The results indicate the views of: (i) individual refugees and immigrants who participated in FGDs that were facilitated by CHCs with refugee and immigrant backgrounds, and (ii) CHCs’ interpretations of what their colleagues believed to be barriers to their service access and utilisation.
In this study, we focus on summative data that were contributed by the refugee and immigrant CHCs since they were the only ones we had direct contact with through our facilitation of the FGDs in classroom settings. They were all (n = 42) assigned homework to investigate health problems and levels of service utilisation in their communities as part of their training on public health practice. Across the metropolises, CHCs were a heterogenenous group of data collectors aged between 29 and 65 years (n = 32) (75%) and mostly females (64.3%). The majority (76.21%) had higher education qualifications to degree level (Table 1), making them capable of collecting basic data as CHCs are expected to.
These socio-demographic characteristics, and the fact that the CHCs originated from countries across the world, to an extent influenced their different experiences in local areas, and challenges experienced in interpreting to synthesise community features, risky lifestyles by individuals, and knowledge about hotspot areas for health problems that contributed to possible barriers to proactive health improvement by increasing local healthcare service utilisation.
Using thematic analysis, the findings from this qualitative study were categorised into five interlinked themes:
Perceived health problems;
Barriers to access and utilisation;
Predisposing factors; and
Priority causes of illness and deaths.
Perceived Health Problems Affecting Refugees and Immigrants
After adjusting for marginal variations in lifestyles and community differences, mental health illnesses, physical incapacitation, drugs and alcohol abuse, modern slavery, sexual abuse and infectious disease exposure emerged as the significant problems impacting on the health and wellbeing of refugees, asylum-seekers and immigrants. Across the three cities, those who had settled for longer than 10 years had better knowledge about NHS arrangements for care access, which made them more likely to utilise healthcare services. While significantly less affected by health problems compared to recent arrivals (< 5 years), their level of service utilisation was to an extent still suboptimal.
Health problems concerning increased drug and alcohol abuse, and exposure to infectious diseases were identified. Both the male and female individuals were affected as they tend to use substances as solace for missing home, families and friends. To an extent, “some of them become careless and risk poor health and sometimes death, by abusing drugs and alcohol to treat their loneliness”. Desperation deployed by refugees and asylum-seekers was also found to increase their vulnerability. It drove some into modern slavery, which further risked their physical health through overworking, sexual exploitation and serious infectious diseases including HIV/AIDS (Table 2).
Meanwhile, mental health illnesses and sexual abuse were found to be significant health problems. However, those from Africa and Asia “do not openly discuss mental health illnesses and sexual abuse for reasons to do with cultural beliefs or feeling ashamed”. The people who experienced these problems were associated with mainly drug, substance and alcohol abuse. Those with psychological problems were mostly previous victims of some forms of torture in their home countries. They were still haunted by their experiences “(…) of escaping from home, and being denied food, shelter and treatment of their injuries” so many years after arriving in the UK. The experiences drove them into desperation to accept suboptimal conditions, even sharing “private accommodation that have neither furniture nor heating with strangers” compared to returning home. Yet their status as refugees and immigrants frightens them from complaining and continue to experience unconducive conditions.
Barriers to Access and Utilisation
We analysed the data to understand some of the possible barriers to refugees, asylum-seekers and immigrants taking actions to avoid these health risks. What emerged were ideas around themes described in Table 3. Most refugees and immigrants in the UK are so convinced that they benefit from continuously searching for more comfortable places for settlement. Being transient was, however, perceived to be a behavioural and systemic barrier to getting continuous care by health professionals. This is not because they initiate the movements themselves. On the contrary, the government often settles successful applicants for refugee status in regions other than the West Midlands where the initial application was made. By frequently changing their residential locations and cities, immigrants generally perceive it as non-prioritisation of their individual health and wellbeing. It also prevented them from maintaining their homes in order to live in conducive environments.
Refugees, asylum-seekers and immigrants were described as depicting chaotic behaviours and unsettled lifestyles, which were perceived to be barriers to disease avoidance and healthcare service utilisation. There was concern that “it didn’t help care professionals to understand effectiveness of their activities if people are “sofa-surfing” and wilfully not complying with getting treatment and rehabilitation services”. This is not because they would have recovered. Most of them will still be sick but cannot be easily traced by the professionals because they lack permanent addresses.
Inability to pay and lacking the right papers to register with GPs also emerged as two important barriers to access. Participants in the FGDs believed that “presenting to GPs with all the paperwork which they ask for was risky”. There is a mythical fear of possible deportation if their information was passed on to the authorities. These misconceptions prevented especially undocumented refugees and asylum-seekers from registering to utilise primary care services, even for serious illnesses.
The principal factors for experiencing prominent health problems across the metropolises were perceived to hinge on circumstances forcing one to become a refugee or immigrant, and issues in getting settlement documents. Those who fled torture or extreme cases of discrimination in their home countries were found to distance themselves from social activities. Despite robust protections for lesbian, gay, bisexual and transgender (LGBT) rights in the UK, refugees of such sexual orientations, especially those from Asian and African countries feel their “compatriots are not progressive and remain very homophobic like those back home”. These factors prevented affected people from getting the benefits of possible rehabilitation and universal care provided by the NHS. Reliving some heart-wrenching episodes of previous lives also usurped their confidence to seek help from relevant professionals.
The analysis also revealed that increasing numbers of young and adult male and female refugee and immigrant people across the board were taking up drinking and tobacco-smoking habits. A male CHC was surprised that his “(…) barber from Africa had “customers” who regularly used the shop as a place for drinking and listening to music from home”. The health consequences of their habit are disregarded, even though an increased number of males in that particular community group is showing evidence of social problems involving alcohol, drugs and substance abuse.
Having children was also identified as an important predisposing factor with mixed effects on refugee and immigrant people: (i) experiencing health problems, and (ii) propensity to utilise available services. Regardless of circumstances leading to their current status, refugees who left children and family dependents tended to take illegal and risky jobs. Those with permission to work “take multiple jobs, worked long hours and postpone seeking healthcare because they want to continue earning” for their subsistence and remittances home.
The refugees and migrants in this study originated from across the world. Their individual behaviours, culture and lifestyle choices therefore differed in their predisposition to risks of diseases. While the participants identified increased frequency and levels of drinking and tobacco-smoking among refugee and immigrant people, it affected those from African countries south of the Sahara and the Caribbean more than other regions. It contributed to high prevalence of diabetes, heart disease, stroke and cancer in refugee and immigrant people of African and Afro-Caribbean backgrounds.
Priority Causes of Illness and Deaths
A comparison of priority health issues in immigrant communities against officials’ indications about the major public health problems (Table 4) revealed mixed perceptions. Participants in the FGDs were explicit about drug, substance and alcohol abuse-related illnesses as problems affecting their communities. They only also inferred stroke and lung cancer as significant problems due to their respective causal relationships with “physical incapacitation” and “increased rates of tobacco-smoking” by people in their communities.
Meanwhile, public health officials identified infant mortality, heart disease, and acute respiratory infections as major problems across the metropolises. With regard to infant mortality in refugee and immigrant communities, participants in FGDs associated the problem with government disrupting continuity of antenatal care for pregnant women by moving them between locations. It increases infant mortality, especially since the women already experience other forms of barriers to service access linked to refugees and immigrants. Community-based investigations by this study also found infectious disease, sexual abuse and modern slavery as much more problematic in the West Midlands.