Monóxido de carbono

A total of 203 articles were obtained from the systematic search (41 from Medline, 59 from Embase and 103 from Scopus). After discarding 43 duplicate articles, there were 160 remaining articles. After combining with 17 articles from the WHO website and 7 articles from the grey literature database, there were 184 articles left for abstract screening. Of the 184 articles, 37 passed the screening process and then the full text was explored for key messages. The quality assessment result of each article is shown in Appendix 2, and the key messages of each article are exhibited in Appendix 3.

Of the 37 articles, three showed data from multi-country surveys (Dauvrin et al., 2012, Straßmayr et al., 2012, Sandhu et al., 2013), the remaining thirty-four are standalone study projects. About 68% of the reviewed studies (25/37) were carried out in Europe, followed by 24% (9/37) in America, and the rest in Australia and Africa. Only two studies were conducted in developing nations, that is, Costa Rica and Morocco (Goldade and Okuyemi, 2012, van den Ameele et al., 2013).

The quality appraisal table in Appendix 2 reveals that the quality of the selected articles varied considerably. The most common concern regarding article quality was a failure to critically examine the extent of potential bias resulting from the role and experience of the researchers (reflexivity). Examples of articles which had a clear reflexivity issue were Abbot and Riga (2007), Akhavan (2012) and Byrskog et al (2015).

Interaction with patient factors

Almost all the selected articles (35/37) highlighted that language and cultural differences, and lack of knowledge of a host country's health system, are perceived by providers to be common challenges (Abbott and Riga, 2007, Otero-Garcia et al., 2013, Hakonsen et al., 2014, Pergert et al., 2008, Terraza-Núñez et al., 2011, Suurmond et al., 2013, Samarasinghe et al., 2010, van den Ameele et al., 2013). These difficulties significantly impeded effective communication between migrants and providers. The barriers interweaved with unfamiliarity with specific cultural beliefs of migrants, such as

55 patriarchal norms in Muslim culture, making it difficult for providers to address migrants’ illnesses in a holistic fashion. In light of this barrier, primary care physicians, were reluctant to delve into details beyond physical illness, and consequently shaped their practice to be more 'superficial' and 'straight forward'. This problem was highlighted by Rosenberg et al (2006) and Hultsjo and Hjelm (2005), reporting that language barriers made nurses in psychiatric emergency wards adapt the way they took patients’ medical histories, making the accounts less complex to avoid delving into the traumatic experiences of migrants. Dauvrin et al (2012) reported that providers in accident and emergency (A&E) departments, where treatment was more direct, were far less affected by language and cultural divergence than those in mental health and primary healthcare clinics.

Furthermore, cultural beliefs, specifically gender preference, also played an important role. As expounded by Lyberg et al (2012), most male interpreters did not understand the demands of immigrant women receiving maternity care. Since it was difficult to deliver health services effectively, there arose a feeling of mistrust, meaning providers feared accusations of racism if they unintentionally made cultural mistakes (Manirankunda et al., 2012, Worth et al., 2009). The mistrust problem was further complicated when it was combined with the fact that most migrant patients were unfamiliar with the health system of the country of residence (Sandhu et al., 2013, Englund and Rydström, 2012, O'Mahony and Donnelly, 2007).

Interaction with workplace factors

Respondents commonly cited in-house constraints resulting from huge work burdens and inadequate human resources and institutional capacity as common barriers (found in 21 of 37 articles). As discussed by Straβmayr et al (2012), such challenges were more apparent when providers with highly specific expertise were in demand, for example, a shortage of skilled psychotherapists in mental care.

To resolve communication barriers, interpreting services were set up as part of 'migrant- friendly services'. Yet the availability of interpreting assistance neither guaranteed the quality of care nor ensured the interpreting service would be utilised in practice.

56 Akhavan (2012) and Farley et al (2014) highlighted that using interpreters was somewhat time consuming. Eklof et al (2015) and Lindsay et al (2012) emphasised that using phone interpreters increased the workload of nursing staff, especially in situations requiring urgent care. In addition, Lyberg et al (2012) found that an interpreting service was of little use in some circumstances, such as during delivery and maternity care. Nicholas et al (2014) suggested interpretation problems might be eased by using healthcare staff of the same ethnic background to the patients to serve as a bridge between migrants and healthcare providers.

The respondents in some studies (7/37) mentioned contradictions between service provision guidelines of the workplace and beliefs of migrant patients (Foley, 2005, Fowler et al., 2005, Munro et al., 2013, Worth et al., 2009, Høye and Severinsson, 2008, Vangen et al., 2004, Wachtler et al., 2006). Foley (2005) raised an example where nurses in an HIV clinic in the US changed their routine practice by delivering medicine for HIV-positive migrants at places outside the patients' homes in order to avoid disclosing the HIV status of female migrants to their male partners. Hoye and Severinsson (2008) and Wachtler et al (2006) underscored that the mismatch between routine clinical service guidelines and migrant patients' beliefs increased feelings of stress amongst healthcare providers. An instance of intensive care wards in Norway was raised to support this notion, since the wards were often crowded by a large number of family members of immigrant patients, and this hampered care procedures of the nursing staff (Høye and Severinsson, 2008).

Interaction with societal factors

Societal challenges were reported in 25 of 37 articles. Different belief systems of providers and service users was an important challenge. For example, patriarchal values in Muslim migrants made female providers feel that they were not fully trusted by patients (Høye and Severinsson, 2008, Englund and Rydström, 2012). Nicholas et al (2014) mentioned that neonatal intensive care staff in Canada reported negative feelings towards the birthing rites of some immigrant families. The difference in belief systems

57 had some overlapping features with language and cultural barriers as explained above (interaction with patient factors).

Aside from cultural differences, a discrepancy between immigrant laws and professional norms was observed. Professional norms more strongly shaped the behaviours and attitudes of healthcare providers than laws that prohibited migrant rights to care. In cities where policy regarding universal healthcare access was open for 'everybody', clinical practice was more relaxed. Nonetheless, the relaxation of laws that allowed undocumented/illegal migrants to enjoy services (for free or with little expense) did not guarantee that migrants would be able to access health facilities without constraints. In contrast, in countries where the rights of migrants were restricted, most health practitioners did not feel obligated by this mandate. Informing the police or government authorities about the presence of undocumented/illegal migrants was an uncommon practice, even though they were requested to do so (Dauvrin et al., 2012, van den Ameele et al., 2013, Kurth et al., 2010). Common excuses used by the providers were grounded on philanthropic concepts, recognising migrants as a vulnerable group and taking into account the potential threat to the public of leaving sick migrants untreated (Goldade and Okuyemi, 2012).

Besides, administrative and financial burdens usually played an important role in limiting the migrants’ rights to care (Foley, 2005, Munro et al., 2013, Eklof et al., 2015, Donnelly and McKellin, 2007). Donnelly and McKellin (2007) exemplified a case in Canada where a breast cancer screening service for immigrants faced a huge funding cutback. Because of administrative delay, refugees and refugee claimants in Quebec found themselves uninsured despite having the right to participate in the Interim Federal Health Programme (Munro et al., 2013).

Similar challenges also appeared in the US. To be insured at the city health centres in Philadelphia, an immigrant must first provide proof of residence to the accountable authority. Yet some African women had no documentation in their own name since they lived with male partners or relatives (Foley, 2005). Goldabe and Okuyemi (2012) reported healthcare providers’ opinions that allowing migrants to access emergency

58 services was reasonable, since it had advantage in preventing the country from experiencing public health threats (however, respondents reported that the benefit should not include treatment for occupational injuries because the profit of the treatment went to individual companies rather than the wider national population).

Though this review aimed to identify 'challenges' encountered by healthcare providers in managing care for migrants, some 'enabling factors' could be identified. The introduction of an interpreting service as expounded in the earlier subheading (Interaction with workplace factors) could be regarded as a mechanism that facilitated healthcare access for migrants. Another obvious example was a collaboration between public healthcare providers and informal networks, such as charitable groups or non- government organisations (NGOs). A reliance on informal networks/channels could help providers in the public sector overcome administrative and legal constraints since most NGOs or philanthropic agencies were less bound by rules and procedures than government authorities (Straßmayr et al., 2012, Health Protection Agency, 2010). A concrete example was in England where some health staff described confusion in the NHS regulations that limited some benefits (such as housing aid) for certain types of migrants. Therefore, some health professionals resorted to non-statutory organisations or civil networks to help fill this service gap (Health Protection Agency, 2010).