title: Subjective health of undocumented migrants in Germany - a mixed methods approach.
abstract: BACKGROUND
  Health of migrants is known to be above-average in the beginning of the migration trajectory. At the same time reports from non-government organisations (NGOs) suggest that undocumented migrants in Germany tend to present late and in poor health at healthcare facilities. In this paper, we explore the health status of undocumented migrants with a mixed method approach including complementary qualitative and quantitative datasets.
  
  
  METHODS
  Undocumented migrants attending a NGO based in Hamburg, Germany, were asked to fill in the SF-12v2, a standardized questionnaire measuring health-related quality of life (HRQOL). The SF-12v2 was analyzed in comparison to the U.S. American norm sample and a representative German sample. Differences in mean scores for HRQOL were evaluated with a t-test and with a generalized linear model analyzing the impact of living without legal status on HRQOL. The quantitative research was complemented by a qualitative ethnographic study on undocumented migration and health in Berlin, Germany. The study included semi-structured interviews, informal conversations and participant observation with Latin American migrants over the course of three years. The study focused on subjective experiences of illness and health and the impact of illegality on migrants' health and access to health care.
  
  
  RESULTS
  HRQOL was significantly worse in the sample of undocumented migrants (n = 96) as compared to the U.S. American sample (p < 0.005). Living without legal status displayed a significant negative effect on subjective mental and physical health (p ≤ 0.003) in the generalized linear model when adjusted for age and gender compared to the representative German population sample. The ethnographic study, which included 35 migrants, identified socio-economic conditions, the subjective experiences of criminalization, and late presentation at healthcare-facilities as the three main factors impacting on health from migrant perspective.
  
  
  CONCLUSIONS
  The present research suggests a high morbidity and mortality in this comparatively young population. The ethnographic research confirms negative impacts on health of social determinants in general and stress associated with living without legal status in particular, both are further aggravated by exclusion from health care services. In addition to the provision of health care it appears to be important to structurally tackle the underlying social conditions which affect undocumented migrants' health.
  
  
  CONCLUSIONS
  Living without legal status has a negative impact on health and well-being. Limited access to care may further exacerbate physical and mental illness. Possibilities to claim basic rights and protection as well as access to care without legal status appear to be important measures to improve health and well-being.
authors.affiliation: Department of Medical Psychology, Universitaetsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany. anna.kuehne@gmx.de.
authors.forename: Anna
authors.initials: A
authors.lastname: Kuehne
authors.affiliation: School of Public Health (SPH) & African Centre for Migration and Society (ACMS), University of the Witwatersrand, 27 St Andrews Road, Parktown, 2193, South Africa. susann.huschke@gmail.com.
authors.forename: Susann
authors.initials: S
authors.lastname: Huschke
authors.affiliation: Department of Medical Psychology, Universitaetsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany. bullinger@uke.uni-hamburg.de.
authors.forename: Monika
authors.initials: M
authors.lastname: Bullinger
mesh_terms: D000328:Adult; D000884:Anthropology, Cultural; D005260:Female; D005858:Germany / Q000453:epidemiology; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D011788:Quality of Life; D057566:Self Report; D064890:Social Determinants of Health; D012959:Socioeconomic Factors; D014171:Transients and Migrants / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*