Health and access to care for undocumented migrants living in the European Union: A scoping review

Abstract

Background Literature on health and access to care of undocumented migrants in the European Union (EU) is limited and heterogeneous in focus and quality. Authors conducted a scoping review to identify the extent, nature and distribution of existing primary research (1990–2012), thus clarifying what is known, key gaps, and potential next steps.
Methods Authors used Arksey and O’Malley’s six-stage scoping framework, with Levac, Colquhoun and O’Brien’s revisions, to review identified sources. Findings were summarized thematically: (i) physical, mental and social health issues, (ii) access and barriers to care, (iii) vulnerable groups and (iv) policy and rights.
Results Fifty-four sources were included of 598 identified, with 93% (50/54) published during 2005–2012. EU member states from Eastern Europe were under-represented, particularly in single-country studies. Most study designs (52%) were qualitative. Sampling descriptions were generally poor, and sampling purposeful, with only four studies using any randomization. Demographic descriptions were far from uniform and only two studies focused on undocumented children and youth. Most (80%) included findings on health-care access, with obstacles reported at primary, secondary and tertiary levels. Major access barriers included fear, lack of awareness of rights, socioeconomics. Mental disorders appeared widespread, while obstetric needs and injuries were key reasons for seeking care. Pregnant women, children and detainees appeared most vulnerable. While EU policy supports health-care access for undocumented migrants, practices remain haphazard, with studies reporting differing interpretation and implementation of rights at regional, institutional and individual levels.
Conclusions This scoping review is an initial attempt to describe available primary evidence on health and access to care for undocumented migrants in the European Union. It underlines the need for more and better-quality research, increased co-operation between gatekeepers, providers, researchers and policy makers, and reduced ambiguities in health-care rights and obligations for undocumented migrants.

Full text

REVIEW
Health and access to care for undocumented
migrants living in the European Union: a
scoping review
Aniek Woodward
1,2
*, Natasha Howard
1
and Ivan Wolffers
3
1
Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, WC1H 9SH, UK,
2
King’s
International Development Institute and King’s Centre for Global Health, King’s College London, London, WC2R 2LS, UK and
3
Vrije
Universiteit Medical Centre, Amsterdam, 1007 MB, the Netherlands
*Corresponding author. Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London,
WC1H 9SH, UK. E-mail: aniek.woodward@lshtm.ac.uk
Accepted 11 July 2013
Background Literature on health and access to care of undocumented migrants in the
European Union (EU) is limited and heterogeneous in focus and quality.
Authors conducted a scoping review to identify the extent, nature and
distribution of existing primary research (1990–2012), thus clarifying what is
known, key gaps, and potential next steps.
Methods Authors used Arksey and O’Malley’s six-stage scoping framework, with Levac,
Colquhoun and O’Brien’s revisions, to review identified sources. Findings were
summarized thematically: (i) physical, mental and social health issues, (ii)
access and barriers to care, (iii) vulnerable groups and (iv) policy and rights.
Results Fifty-four sources were included of 598 identified, with 93% (50/54) published
during 2005–2012. EU member states from Eastern Europe were under-
represented, particularly in single-country studies. Most study designs (52%)
were qualitative. Sampling descriptions were generally poor, and sampling
purposeful, with only four studies using any randomization. Demographic
descriptions were far from uniform and only two studies focused on undocu-
mented children and youth. Most (80%) included findings on health-care access,
with obstacles reported at primary, secondary and tertiary levels. Major access
barriers included fear, lack of awareness of rights, socioeconomics. Mental
disorders appeared widespread, while obstetric needs and injuries were key
reasons for seeking care. Pregnant women, children and detainees appeared most
vulnerable. While EU policy supports health-care access for undocumented
migrants, practices remain haphazard, with studies reporting differing interpret-
ation and implementation of rights at regional, institutional and individual levels.
Conclusions This scoping review is an initial attempt to describe available primary evidence on
health and access to care for undocumented migrants in the European Union. It
underlines the need for more and better-quality research, increased co-operation
between gatekeepers, providers, researchers and policy makers, and reduced
ambiguities in health-care rights and obligations for undocumented migrants.
Keywords: Undocumented migrants, health, access to care, European Union, review
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
journals.permissions@oup.com Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
ß The Author 2013.
Health Policy and Planning 2013;1–13
doi:10.1093/heapol/czt061
1
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KEY MESSAGES
 Only 54 primary sources were identified in this scoping review on health and access to care for undocumented migrants
in EU27, most of which lacked methodological rigour and consistency—particularly in sampling. This indicates a
significant need for more and higher-quality research on this subject.
 Methodological challenges in accessing this largely invisible population need addressing, requiring co-operation between
the various actors (e.g. NGO and health staff gatekeepers, academic communities and policy makers) at regional,
national, and institutional levels.
 Improved awareness of health-care rights and obligations for undocumented migrants could reduce ambiguities and
anxieties limiting access to this group for health staff and researchers.
Background
Case reports from support organizations suggest high infection
rates, poor disease prevention, and delays in health-care access
among undocumented migrants living in the 27 member states
of the European Union (EU27), reflecting both increased health
risks of undocumented migrants and barriers to health-care
access (Chauvin et al. 2009; Karl-Trummer et al. 2009; MDM
2009). Mladovsky and others associate these increased risks
with a lack of knowledge about host health systems, language
and cultural barriers, legal constraints, financial concerns and
anxiety (Mladovsky 2007; PICUM 2010a). Undocumented
migrants remain under-researched within the EU (Mladovsky
2007). Undocumented migrants are not included in national
statistics due to their insecure status, while legal and social
vulnerabilities make them hard to reach for research. Thus,
data are often based on estimates and conclusions drawn from
findings for the overall migrant population. The quality of data
collection and statistics can be particularly difficult to assess
(Mladovsky 2007; Kovacheva and Vogel 2009).
Although increasing, existing literature on the health and
access to care of undocumented migrants in the EU is
heterogeneous in focus and quality. While some overviews
exist (PICUM 2010a; FRA 2011b; Chauvin et al. 2012), none
have been found in peer-reviewed journals to date. Authors
chose to conduct a scoping review to identify the extent, nature
and distribution of existing research evidence, thus clarifying
what is known and gaps preventing progress in this under-
researched area. Because they do not try to appraise the quality
of evidence formally, scoping reviews allow inclusion of a broad
range of study designs from both peer-reviewed and grey
literature (Arksey and O’Malley 2005; Grant and Booth 2009;
Levac et al. 2010).
Aim and objectives
The aim of this review is to identify the key research priorities
on health and access to health care among undocumented
migrants residing in the EU. Objectives were to summarize the
extent, nature, distribution and main findings of the available
literature. Main gaps in the literature are also discussed.
Methods
Authors used Arksey and O’Malley’s scoping framework with
Levac, Colquhoun and O’Brien’s 2010 revisions (Arksey and
O’Malley 2005; Levac et al. 2010). This six-stage framework
includes: (i) identifying the research question; (ii) identifying
relevant studies; (iii) selecting studies; (iv) charting data; (v)
collating, summarizing, and reporting results and (vi) stake-
holder consultation (Arksey and O’Malley 2005; Levac et al.
2010).
Stage 1: identifying the research question
The York framework suggests a broad, clearly articulated
research question, defining concepts, target population, health
outcomes, and scope whilst accounting for the aim and
rationale of the review (Arksey and O’Malley 2005; Levac
et al. 2010). Authors selected the research question: ‘What are
the scope (i.e. extent, nature, and distribution), main findings
and gaps in the existing literature on health status and access
to health care for undocumented migrants residing in one of 27
member states of the European Union?’
Definitions used can be found in Box 1. Authors used the
WHO definition of health. Thus, the review included all primary
studies referring to physical, mental or social aspects of health
within the target population. While the vagueness of this
definition can challenge operationalization, it was deemed
appropriate due to its broad recognition and frequency of
usage. The literature lacks consensus on the definition of
‘access to care’. Authors used Gulliford and colleagues’
(Gulliford et al. 2001) definition as it is more specific than
most. Authors defined undocumented migrants according to
the European Glossary on undocumented migration, due to its
frequency of use.
Stage 2: identifying relevant studies
The York framework recommends searching multiple literature
sources to increase comprehensiveness (Arksey and O’Malley
2005). Authors searched electronic databases, key journals and
websites.
First, electronic databases PubMed, Web of Science, EMBASE,
Global Health, CINAHL Plus and PsychINFO databases were
searched systematically, using the terms ‘undocumented AND
migrant AND health AND EU countries’ adapted to the MeSH
headings for each database. As ‘undocumented’ is used inter-
changeably with ‘illegal’, ’unauthorised’, ‘irregular’, ‘compliant/
non-compliant/semi-compliant (im)migrants’ (UWT 2008), all
search terms were used.
For example, in PubMed the search strategy was:
(‘‘undocumented’’[All Fields] OR ‘‘illegal’’[All Fields] OR
‘‘unauthori?ed’’[All Fields] OR ‘‘compliant"[All Fields] OR
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‘‘irregular’’[All Fields] OR ‘‘Illegal Migrants’’[MeSH Term])
AND (‘‘migrant*’’[All Fields] OR ‘‘migration’’[All Fields] OR
‘‘immigrant*’’) AND (‘‘Delivery of Health Care’’[MeSH
Heading]) AND (‘‘EU’’[All Fields] OR ‘‘European
Union’’[MeSH Heading] OR ‘‘Europe*’’[All Fields] OR
‘‘Europe’’[MeSH Heading]).
Second, key journals, websites and references were searched
purposefully. Four key journals on migration were hand-
searched (i.e. International Migration; Journal of Ethnic and
Migration Studies; Journal of Refugees Studies and European Journal
of Migration and Law). For websites and references, a four-stage
search strategy was implemented: (i) publications posted on
websites of well-known non-profit organizations and EU-
related migration institutions were searched; (ii) relevant
citations were snowballed to references and websites of other
pertinent organizations, including those of undocumented
migrant projects; (iii) a Google search of ‘undocumented
migrants’ was conducted to include additional relevant docu-
ments and (iv) stakeholder recommendations were assessed
according to inclusion criteria. Table 1 provides a list of
organization and project websites searched.
Stage 3: study selection
Inclusion and exclusion criteria were established via an iterative
process. Authors agreed initial selection criteria based on the
research question, focusing on primary research on health
status and/or health-care access of undocumented migrants in
the EU27. All study designs, intervention types and participants
(e.g. undocumented migrants, health professionals) were con-
sidered. Study outcomes were restricted to health status and
access to health care for undocumented migrants. This study
did not specifically address refugees, asylum seekers or victims
of trafficking, although they may have been included as
undocumented migrants. All authors agreed the final selection
criteria (available in Box 2).
The first author was responsible for screening titles and
abstracts found in electronic databases, documents from
Box 2 Final inclusion and exclusion criteria
Inclusion criteria Primary research studies:
(i) with data on the health status and/or access to health care of undocumented migrants in one or
more of the EU27 countries;
(ii) in a language in which authors were proficient (i.e. Dutch, English, French, German, Italian,
Portuguese, Spanish);
(iii) published from 1 January 1990 to 31 December 2012.
Exclusion criteria Studies were excluded if:
(i) no primary data was collected (e.g. many used hospital-based records or audits from other
health institutions);
(ii) data was not disaggregated by immigration status (e.g. some studies targeted migrants in
general);
(iii) documents duplicated higher-quality study results already included (e.g. meeting abstracts were
excluded if original peer-reviewed articles were available);
(iv) they were not research articles (e.g. small ad hoc surveys, comments, notes, personal views,
discussion papers, books);
(v) they were published in a language other then those in inclusion criteria and no English abstract
was available;
(vi) data was collected before a respective state was a member of the EU; and
(vii) the country was an overseas territory of an EU member state.
Box 1: Key definitions
Health ‘A state of complete physical, mental, and social well-being and not merely the absence of disease or
infirmity’ (WHO)
Access to care ‘Facilitating access is concerned with helping people to command appropriate health care resources in order
to preserve or improve their health’, depending on availability, accessibility, acceptability, barriers to
utilization (Gulliford et al. 2001)
Undocumented migrants ‘Foreign citizens present on the territory of a state, in violation of the regulations on entry and residence,
having crossed the border illicitly or at an unauthorized point: those whose immigration/migration status
is not regular, and can also include those who have overstayed their visa or work permit, those who are
working in violation of some or all of the conditions attached to their immigration status: and failed
asylum seekers or immigrants who have no further right to appeal and have not left the country’
(European Glossary on undocumented migration)
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citations, and key websites according to agreed inclusion and
exclusion criteria (Box 2). Co-authors were consulted during
the study selection process as needed. Figure 1 provides a flow
diagram of the process.
Stage 4: data charting
Relevant sources were charted in Excel using the following
column headings: lead author, publication year, title of source,
type of source (e.g. original article, report), type of search
(i.e. electronic database, hand-search, reference searching,
stakeholder recommendation), name of database, name of
journal or organization, country of data collection, year(s) of
data collection, study design, methods, target population,
sampling method, key demographics (i.e. number, sex and
age of participants), whether undocumented migrants were
defined (i.e. yes/no/unclear), definition used if undocumented
migrant was defined, study objective(s), main study findings
and recommendations. These headings resulted from an
iterative process, with several added during the charting process
as authors agreed the final list. The first author was
primarily responsible for data extraction with support from
the second author on sources in Spanish, Italian and
Portuguese.
Stage 5: collating, summarizing and reporting results
First, results on the nature, extent and distribution of studies
were summarized. Second, summarization of findings was
guided by the research question (i.e. access and barriers to
health care) and WHO definition of health (i.e. physical, mental
and social). Third, important themes that emerged from
analysis were added.
Stage 6: consultation with stakeholders
A stakeholder group was organized as part of this study to
provide feedback on preliminary results. Sixteen experts in the
field were approached via email in August 2012, of whom
thirteen agreed to participate. The consultation process took
place in two stages. First, stakeholders were sent a draft of
results on the extent, nature and distribution of literature and
asked to provide initial feedback addressing questions such as
‘Did you expect these results?’ and ‘What can be done to make
the results more useful?’ and suggesting themes for displaying
summary findings. Feedback was used to develop the coding
manual for analysis. Second, stakeholders were sent a draft of
the results section and asked for feedback, including any policy
and research recommendations that could inform the discus-
sion section.
Results
Extent of the literature
Figure 1 is a flow diagram for the 54 sources included of 598
identified. Initial database searching provided 27 sources (50%).
Hand-searching key websites (N ¼ 10) and reference lists
(N ¼ 7) provided 31%. Stakeholder recommendations (N ¼ 8)
provided 15%. An updated database search provided 4%
(N ¼ 2).
Figure 2 shows numbers of sources by publication year.
During 1990–99, none were found. Two studies each were
published in 2000 and 2001. An increase began in 2005, with
most (26%; 14/54) published in 2011. Forty-four sources
included the health of undocumented migrants in study
objectives, while 10 (19%) included it in a general focus on
migrant health.
Nature of the literature
Publications were from public health, epidemiology, sociology,
medical anthropology and policy disciplines. Thirty (56%) were
original peer-reviewed journal articles, 17 (31%) were reports, 4
(7%) were theses and 3 (6%) were meeting abstracts. Study
designs and methods were not always clearly described, but 28
(52%) were qualitative, 13 (24%) quantitative, 9 (17%) mixed-
methods and 4 (7%) interventions. Qualitative studies often
used multiple methods, such as a combination of semi-
structured interviews, focus groups and/or participant observa-
tions. Quantitative studies usually used one data-collection
Table 1 List of organizations and projects included in targeted website searches, in alphabetical order
Organizations Projects
European Commission–United Nations Joint Migration and
Development Initiative (JMDI)
Clandestino
European Migration Network (EMN) European Best Practices in Access, Quality and Appropriateness of Health Services
for Immigrants in Europe (EUGATE)
European Union (EU) European Programme for Integration and Migration (EPIM)
European Union Agency for Fundamental Rights (FDA) ITSAL project
International Organization for Migration (IOM) - Europe Health and Social Care for Migrants and Ethnic Minorities in Europe (HOME)
Me
´
dicines du Monde (Doctors of the World) Health care in Nowhereland
Me
´
dicines Sans Frontiers (Doctors Without Borders) Health for Undocumented Migrants and Asylumseekers (HUMA) Network
Migrants Rights Network (MRN) MIGHEALTHNET
Platform for International Cooperation on
Undocumented Migrants (PICUM)
PROMO
Quality in and Equality of Access to Healthcare Services (HealthQUEST)
Undocumented Workers Transitions (UWT)
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method, often cross-sectional surveys. Only one study was
described as longitudinal (Castan
˜
eda 2008), although several
used follow-up methods (Lebouche
´
et al. 2006; Castan
˜
eda 2009;
Mensinga et al. 2010; Castan
˜
eda 2011).
A few studies clearly described their sampling methodology,
while most provided minimal or no explanation. The majority
used purposeful sampling including snowball, consecutive,
criterion and quota strategies. Only four quantitative studies
Records screened by
database searching (N=557)
- EMBASE (N=224)
- Web of Science (N=116)
- PubMed (N= 65)
- CINAHL Plus (N=56)
- Global Health (N=50)
- Ps
y
chInfo
(
N=46
)
Included for charting
(N=100)
Excluded after screening (N=457)
Records included for
scoping review
(N=54)
Excluded after selection criteria finalised
and reading of available full-text (N=87)
- No primary data (N=45)
- Data not disaggregated by legal status (N=13)
- Data inaccessible (N=12)
- Duplicate (N=10)
- Not within subject range (N=4)
- Books (N=2)
- Data collection prior to EU membership (N=1)
Records included by
hand-searching (N=28)
- Key websites (N=17)
- Reference lists (N=11)
Total records charted
(
N=141
)
Records included by stakeholders’
recommendations
Until 12 December 2012 (N=11)
Records included by update
database search
Until 31 December 2012 (N=2)
Figure 1 Flow diagram of selection of records included in scoping review
Figure 2 Number of publications on health and access to health care for undocumented migrants in the EU27 by publication year
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used some form of random selection. An intervention study
used random sampling to assign participants to three treatment
regimes (Matteelli et al. 2000), one cross-sectional study used
two-stage stratified cluster sampling (Torres and Sanz 2000),
another cross-sectional study used randomization of matched
cohorts (Veenema et al. 2009), and a survey protocol required
random selection of eligible participants (Chauvin et al. 2009).
About half the sources included a definition of ‘undocu-
mented’ migrants. Some of these were clearly defined, while
most used a few descriptive words (e.g. ‘those without
permission to stay’). Most (36; 67%) used the term ‘undocu-
mented’, 10 (19%) used ‘illegal’, 5 (9%) ‘irregular’ and 2 (4%)
‘unauthorised’. One Swedish study used the term ‘Go¨mda’,
meaning ‘hidden’, to refer to those living without legal status
(MSF 2005). Forty sources (74%) included undocumented
migrants as study participants, 13 (24%) only included health
professionals or other experts, and 1 (2%) tested a health
information intervention (Cacciani et al. 2005).
Distribution of the literature
Figure 3 shows the 38 (70%) single-country and 16 (30%)
multi-country studies included, by EU member state. Multi-
country studies included primary data collection in more than
one EU member state, ranging from 2 to all 27. Estonia, Latvia,
Luxembourg and Slovakia were least represented, only included
in one multi-country study. Bulgaria, Cyprus, Finland, Romania
and Slovenia (N ¼ 2), the Czech Republic and Lithuania (N ¼ 3),
Malta (N ¼ 4), Ireland (N ¼ 5), Poland (N ¼ 6), Austria (N ¼ 6),
Hungary (N ¼ 7) and Belgium (N ¼ 12) were also solely repre-
sented in multi-country studies. Remaining member states were
included in both single and multi-country studies, with the
Netherlands most represented in 24% (9/38) single-country and
63% (10/16) multi-country studies.
Descriptions of migrant demographics were far from uniform.
Most (85%) publications included a mix of male and female
participants, with 6 (11%) only including women and 2 (4%)
only including men. There were large variations in ages of study
participants, although the average was just over 30 years old,
with the exception of two studies focusing on children
(Mensinga et al. 2010) and youth (Bloch and Zetter 2011). Of
the 40 publications including participation of undocumented
migrants, 7 (18%) provided no detail on countries of origin.
Only one focused on migrants from a specific country, namely
Afghanistan (Fidan 2010). Remaining sources (N ¼ 32)
included undocumented migrants from various origins, includ-
ing 30 (94%) African, 22 Asian (68%), and 21 each American
(66%) and other European (66%).
Thematic findings
Findings were summarized according to four themes: (i)
physical, mental, and social health issues, (ii) access and
barriers to care, (iii) vulnerable groups and (iv) policy and
rights. Table 2 shows thematic coverage by study, with many
including multiple themes. Most (N ¼ 43; 80%) included
findings on access to care. Perceived or measured physical
and mental health of undocumented migrants were described
by 15 (29%) and 9 (17%) sources, respectively. Approximately
29%, mostly reports, included findings on social health,
particularly occupational health and living conditions.
Vulnerable groups (e.g. children, pregnant women, detainees)
were highlighted by 12 (23%) sources. Two sources described
an intervention to improve data collection. Of 17 that analysed
policy or gave an overview of undocumented migrants’ rights,
most were reports (53%; 9/17) or theses (24%; 4/17).
Physical, mental and social health
Several studies described poor self-reported health among
undocumented migrants. For example, MSF found undocu-
mented migrants’ health deteriorated since coming to Sweden
(MSF 2005). Chauvin found digestive, musculoskeletal, respira-
tory and gynaecological complaints most common among
undocumented migrants in an 11-country study (Chauvin
et al. 2007). A Dutch providers survey found undocumented
migrants had significantly more skin and digestive issues than
documented migrants (Van Oort et al. 2001). Antenatal care
Figure 3 Number of single and multi-country studies on health and access to health care for undocumented migrants by EU member state
(EU 2010)
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Table 2 Coverage of themes for each of the 54 sources (multiple themes possible), displayed in alphabetical order by type of source
Sources
lead author(s) (year)
Themes
Policy and rights Access to care Physical health Mental health Social health Vulnerable groups
Journal article (N ¼ 30) N ¼ 4 N ¼ 25 N ¼ 5 N ¼ 2 N ¼ 5 N ¼ 2
Ahonen (2010) 3
Ahonen (2009) 3
Biswas et al. (2011) 3
Bruno (2005) 3
Carvalho et al. (2005) 33
Castan
˜
eda (2011) 33
Castan
˜
eda (2009) 33
Castan
˜
eda (2008) 33 3
Dauvrin et al. (2012) 33
Dias et al. (2008) 3
Dias et al. (2010) 3
Dias et al. (2010b) 3
Dias et al. (2011c) 3
Dias et al. (2011a) 3
Dias et al. (2011b) 3
Dorn et al. (2011) 33 3
El-Hamad (2001) 3
Grit et al. (2012) 33
Heus (2010) 3
Jensen et al. (2011) 3
Keygnaert et al. (2012)
33
Larchanche
´
(2012) 3
Lebouche
´
et al. (2006) 3
Matteelli et al. (2000) 3
Porthe
´
et al. (2009) 3
Sousa et al. (2010) 3
Strassmayr et al. (2012) 33
Torres and Sanz (2000) 3
Torres-Cantero et al. (2007) 3
Yosofi (2009) 33 3
Report (N ¼ 17) N ¼ 9 N ¼ 13 N ¼ 7 N ¼ 5 N ¼ 9 N ¼ 6
Bloch and Zetter (2011) 33
Burnett and Whyte (2010) 3
Chauvin et al. (2007) 333 3
Chauvin (2009) 3
Collantes (2007) 33
Collantes et al. (2011) 333333
Fidan (2010) 33 3
FRA (2011a) 33
FRA (2011b) 3
FRA (2011c) 3 3
McKay et al. (2009) 33 3
Mensinga et al. (2010) 33
MDM (2009) 33 3
MSF (2005) 33 33
PICUM (2010b) 33 333
Van Oort et al. (2001) 33 3
(continued)
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was the primary reason undocumented migrants visited one
Berlin clinic, followed by chronic, paediatric, dental, acute and
injury care (Castan
˜
eda 2009). While several studies focused on
access to HIV and TB screening, few analysed the burden of
these infections among undocumented migrants. One study
found 7.1% HIV prevalence among 834 undocumented mi-
grants; however, the population was partially drawn from two
HIV clinics (Chauvin et al. 2007). Two studies reported
increased vulnerability to sexual violence among undocumented
migrants (Van Den Muijsenbergh 2007; Keygnaert et al. 2012).
Among studies reporting on health status, psychological
issues appeared most widespread. Two studies associated
increased stress, depressive, anxiety, sleeping and somatic
symptoms among undocumented migrants with their insecure
living and working conditions (PICUM 2010; Biswas et al.
2011). High suicide rates were found among those in detention
centres (MDM 2009). Van Oort found Dutch general practi-
tioners significantly more frequently diagnosed mental dis-
orders among undocumented than documented migrants (Van
Oort et al. 2001), while Schoevers concluded that mental
disorders might be under-reported as female participants
seemed hesitant to discuss them (Schoevers 2011).
While several studies found undocumented migrants worked
in poorer conditions than documented migrants, only one
analysed potential health effects in detail (Sousa et al. 2010). As
part of ‘ITSAL project’, Sousa and colleagues found undocu-
mented workers three times as likely to report health problems
as documented workers (Sousa et al. 2010). Another ITSAL
publication on work conditions (e.g. high job instability,
vulnerability, low remuneration, poor social benefits, long
hours and fast-paced work) concluded undocumented workers’
health depended largely on the health and safety measures
taken by employers (Porthe
´
et al. 2009). McKay found vulner-
ability and disempowerment were particularly severe among
female domestic workers (McKay et al. 2009).
None of the studies analysed the health effects of poor living
conditions, though it is likely these contributed to worsened
health. Chauvin found half of participants in a multi-country
study resided in insecure and overcrowded conditions (Chauvin
et al. 2009). Collantes found 47% of undocumented respondents
living in ‘insanitary or dangerous accommodation’ (Collantes
et al. 2011), seen also in photographic evidence of Afghan
migrants’ living conditions in Greece (Fidan 2010).
Access and barriers to care
Four quantitative studies analysed associations between docu-
mentation status and care seeking and usage. One reported no
significant association between usage and status, although
confounders appeared unadjusted for (Torres-Cantero et al.
2007). A second reported an association for migrant men after
adjusting for gender (Dias et al. 2008). Two found both usage
and care-seeking were significantly associated, even after
adjusting for confounders (Torres and Sanz 2000; Dias et al.
2011b). A study on migrants in detention showed that those of
Asian origin were significantly less likely to seek care than
those from other regions (Dorn et al. 2011). Several qualitative
studies indicated health-care usage was difficult for migrants
from Brazil (Dias et al. 2010) and women who migrated for
personal reasons (Schoevers 2011).
Obstacles to health-care access were reported at primary,
secondary and tertiary level, with access particularly limited for
the latter two. Primary-care access was often delayed, with the
continuum of care particularly lacking for pregnant undocu-
mented migrants (Van Den Muijsenbergh 2007; Castan
˜
eda
2009; PICUM 2010b). Schoevers explored the use of patient-
held records to improve continuity of care and empowerment
among undocumented women, but results were unsatisfactory
(Schoevers 2011). Cacciani and colleagues reported on a shared
information system, to improve health data collection on
undocumented migrants across outpatient clinics in Italy,
which appeared promising enough to scale up (Cacciani et al.
2005).
Hospital referrals were limited (Veenema et al. 2009), with
some cases refused at hospitals (Dorn et al. 2011). Several
studies raised concerns about mental health services access
(Castan
˜
eda 2008; Baghir-Zada 2009; Veenema et al. 2009;
Dauvrin et al. 2012), with one providing in-depth analysis of
barriers in 14 EU member states (Strassmayr et al. 2012). Access
to dental (Castan
˜
eda 2008; Baghir-Zada 2009; Martens 2009),
HIV (Lebouche
´
et al. 2006;
Chauvin et
al. 2007; Heus 2010;
Table 2 Continued
Sources
lead author(s) (year)
Themes
Policy and rights Access to care Physical health Mental health Social health Vulnerable groups
Veenema et al. (2009) 3333 3
Thesis (N ¼ 4) N ¼ 4 N ¼ 4 N ¼ 2 N ¼ 1 N ¼ 1 N ¼ 2
Baghir-Zada (2009) 333 33
Hansen (2005) 33
Martens (2009) 33
Schoevers (2011) 3333 3
Meeting abstract (N ¼ 3) N ¼ 0 N ¼ 1 N ¼ 1 N ¼ 1 N ¼ 0 N ¼ 2
Cacciani et al. (2005)
Coutinho et al. (2011) 3
Van Den Muijsenbergh (2007) 33 3 3
Total (N ¼ 54) (%) 17 (31%) 43 (80%) 15 (29%) 9 (17%) 15 (29%) 12 (23%)
‘3’ indicates theme is covered, but does not reflect depth of coverage.
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Dias et al. 2011c) and TB services (Matteelli et al. 2000;
Carvalho et al. 2005; Schoevers 2011) were also reported as
limited.
About half the studies provided some analysis of reasons
undocumented migrants experienced poor health services
access. Lack of awareness of legal entitlements among both
undocumented migrants and health-care providers was often
cited. Ambiguities on what constituted an ‘emergency’ and lack
of guidelines on treatment options contributed to uncertainty
among health professionals (Biswas et al. 2011; Jensen et al.
2011) and denial of entitled care (MDM 2009). Fear of being
reported to the authorities was cited as an important barrier to
care seeking, even in the absence of any reporting obligations
(PICUM 2010b). Financial obstacles limited access to secondary
care, with access to primary care also affected. Costs prevented
many migrants from accessing care or medicines, while
reimbursement systems increased workloads among health-
care providers. Cultural and language barriers were described as
reducing undocumented migrants’ ability to negotiate treat-
ment options, potentially compromising quality of care (FRA
2011a).
While health-care professionals in two studies reported not
varying treatment by patient documentation status (Biswas
et al. 2011; Jensen et al. 2011), two studies found numbers of
diagnostic and therapeutic interventions differed by status.
Dauvrin and colleagues found both restricted for undocu-
mented patients (Dauvrin et al. 2012). Van Oort found treat-
ments decreased while diagnoses increased for undocumented
patients (Van Oort 2001). Sources indicated quality of care
might be reduced for undocumented patients as they may be
difficult to treat due to the complexity of their health problems,
limited socio-cultural skills among providers, linguistic issues
during consultations, and added administrative efforts
(Veenema et al. 2009; Biswas et al. 2011; Dias et al. 2011a;
Jensen et al. 2011). Thus, access for undocumented migrants
was described as ‘variable and unpredictable’ (Schoevers 2011),
depending on choices of individual health workers (Martens
2009).
Access appeared improved by the presence of voluntary health
organizations. For example, Schoevers concluded better access
to care among asylum seekers compared with undocumented
migrants might be because they were more likely to be exposed
to voluntary organizations at asylum centres (Schoevers 2011).
Voluntary organizations were reported to play an important role
in referring undocumented migrants to ‘accessible’ primary-
and secondary-care providers and in actual health-care provi-
sion via outreach clinics (Baghir-Zada 2009; Yosofi 2009;
PICUM 2010b; Castan
˜
eda 2011; Schoevers 2011). Some
organizations also provided advocacy and legal support if
needed (Baghir-Zada
2009; FRA 2011b). However, financial
constraints limited their activities (Baghir-Zada 2009).
Additionally, one source cautioned that they should not be
become an ‘alternative structure of care’ for undocumented
migrants (PICUM 2010b).
Several sources indicated that lack of health-care access
encouraged alternative health-seeking behaviours. One in-depth
analysis showed undocumented migrants self-medicated,
sought advice from doctors in their country of origin, and
borrowed health insurance cards (Biswas et al. 2011).
Vulnerable groups
Particularly vulnerable groups that emerged from analysis were
pregnant women, children and detainees. Several studies
described lack of or delays for antenatal care. Van den
Muijsenbergh found pregnant undocumented migrants faced
payment barriers at hospitals and lacked referrals to gynae-
cologists (Van Den Muijsenbergh 2007). Castan
˜
eda found
undocumented women most frequently sought obstetric care
(Castan
˜
eda 2009). Schoevers found low contraceptive usage,
limited sexually transmitted infection screening, high abortion
rates, and lack of sexual and gynaecological treatment among
undocumented women (Schoevers 2011).
Delayed health care seeking among undocumented children
and their parents was frequently reported. Mensinga found that
lack of knowledge among parents and health-care providers on
respective rights and obligations caused confusion when
seeking care (Mensinga 2010). Chauvin concluded that un-
hygienic living conditions and frequent house moves adversely
affected physical and mental health of both parents and
children (Chauvin et al. 2009). Two studies discussed missed
vaccinations amongst newborns (PICUM 2010b; Collantes et al.
2011), while Castan
˜
eda described the challenges of registering
an undocumented baby (Castan
˜
eda 2009). Bloch explored the
experiences of young undocumented migrants (18–31 years),
finding their status affected their socioeconomic opportunities
(e.g. limited aspirations, insecure employment) although coping
with adversity resulted in a sense of accomplishment (Bloch
and Zetter 2011).
Two studies reported on the health situation of undocu-
mented migrants in detention centres (MDM 2009; Dorn et al.
2011). Dorn and colleagues analysed health care seeking among
detainees in the Netherlands, finding nearly 50% had sought
care—mostly for injuries and dental problems—25% of whom
were denied care (Dorn et al. 2011). An MDM study reported
high suicide rates among detainees in EU member states (MDM
2009).
Policy and rights
Studies analysing policies and rights concluded that legal
entitlements to health care for undocumented migrants,
including entitlements to emergency care, child immunizations,
antenatal care and mental health services, varied considerably
across EU member states. Legal entitlements did not correspond
with access to care. Dauvrin found similar barriers for
undocumented migrants among different health systems,
including communication, cultural misunderstandings, referral
difficulties and delayed or disrupted care (Dauvrin et al. 2012).
Jensen found emergency room physicians described barriers as
due to a lack of rights-based policies (Jensen et al. 2011).
Several sources also reported within-country differences in
implementation of rights, at regional, institutional and individ-
ual levels among health-care providers and employers.
Authors generally described policies on access to care for
undocumented migrants as increasingly restrictive, largely to
discourage entry of new migrants (MDM 2009; Grit et al. 2012).
However, three studies reporting on the effects of a new
regulation on access to care for undocumented migrants in the
Netherlands found access and awareness of policy and rights
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had increased (Martens 2009; Veenema et al. 2009; Mensinga
et al. 2010).
Discussion
This study provided an overview of the scope and main findings
of empirical work, published in peer-reviewed and grey litera-
ture, on health and access to care of undocumented migrants
residing within the EU27. Only 54 primary sources were
identified, most of which lacked methodological rigour and
consistency—particularly in sampling. This indicates a signifi-
cant need for more and higher-quality research on this subject.
Are conclusions possible from a review of such sources? While
there is a risk that study flaws could be repeated in the review,
some trends appear clear.
Extent, nature and distribution of sources
While some member states (e.g. Netherlands, UK, Spain, Italy)
were included in many more studies than were others, these
have some of the highest estimates of foreign irregular
residents, potentially explaining this difference (Clandestino
2009). Most member states were represented within multi-
country studies rather than those tailored to national contexts.
While large-scale country comparisons are important, they may
lack depth, consistency, or quality (e.g. methodology and data
collection affected by local researchers with differing research
skills). Future multi-country studies would benefit from
increased methodological transparency and consistency.
Much of the available research was conducted by NGOs.
Because of their knowledge of the social, mental and physical
well-being of undocumented migrants and greater access to this
hidden group, NGOs are important actors in this field.
However, potential conflicts of interest between research and
health advocacy missions must be considered when interpreting
their outputs. However, external researchers may be less
knowledgeable of the lived reality of undocumented migrants
and often rely on the same NGOs for data collection or
recruitment. Future collaborative research between NGO and
academic researchers could strengthen the evidence base.
More and better quality research within individual member
states, particularly longitudinal studies, is clearly needed.
Methodological issues (e.g. recruitment, sampling, and follow-
up of undocumented migrants) need to be addressed.
Invisibility of undocumented migrants, especially those not
seeking care, remains a culprit. Research is needed to support
policies on healthy migration and develop interventions and
documentation systems that provide undocumented migrants
with greater stability. Close co-operation between governments
and NGOs may be needed to achieve this.
Health status and access
A possible reason the knowledge base on undocumented
migrant health status was poor is because this often relies on
availability of routine data. The main reason for excluding
studies in this review, after charting, was lack of primary data.
Most of these studies relied on monitoring systems of formal
health-care usage within the population that would likely
under-represent undocumented migrants. It may be impossible
to include this relatively ‘invisible’ population in routine health
data collection, but important lessons can be learned from
initial data-collection interventions, such as that of Cacciani
and colleagues (Cacciani et al. 2005). Existing research on
migrant health often overlooks likely differences in health
status and experiences of documented vs undocumented
migrants (e.g. 13 studies excluded for lacking disaggregated
results). Future research could usefully be disaggregated by
documentation status, as results for these migrant sub-popu-
lations are likely to be different.
Access to care seemed particularly important, as 80% of
studies reported on it. Access is universally defined for those
living in the EU27, under Article 35 of the European Union
Charter of Universal Rights, as ‘Everyone has the right of access to
preventative healthcare and the right to benefit from medical treatment
under the conditions established by national laws and practices’(EU
2000). However, a comparative study of national policies
showed wide disparities in how this right to health care was
exercised (Cuadra 2011). The same barriers to timely health-
care access were found consistently. For example, while
minimal research was conducted on physical, mental, and
social health separately, that available suggested the stressful
environments in which undocumented migrants often live and
work are not conducive to health, particularly mental health.
Policy and rights
One reason for the disappointing number of primary studies is
that research on this topic is relatively new, only increasing
slowly since 2005. Unfortunately, this makes it difficult to
detect any changes in health or health-care access for undocu-
mented migrants in the past years. Research may have
increased because 2005 was the time EU migration policy
began shifting towards national security (Triandafyllidou 2009),
resulting in more stringent internal (e.g. health-care access)
and external migration control (e.g. borders) (Ingleby 2012).
For example, the Treaty of Lisbon strengthened the EU’s legal
position in returning undocumented migrants to countries of
origin (Brady 2008). Increased discussions on international
platforms, such as the 2010 3rd European Health Conference
on Integrated Public Health in Amsterdam, the 2011 9th
International Conference of the European Network for Mental
Health Service Evaluation in Ulm, and the 2011 7th European
Congress on Tropical Medicine and International Health in
Barcelona, likely contributed to increased research interest,
although not the drop in publications in 2012.
Policy advocacy within the EU27 should address prevailing
misconceptions surrounding rights and obligations to health
care for undocumented migrants. This could be described not
only as ‘the right thing to do’ (i.e. in accordance with Article 35
of the European Charter of Universal Human Rights), but also
of public health benefit. Results suggest HIV and tuberculosis
rates may be relatively high among undocumented migrants
(Chauvin et al. 2007), while their access to screening and
treatment is relatively low (Matteelli et al. 2000; Carvalho et al.
2005; Lebouche
´
et al. 2006; Dias et al. 2011c). To control these
and other health issues effectively, public health care would
need to reach all, even those without documentation.
Health care for undocumented migrants could become more
consistent. Several sources showed individual health-worker
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choices, rather than policies, determined access. This indicates
some providers take on the majority of work, which seems an
unfair and sustainable solution (PICUM 2010b; Ingleby 2012).
Undocumented migrants seeking health care they are legally
entitled to should be able to access services at their nearest
facility. Policy makers thus have a responsibility not to shift the
burden of interpreting legal rights to already overburdened
health staff.
Limitations
This study has several limitations. First, a scoping review only
includes studies within authors’ search capacity (e.g. accessible
on databases searched or through stakeholders). That recom-
mended studies were not found during database searches
indicates the challenges of locating all primary research on this
topic and likelihood that much of this research remains
unpublished and inaccessible (e.g. due to the variety of
potential search terms, political sensitivity). Second, some
stakeholders were more active than others (e.g. one recom-
mended three additional Dutch studies, potentially skewing
distribution data). Third, relevant publications may exist
outside of authors’ language capabilities, despite covering
several major European languages. Finally, authors did not
assess evidence quality, as the quantity and quality of studies
were insufficient for a meaningful systematic review. Not
excluding on quality gave authors the opportunity to include a
broader range of evidence from both peer-reviewed and grey
literature. However, this means summary findings should be
interpreted cautiously.
Conclusions
This is a first attempt at a comprehensive overview of available
primary evidence on health and access to care for undocu-
mented migrants. This scoping review underlines the need for
more and better quality research. Methodological challenges, in
accessing this largely invisible population, need addressing. This
requires co-operation between the various actors (e.g. NGO and
health staff gatekeepers, academic communities, policy makers)
at regional, national and institutional levels. Improved aware-
ness of health-care rights and obligations for undocumented
migrants could reduce ambiguities and anxieties limiting access
to this group for health staff and researchers. As international
and national migration policies become increasingly restrictive,
urgent action is likely needed to avoid worsening the status
quo.
Acknowledgements
Authors are grateful for stakeholder contributions. Emily
Ahonen, Indiana University, provided input on results and
discussion sections. Heide Castan
˜
eda, University of South
Florida, gave feedback on structure and recommended an
additional source. Pierre Chauvin, National Institute of Health
and Medical Research (INSERM) Universite
´
Pierre et Marie
Curie, suggested topics and literature for discussion. So
´
nia Dias,
New University of Lisbon, provided general feedback and an
additional source. David Ingleby, University of Utrecht, sug-
gested topics and literature for discussion. Michele LeVoy,
Platform for International Cooperation on Undocumented
Migrants (PICUM), recommended two additional sources.
Sonia McKay, London Metropolitan University, provided feed-
back on results and suggested discussion points. Maria van der
Muijsenbergh, St Radboud University Medical Centre Nijmegen,
suggested clarifications of results, discussion points, and three
additional sources. Elena Riza, University of Athens Medical
School, commented on methods and results. Marianne
Schoevers, St Radboud University Medical Centre Nijmegen,
provided feedback on methods and results. Ursula Trummer,
Centre for Health and Migration in Vienna, provided input on
results and discussion. Authors thank the two anonymous
reviewers for their encouraging and useful feedback.
Funding
This study was conducted on a voluntary basis.
Conflict of interest
None declared.
References
Ahonen EQ, Lopez-Jacob MJ, Vazquez ML et al. 2010. Invisible work,
unseen hazards: The health of women immigrant household
service workers in Spain. American Journal of Industrial Medicine
53: 405–16.
Ahonen EQ, Porthe
´
V, Vazquez ML et al. 2009. A qualitative study about
immigrant workers’ perceptions of their working conditions in
Spain. Journal of Epidemiology & Community Health 63: 936–42.
Arksey H, O’Malley L. 2005. Scoping studies: towards a methodological
framework. International Journal of Social Research Methodology 8:
19–32.
Baghir-Zada R. 2009. Illegal aliens and health(care) wants. The cases of
Sweden and the Netherlands. Doctoral Thesis, Malmo
¨
University.
Biswas D, Kristiansen M, Krasnik A, Norredam M. 2011. Access to
healthcare and alternative health-seeking strategies among
undocumented migrants in Denmark. BMC Public Health 11: 560.
Bloch A, Zetter R. 2011. ‘No Right To Dream’. The Social and Economic Lives
of Young Undocumented Migrants in Britain. London: Paul Hamlyn
Foundation.
Brady H. 2008. EU Migration Policy: An A-Z. London: Centre for European
Reform.
Bruno S, Federico B, Geraci S et al. 2005. Designing an organizational
pathway for illegal immigrants to perform vaccino-prophylaxis
interventions. Journal of Preventative Medicine and Hygiene 46: 99–102.
Burnett J, Whyte D. 2010. The Wages of Fear: Risk, Safety and Undocumented
Work. Leeds: Positive Action For Refugees & Asylum Seekers (PAFRAS).
Liverpool: The University of Liverpool.
Cacciani L, Baglio G, Forcella E et al. 2005. Testing a new health data
information system for illegal immigrants in Italy. 13th Annual
EUPHA Meeting. Graz. European Journal of Public Health 15: 175–6.
Carvalho ACC, Saleri N, El-Hamad I et al. 2005. Completion of screening
for latent tuberculosis infection among immigrants. Epidemiology
and Infection 133: 179–85.
Castan
˜
eda H. 2008. Paternity for sale. Medical Anthropology Quarterly 22:
340–59.
REVIEW OF EU UNDOCUMENTED MIGRANT HEALTH 11
by guest on March 1, 2014http://heapol.oxfordjournals.org/Downloaded from

Castan
˜
eda H. 2009. Illegality as risk factor: a survey of unauthorized
migrant patients in a Berlin clinic. Social Science & Medicine 68:
1552–1560.
Castan
˜
eda H. 2011. Medical humanitarianism and physicians’ organized
efforts to provide aid to unauthorized migrants in Germany.
Human Organization 70: 1–10.
Chauvin P, Mestre MC, Simonnot N. 2012. Access to Health Care for
Vulnerable Groups in the European Union in 2012. An Overview of the
Condition of Persons Excluded from Healthcare Systems in the EU. Paris:
Me
´
decins du Monde.
Chauvin P, Parizot I, Drout N, Simonnot N, Tomasin A. 2007. European
Survey on Undocumented Migrant’s Access to Health Care. Paris:
Me
´
decins du Monde European Observatory on Access to
Healthcare.
Chauvin P, Parizot I, Simonnot N. 2009. Access to Healthcare for
Undocumented Migrants in 11 European Countries. Paris: Me
´
decins
du Monde European Observatory on Access To Healthcare.
Clandestino. 2009. Comparative Policy Brief—Size of Irregular Migration.
Athens: Hellenic Foundation for European and Foreign Policy.
Collantes S, Soler A, Klorek N, Maslinski K. 2011. Access to Healthcare and
Living Condition of Asylum Seekers and Undocumented Migrants in
Cyprus, Malta, Poland and Romania. Paris: Me
´
decins du Monde
HUMA Network.
Collantes S. 2007. Access to Health Care for Undocumented Migrants in
Europe. Brussels: PICUM.
Coutinho E, Pereira C, Silva A. 2011. Illegal stay and prenatal care in
immigrant pregnant women living in Portugal. Journal of
Epidemiology & Community Health 65(Suppl 1):A328.
Cuadra CB. 2011. Right of access to health care for undocumented
migrants in EU: a comparative study of national policies. European
Journal of Public Health 22: 267–71.
Dauvrin M, Lorant V, Sandhu S et al. 2012. Health care for irregular
migrants: pragmatism across Europe: a qualitative study. BMC
Research Notes 5: 99.
Dias S, Gama A, Cortes M, De Sousa B. 2011a. Healthcare-seeking
patterns among immigrants in Portugal. Health & Social Care in the
Community 19: 514–521.
Dias S, Gama A, Rocha C. 2010. Immigrant women’s perceptions and
experiences of health care services: Insights from a focus group
study. Journal of Public Health 18: 489–496.
Dias S, Gama A, Severo M, Barros H. 2011b. Factors associated with HIV
testing among immigrants in Portugal. International Journal of Public
Health 56: 559–66.
Dias S, Gama A, Silva AC, Cargaleiro H, Martins MO. 2011c. Barreiras
no acesso e utilizac¸a
˜o
dos servic¸os de sau
´
de pelos imigrantes.
A perspectiva dos profissionais de sau
´
de
[Barriers in access
and utilization of health services among immigrants. The
perspective of health professionals]. Acta Medica Portuguesa 24:
511–16.
Dias SF, Severo M, Barros H. 2008. Determinants of health care
utilization by immigrants in Portugal. BMC Health Services Research
8: 207.
Dorn T, Ceelen M, Tang MJ et al. 2011. Health care seeking among
detained undocumented migrants: a cross-sectional study. BMC
Public Health 11: 190.
El-Hamad I, Casalini C, Matteelli A et al. 2001. Screening for
tuberculosis and latent tuberculosis infection among undocumen-
ted immigrants at an unspecialised health service unit. Journal of
Tuberculosis and Lung Disease 5: 712–16.
EU. 2000. Charter of Fundamental Rights of the European Union. http://
www.europarl.europa.eu/charter/pdf/text_en.pdf, accessed 4 April
2012.
EU. 2010. How the EU works - countries. http://europa.eu/about-eu/
countries/index_en.htm, accessed 5 January 2012.
Fidan GO. 2010. An Approach to Undocumented Migrants in Greece Focusing
on Undocumented Afghans. Athens: Greek Council of Refugees.
FRA. 2011a. Migrants in an Irregular Situation: Access to Healthcare in 10
European Union Member States. Solidarity. Luxembourgh: European
Union Agency for Fundamental Rights (FRA).
FRA. 2011b. Fundamental Rights of Migrants in an Irregular Situation in the
European Union. Solidarity. Luxembourgh: FRA.
FRA. 2011c. Migrants in an Irregular Situation Employed in Domestic Work:
Fundamental Rights Challenges for the European Union and its Member
States. Luxembourgh: FRA.
Grant MJ, Booth A. 2009. A typology of reviews: an analysis of 14
review types and associated methodologies. Health Information &
Libraries Journal 26: 91–108.
Grit K, Den Otter JJ, Spreij A. 2012. Access to health care for
undocumented migrants: a comparative policy analysis of
England and the Netherlands. Journal of Health Politics, Policy and
Law 37: 37–67.
Gulliford M, Hughes D, Figeroa-Munoz J et al. 2001. Access to Health Care.
Report of a Scoping Exercise for the National Co-ordinating Centre for NHS
Service Delivery and Organisation R&D (NCCSDO). London: The Public
Health and Health Services Research Group, King’s College
London.
Hansen AR. 2005. Access to Health Care for Undocumented Immigrants in
California (USA) and Denmark—Rights and Practice. MSc Thesis,
University of Copenhagen.
Heus L. 2010. ‘There is no love here anyway.’ Sexuality, identity and
HIV prevention in an African sub-culture in Amsterdam, The
Netherlands. Sexual Health 7: 129–34.
Ingleby D. 2012. Social Exclusion, Disadv antage, Vulnerability and Health
Inequalities. A Task Group Supporting the Marmot Region Review of Social
Determinants of Health and the Health Divide in the EURO region.
Amsterdam: University of Amsterdam.
Jensen NK, Norredam M, Draebel T et al. 2011. Providing medical care
for undocumented migrants in Denmark: what are the
challenges for health professionals? BMC Health Services Research
11: 154.
Karl-Trummer U, Metzler B, Novak-Zezula S. 2009. Health Care for
Undocumented Migrants in the EU: Concepts and Cases.
Brussels:
International Organisation for Migration.
Keygnaert I, Vettenburg N, Temmerman M. 2012. Hidden violence is
silent rape: sexual and gender-based violence in refugees, asylum
seekers and undocumented migrants in Belgium and the
Netherlands. Culture Health & Sexuality 14: 505–20.
Kovacheva V, Vogel D. 2009. The Size of the Irregular Foreign Resident
Population in the European Union in 2002, 2005 and 2008: Aggregated
Estimates. Database on Irregular Migration. Working Paper No.4/2009.
Hamburg: Hamburg Institute of International Economics.
Larchanche
´
S. 2012. Intangible obstacles: health implications of
stigmatization, structural violence, and fear among undocumented
immigrants in France. Social Science & Medicine 74: 858–63.
Lebouche
´
B, Yazdanpanah Y, Ge
´
rard Y et al. 2006. Incidence rate and
risk factors for loss to follow-up in a French clinical cohort of HIV-
infected patients from January 1985 to January 1998. HIV Medicine
7: 140–5.
Levac D, Colquhoun H, O’Brien KK. 2010. Scoping studies: advancing
the methodology. Implementation Science 5:69.
Martens MJC. 2009. Accessibility of health care for undocumented
migrants in the Netherlands. Masters Public Health Thesis , Maastricht
University.
12 HEALTH POLICY AND PLANNING
by guest on March 1, 2014http://heapol.oxfordjournals.org/Downloaded from

Matteelli A, Casalini C, Raviglione MC et al. 2000. Supervised preventive
therapy for latent tuberculosis infection in illegal immigrants in Italy.
American Journal of Respiratory and Critical Care Medicine 162: 1653–5.
McKay S, Markova E, Paraskevopoulou A, Wright T. 2009. The
Relationship Between Migration Status and Employment Outcomes.
London: Undocumented Worker Transitions.
MDM. 2009. Access to Health Care for Undocumented Migrants and Asylum
Seekers in 10 EU Countries. Law and Practice. Paris: Me
´
decins du
Monde HUMA Network.
Mensinga M, Van Bommel H, Goeman M, Kloosterboer K. 2010.
Ongedocumenteerde kinderen en de toegang tot ziekenhuiszorg
[Undocumented children and the access to healthcare at the hospital].
Utrecht: Pharos.
Mladovsky P. 2007. Migration and Health in the EU. http://ec.europa.eu/
employment_social/social_situation/docs/rn_migration_health.pdf,
accessed on 5 May 2012.
MSF. 2005. Experiences of Go¨mda in Sweden: Exclusion from Health Care for
Immigrants Living without Legal Status. Stockholm: Me
´
decins Sans
Frontie
`
rs.
PICUM. 2010a. PICUM’s Main Concerns about the Fundamental Rights of
Undocumented Migrants in Europe. Brussels: PICUM.
PICUM. 2010b. Workpackage No. 6: The Voice of Undocumented Migrants.
Undocumented Migrants’ Health Needs and Strategies to Access Health
Care in 17 EU countries. Brussels: Platform for International
Cooperation on Undocumented Migrants (PICUM).
Porthe
´
V, Benavides FG, Vazquez ML et al. 2009. La precariedad laboral
en inmigrantes en situacio
´
n irregular en Espan
˜
a [Precarious
employment in undocumented immigrants in Spain and its
relationship with health]. Gaceta Sanitaria 23(Suppl 1):107–14.
Schoevers MA. 2011. ‘‘Hiding and Seeking’’ health problems and problems
in accessing health care of undocumented female immigrants in the
Netherlands. Doctoral Thesis. Radboud University Medical Centre.
Sousa E, Agudelo-Suarez A, Benavides FG et al. 2010. Immigration,
work and health in Spain: the influence of legal status and
employment contract on reported health indicators. International
Journal of Public Health 55: 443–51.
Strassmayr CC, Matanov AA, Priebe SS et al. 2012. Mental health care
for irregular migrants in Europe: Barriers and how they are
overcome. BMC Public Health 12: 367.
Torres AM, Sanz B. 2000. Health care provision for illegal immigrants:
should public health be concerned? Journal of Epidemiology &
Community Health 54: 478–9.
Torres-Cantero AM, Miguel AG, Gallardo C, Ippolito S. 2007. Health care
provision for illegal migrants: may health policy make a difference?
European Journal of Public Health 17: 483–5.
Triandafyllidou A. 2009. Undocumented Migration: Counting the
Uncountable. Data and Trends Across Europe. Athens: Hellenic
Foundation for European and Foreign Policy.
UWT. 2008. Undocumented Migration Glossary. Work Package 5. London:
UWT, Roskilde University & Working Lives Research Institute.
Van Den Muijsenbergh M. 2007. Maternity care and undocumented
female immigrants. 5th European Congress on Tropical Medicine
and
International Health, Amsterdam. Tropical Medicine and
International Health 12: 18–19.
Van Oort M, Kulu Glasgow I, Weide M, De Bakker D. 2001.
Gezondheidsklachten van illegalen. Een landelijk onderzoek onder huisart-
sen en Spoedeisende Hulpafdelingen [Health complaints of illegals. A
national study amongst physicians and emergency departments]. Utrecht:
Nivel.
Veenema T, Wiegers T, Deville
´
W. 2009. Toegankelijkheid van gezondheids-
zorg voor ‘illegalen’ in Nederland: een update [Accessibility of healthcare for
‘illegals’ in the Netherlands: an update]. Utrecht: Nivel.
Yosofi T, Van den Muijsenbergh M. 2009. Mannen zonder documenten
en de huisarts. Gezondheidsklachten van ongedocumenteerde
asielzoekers en hun ervaringen met huisartsen [Men without
documents and the physician. Health complaints by undocumented
asulym seekers and their experiences with physicians]. Cultuur
Migratie Gezondheid 7: 150–7.
REVIEW OF EU UNDOCUMENTED MIGRANT HEALTH 13
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