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A world on the move: challenges and opportunities for hiv/aids and tuberculosis care and prevention among vulnerable migrant populations in Sweden
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Migration is a global phenomenon that characterize today’s globalized world. Although, the relationship between migration and health in the host countries is not always negative, many countries, including Sweden are concerned about possible spread of infectious diseases of public health significance such as HIV/AIDS and tuberculosis (TB). Moreover, apart from disease profiles, migrants also have different socio-cultural backgrounds, which may challenge health care access and provision.

Objectives: To investigate, identify, and delineate potential challenges of relevance in the care and prevention of communicable diseases of public health significance in general and particularly HIV/AIDS and TB among migrants from countries where these infections are endemic, and eventually generate knowledge that could inform policies and practice.

Methods: Data for this thesis were collected in four of the five counties of the Northern region in Sweden. Quantitative and qualitative methods were used including a survey of 268 migrant students in two language schools (I & II); an interview study with 10 care providers caring for patients with migrant backgrounds and observations of care encounters (III) and an interview study with 15 care providers experienced in screening migrants (IV). Descriptive and logistic regression analyses were used to summarize survey data whereas a thematic analysis approach was applied to the qualitative data within the interpretive description framework.

Results: The students scored on average low on both HIV/AIDS and TB knowledge and displayed misconceptions and negative attitudes towards the two diseases and infected/sick persons. Knowledge level and attitude could be predicted by prior knowledge, years of previous education and geographic origin. In contrast, no association was found between being screened and the level of TB knowledge or attitude towards TB and infected/sick persons. However, fear of being deported appeared to be the main predictor of reluctance to seek HIV/AIDS care after controlling for socio-demographic factors, knowledge level, stigmatizing attitudes and fear of disclosure. Health care providers described complex and intertwined challenges that influenced both care delivery and receipt. The challenges described included language, the socio-cultural diversity within migrant groups and between migrants and the caregivers. These often resulted in divergent perceptions and expectations about care and caring. The participants highlighted the complexities of caring for diverse patients within different institutions with conflicting policies and frameworks. They also described the difficulties the migrants face in navigating the Swedish care system.

Conclusions: This thesis illuminates complex challenges in the care of migrants. The findings emphasize the need for multilevel strategies in order to remove identified barriers. This requires accommodating diversity by improving care providers’ cultural competence and migrants’ health literacy. It further requires policies and practices that emphasize health services responsiveness in order to provide equal access and equitable care. Finally, it entails revisiting existing policies and legislative frameworks to promote a change in ways of thinking about and approaching migration, HIV/AIDS and TB issues, to address the specific vulnerabilities of mobile populations in a world on the move.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2013. , 78 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1555
Keyword [en]
HIV/AIDS, Tuberculosis, Caregivers/caregiving, Culture/cultural competence, Discrimination, Diversity, Immigrants/Migrants, Interpretive description, Language/linguistics, Interpreters, Thematic analysis, Screening, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-67636ISBN: 978-91-7459-570-3 (print)OAI: oai:DiVA.org:umu-67636DiVA: diva2:612877
Public defence
2013-04-19, Sal 135, Allmänmedicin, Byggnad 9 A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2013-03-27 Created: 2013-03-25 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Screening migrants for tuberculosis - a missed opportunity for improving knowledge and attitudes in high-risk groups: a cross-sectional study of Swedish-language students in Umeå, Sweden
Open this publication in new window or tab >>Screening migrants for tuberculosis - a missed opportunity for improving knowledge and attitudes in high-risk groups: a cross-sectional study of Swedish-language students in Umeå, Sweden
2010 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 10, article nr 349- p.Article in journal (Refereed) Published
Abstract [en]

Background: Migrants from countries with a high-burden of tuberculosis (TB) are at a particular risk of contracting and developing the disease. In Sweden, new immigrants are routinely offered screening for the disease, yet very little is known about their beliefs about the disease which may affect healthcare-seeking behaviours. In this study we assessed recent immigrant students' knowledge of, and attitudes towards TB, and their relationship with the screening process.

Methods: Data were collected over a one-year period through a survey questionnaire completed by 268 immigrants consecutively registered at two Swedish-language schools in Umea, Sweden. Participants originated from 133 different countries and their ages varied between 16-63 years. Descriptive and multivariate logistic regression analyses were then performed.

Results: Though most of them (72%) were screened, knowledge was in general poor with several misconceptions. The average knowledge score was 2.7 +/- 1.3 (SD), (maximum = 8). Only 40 (15 %) of the 268 respondents answered at least half of the 51 knowledge items correctly. The average attitude score was 5.1 +/- 3.3 (SD) (maximum = 12) which meant that most respondents held negative attitudes towards TB and diseased persons. Up to 67% lacked knowledge about sources of information while 71% requested information in their vernacular. Knowledge level was positively associated with having more than 12 years of education and being informed about TB before moving to Sweden. Attitude was positively associated with years of education and having heard about the Swedish Communicable Disease Act, but was negatively associated with being from the Middle East. Neither knowledge nor attitude were affected by health screening or exposure to TB information after immigration to Sweden.

Conclusions: Though the majority had contact with Swedish health professionals through the screening process, knowledge about tuberculosis among these immigrants was low with several misconceptions and negative attitudes. Information may currently be inaccessible to most of these immigrants due to the language barrier and unfamiliarity with the Swedish healthcare system. If TB education was included as a component of screening programmes, ensuring that it was tailored to educational background, addressed misconceptions and access problems, it could well help improve TB control in these communities.

Place, publisher, year, edition, pages
BioMed Central, 2010
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-38478 (URN)10.1186/1471-2458-10-349 (DOI)000281848200001 ()20565732 (PubMedID)
Funder
FAS, Swedish Council for Working Life and Social Research, 2006-1512
Available from: 2010-12-15 Created: 2010-12-15 Last updated: 2017-12-11Bibliographically approved
2. Fear of deportation may limit legal immigrants' access to HIV/AIDS-related care: a survey of Swedish language school students in Northern Sweden
Open this publication in new window or tab >>Fear of deportation may limit legal immigrants' access to HIV/AIDS-related care: a survey of Swedish language school students in Northern Sweden
2012 (English)In: Journal of Immigrant and Minority Health, ISSN 1557-1912, E-ISSN 1557-1920, Vol. 14, no 1, 39-47 p.Article in journal (Refereed) Published
Abstract [en]

The increasing rates of HIV infection that are currently being reported in high-income countries can be partly explained by migration from countries with generalized epidemics. Yet, early diagnosis of HIV/AIDS in immigrants remains a challenge. This study investigated factors that might be limiting immigrants' access to HIV/AIDS care. Data from 268 legal immigrant students of two Swedish language schools in Northern Sweden were analyzed using logistic regression. Thirty-seven percent reported reluctance to seek medical attention if they had HIV/AIDS. Fear of deportation emerged as the most important determinant of reluctance to seek care after adjusting for socio-demographic factors, knowledge level, stigmatizing attitudes and fear of disclosure. Targeted interventions should consider the heterogeneity of migrant communities and the complex interplay of various factors which may impede access to HIV-related services. The myth about deportation because of HIV/AIDS should be countered.

Place, publisher, year, edition, pages
Springer-Verlag New York, 2012
National Category
Infectious Medicine Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-48354 (URN)10.1007/s10903-011-9509-y (DOI)000299123200006 ()21814777 (PubMedID)
Note

Published online: 4 August 2011

Available from: 2011-10-18 Created: 2011-10-18 Last updated: 2017-12-08Bibliographically approved
3. "It is a challenge to do it the right way": an interpretive description of caregivers' experiences in caring for migrant patients in Northern Sweden
Open this publication in new window or tab >>"It is a challenge to do it the right way": an interpretive description of caregivers' experiences in caring for migrant patients in Northern Sweden
2012 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, 433- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Experiences from nations with population diversity show extensive evidence on the need for cultural and linguistic competence in health care. In Sweden, despite the increasing diversity, only few studies have focused on challenges in cross-cultural care. The aim of this study was to explore the perspectives and experiences of caregivers in caring for migrant patients in Northern Sweden in order to understand the challenges they face and generate knowledge that could inform clinical practice.

METHODS: We used an interpretive description approach, combining semi-structured interviews with 10 caregivers purposively selected and participant observation of patient-provider interactions in caring encounters. The interviews were transcribed and analyzed using thematic analysis approach. Field notes were also used to orient data collection and confirm or challenge the analysis.

RESULTS: We found complex and intertwined challenges as indicated in the three themes we present including: the sociocultural diversity, the language barrier and the challenges migrants face in navigating through the Swedish health care system. The caregivers described migrants as a heterogeneous group coming from different geographical areas but also having varied social, cultural and religious affiliations, migration history and status all which influenced the health care encounter, whether providing or receiving. Participants also described language as a major barrier to effective provision and use of health services. Meanwhile, they expressed concern over the use of interpreters in the triad communication and over the difficulties encountered by migrants in navigating through the Swedish health care system.

CONCLUSIONS: The study illuminates complex challenges facing health care providers caring for migrant populations and highlights the need for multifaceted approaches to improve the delivery and receipt of care. The policy implications of these challenges are discussed in relation to the need to (a) adapt care to the individual needs, (b) translate key documents and messages in formats and languages accessible and acceptable to migrants, (c) train interpreters and enhance caregivers' contextual understanding of migrant groups and their needs, (d) and improve migrants' health literacy through strategies such as community based educational outreach.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-64326 (URN)10.1186/1472-6963-12-433 (DOI)23194441 (PubMedID)
Available from: 2013-01-23 Created: 2013-01-23 Last updated: 2017-12-06Bibliographically approved
4. Perspectives of caregivers on screening migrants: managing conflicting discourses, policies and practices
Open this publication in new window or tab >>Perspectives of caregivers on screening migrants: managing conflicting discourses, policies and practices
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-67684 (URN)
Available from: 2013-03-27 Created: 2013-03-27 Last updated: 2015-04-29Bibliographically approved

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