Refugees and Dutch healthcare

Worldwide in 2015, 65.5 million people were on the move, fleeing war or persecution [1]; of them, 1.3 million reached Europe, and 58,000 arrived in the Netherlands – a sharp increase over the previous years [2]. The current newly arriving refugees are mainly from Syria, Eritrea, Iraq and Afghanistan. As many of them will be granted (temporary) permission to stay, we may expect that the number of refugees settling in municipalities and accessing regular healthcare in the Netherlands will grow in the next few years.
What are the main health issues among refugees in the Netherlands? What healthcare do they need, and what do doctors have to keep in mind when they are consulted?

Health status of refugees often gets worse over time

Refugees who are able to undertake the sometimes dangerous and difficult journey to Europe are often relatively healthy compared to the general population in their countries of origin. This is called the “healthy migrant effect” [3]. However, after arrival in the host country, their health often deteriorates. Compared to the population in the host country, refugees rate their own health as worse, and the older they become, the larger the difference [4,5]. Factors that play a role concern social determinants of health: the length of the asylum procedure (the longer the procedure, the more mental health problems surface), the possibilities for family reunion (the sooner they can be reunited with their families the better), and most importantly for a healthy life, social support in their new environment as well as opportunities to obtain employment commensurate with their abilities and experience. Highly educated and young refugees have better prospects than less educated or older refugees [6]. When it comes to children’s health, additional factors come into play, which may be either protective or carry further risks for a healthy development (see table 1) [6].

Table 1 Factors that influence the health development of children

The most common health problems found among refugees in the Netherlands are stress related complaints and mental health problems, certain infectious diseases, diabetes, and reproductive health conditions [6].

Mental health problems

Although refugees may appear quite resilient, they may have had traumatic experiences resulting in posttraumatic stress disorder (PTSD), depression and anxiety disorders; it is estimated that 13-25% of refugees in the Netherlands develop psychiatric disorders [6]. The actual development of such problems depends on the forementioned social determinants (participation in society, social support), preventive measures targeting the development of mental health problems and on timely diagnosis and treatment [7]. However, the use of mental health services is suboptimal among refugees. Avoidance of care often occurs due to taboos and stigma on mental health problems, mistrust or lack of knowledge about the Dutch healthcare system, or fear of being stigmatized. Children who flee their home country – with or without their parents – are prone to abuse, which may have long lasting implications for their mental development [6].

Infectious diseases

Refugees seldom pose a risk to public health in their host countries [8], but they are more at risk of certain infectious diseases due to the high prevalence in the country of origin. These include active tuberculosis, chronic hepatitis B and C, infection with HIV, parasitic infections, and multi-resistant microbes [6].

The prevalence of tuberculosis among refugees from Syria is low, so they are not screened for TB after arrival in the Netherlands. Among other refugee populations, however, it is high, especially among Eritrean and Somali refugees (100 times higher than among the Dutch general population) [6]. The prevalence of hepatitis B and C varies from country to country, but in general it is 2 to 10 times higher than in the Dutch population [6]. The HIV infection rate among migrants from Eritrea is seven times higher than in the Dutch general population [6].

Diabetes

Refugees who reside for a longer period in the Netherlands develop diabetes twice as often as other people of the same age [6]. This is attributed to physical inactivity, overweight, chronic stress, and mental health problems. Asylum seekers with a PTSD diagnosis develop diabetes 1.4 times more often than asylum seekers without PTSD [9]. Diabetes is also more prevalent among lowly educated persons, and the outcome of diabetes care is worse among non-western immigrants [10]. These poor health outcomes are caused by limited health literacy, language barriers, and a lack of cultural competent healthcare. In Syria before the war, overweight was highly prevalent, affecting 23.5% of the adult population compared to 19.8% in the Netherlands [6]. Studies among previous groups of asylum seekers in the Netherlands have revealed a higher prevalence of diabetes among Syrians [6]. It is likely that an unhealthy lifestyle will be found among the current group of Syrians as well, with an elevated risk of diabetes. Overweight is less prevalent among Eritrean refugees, but the low level of education in this group will increase the likelihood that they develop diabetes.

Reproductive health issues

Unintended pregnancies, teenage pregnancies, induced abortion, and maternal morbidity are more prevalent among refugees, especially those from Africa. Causes of these elevated reproductive health risks include sexual violence, female genital mutilation, and a general lack of knowledge about contraception. Unfamiliarity with the Dutch healthcare system is another constraint. Some women refugees who are pregnant mistrust Dutch midwives or do not know the possibilities of antenatal care. Young female refugees and unaccompanied minors are at risk of sexual abuse, even when they are already in the Netherlands [6].

Healthcare needs of refugees

When a refugee who had obtained asylum in the Netherlands was interviewed, he said, ‘Show me the way, explain how things work over here, teach me the language, and give me a job’ [7]. This person emphasised integration into Dutch society as his main concern. The general experience of refugees with healthcare in the Netherlands is not always very positive. They complain about the family physician, whose role as gatekeeper is not well appreciated, as it hinders them in directly visiting the hospital. They also do not understand or appreciate certain typical features of Dutch healthcare culture. These include the small difference in status between doctor and patient (doctors accessing information during consultations), the emphasis on shared decision making (‘What do you think yourself?’) and the reticent policy on providing prescriptions for medication (‘We only get paracetamol’). Refugees indicate they want to receive more information about the healthcare system and about regulations and procedures [7]. All refugees interviewed expressed a wish for compassionate doctors, who take enough time to get to know their patients and who show interest in their cultural background. Besides, recently arriving refugees need interpreters to overcome the language barrier [11]. These barriers and healthcare needs expressed by the recent group of refugees, are consistent with the known barriers migrants encounter in accessing good quality healthcare [11,12]. Sometimes, financial barriers play a role, for example in accessing dental care.

The need for culturally sensitive person-centred care and for community oriented prevention

To prevent the health of refugees from deteriorating and to adequately treat the conditions from which they suffer, the Dutch healthcare system and health care workers in particular need to better adjust their care to the needs and concerns of refugees. The social determinants of health among refugees need to be optimised. This asks for integrated actions of healthcare professionals, community workers, municipalities, social workers, and schools. An integrated, community oriented approach, which actively involves refugees, is needed to inform them about Dutch society and healthcare as well as healthy lifestyle and activities to improve their health literacy, with a view to strengthening their resilience and reducing mental stress.

Refugees, like anybody else, benefit from person-centred care, i.e. care that is tailored to their needs and background. To be able to deliver such care, health care professionals need cultural competences. These include a good dose of an open, non-judgemental, curious and compassionate attitude, a basic knowledge of ethnic and socio-economic health differences and conditions that often occur among migrants, and good communication skills to overcome linguistic and cultural differences and to interact with low-literate persons [11,13,14,15]. Very important is the use of interpretation services [11,15,16], which unfortunately has sharply decreased in the Netherlands since the government ceased to pay for these services in healthcare [17]. Several good sources of information on refugee care are available, including the website www.huisartsmigrant.nl and the Canadian guidelines for refugee care [14]. The main ingredient for good healthcare for refugees is something all doctors should be able to provide – a smiling face, a welcoming gesture, and sufficient time, compassion and respect.

References

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