INTRODUCTION

The Universal Declaration of Human Rights is established in Article 13: Everyone has the right to move freely, they can choose their residence in the territory of a State and every person has the right to leave any country, including his own, and return to his country¹.

Emigration is considered, therefore, a fundamental right of people².

From the beginning of the 50s to the 80s, the Spanish society migrated mainly to America and Europe, the trend is reversed in 1973 and Spain becomes a recipient of immigrants. With the beginning of the economic crisis, the number of immigrants arrived in Spain decreased, although nowadays, these groups continue to reach the most moderate levels^2)(3)(4. Spain and Germany were the countries of Europe, with mutual alternations, occupying the first position in the number of immigrants coming abroad during the period 2001-2011^3).

Currently, Spain, like other countries of the European Union, receives a significant percentage of the foreign population. According to data from the National Institute of Statistics, in the first semester of 2016, the immigrant population in Spain corresponds to 4,418,898 people⁵.

Despite the fact that Europe is in a difficult situation for immigrants, a migratory demand is maintained in poor and rich countries². According to the SESPAS 2014 report (6), the causes of migration are heterogeneous and complex, mainly focused on the searching for new job opportunities.

In recent years, the immigration has settled in our society by legal and illegal ways. In a greater proportion, our nearest neighbours The Moroccans⁵, separated from Spain by a strict barrier of laws and controls, due to the efforts of the government are mainly destined to the control of the borders leaving out the importance of the access of this population to the Social Services, especially the health services^2).

Spain, a developed country, has a public health system, providing services to the entire population, whose basis is to ensure equal access and use of services for all citizens⁷⁾⁽⁸.

The establishment in our society of foreign individuals, is a determining phenomenon in Spain, causing changes in the population, with repercussions in multiple sectors: service sector, school sector, health sector, etc.³

At the level of the health sector, these changes cause an important challenge in the National Health System, to cover and meet the needs of this group⁹.

Since 2000, a number of actions to promote equality in health and access to health services for all citizens, both immigrants, and natives⁹, have been approved in Spain through: Law 14/1986, of April 25, General of Health¹⁰and Organic Law 4/2000, of January 11, on rights and freedoms of foreigners in Spain and their social integration^11).

Until 2010, progress was shown to improve health protection and access to health care for the immigrant population⁶⁾⁽¹², with the onset of the crisis, and the consequent reductions in public health spending.⁶⁾⁽¹³, The government instituted a series of new measures that directly affected the immigrant community: Royal Decree-Law 16/2012, of April 20, on urgent measures to guarantee the sustainability of the National Health System and improve the quality and safety of its benefits¹⁴.

Measures that not only have negative consequences for this population group, also for public health in general (8), because the health access is reduced for immigrants in an irregular situation and therefore, it is more difficult the detection, control and monitoring of imported diseases favouring the transmission of them⁶⁾⁽⁸.

This is compounded by the lack of knowledge of professionals about these imported diseases and the difficulty in accessing health services and benefits of this population group derived from multiple specific factors such as culture, religion, ignorance of the functioning of the Health System, language, etc.⁷⁾⁽⁹.

It requires joint work, by all health professionals, in the health care of the immigrant community, to avoid inequalities. These health inequalities are a priority concern for the World Health Organization¹⁵.

The health system should pay special attention to those who need it most, by putting in place health programs and health interventions that address the most frequent problems, targeting these groups¹⁵.

With attention to the people who need it most, health professionals have the opportunity to demonstrate one of the great achievements of Spain, its Health System which is developed, universal, free and leading worldwide²⁾⁽¹⁶.

Most of the health workers do not know about the legislation that abates these immigrant groups, and they are not aware of what is the appropriate way to deal with imported pathologies. It is fundamental to dominate, within our possibilities, certain aspects of care to be able to act in an ethical, timely and correct manner.

Given these scenarios, we propose to conduct a study with the general objective of promoting health knowledge regarding immigration in Spain.

OBJECTIVES

METHODOLOGY

A descriptive review was carried out with the purpose of responding to the objectives of this work, consulting in bases of the sanitary field such as Medical Literature Analysis and Retrieval System Online (MEDLINE), Elsevier, Scielo, and Dialnet.

In addition, reports published in websites of different organizations and scientific societies were taken into account, such as:

Inclusion criteria were defined as publications in Spanish or English related to the subject of the study, published in the period between 2007 and 2017 and made available online in the form of a report, guide, protocol, and full article.

As exclusion criteria were defined publications which did not contemplate the subject in question and did not meet the criteria described above.

The search was conducted from January 2017 to April 2017. After the selection of the studies, all of them were fully read, in order to minimize selection biases and to extract key data to respond to the objectives of the study.

The following keywords were used: Immigration; Spain; Nursing staff; Health services; Imported diseases; Communication Barriers

The operators used, combined with the keywords for the search of articles related to the subject of the study were mainly: AND, to be able to specify more specifically the search, and others to a lesser extent: OR And NOT.

RESULTS

A total of 173 articles indexed in the databases described above were obtained. Only 32 of them were adjusted to the inclusion criteria, of which 15 productions were adapted to the objective of this study. After analyzing the bibliographic material found, some thematic categories could be created, and according to them the following results have been found:

DISCUSSION

The data analyzed in this paper show that the massive arrival of immigrants to our country has been accompanied by legislative changes in health matters.

Revised studies sustain the presence of inequalities in access to the health system in relation to these legislative changes that are defined as unjust and avoidable¹⁵. This is corroborated through the revision made given that the measure imposed by the government (Royal Decree-Law 16/2012) blocks access to health services through the exclusion of immigrants in an irregular situation. This has a direct impact to the population and public health in general, with the appearance of the so-called imported diseases, as is the case of leprosy that had an incidence of 19 cases declared in 2007 when the arrival of immigrants was massive, 12 cases declared in 2012 when said Organic Law 16/2012 was approved and an incidence of 6 cases declared in 2015, when the arrival of immigrants was lower.

With the analysis of Royal Decree-Law 16/2012, it is observed how this hinders the performance of professionals before this group, thus creating ethical conflicts. Health professionals must abide by the regulations imposed by the government, leaving aside their moral and ethical criteria that are generally based on offering universal health care.

Health professionals criticize the measures established by the government and manifest an absence in professional participation for decision making regarding this population group. They point out that these approved measures, in relation to this group, are hasty and that they do not achieve the objective of health savings marked by the government³².

This review argues that the presence of language and socioeconomic difficulties are the most important barriers to access the Health System of the immigrant t community, however we must not forget other perceived difficulties such as the ignorance of the presence of some health services and the misuse of them generating collapse in the emergency department for pathologies that could be covered in primary care. For this reason, the involvement of immigrants for proper training on health issues is essential, such as access and proper use of the health system through talks or material available on the web.

It is demonstrated that the obstacles reduce the possibility of a correct access to the Health System in Spain and as a consequence, it reduces the contact of the professional with the ill immigrant making it difficult to detect imported diseases putting at risk the health of the population in general. Data from Carlos III Health Institute reveals that in 2007 Spain had an incidence of pertussis of 554 reported cases, following the imposition by the government of Royal Decree-Law 16/2012, and the consequent restriction of access to the health service by the immigrant population, in that same year (2012), the reported cases of Tosferina rise to 3439.

Despite the changes in the incidence of diseases in Spain, there are studies such as the one carried out in Barcelona in 2007, which confirmed that most professionals perceived the absence of access barriers¹⁹.

With the analysis of our results it is also observed that other reasons that should concern us is the increase in the number of international travellers, as our results show that most of the diseases currently imported come from people who travel to endemic countries, with low income, where the risk of contracting an infectious disease is high (23). That is why diseases not common for our environment appear in Spain.

CONCLUSIONS

With the massive arrival of the immigrant community, changes are introduced in the legislation generating negative consequences in the immigrant population and leaving this group without the right to public health coverage which also affect the public health.

The presence of barriers in the access to the Health System by the immigrant population is confirmed. Most of the studies reviewed confirm that the biggest obstacle is language, preventing adequate professional-patient communication.

The relationship between imported disease, immigration and international travel is verified. Currently, most of this pathologies are related to international travel.

It is confirmed the presence of difficulties and needs in health professionals to offer adequate care in the immigrant patient.