Introduction

Migrants coming from less economically developed countries are a vulnerable group regarding access to health care services, especially those recently arrived and facing socioeconomic precariousness and cultural and linguistic barriers [1]. If they carry no legal authorization to stay in the host country (undocumented migrants) this vulnerability is even greater [2]. This condition puts migrants at a higher risk of contracting transmissible diseases as HIV/AIDS. In several Western countries, rates of HIV infection are higher in migrants than in general population [3]. In Spain, 35% of new HIV diagnoses are in foreigners, being sub-Saharan African migrants (SSAM) one of the most affected groups [4]. Our research team noticed that SSAM were reluctant to have their blood tested: An own-made questionnaire conducted in 177 SSAM showed that 8% thought hospitals re-used or sold the blood drawn from the analysis and 40% had doubts about what was done with their blood (Poster THPE0421; The XVII International AIDS Conference, Mexico, August 2008).

Refusal to do blood tests means a lost opportunity for fighting against this devastating disease. Few studies tackle specific socio-cultural barriers regarding access to HIV test. The reason of this study is to understand why SSAM may be unwilling to test their blood and specifically to undergo HIV testing. Consequently, it would be possible to find appropriate measures to improve access to HIV test, reduce late HIV diagnosis, achieve a better follow-up and increase confidence in health care services.

Methods

Design and Settings

This study is based on Ethnography research. It was conducted by the Tropical Medicine and Clinical Parasitology Unit of the Ramón y Cajal Hospital, in Madrid, Spain (TMU) in 23 NGOs located in 12 Spanish regions in the frame of an HIV prevention program. The study period was September 2006–September 2009.

Participants

The total number of SSAM attending the HIV informative talks where this study was developed was 1325. The majority were men between 20 and 30 years old, came from Western Africa, had a diverse educational level, were Muslims or Catholics and had been living in Spain for less than 2 years. Given the diversity of SSAM taking part in the HIV prevention talks, we decided to use other techniques (focus groups (FG) and semi-structured interviews (I)) to reach our purposive sample and observe the profile of the SSAM attended at the TMU: a young man from Senegal, Nigeria, Cameroon, Mali or Guinea Conakry, Muslim, undocumented, living in Spain for less than 1 year and with secondary or lower education (Table 1). Thirteen people participated in the I & FG, rising the number of participants up to 1338.

Table 1 Data collection techniques
Full size table

The main form of data collection was participant observation (PO) during HIV informative talks organized by the research team, which was composed of doctors, translators/interpreters, intercultural mediators and a psychologist. One of the researchers stayed in the talks and took notes of all commentaries and reactions of participants when talking about blood test. This technique was chosen because it allowed us to find the key informants and to establish informal chats with participants where relevant information was collected. PO was developed in 100 talks (average duration of each session: 1 h 30 min).

Three in-depth interviews (I) and two focus groups (FG) were also organized so that we were able to triangulate techniques and to assure data saturation.

Analysis and Quality of Data

Notes taken by researchers during the PO sessions and narrative content of interviews and FG were analysed by two different researchers using the Health Action Process Model [5].

HIV talks were conducted in Spanish and interpreted (orally translated) by intercultural mediators into English, French, Wolof and Bambara.

Participants of I & FG didn’t speak Spanish and languages used were English and French. Speeches were audio-taped, transcribed and translated into Spanish by professional translators collaborating in this research. The interactive collaboration with translators and intercultural mediators strengthens the rigor of multilingual research, especially when cultural parameters may determine the meaning of data. Techniques and researchers were triangulated and results of analysis were validated by the target population in order to assure the reliability and validity of results. This research obtained the approval from the Ethics Committee for Clinical Research of the Ramón y Cajal Hospital.

Results

The analysis of the information let us classify eight interrelated categories regarding perception of blood tests in SSAM: (1) socio-cultural determinants in health (2) health-related rights, (3) symbolic value of blood, (4) amount of blood and fear to recovery, (5) illness approach, (6) HIV/AIDS perception, (7) myth of reutilization and selling of blood, and (8) mistrust towards health care professionals.

Socio-Cultural Determinants in Health

Participants affirmed they trusted traditional medicine and the natural remedies they took back home. In their countries of origin, the contact with traditional medicine was normally greater than with western medicine. Sometimes, traditional healers were more appreciated than hospital staff.

Traditional medicines…the marabouts [traditional healer] are better than going to hospital. Because, you know, in African hospitals, they don’t take care of you properly and then…

Man, Senegal, 29 years.

SSAM stated that, in their countries, going to the hospital was very expensive. Sometimes, to have free access to health care services, tests and treatment was perceived as something “strange”.

In my country, going to the hospital is very expensive, some people cannot afford it.

Man, Mali, 25 years.

SSAM were not used to undergo preventative tests; they used to go to the hospital only when they already had some health problem.

African people don’t go every month or every two months to hospital, to see how their health is. We go when it is needed. For example, me, I have a headache, well, I am going to see my doctor. But, like you…even if we have nothing, to go to see if we have something…well, African people don’t do it that way.

Man, Senegal, 27.

Health-Related Rights

Cultural differences along with the linguistic barriers sometimes lead to the unawareness of rights and duties in relation to Spanish health care system.

If it is an emergency, sometimes, in hospitals, they not even ask you for the documentation!

Man, Mali, 31.

The surprise of this participant proved he didn’t know that Spanish legislation guarantees emergency services for any person with no need of any documentation [6]. Many participants were undocumented and some of them thought that a connection between the health care system and the police may exist. Others also feared the possibility of being repatriated if they were diagnosed with a serious disease, even if that is not permitted by the Spanish law.

As participants were travelling around Spain looking for a job, sometimes they left one city without receiving the results of tests they have done at hospitals.

I did the blood test in Melilla, and then again in Madrid…they took my blood again!

Man, Nigeria, 26.

The possibility of receiving those results in their new hospital, as well as the procedures to do so, were broadly unknown by participants.

Symbolic Value of Blood

Blood was perceived by participants as a symbol of life and strength. SSAM use to state that in order to work, they needed to be strong.

Blood is live. If they take our blood, we’ll be weak; we won’t be able to work.

Man, Nigeria, 29.

Results showed that blood and, specifically African blood, was considered as an estimated good. This idea was also identified in previous researches along with the idea that the Europeans seek African blood because it is “stronger” [7].

Amount of Blood and Fear to Recovery

The majority of SSAM thought that too much blood was taken for the tests. SSAM stated that they were more used to other tests “where only a couple of drops of blood are needed”. They were referring to the rapid diagnostic test for malaria (thick blood smear test).

At home, they take just one tube, some drops for testing, and you have blood, but here, they take hundreds of litres!

Man, Ivory Coast, 25.

Most of them were afraid of remaining weak or ill after undergoing blood testing.

They take too much blood, many tubes; it is not good for the body.

Man, Burkina Faso, 34.

The quantity of blood in the human body and the capacity to an easy recovery was frequently unknown to SSAM. Some of them stated that physicians should first verify their level of blood before deciding to do the test.

Illness Approach

SSAM talked about health not only from a biomedical point of view but also regarding physiological and emotional aspects.

Health is life. You need to be happy but when you are ill, something is preventing you from being happy, so, in some way, you cannot be happy until you are cured.

Man, Guinea Conakry, 34 years.

They made also the relationship between a good health state and the strength, especially related to the capacity to work.

Health is to be strong, to be able to do anything a man can do, any work that a man can do.

Man, Gambia, 30 years.

When analyzing the causes of illness, SSAM ask themselves not only how the illness is contracted but also why it affects a specific person. The metaphysical and religious factor is critical to answer this question. Nonetheless, these topics are normally considered taboos and migrants didn’t directly mention them in discussion groups or interviews.

HIV/AIDS Perception

In many HIV preventative talks participants discussed the existence of HIV. Some SSAM stated that it was an infection created by Western societies that had been introduced in Africa; these conspiracy beliefs have been associated with risk sexual behaviour in previous studies [8]. In fact, some participants had their own interpretations of the acronym AIDS in French:

Le SIDA est le Syndrome Imaginaire pour Décourager les Amoureux. [Imaginary Syndrome to Discourage Lovers]

Man, Cameroon, 38 years.

We also observed that HIV/AIDS was considered a dangerous disease that will prevent them from working and carrying out their migration project. Participants made a relationship between “bad” or “spoiled” blood and HIV infection.

If they tell you: ‘You have HIV’, your blood is spoiled.

Man, Mali, 34.

Most participants expressed their fear to be rejected and stigmatized by their communities in case they were infected by HIV.

In a country that is an undeveloped country, people will just separate you, people will just see you as…a forgotten person, like a cursed person, like a person that has committed many…many things…and that’s why the person gets that.

Woman, Kenya, 23.

These worries may decrease the willingness to do a diagnosis test for HIV/AIDS.

You feel uneasy…if they are going to tell you that…well, your life is spoiled, it is worthless to know it (…). There are people that don’t want to know anything. Even if they are in pain, they prefer to die rather than knowing the truth.

Man, Mali, 22.

The Myth of Reutilization and Selling of Blood

The preciousness of blood prevents a lot of SSAM from believing or imagining that blood drawn for testing, from a healthy person, is treated as waste.

They verify your blood to know if you have a good blood. They don’t throw it away, obvious. That is what is given to other people.

Man, Cameroon, 28.

They don’t know what is done with the blood after the tests, and this is a factor that let them into thinking that blood can be given to other people.

And after the test? That is what I want to know, what do they do with my blood? They tell you the results are ok…but afterwards? Where is my blood? Maybe they give it Ms so-and-so.

Woman, Senegal, 32.

Mistrust Towards Health Care Professionals

Socio-cultural differences as well as linguistic barriers can represent an obstacle to effective communication between Spanish health care professionals and SSAM.

Doctors have to be patient and understanding with migrants. I’ve been living here 7 years and …I didn’t like some things. I don’t want to talk about that, I just want to say « patience and understanding». With someone that does not speak your language; you have to be patient, don’t you?

Woman, Senegal, 35.

In Africa, when you go for a blood test, they take, more or less, one or two drops of blood. They shoot you up with a needle, blood comes out and that’s what they need for the test, but here is different. I don’t know if it only happens with us, migrants, or if they take so much blood to everybody.

Man, Cameroon, 28.

As reflected in the previous verbatim, some SSAM wonder if their migrant status makes a difference in the health care attention they receive. They don’t express much reliance in health care professionals and some of them even feel afraid of going to hospital to test their blood.

Yes, I am happy, it is just that…since I arrived here, I didn’t want to do blood tests…with all those rumours, friends tell you that when you go for a blood test, they take litres…I am scared.

Man, Senegal, 23.

Discussion

SSAM carry a great cultural diversity, therefore, results of this study could not reflect a general belief about blood testing. Nevertheless, we believe that the chosen sample may represent the profile of a great number of SSAM recently arrived to the South of Europe: men, young, with heterogeneous educational level and no-native speakers. Even more relevant is the fact that the chosen profile of participants (single men just arrived in a new country and far from relatives and friends) represents a susceptible group to enter the HIV epidemiological chain.

Results of this study highlight the importance for SSAM of what has been called “ultimate causes” of illness, the reason why a person is affected by a specific disease [9]. A person infected by HIV can be seen in Africa as a “cursed” person. As they come from cultures where collectivism is something crucial, rejection is seen as something fatal. To the fatalism and stigma related to this disease we have to add the clash between HIV diagnosis and their migration project. Polemic declarations of some African leaders questioning HIV existence may have an influence in the denial of this disease and also the unwillingness of some SSAM to undergo HIV testing, as home country experience and community mobilization has been proved to be highly influential on HIV awareness [10].

Some of SSAM thought that blood for testing was re-used or sold. They may be afraid of blood testing due to myths surrounding the weakening of the body and the reutilization of blood. Some authors reported a reluctance to give blood due to the fear of becoming weak in some African countries, making a link between and blood donation and concerns about blood recuperation. Cases have also been reported about people trafficking with blood in Africa and the belief that European people wanted to buy it because African blood was “stronger” [7].

HIV testing becomes less accessible due to legal pitfalls. Spanish law stipulates that any person registered in the town council has the right to get a health care card, which enables access to health care services, regardless of the legal status of migrants [6]. Nonetheless, SSAM sometimes lack of an official document proving their identity and preventing them from registering in the town council. This is one of the main barriers they find to access health care services. Furthermore, the unawareness of their health-related rights may let them into thinking that a connection between health care services and the police may exist. HIV diagnosis and treatment in SSAM may be beset by the encounter with a new and different health system where language and cultural barriers may lead to misunderstandings and mistrust towards health care professionals. As reflected in literature, cultural and linguistic barriers may cause misunderstandings between health-care staff and sub-Saharan migrants [11] and these obstacles may also be detrimental to gain access to HIV testing [12].

Conclusion

It is necessary to avoid the risk of overemphasizing the cultural dimension and falling into stereotypes. Nevertheless, it is also important to be aware of cultural, social and linguistic gaps that may put at stake communication in medical settings. This study identifies different socio-cultural barriers to HIV screening in relation to blood test perception of SSAM living in Spain. These barriers should be taken into account in health promotion actions. Inadequately tailored programmes lead to SSAM often relying on informal networks and word of mouth for information [12]. A cross-cultural perspective in HIV prevention programs aimed at migrants, with the participation of intercultural mediators and professional interpreters with cross-cultural competencies can be a key factor to guarantee their effectiveness. We strongly believe that HIV prevention talks aimed at SSAM living in Spain should include specific information about blood tests: why they are necessary, how our body recovers afterwards, how long it takes to get the results and what is done with that blood afterwards. This information can be very useful for assuring not only the access to HIV diagnosis but also a general health care uptake and follow-up.