to improve service utilization, access and health outcomes [
1].
Screening and health examinations
Migration has raised concerns about the transmission of infectious diseases. Screening programmes targeting newly arrived asylum seekers are common in host countries as a means to minimize transmission [
6,
8,
11]. Screening newly arrived refugees has been criticized as ineffective, discriminative and of contestable value. There is no clear evidence of individual and public health benefits or cost-effectiveness of such procedure and it remains open to considerable doubt [
11‐
13]. Despite this, medical screening exists in many countries. There are differences in practice and implementation in terms of timing of the screening, location, specific medical screening programme (mental and physical) and whether it is done on a voluntary or compulsory basis [
8,
14]. Screening practices in the European Union (EU) region more often focus on communicable diseases while mental health screening is only offered in 11 EU countries (three compulsory, eight voluntary) [
8,
14]. Focusing on infectious diseases might not accurately reflect health needs. In addition, legal access to health services vary between countries. Countries such as Denmark, Norway and The Netherlands grant asylum seekers unconditional entitlements to the same range of services as nationals/citizens while in other countries such as Sweden, it is more restrictive [
8,
12‐
14].
Health examination in Sweden
During the period 2015–2016 almost 200,000 people sought asylum in Sweden [
15]. Asylum seekers in Sweden are entitled to necessary medical care as provided by the Swedish reception of asylum seekers’ Act (LMA). This includes emergency or urgent medical and dental care, maternity and childbirth care, contraceptive advice and abortion. Children asylum seekers under the age of 18 are entitled to the same health care as natives. Asylum seekers who are granted a residence permit, referred to as newly arrived refugees are entitled to the same healthcare as other citizens [
16]. By law, all asylum seekers must be offered a free-of-charge health examination (HE) by the region/county where they reside. Newly arrived refugees are entitled to a HE within 1 year of receiving a residence permit. Other migrants such quota refugees and refugees coming on family reunification are entitled to a HE, however in this case, the examinations are neither systematically offered, nor regulated in the law in the same way as for asylum seekers [
16,
17]. Data shows poor participation within the HE, with less than 50% of asylum seekers undergoing the HE [
18]. Limited research has been carried out investigating reasons behind this, however structural and organizational shortcomings have been suggested [
19,
20]. Studies have shown that poor communication, inadequate information and lack of clarity regarding the purpose of the HE, ambiguity and mistrust could to some extent explain the poor attendance [
19,
20]. Asylum seekers in Sweden felt they received insufficient information both ahead and during the HE, perceived health needs were not met and focus was partly given to infectious disease control [
20]. Other studies have found that low levels of comprehensive health literacy, individual’s competence in accessing, understanding, appraising and applying health information was negatively associated with the quality of the communication and usefulness of the HE [
21].
In Sweden, responsibility for health care is shared by central government, county councils and municipalities. The central government, through the Ministry of Health and Social affairs is responsible for the overall health policies. County councils, together with the municipalities, operate autonomously and they hold the responsibility for public services across various sectors. The principle of local self-government gives the county councils and regions the right to design and structure their activities in the light of local conditions [
22].
The organization around the HE involves different entities. The content and recommendations are regulated by the National Board of Welfare and the Public Health Agency and represent the minimum level. Each county council can develop their own templates for the HE and the content can vary widely across and within counties and between health care providers [
23]. The Migration Board is obliged to inform the asylum seekers about the right to a HE and health care providers are responsible for the invitation and provision [
24]. Training is provided to health care professionals conducting the HE, however this varies and literature shows there is a need for more education with regards to transcultural nursing and cultural competence [
23]. The purpose of the HE is to: identify mental and physical health needs demanding care, in line with concept of “care that cannot be postponed” and to detect and control for infectious diseases such as human immunodeficiency virus (HIV), hepatitis and tuberculosis [
17]. The examination should, ideally, include a discussion about health issues in addition to testing for infectious disease which is regulated by the National Prevention and Control strategy. Guidelines and indications for screening depend on infectious disease epidemiology in the country of origin of the asylum seeker/newly arrived refugee [
25].
In Stockholm County there are 7 designated health care centers responsible for the provision of HE for asylum seekers and newly arrived refugees.
In this study, we aimed to investigate perceptions and attitudes among actors involved in the implementation process of the HE and health care professionals carrying out the HE in Stockholm County concerning barriers and facilitators of implementing the HE, as well as on the purpose, content and value of HE.