Elsevier

Health Policy

Volume 97, Issue 1, September 2010, Pages 26-31
Health Policy

It is more than the issue of taking tablets”: The interplay between migration policies and TB control in Sweden

https://doi.org/10.1016/j.healthpol.2010.02.014Get rights and content

Abstract

Objectives

Tuberculosis is re-emerging as a critical public health concern in Sweden among the immigrants. The aim of this study was to explore the experiences of the Somali community of TB care in the Stockholm area.

Methods

Focus group discussions were conducted with 34 adult women and men by a Somali speaking moderator. Each group consisted of 6–9 participants—men and women separately. The audio taped discussions were transcribed, translated and read many times and in the process patterns and codes were identified and migration emerged as important theme in the context of TB control.

Results

Fear of being deported emerged as barrier to sharing of complete health information with the doctor. The routine contact tracing and follow-up of infected cases in TB control was expressed as a source of concern since it was feared the health care providers could share the information with the immigration authorities. Interpreter use was expressed as barrier particularly if of same female gender.

Conclusion

It is important to be aware of how a country's immigration policies impact on TB control activities among immigrants The existing TB control measures, such as contact tracing, assume new meanings for immigrants. Further research is therefore needed to understand this emerging complexity in order to make TB control more effective.

Introduction

Tuberculosis among immigrants is a growing public health concern in many high-income countries [1]. The European Centre for Communicable Disease Control (ECDC) reports that TB is re-emerging in previously low prevalence countries [2]. Sweden is one of these countries that have experienced a growing number of TB cases, with over 5% mean increase per year in the period 2003–2008 [3], with the increase more prominent among the migrant groups. This reflects the current global movement of people that has not only changed the demographic picture in countries but also disease patterns including TB.

Multiple factors including socio-economic, cultural, environmental and political situation contribute to the increase of TB in previous low prevalent settings [4]. Moreover these factors do not occur in parallel. Rather they interact with each other, making TB and its control much more complex as well as increasing vulnerability to TB [5], [6]. In the recent past, migration has become an important factor that is not very well understood and is under researched in Sweden, compared to countries such as Canada, New Zealand and USA which notably have large studies on TB among refugees [4], [7].

The existing literature in Sweden on migrant's health has focused on immigrants as a group, therefore masking the variation between ethnic groups. Most of these studies have moreover used quantitative methods that show the magnitude of the TB [8], [9], [10], without explaining the way individuals and affected communities experience and reason around TB or how they seek care for TB.

Most notable among communities with high TB prevalence in the Stockholm area is the Somali community, which is reported to represent a large proportion of immigrants from high TB-prevalence countries [11] with about 25% of all TB-cases during the last 10 years.

The main immigration began in the late 1980s. There are now around 22 000 [12] of whom about one-third live in the Stockholm area. Although the main immigration occurred from the late 1980s mainly as a result of political chaos in Somalia, the Somali community in Sweden is diverse in the sense that they came from different parts of Somalia, have different dialects and they differed in professional status held back home. Above all, people came to Sweden for myriad of reasons. Countries with previous historical relations with Somalia such as Italy and UK [13], [14] are most commonly selected for settlement. Nonetheless Sweden with no such colonial ties with Somalia hosts, almost as large numbers of Somali people, perhaps due to family reunion, asylum policy and/or options given by smuggling agents [15]. The majority were asylum-seekers and refugees but in later years immigration of relatives dominates. The population is young; 70% less than 30 years with high unemployment. Moreover language is another barrier that necessitates use of interpreters when seeking care in general but also for TB [16].

Tuberculosis is a notifiable disease in Sweden. The Communicable Diseases Act obliges a person suspected of TB to seek medical attention, undergo examination and submit information to the physician to facilitate contact [17]. As for other notifiable diseases “dangerous to public health”, all medical care is free of charge regardless of the migrant position. Illegal immigrants cannot be expelled as long as their TB is considered infectious. However, there is law under the Dublin Convention [18] that took effect in 1997, although already in 1994 the EU member states adopted an instrument concerning means to determine which member state is responsible for examining asylum application. According to this convention, asylum-seekers are returned to the point of entry and Sweden is rarely the point of entry. This can affect the TB information given in order to avoid being returned.

The primary care is the level to which people turn to with their health problems although in addition, primary care is also provided by private doctors. For conditions that require hospital treatment, medical services are provided at county and regional levels. It is almost impossible to see a specialist without referral from the primary care. Medical practitioners of Somali background are few.

According to the Swedish policy, all residents in Sweden regardless of nationality are entitled to health services at subsidized prices amounting to 140 SEK per visit and 300 SEK for specialist care. Immigrants including refugees thus have, according to the Swedish law access to health care. Asylum-seekers are entitled to a health care consultation and a medical examination, although a report from the National Board of Health and Welfare indicates that few asylum-seekers and their children get the free health screening they are entitled to [19].

Little is known about social, cultural and environmental factors that may act as barriers for access to health care among the Somali people living in Stockholm. This study therefore aimed to explore the experiences of the Somali community in the Stockholm are of TB care, as well as how they reason around TB control in order to determine how the current TB control policies address their contexts and realities.

Section snippets

Study area

The study was conducted in Stockholm County that consists of 26 municipalities. The total population is about 2 million, of which 20% are of foreign origin [11] and 1.96% estimated to be of Somali origin.

Primary health care facilities are the first contact for patients. Suspected cases of TB are referred to the hospital, TB clinics where the patients are finally diagnosed, treated and followed-up. The TB clinics are also responsible for tracing of contacts. They collaborate with the Department

Findings

In this section we present how the participants in this study described their experiences of TB care. Stigma was prominent crosscutting theme that particularly hindered providing proper information during encounters with health care providers. Moreover, migration and policies on migration, particularly the fear of being deported to the port of entry into EU, emerged as a central issue that pose challenge to TB care and control. Relevant here are the encounters with doctors, the contact tracing

Discussion

It appears from the literature search that this is the first study to explore perceptions, experiences or the way the Somali community in Stockholm reason around TB care and control. The findings provide new insight on how policies set for immigrants, within and outside the health sector interact with TB control.

Informants in this study revealed that complete information is not given to health care providers for fear of expulsion from the country. Since people are aware of the Dublin convention

Acknowledgments

We would like to thank the participants for their kind co-operation. Special thanks go to the FGD note-takers Fousia Dini and Asha Jama and resource persons Ibrahim Bouraleh and Abdullahi Ali-Salad Abdi for assisting us in reaching the community. The study was funded by Unit for Infectious Disease Control of Stockholm County and Stiftelsen Right Now.

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