The physical health status, service utilisation and barriers to accessing care for asylum seekers residing in the community: a systematic review of the literature

Additional keywords: community, healthcare utilisation, physical health.

According to the 1967 Protocol of the 1951 Convention Relating to the Status of Refugees, a refugee is any person owed protection outside the country of their nationality or birth because they have a well-founded fear that they will be persecuted because of their race, religion, nationality, political opinion or membership of a particular social group.¹ When that person’s claim for protection is not approved and/or still being assessed, they are referred to as asylum seekers. At the end of 2011, there were 42.5 million forcibly displaced people worldwide, of which 15.2 million were refugees and 895 000 were asylum seekers.² Australia, a signatory of the 1951 Refugee Convention, is one of 26 countries participating in the United Nations High Commissioner for Refugees (UNHCR) resettlement program,³ granting 13 759 visas under the Refugee and Humanitarian Program in the financial year 2011–12.⁴ Although the majority of people seek protection through the UNHCR ‘offshore’, there are also a significant number of people arriving by plane or boat who claim asylum once in Australian territory (‘onshore’). Onshore asylum seekers who arrive by plane are granted bridging visas, which allow them to remain lawfully in the community while their refugee claims are assessed, unlike asylum seekers arriving by boat, who are more likely to be detained.

Since November 2011, the Australian government has been releasing some asylum seekers from detention centres into the community with a bridging visa, while their applications are being processed.⁵ More recent policy changes have resulted in the withdrawal of work rights for some community-residing asylum seekers,⁶ and the reintroduction of offshore processing – both conditions related to the means and time of arrival. Complex conditions around permission to work mean there are some asylum seekers on bridging visas, including some arriving by plane, that are denied Medicare.⁷ Complete data on the number of Medicare-ineligible asylum seekers (at all stages of processing) in the community are very difficult to determine.

Allowing some asylum seekers to reside in the community is welcomed by many health and community groups, who have persistently lobbied to reduce the harms incurred in detention centres. However, it now means there are increasing numbers of asylum seekers in the community with complex health needs and relatively little material or social support. Many face difficulties paying for health-related needs and rely on the generosity of pro-bono services and other fee-waivers.⁸ For some asylum seekers, poverty, unsanitary and crowded living conditions, inadequate nutrition and poor access to healthcare services before coming to Australia may contribute additional health burdens.^9,10 Existing health issues may be further exacerbated by post-migration experiences such as immigration detention before being released in the community, the indeterminate visa status, social isolation, language barriers, financial instability and poor service access.^8,11

In the current political context, with a dramatic increase in the number of people living in the community while seeking asylum in Australia, it is imperative that we have a clear understanding of their health-related needs in order to develop appropriate services. The health of asylum seekers in the community is likely to reflect environmental and social factors, and they face unique challenges navigating the host country’s health system. The policy environment around healthcare and social service entitlements in Australia and internationally is constantly evolving and highly politicised, which impacts on the ability to conduct proper research and translate it into evidence-based practice. To date, however, there has been a predominant focus on the mental health implications of immigration detention, with several systematic reviews having already been conducted.^12–14 Research with asylum seekers in Australia’s community is currently lacking due to reluctance by the government to provide statistics or registers of those living in the community¹⁵ as well as ethical issues and recruitment difficulties in gaining access to ‘hidden’ populations that may be fearful of authority.¹⁶ Drawing from the international literature, the aim of this systematic review was to document physical health problems that asylum seekers experience on settlement, to assess the utilisation of healthcare services and barriers to care.

The conduct of the systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.¹⁷ MEDLINE, PsycINFO, Embase and CINAHL databases were searched. Search terms included: (asylum seek*, seek* asylum, refugee claimant* or forced migrant*) and (health, health disparity, health care access, health care utilisation, primary health care or tertiary health care).

Mesh keywords, indexed terms and subheadings were used as appropriate, depending on the specifications of the database.

All studies yielded from the database search were reviewed and assessed for eligibility based on the following criteria: (i) the primary participant group were adult asylum seekers or failed asylum seekers residing in the community (i.e. not a closed detention facility); (ii) the studies were conducted in a high-income country (World Bank Organisation for Economic Co-operation and Development criteria¹⁸); and (iii) the results were published in a peer-reviewed journal in English between 2002 and October 2012. In studies where the sample included refugees, the study was included if the proportion of asylum seekers was greater than 50% of the sample. Physical health was defined as any condition affecting the functioning of the body and involving symptoms or diagnoses related to disease or injury of the body. It did not include articles focusing on mental health problems or studies that were not concerned with assessment of disease burden in asylum seekers to inform service provision, for example studies assessing the effectiveness of tuberculosis screening.

The systematic review included both quantitative and qualitative studies. Quantitative studies were examined to assess physical health status, correlates of physical health and utilisation of health services, whereas qualitative studies were included to explore barriers and facilitators to service access. The inclusion of qualitative studies in systematic reviews is becoming increasingly common, as it may enable triangulation of findings or offer alternative explanations.¹⁹

All data extraction and appraisals of retrieved studies were primarily undertaken by the first author (EH) and independently verified by the second author (AR), and there was no disagreement between the two reviewers. The extraction of the data followed a tree-stepped process filtering first by title, then the abstract and finally full text were obtained and reviewed. In addition, the reference lists of included articles and any relevant reviews were manually scanned to identify any additional studies that our search strategy could have missed (Fig. 1).

Fig. 1.  Flow diagram of the study selection process.

For quantitative studies, data extraction and critical appraisal of the quality of studies were informed by the ‘Strengthening the Reporting of Observational studies in Epidemiology’ guidelines.²⁰ Eight quality-appraisal criteria were generated: study objective; representativeness; size of the sample; instrumentation/outcome measures; statistical analyses used; control for confounding; study limitations acknowledged; and ethical considerations. Qualitative studies were appraised using a critical review form informed by several guidelines^21–24 and included: study objective; the use of theoretical perspective to inform the study design and data analysis; sampling technique and size; procedural rigour; triangulation of data analysis and reporting (i.e. consistency); reflexivity; limitations of the study acknowledged; and ethical considerations. The quality of the studies was rated according to their summary score: poor (0–3), adequate (4–6), or high (7–8) quality.

Due to the heterogeneity of study designs, measures of physical health and settings, a meta-analysis was not appropriate. For quantitative studies, an integrative approach to content analysis was achieved by identifying key concepts a priori. These findings were then reported in a narrative style based on similarities and dissimilarities observed between studies utilising similar outcome measures. Synthesis of evidence from qualitative studies was undertaken using a thematic analysis approach (by the two authors),²⁵ which involved identifying prominent and recurring themes across study findings exploring barriers and facilitators to healthcare. A summary table was employed to improve transparency, assist with reflecting on the frequency or weight of themes and conduct cross-study analysis.

The initial database search yielded 1499 articles (Fig. 1), of which a total of 32 studies met the inclusion criteria (23 quantitative and nine qualitative studies), of which only three were in Australia (Tables 1, 2). All of the quantitative studies were cross-sectional and included mostly audits of medical records or clinical databases (15 studies), or questionnaires (eight studies). Of the qualitative studies, five involved focus group interviews and four employed both focus groups and in-depth interviews. The quality of the 32 studies varied significantly. For quantitative studies, three were of poor quality, 10 were of adequate quality and 10 were of high quality. The majority of qualitative studies were of adequate quality (six), with two of poor quality and only one of high quality.

Table 1.  Quantitative studies: general study characteristics, findings and quality appraisal
ICPC, International Classification of Primary Care; ICD, International Classification of Diseases; N/S, not specified; PMLP, Post-Migration Living Problems; SAMM, severe acute maternal morbidity

Table 2.  Qualitative studies: general study characteristics and quality appraisal
N/S, not specified

Of the 23 quantitative studies included in the review, 18 provided data on the physical health status of asylum seekers (eight based on self-report and 10 based on medical record or clinical database data with standardised diagnostic criteria as summarised in Table 1 under ‘outcome measure’).^26–43

Compared with other population groups using the same outcome measures, perception of poor general health status was much worse among asylum seekers (around 60%^32,42) than comparative refugee samples (around 42%^32,42), immigrants (39%³²) or a general, non-immigrant population (18%³²).

Overall, chronic physical symptoms or complaints were self-reported by 49–77% of asylum seekers.^{29,32,37,40,42} Prevalence differed between study populations, but symptoms and medical diagnoses were commonly noted for the following conditions: dental; headache or migraine; musculoskeletal; neck, back or shoulder pain; dermatological; respiratory; and gastrointestinal problems. Four studies focussed specifically on sexual and reproductive health issues.^33,35,41,43 These studies showed that asylum seeker women faced a range of complex gynaecological diagnoses and obstetrical issues, including an incidence of severe acute maternal morbidity 4.5 times higher than the general population.⁴³ Asylum seekers were also more likely to have experienced sexual assault^35,41 and had higher rates of unwanted pregnancies and induced abortions^33,35 than the host population.

Hobbs et al. reported the results of a physical health screening program.³⁴ The study found a high prevalence − compared with the host population − of infectious diseases including active tuberculosis, HIV, Hepatitis B and C, gastrointestinal infections, and helminths.³⁴ Bischoff et al. identified eight International Classification of Diseases (ICD) categories: musculoskeletal, respiratory, mental, skin, injury, infectious and parasitic, cardiovascular and pregnancy/childbirth. Of these, infectious and parasitic diseases accounted for only 6.3% of individual diagnoses, which was among the lowest frequency of the eight ICD categories and required the least number of clinic visits per person diagnosed, whereas musculoskeletal and respiratory had the highest frequencies of diagnosis.²⁸ Only one study reported on dental needs, and found that 68.5% of asylum seekers self-reported a need for dental consultation.²⁹

Of the 23 quantitative studies included in the review, 11 studies examined the association between sociodemographic factors and physical health.^{26,28,32–34,36,37,42–45} These findings suggest that older age is associated with an increased risk of all ICD diagnostic categories (excluding reproductive health issues),²⁸ poorer self-reported general health status,³² functional disability,³⁷ chronic conditions^32,37 and a higher medical referral rate.²⁶ Female gender was associated with a greater likelihood of reporting chronic conditions^32,37 and physical symptoms²⁶ but not with any specific ICD diagnoses.²⁸ Ethnicity was another sociodemographic characteristic affecting health outcomes; however, due to heterogeneity of sample characteristics, it was too methodologically complex to draw comparison between different ethnic groups or source countries.^26,28,32,34 One study found that participants from countries experiencing violent conflict had higher frequencies of several ICD diagnoses as well as requiring a greater number of consultations and higher healthcare costs.⁴⁵ Compared with those who had arrived within the previous 6 months, asylum seekers with a longer length of stay had a higher level of disability, greater physical complaints, perceived lower physical health status and lower quality of life.^36,37 Longer length of stay was also associated with a lower live birth and abortion rate among asylum seekers.³³ A greater number of pre-migration traumatic events resulted in higher medical referral rates,²⁶ and was associated with chronic conditions and poor general health status.³² Similarly, post-migration living conditions and stressors were associated with chronic diseases and poor general health status across several studies.^32,37,42

Of the 23 quantitative studies included in the review, 11 provided data on asylum seekers’ utilisation of health services, of which five were based on self-reported measures,^{29,36,41,42,46} and six studies used objective measures (medical records or clinical data).^{27,28,31,38,47,48} The proportion of asylum seekers accessing primary care services (facilitated by a nurse or general practitioner) ranged from 55 to 73% in the last 2 months^36,42,46 to 81% over a 3-year timeframe.²⁷ Asylum seekers’ annual primary care attendance averaged 5.8 visits per year in Switzerland,²⁸ 5.2 in the UK (double that of the host population)³⁸ and 3.4 in Australia.³¹ Annualised hospitalisation rates reported in two studies, as measured by the number of admissions in the previous 12 months, varied from 12⁴⁶ to 20%⁴² compared with 7% reported in the general population.⁴⁶ Medication prescriptions (any type) were a frequent outcome of primary care visits, with over half of encounters involving the recommendation or prescription of medication.^31,38 The proportion of asylum seekers reporting recent medication use ranged from 39 to 72%.^36,42,46

Asylum seekers’ utilisation of preventative health services, such as screening, health education and immunisation, as well as dental care, allied health and other specialist services were limited or not commonly measured. The few available data suggest that less than 25% of female asylum seekers in Blackwell et al. and Rogstad and Dale reported having undergone a cervical pap screening test (v. 62% reported in the host population),^29,41 and overall preventative assessment, including general check-up and health education, occurred in 1 out of 20 encounters in Correa-Velez et al.’s study in Australia.³¹

Finally, in comparing the consumption and costs of health services by asylum seekers with a local comparable sample, Bischoff et al.²⁷ found that the mean (±s.d.) number of consultations over a 3-year period was 27 ± 50.9 among asylum seekers compared with 33.9 ± 26.7 among the host population. In addition, asylum seekers received shorter duration of care. Therefore, in economic terms, asylum seekers’ average monthly cost to the health system was less than half that of the local population. In contrast, Maier et al.’s study into asylum seekers’ use of health services found that they were more than twice as likely to consult a general practitioner or a specialist and their healthcare costs were 1.8 times higher than that of the local population.⁴⁸

Nine qualitative studies were identified that provided information on barriers and facilitators to healthcare.^8,49–56 Six major themes were identified within these studies.

Inability to pay for medical consultation was cited as an inhibitory factor in some contexts where, at the time of the study, access to free healthcare was not universal.^8,49,55,56 Aside from consultation fees, there appear to be other costs that serve as barriers, including the cost of transportation to appointments, difficulties paying for pharmaceuticals and other health-related expenses,^8,52–56 including contraception.³⁵

Many asylum seekers originate from low- and middle-income countries where the structure of the health system is very different to that of highly industrialised countries. The participants in the majority of the studies found navigating the healthcare system to be problematic due to inadequate knowledge of the availability of, and their eligibility for, health services.^{49,50,52–56} Problems cited were a lack of provision of health service information on arrival in the country, poor understanding of the concept of primary healthcare and referral pathways, and logistical difficulties in accessing a service. Social and community supports were seen as integral for providing information and resources to facilitate service access.^49,51,52

Participants complained of long waiting times for all types of services and a lack of continuity of care, which served as deterrents for future help-seeking.^49,50,53,54 Continuity of care was perceived to be a facilitator to service access because it improved asylum seekers’ trust and confidence in health professionals. Some asylum seekers were concerned about the ‘generalist’ role of doctors in primary care. They felt that GPs were not specialised enough or did not have sufficient knowledge about refugee health issues to be able to provide adequate care.^49,53,54

The participants in Asgary and Segar’s study held concerns over the degree of confidentiality and security that was maintained with their health information. This appeared to be linked to the perception that the immigration and health systems were interconnected, and that their health information, lack of documentation or inability to pay would have an effect on the asylum process, or increase their risk of deportation or detention.⁴⁹ The participants of other studies expressed issues of trust relating to the presence of interpreters during consultations, as they could not be assured of the accuracy and quality of translation and whether confidentiality was upheld.^50,51,53,54

Themes of discrimination were highlighted in multiple qualitative studies.^{49–54,56,57} This included witnessed or observed hostility from staff, feeling that they weren’t being respected, were being denied care or were offered a poorer quality of care as a result of their race or immigration status. In contrast, staff that demonstrated kindness, listened carefully and built rapport with asylum seeker patients fostered a sense of trust and facilitated service access.^{49,51–54,57}

In most countries, asylum seekers are eligible for interpreter services in a range of health settings but communication and linguistic barriers were consistently described as major barriers to healthcare.^{8,49–51,53,54,56} Asylum seekers frequently encountered a lack of available, professional or culturally appropriate interpreters, resulting in the inappropriate use of family or friends as informal interpreters.

Studies utilising both patient- and physician-reported data consistently demonstrate that asylum seekers have a high prevalence of one or more medical conditions, and where a comparison group is available, this is significantly greater than the host population. This is not limited to infectious diseases, as is commonly thought, but encompasses a complex array of acute and chronic medical conditions, reflected in asylum seekers’ tendency to report their general health as poor. Cross-sectional studies correlating demographic risk factors, albeit limited, indicate that female gender, a history of experiencing violent conflict or pre-migration trauma, and a lengthy asylum process are associated with poorer health outcomes.

Patterns of healthcare consumption appeared to be high in most studies but varied between settings; heterogenous study designs and the absence of a comparative host sample in many studies made it difficult to contextualise these findings. Utilisation rates can reflect both morbidity patterns and health service entitlements or access, making interpretation somewhat challenging.⁵⁸ Bischoff et al. found that despite a higher number of diagnoses, asylum seekers had fewer medical consultations, shorter duration of care and lower costs than the host population,²⁷ suggesting that they face barriers in seeking care. These findings conflict with another study from the same country concluding that asylum seekers had more frequent consultations and higher costs.⁴⁸ The contradictory findings could be a result of different study methodology and costing models, but nevertheless highlight the difficulties in examining healthcare consumption.

Of the studies included in the review, only one quantitative³¹ and two qualitative studies^8,55 were undertaken in Australia. Therefore findings from research conducted with asylum seekers in other host countries should be considered in the context of the healthcare system, entitlements, socio-environmental factors, and other humanitarian policy such as the profile of asylum seeker intakes. For example, all countries identified in the research appear to have a health screening process for asylum seekers on arrival and most provide healthcare beyond emergency needs, but there are important differences in the extent and delivery of services. In the Netherlands a gatekeeper system is in place, where on-site in government-provided residences asylum seekers have access to a doctor or nurse whom they are required to see before being referred externally. In Switzerland and the UK, asylum seekers are allocated to or register with a primary care service in the community and provided with free, comprehensive health coverage. The Swiss example is particularly unique where research was embedded within a specialised, integrated primary care service founded within a tertiary teaching hospital, specifically to provide comprehensive primary care for asylum seekers. Data collected over a 3-year period were used to monitor the needs of asylum seekers attending the service and make improvements accordingly.

The above examples of other host countries are in contrast to Australia, where health services are fragmented and increasingly difficult to navigate for asylum seekers and health providers alike, and very limited data are collected on asylum seekers attending public health services. The findings from qualitative data suggest that asylum seekers face many barriers in accessing care, which presents opportunities for improvements that could be adopted in the Australian context. Due to their unique and diverse health profiles, linguistic barriers, cultural differences and longer consultation requirements, some health professionals may be under-resourced or reluctant to provide care to asylum seekers.⁵⁹ The continued development and wide dissemination of evidence-based clinical guidelines, innovative service models and incentives for professional development need to be complemented with a national cultural competence framework to assist health professionals to better meet the needs of asylum seekers. Specialist refugee health roles, such as Refugee Health Fellows and Refugee Health Nurses, as well as bicultural health and welfare workers can be integral resources for other health professionals seeking advice and support.

Other policy considerations to improve access and health outcomes for asylum seekers in Australia include the adoption of universal access to Medicare, the Pharmaceutical Benefits Scheme and the provision of Health Care Cards to those meeting eligibility criteria. This would make healthcare and medications more affordable, reduce the burden on community services willing to provide fee-free consultations⁶⁰ and address the inconsistencies between state fee-waiver directives for Medicare-ineligible asylum seekers.^61,62 Reducing such inequities for asylum seekers is likely to prevent long-term health complications due to delayed intervention⁶³ and perhaps provide greater uptake of preventive services.

In Australia, asylum seekers are not eligible for many of the settlement services provided to refugees, such as extensive information and orientation, language classes, Centrelink income benefits, skills training and employment services. Being largely dependent on community welfare organisations disempowers individuals and exposes them to greater health risks as they face poverty and homelessness.^64,65 More research into social and environmental factors that may increase the susceptibility of asylum seekers to poor health is urgently required. Addressing such determinants of asylum seeker health requires a framework that seeks greater collaboration between health and welfare organisations and policy makers.

There were several limitations in the quality of the studies reviewed, which should be acknowledged. Although a few studies did use random sampling from non-clinical settings, there was a tendency to recruit convenience samples through health and support centres. This may have resulted in an over-representation of health problems, or a bias toward those already seeking care and with greater social supports, rather than the more marginalised asylum seeker population. Other limitations include the predominance of cross-sectional methodology, reliance on self-reported health data, inadequate survey instruments that were not always cross-culturally validated and back-translated, and a lack of testing of the reliability of interpreters.

There were also some challenges and limitations in conducting this systematic review. Incorrect or inexplicit use of the correct legal terminology related to asylum seekers may have resulted in the unintended exclusion of some articles, as the broader term ‘refugees’ was not used in the database search. Despite the heterogeneity of study designs, inclusion of qualitative studies enabled the assessment of complex concepts and triangulation of data.

Asylum seekers residing in community settings while they await a decision on their refugee status have a disproportionate burden of physical morbidity that is not only limited to infectious diseases, but also chronic, non-communicable conditions and sexual and reproductive health issues. There are several unique factors that place them at greater risk of poorer health outcomes, some of which are related to the host country environment and amenable to intervention. There are a multitude of barriers that continue to impede healthcare access for asylum seekers. Despite increasing numbers of people seeking asylum in many countries throughout the world, little research has been conducted to help us understand the health needs of this vulnerable group. Further studies are urgently required to promote the development of policy and a national cultural competence framework to guide the provision of healthcare to asylum seekers and to address the current health inequities they face.

The authors report no conflicts of interest.