J Immigrant Minority Health DOI 10.1007/s10903-014-0009-8
BRIEF COMMUNICATION
Access to Health Services for Undocumented Immigrants in Apulia G. Brindicci • G. Trillo • C. R. Santoro A. Volpe • L. Monno • G. Angarano
•
Springer Science+Business Media New York 2014
Abstract This paper, part of a larger epidemiological study carried out between 2004 and 2010, analyzed immigrants frequenting the largest Apulian regional hospital (Bari Policlinico). Our aim was to evaluate the perception on the part of undocumented immigrants of their rights of access to the National Health Care services and whether this privilege is actually utilized. An anonymous multi-language questionnaire was distributed to all patients with STP (code number for temporary presence of foreigners) at the immigrant outpatient Infectious Diseases Clinic of Bari from June 2009 to June 2010. Questions were related to nationality, date of arrival in Italy, use of health facilities in the 2 years prior to the compilation of the questionnaire, and their understanding of STP. The patients were also screened for infectious diseases (HIVAb, HBsAg, HCV-Ab, VDRL, TPHA and Mantoux). A total of 256/272 patients completed the questionnaire; the meaning of STP was unknown to 156/256 (60.9 %) patients, only 54/256 (21 %) knew the exact meaning of STP and only 42/54 (76.6 %) of the latter knew how long STP was valid. Moreover, 128/256 (50.7 %) were aware that doctors from the emergency unit were not allowed to notify police regarding presence of illegal immigrants. Regarding clinical data 3 % were HIV? (8/256), 5 % (13 patients) positive for TPHA, 5 % for HBsAg, 2 % were HCV (five patients). A [10 mm diameter infiltrate of Mantoux test was noted for 44 % of patients. A lower prevalence than expected for infections such as HIV, HBV or HCV was noted for immigrants compared to data from
G. Brindicci G. Trillo C. R. Santoro A. Volpe (&) L. Monno G. Angarano Clinic of Infectious Diseases, University of Bari, Policlinico, Piazza G. Cesare 11, 70124 Bari, Italy e-mail: [email protected]
their countries of origin. At present, large-scale political solutions to the challenges of facilitating access to health facilities for undocumented immigrants are lacking in Italy. The development of communication systems is fundamental to improving access to health services and to creating links between immigrants and the healthcare system. Keywords
Immigration Apulia Access to health
Introduction According to Italian National Statistics Institute (ISTAT) data, the number of immigrants in Italy is steadily increasing; in fact, the number of documented immigrants in Italy was 2,900,000 at the end of 2006 [1] while 4.3 million regular immigrants (7.2 % of the Italian population), including EU nationals, were reported at the end of 2008. The majority (62.5 %, more than two million) live in the North while 25 % reside in the Centre and 12.5 % in Southern Italy. In Apulia, immigration is also on the increase, even if immigrants generally leave for other regions in Italy or other EU countries [2]. Precise data regarding illegal immigrants is difficult to obtain, but the 2008 Caritas/Migrantes report estimates that there were between 500,000 and 700,000 unauthorized immigrants in Italy, which places Italy at the top of EU list for illegal aliens [2]. Moreover, Apulian ISTAT data reports that the number of regular immigrants increased from less than 37,000 at the end of 2005 to about 80,000 at the end of 2010 [3]. According to the 2009 Caritas report, the largest immigrant group was Albanian who accounted for more than 50 % of the total immigrant population. The remaining immigrant residents were comprised of Moroccans
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(10 %), together with Romanians, Chinese and Ukrainians (more than 5 %, respectively) [2]. However, according to SPRAR (System of protection for refugees requesting asylum), the most common countries of origin of those who arrive in Italy are Eritrea and Afghanistan, while from 2006 to 2008, the number of irregular migrants from Somalia and Nigeria demonstrated the highest increase. This apparent discrepancy is explained by the fact that generally individuals from Afghanistan, Ethiopia or Eritrea) have less difficulty obtaining a refugee status and therefore are no longer counted as ‘‘irregulars’’ [4]. As it is a coastal region, according to SPRAR, 76 % of undocumented immigrants arrive in Italy by sea; this number increased by 34 % in the 2007–2008 period thus determining Apulia as the fourth largest region for total number of admitted immigrants [4]. On the contrary, Caritas states that the number of legal immigrants passing through the maritime borders is less than 2 % of the total number of immigrants arriving in Italy [2]. The health of immigrants is a key indicator of ‘integration’ into the receiving societies [5]. Disparities clearly exist in the health care for ethnic minorities [6–11]. This is particularly obvious when considering the United States where access to health care is not guaranteed as a right of citizenship and there is a net difference between those who can and cannot afford health insurance, thus explaining divergence in health care available for blacks and whites, as well as for drug and non-drug abusers [12–15]. In Italy, access to health care facilities is gratis and the health of immigrants is not likely to be influenced by their economic/ social status. However, since the introduction of the code number for temporary illegal immigrants (STP) contained in the Bossi–Fini law (30.07.2002 n.189) [16], the concept of accessible health care has been called into question. This Law on immigration (‘‘Amendments to legislation on immigration and asylum’’ published in the Official Gazette no. 199 of 26 August 2002) is more severe and restrictive for irregular migrants and make regularization more difficult, but the access to health care is not limited in any way, at least theoretically. In fact, the law guarantees, in particular, the following benefits to undocumented immigrants too: (a) (b) (c) (d) (e)
the social protection of pregnancy and maternity; the protection of health of the child; vaccinations, according to the regulations authorized by the Regions; the intervention of international prophylaxis; the prevention, diagnosis and treatment of infectious diseases.
The above services are provided gratis to documented applicants, if lacking sufficient economic resources.
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Table 1 The multiple-choice questionnaire distributed to patients with STP code numbers from June 2009–June 2010 1. In general, how would you describe your own health? 2. In the last 12 months, have you visited a doctor or medical clinic for any reason, including check-ups or visits to the emergency room or hospital outpatient department? 3. In the last 12 months, have you been admitted to hospital? 4. Where do you usually go when you are sick or need health care? 5. Earlier you mentioned that you had visited a doctor within the past couple of years. The last time you visited a doctor, did the doctor listen to everything you had to say, to most, to some, or only a little of what you had to say? 6. During the visit, did you understand everything the doctor said, most of what the doctor said, some, or only a little of what the doctor said? 7. How much confidence and trust did you have in the doctor treating you—a great deal, a fair amount, not too much, or none at all? 8. Did the doctor treat you with a great deal of respect and dignity, a fair amount, not too much, or none at all? 9. Did the doctor involve you in decisions about your care? 10. Did the doctor spend as much time with you as you wanted, almost as much as you wanted, less than you wanted, or a lot less than you wanted? 11. Has there been a time in the last 2 years when you didn’t follow the doctor’s advice, or treatment plan, get a recommended test or see a referred doctor? 12. Overall, how satisfied or dissatisfied are you with the quality of health care you have received during the last 2 years? 13. If you could choose, would you prefer to be treated by a doctor (race ethnic group) 14. Do you know what STP means? 15. Do you know how long STP is valid? 16. In you opinion, can a foreigner in Italy without a residency permit take advantage of the hospital emergency unit? 17. How do you think a doctor in the emergency unit should behave according to the Italian law when taking care of a patient without a residency permit?
Moreover, access to health facilities by the illegal immigrant cannot result in any type of reporting to authorities (except, as also for Italians, in cases where it is mandatory to report). However, we must also recall that between March and June of 2009, the Italian incumbent government in office was preparing to present the so-called ‘‘security package’’ containing the possible obligation for doctors (who were aware of the status of irregularities of a foreign patient) to report the illegal status to authorities. Herein, we aimed to analyze the perception of the right to access to health care on the part of illegal immigrants in this politically difficult moment due to sanctions and restrictions for illegal immigrants contained in the new law (number 125, July 24, 2008) [17] and whether they are effectively able to obtain medical care from public services.
J Immigrant Minority Health
Methods An anonymous questionnaire mainly consisting of multiple-choice questions was distributed to all patients with STP code numbers referring to the Immigrant Out-patient infirmary of the Infectious Diseases Clinic of Bari from June 2009–June 2010. Questions related to nationality, date of arrival in Italy, use of health facilities in the 2 years prior to the compilation of questionnaire, immigrants’ understanding of STP and expiry date of STP, admission to the hospital or to the hospital outpatient department, satisfaction with quality of assistance and health care and illegal immigrants health rights in Italy. The questionnaire is reported in Table 1. The patients were also screened with serological tests for infectious diseases (HIV-Ab, HBsAg, HCV-Ab, VDRL, TPHA), the Mantoux skin test and a general blood chemistry. In the case of chronic diarrhea (defined as lasting more than 15 days), a copro-parasitological examination was required for anal or generalized itching, absolute number of eosinophils ([400 cells/mm3), or other signs suggestive of parasitic diseases.
Results A total of 256/272 patients completed the questionnaire (response rate 94 %). Countries of origin included: Africa 185/256 (72 %) patients with 12 different nationalities including 76/256 (41 %) from Nigeria, 20/256 (11 %) from Morocco and Tunisia; Eastern Europe 24/256 (9 %) patients with 14/24 (58 %) from Romania; Asia 47/256 (18 %) patients with 25/47 (54 %) from Bangladesh and 12/47 (25 %) from Afghanistan. A total of 166/256 patients (65 %) resided in Italy since 2007, 20 % since 2004 and 15 % of illegal immigrants had been living in Italy for more than 5 years. The average age was 25 years (range from 18 to 63 years). At time of admission, 82/256 (82 %) of patients considered their own health as good, very good or excellent, while 46/256 (18 %) considered their health as poor or very poor. Regarding the last year (June 2010) covered by the questionnaire, 148/256 patients (56 %) were visited by a doctor at least once and 61/256 (24 %) were admitted to hospital. A general practitioner (GP) was consulted by 53/256 (21 %) of patients when they were sick or required health care while 46/256 (18 %) used Emergency Services; 59/256 (23 %) said that they had been healthy since their arrival in Italy. Of the 148/256 patients who took advantage of the National Health System in Apulia, 34/148 (22.9 %) were from Nigeria followed by 18/148 (12.1 %) from Bangladesh, 10/148 (6.75 %) from Afghanistan,
Romania and Gambia. The immigrant population utilizing our health services according to nationality (Fig. 1a) compared to the regularly documented patients present in Puglia during the same period can be found in Fig. 1b. The 59/148 patients (40 %) who visited a doctor were very satisfied with the quality of health care while only 34 (22 %) were either not satisfied or fairly dissatisfied (question n. 12). A total of 75 patients (83.6 %) stated that they had been treated with dignity and respect while 26 (16.4 %) reported that they had been treated badly (question 8). See Fig. 2 for more details regarding the patient’s perception of doctors behaviour (questions 5–10). A total of 31/148 (21 %) of interviewees said they would have preferred to have been visited by a doctor from their own country, as opposed to 47 % who did not express a preference. The meaning of STP was not known by 156/256 (61.1 %) patients. Only 54/256 (21.0 %) knew the exact meaning of STP and 42/54 (76.6 %) were aware of the expiration date for STP. Only 180 (46.1 %) of patients realized that doctors in the emergency unit were not obliged to inform the police of the presence of illegal immigrants, as everyone in Italy has the right to medical care while 76 (30 %) were not aware of the contents of the law regarding immigration in Italy. A total of 20 patients (7.8 %) thought that doctors should inform the police and 32 (12.5 %) thought that doctors were obliged to inform the police. Regarding clinical data, 8/256 (3 %) were HIV?, 13/256 (5 %) were positive for TPHA (no patients were VDRL positive), 13/256 (5 %) were positive for HBsAg, 5/256 (2 %) for HCV while 113/256 (44 %) of patients had more than 10 mm infiltrate of Mantoux test. No patient referred to previous knowledge of his own virological status. A total of 65/256 (25.3 %) patients presented a eosinophil count greater than 400 cells/mm3, 35 of whom (53.8 %) were subjected to a parasitical exam of stools (three specimens collected on alternate days). Five patients (14.2 %) were positive for Ascarides lumbricoides and five (14.2 %) presented Entamoeba coli cysts. Five patients (14.2 %) complained of generalized itching, three of whom (60 %) were administered anti-scabbia treatment thus resolving the problem.
Discussion Our data confirms that immigrants in Italy (EU) are generally young, fit, and healthy, thus corresponding to the picture of the so-called first-phase immigration individual, selected because the chance of fulfilling the family aim to settle in a foreign was greater. However, while reporting
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J Immigrant Minority Health 35
30
(a)
30
(b)
25
25
20
20
15
15 10
10
5
5
Others
Mauritius
India
Philippines
Tunisia
Senegal
Ukrain
Bulgaria
China
Poland
Morocco
Albania
Others
Ghana
Algeria
Iraq
Ivory
Afghanis
Romania
Gambia
Tunisia
Somalia
Morocco
Nigeria
Banglad
Romania
0
0
Fig. 1 General population utilizing our health services according to nationality (a) compared to the regularly documented patients present in Puglia (in according to ISTAT data) in the same period (b)
Fig. 2 Details regarding the patient’s perception of doctors behaviour (questions 5–10). Il valore dell’asse delle ordinate corrisponde per tutte le figure alla % dei pazienti
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high levels of self-esteem and good skills for adapting to new living conditions, many aliens also report unrecognized health needs and describe barriers when seeking help. The difficulties when lacking a regular status in immigrant families was particularly experienced by children [18, 19]. Other studies have described a high prevalence of trauma (post-traumatic stress), depression, chronic stress, family separation and stress-related physical illnesses among the immigrant population [20–23]. Stress-related physical illnesses could explain the high percent of patients who described their health as poor or very poor in our questionnaire, but who do not demonstrate abnormal blood tests or negative physical examinations [18, 24, 25]. Our data regards communities of illegal immigrants present in the Italian Apulia region. It must be emphasized that in spite of the increase in illegal immigrants in Apulia, the number is still low compared to other areas. Our outpatient clinic provides services to immigrants from more than 25 countries which tends to confirm previous statistical analyses of the migratory phenomenon in Italy [3, 26]. Regular migrants come from 150 different countries and speak more than 50 different languages. According to the CARITAS statistical report on immigration from 2009, however, there has been a decrease in the number of legal immigrants up to 31/12/07 (from 73,600 to 70,000) in Apulia, as a consequence of the decrease in numbers in Bari (from 32,300 to 30,300) and Foggia (from 17,000 to 14,600) provinces [2]. The number of immigrants would probably be higher if Apulia offered more social services and opportunities for employment. In fact, according to the Italian National Council of Economy and Labour (CNEL) 2007 report, Apulia demonstrates one of the lowest levels of social integration of immigrants compared to other Italian regions [27]. Regarding illegal immigrants, the majority of patients at our outpatient clinic are from Nigeria and East African countries, which tends to confirm the figures for illegal immigrants published by SPRAR [4]. Studies on immigration and the job market from the CNEL index indicate the kinds of employment which draw immigrants to the various Italian regions. This type of analysis is based on a series of factors such as request for immigrant labour, quality of work offer/proposals, income, tax declaration, etc. The CNEL index reports that immigrants tend to settle in the North of Italy. Apulia is third from last above Sicily and Campania in the classification of immigrant integration [27]. Other factors besides work are also considered to calculate level of integration among immigrants, such as housing, schooling and access to welfare services. Their employment is generally that of sex workers in the case of Nigerians and seasonal manual laborers for North and Sub-Saharan Africa immigrants. Other illegal
immigrants from Eastern Europe work as domestic workers or care takers of the elderly. The most important issue concerns the Italian immigration law; articles 34–36 on immigration (Bossi–Fini law: changes to the rules on immigration and asylum Law 30.07.2002 No. 189, G.U. 26.08.2002) states that ‘‘…Foreign citizens on national territory who do not have leave of stay and do not have residence are insured for urgent or essential medical assistance and hospital care and for extensive programs of preventive and collective medicine…’’. In addition, ‘‘…Access to health care for foreigners who do not leave of stay or residence cannot be reported to state authorities, except in cases where reporting to state authorities is required for Italian citizens…’’ [16]. Our data demonstrate that more than 60 % of illegal immigrant patients were not aware of STP and rights linked to STP. Ignorance of this law has important implications especially for public health and the health of mothers and infants (transmitted diseases, vaccinations, etc.) as well as for health in the workplace (accidents and injuries). Our research shows that access to Italian health services is poor and badly organized for illegal immigrants’.
Conclusion As demonstrated by data from the Central Service for Protection of Asylum seekers and Refugees (SPRAR), the number of illegal immigrants has increased but a distinction should be made between illegal and legal immigrants [4]. Illegal immigrants have a number of difficulties in accessing health care in Apulia which is, in turn, linked to problems of integration in the Italian society. In Italy, large-scale political solutions to the challenges of undocumented immigrants, facilitating healthcare access and improving healthcare of immigrants are absent from the political agenda. Obviously, this has also influenced the health of illegal immigrants in Apulia where the regional administration has looked to improve with the introduction of important initiatives, such as allowing GPs to prescribe for illegal immigrants [28]. The state must recognize the same social rights for undocumented immigrants as those for legal immigrants [29, 30]. Information and communication systems must also be developed to improve access to healthcare for immigrants and integrate immigrants within the healthcare system. Acknowledgments We thank Sedley Proctor and Paulene Butts for the helpful review of the article. We thank Dr. Michela Moretti (ASL Bari) and the following non-profit organizations: Associazione Micaela o.n.l.u.s.; CAPS and CSISE (social cooperatives); ARCI, Comitato Territoriale di Bari; Giraffa onlus; Gruppo Lavoro Rifugiati Onlus; OASI 2; Esedra; Surprise.
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References 1. Caritas/Migrantes: Immigrazione dossier statistico 2007, XVII Rapporto. 2007. 2. Caritas/Migrantes: Immigrazione dossier statistico 2009, XIX Rapporto. 2009. 3. ISTAT: http://en.istat.it/dati/. 2009. 4. SPRAR: I numeri dell’accoglienza. Compendio statistico del Sistema di protezione per richiedenti asilo e rifugiati. 2008. 5. Spencer S, Cooper B. Social integration of migrants in Europe: a review of the European literature 2000–2006. In: Gaining from migration (A joint European Commission/Organisation for Economic Co-operation and Development project of July 2007). 6. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. Los Angeles: UCLA Center for Health Policy Research; 2000. 7. Vargas Bustamante A, Chen J, Rodriguez HP, Rizzo JA, Ortega AN. Use of preventive care services among Latino subgroups. Am J Prev Med. 2010;38(6):610–9. 8. Saracino A, El-Hamad I, Prato R, Cibelli DC, Tartaglia A, Palumbo E, Pezzoli MC, Angarano G, Scotto G, SIMIT Study Group. Access to HAART in HIV-infected immigrants: a retrospective multicenter Italian study. AIDS Patient Care STDS. 2005;19(9):599–606. 9. Stimpson JP, Wilson FA, Su D. Unauthorized immigrants spend less than other immigrants and US natives on health care. Health Aff (Millwood). 2013;32(7):1313–8. 10. Antonucci G, Mazzotta F, Puoti M, Angeletti C, Girardi E, Santantonio T, Ambu S, Gaeta GB, Colucci M, Angarano G, Marino N, Rinaldi R, Bellissima P, Armignacco O, Carosi G, Sagnelli E, Coorte Epatiti B SIMIT (COESI-B) Group. Factors associated with access to antiviral treatment in a multicentre cross-sectional study of patients with chronic hepatitis B in Italy. J Viral Hepat. 2012;19(12):881–9. 11. Fasano M, Saracino A, Carosi G, Mazzotta F, Marino N, Sagnelli E, Gaeta GB, Angarano G, Verucchi G, Bellissima P, Angeletti C, Santantonio T. Hepatitis B and immigrants: a SIMIT multicenter cross-sectional study. Infection. 2013;41(1):53–9. 12. Cunningham WE, Markson LE, Andersen RM, Crystal SH, Fleishman JA, Golin C, Gifford A, Liu HH, Nakazono TT, Morton S, Bozzette SA, Shapiro MF, Wenger NS. Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the United States. J Acquir Immune Defic Syndr. 2000;25(2):115–23. 13. Derose KP, Escarce JJ, Lurie N. Immigrants and health care: sources of vulnerability. Health Aff (Millwood). 2007;26(5): 1258–68. 14. Suurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot ML. Negative health care experiences of immigrant patients: a qualitative study. BMC Health Serv Res. 2011;11(1):10.
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15. Earner I. Immigrant families and public child welfare: barriers to services and approaches for change. Child Welf. 2007;86(4): 63–91. 16. Gazzetta Ufficiale n. 199 del 26 agosto 2002—Suppl. Ordinario n.173. 17. Gazzetta Ufficiale n. 173 del 25-7-2008. 18. Fedeli U, Baussano I. Health of immigrants in Italy: increasing evidences and forgotten issues in the epidemiological research. Epidemiol Prev. 2010;34(3):120–4. 19. Festini F, Focardi S, Bisogni S, Mannini C, Neri S. Providing transcultural to children and parents: an exploratory study from Italy. J Nurs Scholarsh. 2009;41(2):220–7. 20. Aragona M, Catino E, Pucci D, Carrer S, Colosimo F, Lafuente M, Mazzetti M, Maisano B, Geraci S. The relationship between somatization and post traumatic symptoms among immigrants receiving primary care services. J Trauma Stress. 2010;23(5): 615–22. 21. Vieno A, Santinello M, Lenzi M, Baldassari D, Mirandola M. Health status in immigrants and native early adolescents in Italy. J Community Health. 2009;34(3):181–7. 22. Di Sabato F, Di Vito M, Foti M. Immigrants in Italy and tensiontype headache: correlated personality traits. J Headache Pain. 2006;7(6):438–9. 23. Aragona M, Tarsitani L, Colosimo F, Martinelli B, Raad H, Maisano B, Geraci S. Somatization in primary care: a comparative survey of immigrants from various ethnic groups in Rome, Italy. Int J Psychiatry Med. 2005;35(3):241–8. 24. Saracino A, Scotto G, Tartaglia A, Fazio V, Cibelli DC, Di Tullio R, Fornabaio C, Lipsi MR, Angarano G. Low prevalence of HIV infection among immigrants within two months of their arrival in Italy. AIDS Patient Care STDS. 2008;22(9):691–2. 25. Ding H, Hargraves L. Stress-associated poor health among adult immigrants with a language barrier in the United States. J Immigr Minor Health. 2009;11(6):446–52. 26. Gualdi-Russo E, Zironi A, Dallari GV, Toselli S. Migration and health in Italy: a multiethnic adult sample. J Travel Med. 2009;16(2):88–95. 27. http://www.portalecnel.it/portale/HomePageSezioniWeb.nsf/vwhp/ HP. 28. Department of Health Policy Apulia region: Piano regionale di salute 2008-10. D.L.L. 13-06-2008. 29. Beneduce R, Martelli P. Politics of healing and politics of culture: ethnopsychiatry, identities and migration. Transcult Psychiatry. 2006;43(1):157. 30. Giger JN, Davidhizar R. Promoting culturally appropriate interventions among vulnerable populations. Annu Rev Nurs Res. 2007;25:293–316.
BRIEF COMMUNICATION
Access to Health Services for Undocumented Immigrants in Apulia G. Brindicci • G. Trillo • C. R. Santoro A. Volpe • L. Monno • G. Angarano
•
Springer Science+Business Media New York 2014
Abstract This paper, part of a larger epidemiological study carried out between 2004 and 2010, analyzed immigrants frequenting the largest Apulian regional hospital (Bari Policlinico). Our aim was to evaluate the perception on the part of undocumented immigrants of their rights of access to the National Health Care services and whether this privilege is actually utilized. An anonymous multi-language questionnaire was distributed to all patients with STP (code number for temporary presence of foreigners) at the immigrant outpatient Infectious Diseases Clinic of Bari from June 2009 to June 2010. Questions were related to nationality, date of arrival in Italy, use of health facilities in the 2 years prior to the compilation of the questionnaire, and their understanding of STP. The patients were also screened for infectious diseases (HIVAb, HBsAg, HCV-Ab, VDRL, TPHA and Mantoux). A total of 256/272 patients completed the questionnaire; the meaning of STP was unknown to 156/256 (60.9 %) patients, only 54/256 (21 %) knew the exact meaning of STP and only 42/54 (76.6 %) of the latter knew how long STP was valid. Moreover, 128/256 (50.7 %) were aware that doctors from the emergency unit were not allowed to notify police regarding presence of illegal immigrants. Regarding clinical data 3 % were HIV? (8/256), 5 % (13 patients) positive for TPHA, 5 % for HBsAg, 2 % were HCV (five patients). A [10 mm diameter infiltrate of Mantoux test was noted for 44 % of patients. A lower prevalence than expected for infections such as HIV, HBV or HCV was noted for immigrants compared to data from
G. Brindicci G. Trillo C. R. Santoro A. Volpe (&) L. Monno G. Angarano Clinic of Infectious Diseases, University of Bari, Policlinico, Piazza G. Cesare 11, 70124 Bari, Italy e-mail: [email protected]
their countries of origin. At present, large-scale political solutions to the challenges of facilitating access to health facilities for undocumented immigrants are lacking in Italy. The development of communication systems is fundamental to improving access to health services and to creating links between immigrants and the healthcare system. Keywords
Immigration Apulia Access to health
Introduction According to Italian National Statistics Institute (ISTAT) data, the number of immigrants in Italy is steadily increasing; in fact, the number of documented immigrants in Italy was 2,900,000 at the end of 2006 [1] while 4.3 million regular immigrants (7.2 % of the Italian population), including EU nationals, were reported at the end of 2008. The majority (62.5 %, more than two million) live in the North while 25 % reside in the Centre and 12.5 % in Southern Italy. In Apulia, immigration is also on the increase, even if immigrants generally leave for other regions in Italy or other EU countries [2]. Precise data regarding illegal immigrants is difficult to obtain, but the 2008 Caritas/Migrantes report estimates that there were between 500,000 and 700,000 unauthorized immigrants in Italy, which places Italy at the top of EU list for illegal aliens [2]. Moreover, Apulian ISTAT data reports that the number of regular immigrants increased from less than 37,000 at the end of 2005 to about 80,000 at the end of 2010 [3]. According to the 2009 Caritas report, the largest immigrant group was Albanian who accounted for more than 50 % of the total immigrant population. The remaining immigrant residents were comprised of Moroccans
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(10 %), together with Romanians, Chinese and Ukrainians (more than 5 %, respectively) [2]. However, according to SPRAR (System of protection for refugees requesting asylum), the most common countries of origin of those who arrive in Italy are Eritrea and Afghanistan, while from 2006 to 2008, the number of irregular migrants from Somalia and Nigeria demonstrated the highest increase. This apparent discrepancy is explained by the fact that generally individuals from Afghanistan, Ethiopia or Eritrea) have less difficulty obtaining a refugee status and therefore are no longer counted as ‘‘irregulars’’ [4]. As it is a coastal region, according to SPRAR, 76 % of undocumented immigrants arrive in Italy by sea; this number increased by 34 % in the 2007–2008 period thus determining Apulia as the fourth largest region for total number of admitted immigrants [4]. On the contrary, Caritas states that the number of legal immigrants passing through the maritime borders is less than 2 % of the total number of immigrants arriving in Italy [2]. The health of immigrants is a key indicator of ‘integration’ into the receiving societies [5]. Disparities clearly exist in the health care for ethnic minorities [6–11]. This is particularly obvious when considering the United States where access to health care is not guaranteed as a right of citizenship and there is a net difference between those who can and cannot afford health insurance, thus explaining divergence in health care available for blacks and whites, as well as for drug and non-drug abusers [12–15]. In Italy, access to health care facilities is gratis and the health of immigrants is not likely to be influenced by their economic/ social status. However, since the introduction of the code number for temporary illegal immigrants (STP) contained in the Bossi–Fini law (30.07.2002 n.189) [16], the concept of accessible health care has been called into question. This Law on immigration (‘‘Amendments to legislation on immigration and asylum’’ published in the Official Gazette no. 199 of 26 August 2002) is more severe and restrictive for irregular migrants and make regularization more difficult, but the access to health care is not limited in any way, at least theoretically. In fact, the law guarantees, in particular, the following benefits to undocumented immigrants too: (a) (b) (c) (d) (e)
the social protection of pregnancy and maternity; the protection of health of the child; vaccinations, according to the regulations authorized by the Regions; the intervention of international prophylaxis; the prevention, diagnosis and treatment of infectious diseases.
The above services are provided gratis to documented applicants, if lacking sufficient economic resources.
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Table 1 The multiple-choice questionnaire distributed to patients with STP code numbers from June 2009–June 2010 1. In general, how would you describe your own health? 2. In the last 12 months, have you visited a doctor or medical clinic for any reason, including check-ups or visits to the emergency room or hospital outpatient department? 3. In the last 12 months, have you been admitted to hospital? 4. Where do you usually go when you are sick or need health care? 5. Earlier you mentioned that you had visited a doctor within the past couple of years. The last time you visited a doctor, did the doctor listen to everything you had to say, to most, to some, or only a little of what you had to say? 6. During the visit, did you understand everything the doctor said, most of what the doctor said, some, or only a little of what the doctor said? 7. How much confidence and trust did you have in the doctor treating you—a great deal, a fair amount, not too much, or none at all? 8. Did the doctor treat you with a great deal of respect and dignity, a fair amount, not too much, or none at all? 9. Did the doctor involve you in decisions about your care? 10. Did the doctor spend as much time with you as you wanted, almost as much as you wanted, less than you wanted, or a lot less than you wanted? 11. Has there been a time in the last 2 years when you didn’t follow the doctor’s advice, or treatment plan, get a recommended test or see a referred doctor? 12. Overall, how satisfied or dissatisfied are you with the quality of health care you have received during the last 2 years? 13. If you could choose, would you prefer to be treated by a doctor (race ethnic group) 14. Do you know what STP means? 15. Do you know how long STP is valid? 16. In you opinion, can a foreigner in Italy without a residency permit take advantage of the hospital emergency unit? 17. How do you think a doctor in the emergency unit should behave according to the Italian law when taking care of a patient without a residency permit?
Moreover, access to health facilities by the illegal immigrant cannot result in any type of reporting to authorities (except, as also for Italians, in cases where it is mandatory to report). However, we must also recall that between March and June of 2009, the Italian incumbent government in office was preparing to present the so-called ‘‘security package’’ containing the possible obligation for doctors (who were aware of the status of irregularities of a foreign patient) to report the illegal status to authorities. Herein, we aimed to analyze the perception of the right to access to health care on the part of illegal immigrants in this politically difficult moment due to sanctions and restrictions for illegal immigrants contained in the new law (number 125, July 24, 2008) [17] and whether they are effectively able to obtain medical care from public services.
J Immigrant Minority Health
Methods An anonymous questionnaire mainly consisting of multiple-choice questions was distributed to all patients with STP code numbers referring to the Immigrant Out-patient infirmary of the Infectious Diseases Clinic of Bari from June 2009–June 2010. Questions related to nationality, date of arrival in Italy, use of health facilities in the 2 years prior to the compilation of questionnaire, immigrants’ understanding of STP and expiry date of STP, admission to the hospital or to the hospital outpatient department, satisfaction with quality of assistance and health care and illegal immigrants health rights in Italy. The questionnaire is reported in Table 1. The patients were also screened with serological tests for infectious diseases (HIV-Ab, HBsAg, HCV-Ab, VDRL, TPHA), the Mantoux skin test and a general blood chemistry. In the case of chronic diarrhea (defined as lasting more than 15 days), a copro-parasitological examination was required for anal or generalized itching, absolute number of eosinophils ([400 cells/mm3), or other signs suggestive of parasitic diseases.
Results A total of 256/272 patients completed the questionnaire (response rate 94 %). Countries of origin included: Africa 185/256 (72 %) patients with 12 different nationalities including 76/256 (41 %) from Nigeria, 20/256 (11 %) from Morocco and Tunisia; Eastern Europe 24/256 (9 %) patients with 14/24 (58 %) from Romania; Asia 47/256 (18 %) patients with 25/47 (54 %) from Bangladesh and 12/47 (25 %) from Afghanistan. A total of 166/256 patients (65 %) resided in Italy since 2007, 20 % since 2004 and 15 % of illegal immigrants had been living in Italy for more than 5 years. The average age was 25 years (range from 18 to 63 years). At time of admission, 82/256 (82 %) of patients considered their own health as good, very good or excellent, while 46/256 (18 %) considered their health as poor or very poor. Regarding the last year (June 2010) covered by the questionnaire, 148/256 patients (56 %) were visited by a doctor at least once and 61/256 (24 %) were admitted to hospital. A general practitioner (GP) was consulted by 53/256 (21 %) of patients when they were sick or required health care while 46/256 (18 %) used Emergency Services; 59/256 (23 %) said that they had been healthy since their arrival in Italy. Of the 148/256 patients who took advantage of the National Health System in Apulia, 34/148 (22.9 %) were from Nigeria followed by 18/148 (12.1 %) from Bangladesh, 10/148 (6.75 %) from Afghanistan,
Romania and Gambia. The immigrant population utilizing our health services according to nationality (Fig. 1a) compared to the regularly documented patients present in Puglia during the same period can be found in Fig. 1b. The 59/148 patients (40 %) who visited a doctor were very satisfied with the quality of health care while only 34 (22 %) were either not satisfied or fairly dissatisfied (question n. 12). A total of 75 patients (83.6 %) stated that they had been treated with dignity and respect while 26 (16.4 %) reported that they had been treated badly (question 8). See Fig. 2 for more details regarding the patient’s perception of doctors behaviour (questions 5–10). A total of 31/148 (21 %) of interviewees said they would have preferred to have been visited by a doctor from their own country, as opposed to 47 % who did not express a preference. The meaning of STP was not known by 156/256 (61.1 %) patients. Only 54/256 (21.0 %) knew the exact meaning of STP and 42/54 (76.6 %) were aware of the expiration date for STP. Only 180 (46.1 %) of patients realized that doctors in the emergency unit were not obliged to inform the police of the presence of illegal immigrants, as everyone in Italy has the right to medical care while 76 (30 %) were not aware of the contents of the law regarding immigration in Italy. A total of 20 patients (7.8 %) thought that doctors should inform the police and 32 (12.5 %) thought that doctors were obliged to inform the police. Regarding clinical data, 8/256 (3 %) were HIV?, 13/256 (5 %) were positive for TPHA (no patients were VDRL positive), 13/256 (5 %) were positive for HBsAg, 5/256 (2 %) for HCV while 113/256 (44 %) of patients had more than 10 mm infiltrate of Mantoux test. No patient referred to previous knowledge of his own virological status. A total of 65/256 (25.3 %) patients presented a eosinophil count greater than 400 cells/mm3, 35 of whom (53.8 %) were subjected to a parasitical exam of stools (three specimens collected on alternate days). Five patients (14.2 %) were positive for Ascarides lumbricoides and five (14.2 %) presented Entamoeba coli cysts. Five patients (14.2 %) complained of generalized itching, three of whom (60 %) were administered anti-scabbia treatment thus resolving the problem.
Discussion Our data confirms that immigrants in Italy (EU) are generally young, fit, and healthy, thus corresponding to the picture of the so-called first-phase immigration individual, selected because the chance of fulfilling the family aim to settle in a foreign was greater. However, while reporting
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J Immigrant Minority Health 35
30
(a)
30
(b)
25
25
20
20
15
15 10
10
5
5
Others
Mauritius
India
Philippines
Tunisia
Senegal
Ukrain
Bulgaria
China
Poland
Morocco
Albania
Others
Ghana
Algeria
Iraq
Ivory
Afghanis
Romania
Gambia
Tunisia
Somalia
Morocco
Nigeria
Banglad
Romania
0
0
Fig. 1 General population utilizing our health services according to nationality (a) compared to the regularly documented patients present in Puglia (in according to ISTAT data) in the same period (b)
Fig. 2 Details regarding the patient’s perception of doctors behaviour (questions 5–10). Il valore dell’asse delle ordinate corrisponde per tutte le figure alla % dei pazienti
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high levels of self-esteem and good skills for adapting to new living conditions, many aliens also report unrecognized health needs and describe barriers when seeking help. The difficulties when lacking a regular status in immigrant families was particularly experienced by children [18, 19]. Other studies have described a high prevalence of trauma (post-traumatic stress), depression, chronic stress, family separation and stress-related physical illnesses among the immigrant population [20–23]. Stress-related physical illnesses could explain the high percent of patients who described their health as poor or very poor in our questionnaire, but who do not demonstrate abnormal blood tests or negative physical examinations [18, 24, 25]. Our data regards communities of illegal immigrants present in the Italian Apulia region. It must be emphasized that in spite of the increase in illegal immigrants in Apulia, the number is still low compared to other areas. Our outpatient clinic provides services to immigrants from more than 25 countries which tends to confirm previous statistical analyses of the migratory phenomenon in Italy [3, 26]. Regular migrants come from 150 different countries and speak more than 50 different languages. According to the CARITAS statistical report on immigration from 2009, however, there has been a decrease in the number of legal immigrants up to 31/12/07 (from 73,600 to 70,000) in Apulia, as a consequence of the decrease in numbers in Bari (from 32,300 to 30,300) and Foggia (from 17,000 to 14,600) provinces [2]. The number of immigrants would probably be higher if Apulia offered more social services and opportunities for employment. In fact, according to the Italian National Council of Economy and Labour (CNEL) 2007 report, Apulia demonstrates one of the lowest levels of social integration of immigrants compared to other Italian regions [27]. Regarding illegal immigrants, the majority of patients at our outpatient clinic are from Nigeria and East African countries, which tends to confirm the figures for illegal immigrants published by SPRAR [4]. Studies on immigration and the job market from the CNEL index indicate the kinds of employment which draw immigrants to the various Italian regions. This type of analysis is based on a series of factors such as request for immigrant labour, quality of work offer/proposals, income, tax declaration, etc. The CNEL index reports that immigrants tend to settle in the North of Italy. Apulia is third from last above Sicily and Campania in the classification of immigrant integration [27]. Other factors besides work are also considered to calculate level of integration among immigrants, such as housing, schooling and access to welfare services. Their employment is generally that of sex workers in the case of Nigerians and seasonal manual laborers for North and Sub-Saharan Africa immigrants. Other illegal
immigrants from Eastern Europe work as domestic workers or care takers of the elderly. The most important issue concerns the Italian immigration law; articles 34–36 on immigration (Bossi–Fini law: changes to the rules on immigration and asylum Law 30.07.2002 No. 189, G.U. 26.08.2002) states that ‘‘…Foreign citizens on national territory who do not have leave of stay and do not have residence are insured for urgent or essential medical assistance and hospital care and for extensive programs of preventive and collective medicine…’’. In addition, ‘‘…Access to health care for foreigners who do not leave of stay or residence cannot be reported to state authorities, except in cases where reporting to state authorities is required for Italian citizens…’’ [16]. Our data demonstrate that more than 60 % of illegal immigrant patients were not aware of STP and rights linked to STP. Ignorance of this law has important implications especially for public health and the health of mothers and infants (transmitted diseases, vaccinations, etc.) as well as for health in the workplace (accidents and injuries). Our research shows that access to Italian health services is poor and badly organized for illegal immigrants’.
Conclusion As demonstrated by data from the Central Service for Protection of Asylum seekers and Refugees (SPRAR), the number of illegal immigrants has increased but a distinction should be made between illegal and legal immigrants [4]. Illegal immigrants have a number of difficulties in accessing health care in Apulia which is, in turn, linked to problems of integration in the Italian society. In Italy, large-scale political solutions to the challenges of undocumented immigrants, facilitating healthcare access and improving healthcare of immigrants are absent from the political agenda. Obviously, this has also influenced the health of illegal immigrants in Apulia where the regional administration has looked to improve with the introduction of important initiatives, such as allowing GPs to prescribe for illegal immigrants [28]. The state must recognize the same social rights for undocumented immigrants as those for legal immigrants [29, 30]. Information and communication systems must also be developed to improve access to healthcare for immigrants and integrate immigrants within the healthcare system. Acknowledgments We thank Sedley Proctor and Paulene Butts for the helpful review of the article. We thank Dr. Michela Moretti (ASL Bari) and the following non-profit organizations: Associazione Micaela o.n.l.u.s.; CAPS and CSISE (social cooperatives); ARCI, Comitato Territoriale di Bari; Giraffa onlus; Gruppo Lavoro Rifugiati Onlus; OASI 2; Esedra; Surprise.
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