A cross-sectional study of immigrant and nonimmigrant children admitted to a large public sector hospital in the Gauteng Province of South Africa

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Data Availability: Data cannot be shared publicly because of the sensitivity of the information (migrant population) as well as the ethical and legal implications thereof. Data can be made available after approval by the Ethics committee of the University of Pretoria for individuals who meet the criteria for access to confidential data. Once ethical clearance is obtained, the data underlying the results presented in the study will be made available to the individual by the Research Ethics Committee. Contact details: Research Ethics Committee, Faculty of Health Sciences, University of Pretoria. Private Bag X323 Arcadia, 0007, Pretoria, Gauteng, South Africa. [email protected].

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations:
ANC,
antenatal care; ART,
antiretroviral therapy; CI,
confidence interval; FFHE,
Fisher Freeman Halton Exact; HIV,
human immunodeficiency virus; KPTH,
Kalafong Provincial Tertiary Hospital; MWU,
Mann–Whitney U; OR,
odds ratio; PMTCT,
prevention of mother-to-child transmission; SA,
South Africa; TB,
tuberculosis

1]. Cross-border migration has continually increased in South Africa (SA) in the recent past due to available social infrastructure, educational opportunities, medical infrastructure, as well as political instability in neighbouring countries [2]. This has resulted in increased attention of issues pertaining to immigrants from SA governmental organisations, the media, and communities themselves.

3]. Migrants in SA face many social and psychological challenges, as demonstrated by the xenophobic violence during 2008, which resulted in numerous deaths, injuries, and displacement of more than 100,000 immigrants [4]. More recently, in March 2018, the SA Human Rights Commission reported on public hospitals in the Gauteng Province denying migrants healthcare services linked to their nationality and/or legal status [5].

6].

7].

8]. Language and communication barriers, as well as unfamiliar healthcare services and fear of deportation, all play a crucial role in creating barriers to healthcare access. The use of qualified interpreters, often unavailable in the SA healthcare setting, is necessary for adequate care of immigrant children, as lack of language support has been identified as a common barrier to healthcare success with an increased risk of medical errors and decreased patient satisfaction [9,10].

9]. Migrants are also at risk of malnutrition, growth retardation, and developmental delay associated with poor nutrition and other causes [11]. Resettlement experiences may negatively impact important stages of development (physical, intellectual, social, and emotional), as outlined by a report from the United Nations High Commissioner for Refugees [12]. Immigrant families may also be more vulnerable to mental health problems. Many of these families face separation, with some of the siblings, or even parents, not living with them or not even residing in the same province or country, potentially leading to high levels of stress and anxiety [10]. This, combined with fear and discrimination in their residing community, can also exacerbate feelings of isolation and lead to mental health problems [10].

9]. In many cases, immunisation records will be lost. Other factors that need to be taken into consideration when deciding on which immunisations are needed are possible incomplete or missing health records or severe malnutrition at the time of immunisation, which could impair adequate immune response [9,11]. Immigrants and refugees may import infectious diseases, and many old and new diseases may emerge or reemerge because of immigration. Therefore, immigrant children should be screened for infectious diseases, although this requires knowledge of the disease patterns in the country of origin [3].

S1 Questionnaire). We further documented aspects related to maternal and child health, including access to antenatal care (ANC), birth history, maternal human immunodeficiency virus (HIV) status as well as prevention of mother-to-child transmission (PMTCT) interventions, as outlined by SA national guidelines. We evaluated infant feeding practices, immunisation coverage (assessed as missed immunisations whether using the SA or country of origin immunisation schedule), and ease of healthcare access. This included participants being asked about access to care problems, such as refusal of healthcare based on nationality, immigration status, documentation problems regarding nationality and citizenship, high unaffordable consultation fees for foreigners, communication problems between patient and healthcare personnel, xenophobic comments, verbal insults, discriminatory behaviour from medical personnel, long waiting times, medicine shortages, and transport problems.

Fig 1). Immigrant mothers were on average younger than the SA group (26.6 years versus 30.8 years; p < 0.0001) (Table 1). The immigrant group faced many socioeconomic challenges when compared to the SA group. They had a lower educational level (p < 0.0001) and income (p < 0.001) and the majority (66.1% versus 40.6%; OR 0.4, 95% CI: 0.2 to 0.6) resided in informal settlements, with fewer children in the family structure.

1 and 2). There was no difference in the number of ANC visits, type of delivery, gestational age, and birth weight (Table 1).

Fig 1). The mean age of the mothers (29.8 years [SA] versus 29.2 years [immigrant]; p = 0.562) and fathers (34.3 years [SA] versus 34.0 years [immigrant]; p = 0.773) were similar (Table 3).

Table 4).

5,13]. Reported episodes of being denied access to care might be isolated to specific healthcare facilities and not be generalisable to the whole immigrant population. It may, however, reflect reporter bias with underreporting of access to care problems by the immigrant group, despite our best efforts to build rapport and ensure confidentiality during the interview process. It also needs to be taken into account that the study group consisted only of patients that were able to access the hospital. There could be many reasons for underreporting issues relating to access to care, including fear of prosecution, deportation, ostracisation, or discrimination in terms of medical care. Being said, all the patients whose parents/caregivers were interviewed in the study had already been already admitted to hospital and were receiving medical treatment, which could negate the aforementioned problems.

14]. Added to these problems is English proficiency, which was found to be worse in the immigrant group and may be linked to the level of education. This too is a potential barrier when caregivers seek healthcare and employment.

7]. Considering reports of cases where immigrants were denied healthcare, based on nationality and legal status, this law is clearly ethically problematic. Doctors should advocate for all children in the community they are serving and promote tolerance, respect, and equal healthcare access [9,15]. This apparent discordance between the Hippocratic Oath and professional obligations highlights the need for a discussion in the broader South African context, where migration from other African countries to SA is a prominent feature in the sociopolitical context, but with a need for a clarity in terms of the policies.

http://www.statssa.gov.za/publications/Report-03-01-79/Report-03-01-792011.pdf
  • 3.
    https://www.dailymaverick.co.za/article/2018-03-29-medical-xenophobia-public-hospitals-deny-migrants-health-care-services-sahrc/#.WwL7BkxuKM8 https://doi.org/10.1021/acs.jpca.8b05393 pmid:30060668
  • 6.
    http://www.cdc.gov/immigrantrefugeehealth/pdf/nutrition-and-growth-guidelines.pdf
  • 12.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6189880/
  • 13.
    https://www.iol.co.za/news/refugee-dies-before-court-challenge-1785858
  • 14.
    Fotso J. Urban–rural differentials in child malnutrition: Trends and socioeconomic correlates in sub-Saharan Africa. Health Place. 2007;13(1):205–223. pmid:16563851
  • 15.
    AAP Diversity and Inclusion Statement. Pediatrics. 2018;141(4):e20180193. pmid:29555690
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