Health Assessment and the Right to Health in Sweden: Asylum seekers’ Perspectives PLoS ONE 11(9) e0161842. doi:10.1371/journal.pone.0161842. September 2, 2016 Lubin Lobo Pacheco MA, PhD-student Dept. of Public Health and Clinical Medicine, Umeå University, Sweden Robert Jonzon RNT, BA, MPH, PhD-student The Public Health Agency of Sweden Dept. of Public Health and Clinical Medicine, Umeå University, Sweden Anna-Karin Hurtig MD, PhD Dept. of Public Health and Clinical Medicine, Umeå University, Sweden

Background Swedish law entitles asylum seekers to a voluntary Health Assessment [HA], the sole active effort from Swedish authorities to fulfill asylum seekers right to health

The right to health - medical and dental care for migrants in Sweden The Health and Medical Care for Asylum Seekers and others Act (2008:344) “Others” = quota refugees, other refugees (family reunification), undocumented or irregular migrants Health assessment Emergency care and care that cannot be deferred, including dental care, maternity care, care when seeking abortion and advice on contraception

Each of Sweden´s 21 counties has a county council, responsible for the health and medical services within the county. This responsibility include healthcare for asylum seekers, such as the health assessment.

The health assessment A dual purpose; To identify health problems that need immediate attention (for the individual person) To detect and prevent spread of infectious diseases (for public health reasons)

Background (cont.) Few asylum seekers undergo the HA on arrival to Sweden Structural weaknesses identified The asylum seekers’ own perception of the HA has not yet been sufficiently explored

Proportion (%) asylum seekers in Sweden undergoing the HA Source: The Swedish Association of Local Authorities and Regions (SALAR) 2013 43% 2014 44% 2015 39%

Conceptual Framework The right to health implies liberties and entitlements, which include the right to a health system that provides equal opportunities for everyone to enjoy the highest attainable level of health.

Conceptual framework (cont.) To monitor its implementation, WHO suggests the rights to be broken down into operational indicators and have proposed four interrelated dimensions to analyze the right to health; Availability Accessibility Acceptability Quality

Aim Assessing how the information, procedures and services related to the HA were accessible and acceptable to fulfill the right to health of asylum seekers, from their own perspective.

Method A cross-sectional quantitative design Among all 132 language schools in four Swedish counties, (total 21), 20 were randomly selected and among them 16 language schools agreed to participate in the study A questionnaire was distributed to 1 447 students. Of them only 386 fulfilled the inclusion criteria; Being a language student, Having sought asylum in Sweden in 2010 or later, and mastering at least one of the languages used in the questionnaire (Swedish, English, French, Spanish, Arabic, Somali, Farsi and Tigrinya).

Selection of participants (Method cont.) Information about the students’ reasons to migrate and year of arrival was not possible to be obtained prior to the survey, since the schools did not register this data. Moreover, the disclosure of reasons for migration is considered to be a sensitive matter, particularly concerning refugees and asylum seekers. To overcome these difficulties, the questionnaire included questions that allowed us to identify and separate the group of interest for the study, namely asylum seekers, who arrived in 2010 and after.

Method cont. Frequency distributions were calculated using the statistical package Stata 13.0. We analyzed to what extent the respondents considered the information, procedures and services related to the HA to be accessible and acceptable.

Data analysis (Method cont.) Accessibility was analyzed by three variables: universal access, language and communication, and health-related information. Acceptability was analyzed by the variable: cultural appropriateness i.e. respect for cultural differences.

48 (12.4%) respondents did not undergo the HA. Findings 48 (12.4%) respondents did not undergo the HA. Of them, a majority, 31 respondents, did not receive the invitation letter. They indicated that they had lost the opportunity to know their health status, to obtain treatment for or advice about their health problems.

Findings (cont.) Additionally, 213 (55.2%) of those who attended the HA indicated that their needs were overlooked, particularly when these were of mental health nature. Two in three participants also considered the HA to merely be a communicable disease control, rather than an effort to deal with their perceived health needs. Nevertheless, the respondents had a positive attitude towards the HA as such.

Conclusions Although being an important contribution, the HA does not suffice to fulfill the right to health of asylum seekers, due to shortcomings regarding the accessibility and acceptability of the information, procedures and services that it contains.

Take home message The health of asylum seekers is a human rights concern, that health authorities are obliged to materialize by securing HAs that is proved accessible and acceptable

Ethical considerations The study was approved by the Regional Ethical Review Board in Umeå (Reg. no. 2014-11-32M) Permission was acquired from the principal of each language school The respondents were informed, verbally and written, about the purpose of the study, that participation was voluntary and that they could withdraw at any time without explanation. Further, it was explained that the answers were to be given anonymously and that no individual could be identified in the results or reports.

Thank you! robert.jonzon@folkhalsomyndigheten.se