Structural and procedural barriers to health assessment for asylum seekers and other migrants - an explorative survey in Sweden.

BACKGROUND: Health assessments (HAs) for newly arrived asylum seekers have become a regular practice in most EU countries, but what is performed, how they are organized, and whether it is mandatory or not to attend varies between countries. Swedish national statistics have shown that only about 45% of asylum seekers attend the optional HA offered upon their arrival in Sweden. There are significant variations among Sweden's 21 counties, ranging from 20 to 90%. The reasons for the low attendance have not yet been fully explored, though there are indications of structural weaknesses within the healthcare system. This study aimed to identify variations in policies and implementation of HAs targeting asylum seekers and other migrants. The study analyzes the structure and processes in different Swedish counties and discusses how this might influence the coverage. METHODS: This research project had an exploratory quantitative descriptive design applying a cross-sectional survey based on two structured questionnaires. Descriptive statistics were performed to summarize the data. RESULTS: The number of healthcare centers in each county that carried out HAs on asylum seekers varied independently of the size of the county. Variations in regard to structure, organization, processes, and performance monitoring of the HA process also appeared diverse, and these were in some cases also reported differently by administrators and healthcare professionals in the same county. Most commonly, the HAs were carried out in ordinary health centers, though some counties presented alternative solutions on how to organize the HAs. CONCLUSIONS: There seems to be no coherent national system for carrying out HAs on asylum seekers in Sweden. The structure, organization, processes, and outcomes vary between the counties, and the reasons for the low coverage of HAs appear to be multifaceted.

A state of limbo--in transition between two contexts: Health assessments upon arrival in Sweden as perceived by former Eritrean asylum seekers.

BACKGROUND: National statistics have shown that only about 40% of asylum seekers actually attend the optional health assessment offered upon their arrival in Sweden, but the reasons for this have not been fully explored. Health assessments for newly arrived asylum seekers have become a regular practice in most EU countries, but what is performed, how it is organized and whether it is mandatory or not varies between countries. AIM: The aim of the study was to explore and improve our understanding of how former asylum seekers from Eritrea perceived and experienced the health assessment during their asylum-seeking process. METHODS: We used a qualitative research approach guided by grounded theory. Semi-structured interviews were conducted with 11 former asylum seekers from Eritrea. Data were analysed based on constant comparative analysis. FINDINGS: The asylum seekers expressed feelings of ambiguity and mistrust and felt that they were seen only as objects by the Swedish healthcare system during their asylum-seeking process. Poor communication and inability to overcome language and cultural barriers seemed to be the most important findings in the narratives. The core category was defined as 'A state of limbo - in transition between two contexts'. CONCLUSIONS: There are reasons to believe that these issues with communication negatively affected both the quality of the health assessment and the number of asylum seekers attending the health assessment. Improved communication by the authorities towards the asylum seekers is, therefore, of vital importance.

Fogging the issue of HIV - barriers for HIV testing in a migrated population from Ethiopia and Eritrea.

BACKGROUND: The outcome of HIV treatment has dramatically improved since the introduction of antiretroviral therapy. Studies confirm that if treatment of HIV is initiated when the immune system is not severely affected by the virus the prognosis for the outcome is significantly better. There is also evidence that many immigrants come late for their first HIV test. If found to be HIV positive, and if the immune system is already significantly affected, this will compromise the treatment outcome. This study was performed in an attempt to understand the barriers for early HIV testing in a migrant population from Ethiopia and Eritrea in Stockholm, Sweden. METHODS: Participants were theoretically sampled and consisted of individuals who had immigrated from Ethiopia and Eritrea. Data were collected using 14 focus group discussions and seven semi-structured interviews. The analysis was performed according to a Grounded Theory approach using the paradigm model. RESULTS: Denial and fear of knowing one's HIV status dominated all aspects of behavior in relation to HIV. The main strategy was a "fogging" of the issue of HIV. People were said to not want to know because this would bring social isolation and exclusion, and it was often believed that treatment did not help. This attitude had strong roots in their culture and past experiences that were brought along to the new country and maintained within the immigrant community. The length of time spent in Sweden seemed to be an important factor affecting the "fogging of the HIV issue". CONCLUSIONS: In bridging the gap between the two cultures, Swedish authorities need to find ways to meet the needs of both earlier and newly arrived immigrants as well as the second generation of immigrants. This will require adjusting and updating the information that is given to these different sub-groups of Ethiopian and Eritrean immigrants. Appropriate access to healthcare for a diverse population obviously requires more than simply providing the healthcare services.

"Maybe his blood is still strong": a qualitative study among HIV-sero-discordant couples on ART in rural Uganda.

BACKGROUND: HIV-negative members of sero-discordant couples are at high risk for HIV acquisition but few behavioral prevention interventions have been implemented in sub-Saharan Africa and discordance is not well understood by couples themselves. METHODS: In this nested sub-study, we interviewed 40 HIV sero-discordant couples before and after a 6-month behavioral intervention that was comprised of four group discussions on specific HIV prevention and care topics. The content of the sessions included: 1) understanding HIV serodiscordance and reducing risk, 2) couple communication, 3) reproductive health and HIV serodiscordance, 4) coping with HIV serodiscordance and ongoing support. Couple members were interviewed individually. Data were analyzed thematically using 'Framework Analysis' which incorporated dyadic factors to address couple issues. RESULTS: Analysis revealed pre-identified concepts and emergent themes that were relevant to the final conceptual model. Four major categories of factors affecting couple relations, beliefs and current risk behaviors emerged: intervention factors, structural/contextual factors, physical health factors, and past risk behavior. The topics within the intervention most relevant were communication and reproductive health. The contextual factors highlighted by couples were gender norms around sexual decision-making and multiple partnerships. Individual beliefs regarding HIV serodiscordance persisted over all time points for some couples. Interestingly, some couple members had divergent views about their HIV status; some believing the HIV-negative member was negative while others described multiple beliefs around the negative member's blood surely being positive for HIV. Couple communication emerged as an important theme mediating beliefs and behavior. CONCLUSIONS: In addition to biomedical and behavioral interventions, HIV-serodiscordant couple interventions must embrace the contextual complexity and cultural understanding of HIV infection and discordance as well as the dynamic nature of couple communication to influence risk behavior.

'Pregnancy comes accidentally--like it did with me': reproductive decisions among women on ART and their partners in rural Uganda.

BACKGROUND: As highly active antiretroviral therapy (ART) restores health, fertility and sexual activity among HIV-infected adults, understanding how ART influences reproductive desires and decisions could inform interventions to reduce sexual and vertical HIV transmission risk. METHODS: We performed a qualitative sub-study among a Ugandan cohort of 1,000 adults on ART with four purposively selected categories of participants: pregnant, not pregnant, delivered, and aborted. In-depth interviews examined relationships between HIV, ART and pregnancy, desire for children, perceived risks and benefits of pregnancy, decision-making regarding reproduction and family planning (FP) among 29 women and 16 male partners. Analysis focused on dominant explanations for emerging themes across and within participant groups. RESULTS: Among those who had conceived, most couples stated that their pregnancy was unintentional, and often occurred because they believed that they were infertile due to HIV. Perceived reasons for women not getting pregnant included: ill health (included HIV infection and ART), having enough children, financial constraints, fear of mother-to-child HIV transmission or transmission to partner, death of a child, and health education. Most women reported FP experiences with condoms and hormonal injections only. Men had limited FP information apart from condoms. CONCLUSIONS: Counselling at ART initiation may not be sufficient to enable women who do not desire children to adopt relevant family planning practices. On-going reproductive health education and FP services, with emphasis on the restoration of fertility after ART initiation, should be integrated into ART programs for men and women.

The virus stops with me: HIV-infected Ugandans' motivations in preventing HIV transmission.

Few Positive Prevention interventions have been implemented in Africa; however, greater attention is now being paid to interventions that include messages of personal responsibility or altruism that may motivate HIV-infected individuals towards HIV prevention behaviors in Africa. We conducted 47 in-depth interviews in 2004 with HIV-infected men and women purposefully sampled to represent a range of sexual activities among clients of an AIDS support organization in Uganda. Qualitative interviews were selected from a cross-sectional survey of 1092 HIV-infected men and women. Clients were interviewed about their concerns around sexual HIV transmission, feelings of responsibility and reasons for these feelings, as well as about the challenges and consequences of actions to prevent HIV transmission. The reasons they provided for their sense of prevention responsibility revolved around ethical and practical themes. Responsibility toward sexual partners was linked to the belief that conscious transmission of HIV equals murder, would cause physical and emotional harm, and would leave children orphaned. The primary reason specific to preventing HIV transmission to unborn children was the perception that they are 'innocent'. Most participants felt that HIV-infected individuals held a greater responsibility for preventing HIV transmission than did HIV-uninfected individuals. Respondents reported that their sense of responsibility lead them to reduce HIV transmission risk, encourage partner testing, disclose HIV test results, and assume an HIV/AIDS educator role. Challenges to HIV preventive behavior and altruistic intentions included: sexual desire; inconsistent condom use, especially in long term relationships; myths around condom use; fear of disclosure; gender-power dynamics; and social and financial pressure. Our finding that altruism played an important role in motivating preventive behaviors among HIV-infected persons in Uganda supports the inclusion of altruistic prevention and counseling messages within Positive Prevention interventions.

Processes and outcomes of HIV serostatus disclosure to sexual partners among people living with HIV in Uganda.

Disclosure of HIV serostatus to sexual partners supports risk reduction and facilitates access to prevention and care services for people living with HIV/AIDS. To assess health and social predictors of disclosure as well as to explore and describe the process, experiences and outcomes related to disclosure of HIV-infected men and women in Eastern Uganda, we conducted a study among HIV-infected men and women who were clients of The AIDS Support Organization (TASO) in Jinja, Uganda. We enrolled TASO clients in a cross-sectional study on transmission risk behavior. Demographic and behavioral data and CD4 cell count measurements were collected. Among 1,092 participants, 42% were currently sexually active and 69% had disclosed their HIV serostatus to their most recent sexual partner. Multivariate logistic regression analysis showed that disclosure of HIV-status was associated with being married, having attended TASO for more than 2 years, increased condom use, and knowledge of partner's serostatus. From these clients, 45 men and women were purposefully selected and interviewed in-depth on disclosure issues. Positive outcomes included risk reduction behavior, partner testing, increased care-seeking behavior, anxiety relief, increased sexual communication, and motivation to plan for the future.