Health service utilization in London's African migrant communities: implications for HIV prevention

Health-seeking behaviours of immigrants, asylum seekers and refugees in Europe: a systematic review of peer-reviewed articles

Purpose

Immigrants, asylum seekers and refugees living in Europe face a number of challenges in accessing or using health information and healthcare services available in their host countries. To resolve these issues and deliver the necessary services, providers must take a comprehensive approach to better understand the types of health information and healthcare services that these individuals need, seek and use. Therefore, the purpose of this paper is to develop that comprehensive approach.

Design/methodology/approach

In this paper, a systematic literature review of peer-reviewed publications was performed, with 3.013 articles collected from various databases. A total of 57 qualifying papers on studies conducted in Europe were included in the review after applying the predefined inclusion and exclusion requirements, screening processes and eliminating duplicates. The information seeking and communication model (ISCM) was used in the analysis.

Findings

The findings revealed that while many health information and healthcare services are accessible in Europe for immigrants, asylum seekers and refugees, many of these individuals are unaware of their existence or how to access them. While our findings do not specify what health-related information these groups need, use or seek, they do suggest the importance and value of providing mental health, sexual health and HIV, as well as pregnancy and childbirth information and services. Furthermore, according to our results, health information services should be fact-based, easy to understand and raise awareness about healthcare structure and services available in Europe for this vulnerable population.

Practical implications

This study has a range of practical implications, including (1) highlighting the need for mental health and behavioural health services and (2) stressing the value of addressing cultural context and religious values while investigating (health) information seeking of people with foreign background.

Originality/value

This is one of the first studies to systematically review and examine the behaviour of immigrants, asylum seekers and refugees in relation to health information and healthcare services in the European context.

A Systematic Review of HIV Serostatus Disclosure Among African Immigrants in Europe

As the human immunodeficiency virus continues to devastate large parts of Africa, particularly the Sub-Saharan region, the number of immigrants migrating from these areas to European nations continues to grow. African men and women leave their countries for Europe because of armed conflicts, unemployment, or poverty. Thus, these migration patterns combined with newly contracted infections have resulted in a large and growing number of HIV-positive diagnoses among African immigrants living in Europe. Using the disclosure process model, this systematic review examines the reasons for HIV status disclosure and nondisclosure among African immigrants residing in Europe. PubMed, PsycINFO, Embase, Global Health, and Web of Science were searched. Bibliographies of retrieved studies were also reviewed for other relevant citations. Studies were eligible if they: (1) focused on HIV-positive immigrants from SSA residing in Europe; and (2) described or measured HIV status disclosure. Out of 166 articles found, a total of 17 articles and 1 brief report met the inclusion criteria. Factors such as stigma and social implications of disclosure contribute to avoidance goals leading to nondisclosure while approach goals or disclosure reasons were found to include health status and behaviors such as seeking support, and helping others. The findings highlight the importance of understanding the avoidance and approach goals involved in HIV status disclosure among African immigrants in Europe. Interventions and future research directed at increasing HIV disclosure among African immigrants in Europe should move beyond individual-level to consider multilevel factors including country-specific social behaviors.

Barriers to accessing HIV services for Black African communities in Cambridgeshire, the United Kingdom

The majority of new HIV diagnoses in the United Kingdom (UK) occur in people with heterosexually acquired HIV infection, the majority of whom are African communities. Current research shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This study therefore explored barriers to equal access to HIV services by African migrants in the UK. Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, vol 3. University of California Press, Berkeley, 1980) model of health care systems was applied in this research as a theoretical framework and lens through which the reported findings are viewed as it places health within the broader context of culture. In this research a qualitative approach with focus groups was used. A total of thirty participants were recruited from African migrant community organisations in Cambridgeshire in the East of England strategic health authority in order to study the experiences of African migrants when accessing sexual health services. It was found that barriers to equal access to HIV services exist for African communities in Cambridgeshire. These included language barriers and others bordering on the use of traditional medicine by African migrants, understanding of cultural diversity, awareness of how and where to access HIV services, and getting information about HIV. Findings highlighted the importance of taking the sectors of Kleinman's [1] model into consideration when planning HIV services for African communities.

Transforming the boundaries of health care: insights from Somali migrants

Despite its growing practice, transnational medical care has not yet been embedded as a critical component of health research, professional practice, or analyses of changes in the social determinants of health. Biomedical practitioners in Finland have failed to take into account the transformative role of transnational health care. Consequently, Somali migrants do not receive informed advice on how to incorporate distant practices into physical and mental health plans. By connecting here-and-there (Finland and Somaliland) studies involving outlooks on and experiences of illness, healing, and interactions among Somali migrants and their medical providers, we show how transnational connections augment personal resilience.

Prevalence of at-risk drinking among a national sample of medical students

As limited research exists on medical students' substance use patterns, including over-consumption of alcohol, the objective of this study was to determine prevalence and correlates of at-risk drinking among a national sample of medical students, using a cross-sectional, anonymous, Web-based survey. A total of 2710 medical students from 36 U.S. medical schools (1st to 4th year) completed the survey. Included in the instruments was a 10-item scale (AUDIT) to assess at-risk drinking behaviors within the last 12 months. Over 15% of the subjects (n = 412) scored positive for at-risk drinking (>/= 8). Multivariate analysis of the data revealed the following independent predictors were statistically significant (P </= 0.05) for at-risk drinking: being of younger age, male, unmarried, using illicit drugs, smoking tobacco products within the last 30 days, having low perception of risk, showing impulsive behavior, being depressed, and having gambling problems. Findings from this study provides initial data for investigating further associations between risky drinking behavior, lifestyle, and psychosocial factors, as well as effectiveness of curriculum or campus-wide policy interventions to reduce over-consumption of drinking among this population.

Social, behavioural, and intervention research among people of Sub-Saharan African origin living with HIV in the UK and Europe: literature review and recommendations for intervention

Africans are the second largest group affected by HIV in Western Europe after men who have sex with men (MSM). This review describes and summarises the literature on social, behavioural, and intervention research among African communities affected by HIV in the UK and other European countries in order to make recommendations for future interventions. We conducted a keyword search using Embase, Medline and PsychInfo, existing reviews, 'grey literature', as well as expert working group reports. A total of 138 studies met our inclusion criteria; 31 were published in peer-reviewed journals, 107 in the grey literature. All peer-reviewed studies were observational or "descriptive," and none of them described HIV interventions with African communities. However, details of 36 interventions were obtained from the grey literature. The review explores six prominent themes in the descriptive literature: (1) HIV testing; (2) sexual lifestyles and attitudes; (3) gender; (4) use of HIV services; (5) stigma and disclosure (6) immigration status, unemployment and poverty. Although some UK and European interventions are addressing the needs of African communities affected by HIV, more resources need to be mobilised to ensure current and future interventions are targeted, sustainable, and rigorously evaluated.

Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK

OBJECTIVE

To identify opportunities for earlier HIV diagnosis within primary and secondary care settings in the UK in Africans with newly diagnosed HIV infection.

METHODS

A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was conducted between April 2004 and February 2006. The survey consisted of a confidential self-completed questionnaire linked to clinician-completed clinical records.

RESULTS

A total of 263 questionnaires were completed, representing an uptake rate of 79.5% of patients approached and 49.8% (131/263) of participants presented with advanced HIV disease (CD4 cell count < 200 cells/mul at diagnosis). In the year prior to HIV diagnosis 76.4% (181/237) had seen their GP, 38.3% (98/256) had attended outpatient services, and 15.2% (39/257) inpatient services, representing missed opportunities for earlier HIV diagnosis. Of those attending GP services the issue of HIV and/or HIV testing was raised for 17.6% (31/176) and 37.1% (78/210) had a previous negative HIV test, 32.5% of these within the UK. Medical attention was sought for wide ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge of benefits of testing lacking.

CONCLUSION

Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regards to HIV infection. Comparatively low appreciation of personal risk and lack of perceived ill health within this community means clinicians need to be more proactive in addressing HIV.

Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles

OBJECTIVES

To estimate HIV prevalence and the distribution of high risk sexual behaviours, sexual health service use, and HIV testing among black Africans aged 16 years or over in England. To determine demographic, behavioural and service use factors associated with HIV prevalence.

METHODS

A cross-sectional community-based survey (Mayisha II) in London, Luton and the West Midlands. A short (24-item) anonymous self-completion questionnaire with linked voluntary anonymous oral fluid sampling, using an Orasure device for HIV testing.

RESULTS

A total of 1359 eligible black African men (51.9%) and women (48.1%) were recruited, of whom 74% (1006) provided a sufficient oral fluid sample for HIV testing. 42.9% of men and 50.9% of women reported ever having had an HIV test. Overall, 14.0% (141, 95% CI 11.9 to 16.3) of respondents tested HIV positive (13.1% of men and 15.0% of women); 9.2% (93) had undiagnosed HIV infection, while 4.8% (48) had a diagnosed HIV infection. HIV prevalence was significantly higher in men: born in East Africa; who had had a previous STI diagnosis; or who were recruited in bars and clubs; and in women: born in East or Southern Africa; aged 25 years and over; who had had two new sexual partners in the past 12 months; or who had had a previous STI diagnosis.

CONCLUSIONS

Despite about half the sample having had an HIV test at some time in the past, 9.2% of respondents had an undiagnosed HIV infection. This study supports current policy efforts to further promote HIV testing and serostatus awareness.

Health systems' responses to 25 years of HIV in Europe: inequities persist and challenges remain

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging-where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.

Rural-to-urban migrants and the HIV epidemic in China

China is the next probable frontier for the global HIV epidemic. Central to this anticipated growth of the epidemic is the nation's new and growing population of rural-to-urban migrants. Although there are an estimated 120 million migrants, little information is available about their social and cultural context of their lives in urban areas and their HIV-related perceptions and behaviors. On the basis of the in-depth individual interviews conducted among 90 rural-to-urban migrants in 2 major Chinese cities, Beijing and Nanjing, this qualitative study was designed to explore these issues with a particular focus on their relevance to sexual transmission of HIV. The findings suggest an urgent need for HIV/STI prevention programs that address the cultural, social, and economic constraints facing the migrant population in China.

Assessing the HIV/AIDS health services needs of African immigrants to Houston

This study investigated HIV/AIDS knowledge, risk behaviors and perceptions, and access to services among Black immigrants from more than 20 African nations to Houston, Texas, United States. Three hundred nine respondents completed a 98-item self-administered questionnaire on HIV/AIDS knowledge, risk behaviors, access to services, and stigma. Data analysis revealed this population to be highly educated (70.9% had educational attainment levels beyond high school), with a plurality motivated to immigrate to the United States for academic reasons (45.0%). As a group they displayed a high level of knowledge about modes of HIV transmission. Generally, Christian background respondents had higher knowledge than those of Muslim background. Nevertheless, 36.3% reported that they had never used a condom, with the overwhelming majority of respondents reporting low self-perceived risk for contracting HIV (79.5%). These findings, together with the persistent practice of traditional rituals such as body scarring/tattooing by a significant minority (20.1%), a lack of awareness about vertical transmission (16.3% of women; 29.9% of men), and discouraging scores on an HIV stigma perception scale, suggest that a targeted campaign to raise awareness in this population is warranted.

Are we meeting the psychological needs of Black African HIV-positive individuals in London? Controlled study of referrals to a psychological medicine unit

The changing pattern of HIV infection in the UK includes an increase in the number of infections acquired as a result of heterosexual contact and Black African individuals represent a sizeable proportion of those affected. In most UK centres for the treatment of HIV infection, clinicians have limited experience in caring for Black African patients, and there is a dearth of information about the recognition and management of mental health problems in this patient group. In this investigation the proportion of Black African individuals looked after in a large centre for the care of HIV infection in London was compared with the proportion of such patients referred for specialist mental health help, the results revealing that Black Africans were almost three times less likely to be referred for specialist mental health care. A case control investigation of those referred to mental health services showed that Black Africans were more likely to be suffering from AIDS at the time of referral, be referred for assessment of possible organic brain disease, and more likely to be found to be suffering from major depression or organic brain disease. Reasons for the lesser likelihood of referral to the mental health service are considered, including the possible failure of staff to recognize psychological morbidity in Black Africans, or reluctance and fear on the part of patients to be referred to services that may be perceived as threatening.

Does European or non-European origin influence health care and prognosis for HIV patients in Europe? The EuroSIDA Study Group

BACKGROUND

Previous studies, especially in North America, have shown that socio-economic factors may influence the prognosis for patients with HIV. This study was performed in order to determine if European or non-European origin influence provision of health-care and survival among HIV patients in Europe.

METHODS

Fifty HIV clinics in 17 European countries are involved in a European prospective, observational multicentre study. In total, 7230 consecutive patients with HIV attending a routine clinic visit were included in the study. Data on demographics, treatment and laboratory results were collected at time of recruitment into the study and thereafter every 6 months.

RESULTS

The median CD4+ lymphocyte count at AIDS diagnosis was 60/mm3, and was similar for all ethnic groups (P = 0.87, Kruskall-Wallis test). The median terminal CD4+ lymphocyte count was 17/mm3 and, again, there was no significant difference between continents of origin (P = 0.35, Kruskall-Wallis test). Antiretroviral drugs were initiated at similar median CD4+ lymphocyte counts and there was no statistically significant difference in survival after a diagnosis of AIDS.

CONCLUSIONS

AIDS was diagnosed at the same level of immunodeficiency independent of European or non-European origin and antiretroviral drugs were provided at similar levels of immunodeficiency. No differences in survival depending on continent of origin was found. In spite of these encouraging findings concerns remain that belonging to an ethnic minority can be an obstacle in getting into contact with treatment facilities and thus benefiting from developments in the management of HIV.