Objective: To describe the service use of migrants from eight central and eastern European (CEE) countries at two central London genitourinary medicine (GUM) clinics before and after accession to the European Union on 1 May 2004.
Methods: KC60 data collected between 1 June 2001 and 30 April 2007. Data refer to new attendances and exclude those attending for follow-up appointments.
Results: 102 604 people attended the clinics at least once over the study period. Between May 2006 and 30 April 2007 individuals born in the eight CEE countries accounted for 7.9% of attendances among women and 2.5% of attendances made by men; the proportion increasing significantly over the 6-year study period (p<0.001). Syphilis was more likely in CEE men (age-adjusted odds ratio (OR) 2.98, 95% CI 1.07 to 8.29) and family planning services were more likely to be required for CEE women (23.9% vs 12.4%, age-adjusted OR 2.33, 95% CI 2.02 to 2.68, p<0.001), than for those born elsewhere. A larger proportion of men from CEE countries were recorded as homosexual or bisexual than men from other countries (38.3% vs 31.9%, p = 0.003).
Conclusions: CEE migrants already have a substantial impact on GUM services in London. If attendance rates continue at the current level CEE women will soon account for over 10% of new attendances. Although the majority of CEE migrants are men, proportionately fewer CEE men accessed GUM services than women. Sexual and reproductive health services need to adapt quickly to meet the needs of this growing population.
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On 1 May 2004 eight central and eastern European (CEE) countries—the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia (known as the “accession 8”) joined the European Union (EU). Accession has resulted in a large influx of predominantly young economic migrants to the UK. Since May 2004, 715 000 CEE nationals from the accession countries have registered with the Workers Registration Scheme (WRS), 12% registering in London, 93% of whom were aged 18–44 years, 57% were men and only 5% recorded dependents under the age of 17 years.1 The WRS is a transitional measure to regulate access to the labour market of nationals from the new EU member states; students and self-employed workers do not need to register. A survey found only 64% of Polish migrants had registered with the WRS.2 If this figure was extrapolated to all CEE migrants, then over 1 million CEE nationals from the accession countries may have migrated to the UK in the past 4 years. There is currently no published research in the UK on the impact EU accession has had on genitourinary medicine (GUM) services within the UK. GUM, or sexual health, clinics provide free open access medical services under the National Health Service (NHS), predominantly for the management of sexually transmitted infections (STI).
Our aim was to describe the service use of CEE nationals from the eight accession countries at two central London GUM clinics before and after accession to the EU on 1 May 2004. Throughout the paper when we refer to CEE nationals we are referring only to those nationals from the eight central and eastern European accession countries.
KC60 data3 were collected by two central London GUM clinics between 1 June 2001 and 30 April 2007. Data included for this study’s analysis refer to new attendances; follow-up appointments were excluded unless they resulted in the diagnosis of a new episode of at least one other acute STI. Acute STI are defined according to table 1. Attendees who were known to be HIV positive before their visit, or for whom their country of birth was not recorded, are excluded from this analysis.
The analysis was performed using STATA 8.0.4 The Mann–Whitney test was used to test for differences in the age of patients because of the non-normal age distribution. Binary logistic regression was used to obtain odds ratios (OR) to compare the recording of any acute STI as well as specific acute STI for attendees from CEE countries in contrast to attendees from other countries (including the UK), as well as in contrast to attendees born in or from either the UK or Ireland. We also present OR adjusting for differences in the age of attendees from CEE countries versus other countries. Linear regression was used for trend analysis.
Comparison is made between individuals born in the CEE accession countries and individuals born elsewhere; although this potentially may dilute influences from migration, London is such a cosmopolitan city that to limit the comparator group to those born in the UK/Ireland would fail to compare this “new population” with established practice.
A total of 102 604 people attended the clinics at least once over the study period (1 June 2001 to 30 April 2007 inclusive), 48.9% of whom were men. A total of 154 964 visits were made over this time period by people with a known country of origin; 5805 (3.8%, 95% CI 3.7% to 3.9%) were made by people born in an accession CEE country. This proportion significantly increased over the 6-year study period for men (1.0% to 2.5%, p<0.001) and women (3.4% to 7.9%, p<0.001; table 2), with no significant gender difference in the magnitude of this increase (p = 0.228). Attendances by women born in a CEE country at sessions run specifically for female sex workers (FSW) increased significantly from 13.2% to 39.8% over the study period (p<0.001). However, there was still a significant increase in the proportion of visits made by CEE women when visits to FSW sessions were excluded, from 3.4% to 5.8% (p<0.001). Although a year-on-year increase in the proportion of CEE attendances since 2000 was found, the accession date (1 May 2004) was not associated with a significant shift in the already increasing trend. Country of birth was not recorded for 13.1% overall, and over the study period this decreased from 20.8% to 8.6% (p<0.001). No clinically significant difference was found when CEE nationals were compared with all individuals born elsewhere or when they were compared with just those born in the UK or Ireland.
All subsequent results refer to the most recent year of data (1 May 2006–30 April 2007). In this year 2.2% of 10 691 men with country of birth recorded and 6.6% of 11 287 women with country of birth recorded who attended at least once were from a CEE country (p<0.001 for gender difference). On average, CEE attendees were younger than those born elsewhere: medians of 27 years (lower and upper quartiles: 24 and 31) versus 29 years (lower and upper quartiles: 24 and 36) for men (p<0.001), and 25 years (lower and upper quartiles: 22 and 28) versus 26 years (lower and upper quartiles: 22 and 31) for women (p<0.001). Of the 979 people from CEE countries attending in this year 44.9% were from Poland, 17.8% from Lithuania, 10.8% from Slovakia, 10.5% from the Czech Republic, 7.3% from Hungary, 6.1% from Latvia, 2.2% from Estonia and 0.5% from Slovenia (p = 0.634 for gender difference).
Overall, men were more likely than women to have at least one acute STI diagnosed at their clinic visit(s): 27.3% (95% CI 26.5% to 28.0%) versus 15.6% (95%CI 15.1% to 16.2%), respectively (p<0.001, tables 3 and 4). However, CEE men were just as likely to have an acute STI diagnosis/es as men from other countries: 29.0% (95% CI 24.5% to 33.8%) versus 27.2% (95% CI 26.5% to 27.9%), age-adjusted OR 1.07 (95% CI 0.85 to 1.33, p = 0.578) as were CEE women compared with women from other countries: 14.4% (95% CI 12.6% to 16.4%) versus 15.7% (95%CI 15.1% to 16.3%), age-adjusted OR 0.87 (95% CI 0.74 to 1.02, p = 0.090).
Looking at diagnoses of specific acute STI a higher proportion of clinic attendances by CEE men resulted in syphilis diagnoses (1.0% vs 0.4%, age-adjusted OR 2.98, 95% CI 1.07 to 8.29, p = 0.037). The proportion of these diagnoses recorded as homosexually acquired did not differ by country of birth. However, a significantly larger proportion of men from CEE countries were recorded as homosexual or bisexual than men from other countries (38.3% vs 31.9%, respectively, age-adjusted OR 1.53, 95% CI 1.15 to 2.02, p = 0.003).
Among women’s visits, CEE women were less likely to be diagnosed with herpes, genital warts, or trichomoniasis (age-adjusted OR 0.44, 0.64 and 0.38, respectively; table 4). However, women attending the clinics from CEE countries in the last year were twice as likely to have a family planning-related outcome: 23.9% (95% CI 21.6% to 26.3%) versus 12.4% (95% CI 11.9% to 13.1%) of women from other countries, p<0.001.
In 2006–7, individuals born in the eight CEE accession countries accounted for 7.9% of new attendances by women and 2.5% of new attendances by men, the proportion increasing significantly over the 6-year study period. In particular, the proportion of CEE women attending sessions for FSW rose significantly. Men and women from central and eastern Europe were as likely to have at least one acute STI diagnosed at their clinic visit(s) as men and women born elsewhere. However, CEE men were more likely to be diagnosed with syphilis than men born elsewhere and women from CEE countries required family planning services more frequently than women born elsewhere.
Testing to see whether 1 May 2004 per se was important in the increasing number of patients attending from CEE countries we found that it was not. Although accession formally did occur on a specified date (1 May 2004), in reality it reflects a process of social and economic reform that occurred over time. Therefore we would not expect the date in particular to be significant. What is significant about the date is that as of 1 May 2004 all CEE migrants from the accession countries became legally entitled to NHS services.
The UK has recently experienced a large influx of CEE nationals, these individuals may be at risk of sexual ill health and reproductive morbidity.
The proportion of attendances at two central London sexual health services by CEE nationals from the eight accession countries (men who have sex with men and FSW in particular) have increased significantly over the past 6 years.
Men from central and eastern Europe were more likely to be diagnosed with syphilis and women from central and eastern Europe were more likely to require family planning services than those born elsewhere.
Sexual health services need to adapt quickly to ensure the sexual and reproductive health needs of this growing population are met.
The collapse of communism in 1989–91 heralded monumental socioeconomic change throughout central and eastern Europe. The transformation of the social, economic and political environment prompted by falling incomes, job loss, insecurity, migration, changing values and sexual mores contributed to an unprecedented rise in STI and HIV throughout the 1990s.5 6 The incidence of syphilis increased from 4.8 per 100 000 in 1990 to 33.4 per 100 000 in 1998 and as the economic decline led in many instances to a marked deterioration of public health services, including the treatment and surveillance of STI7 8 this figure may be an underestimate.5 In addition, the introduction of user fees in some countries means healthcare is sought later or not at all, awareness about STI and their consequences is low, antibiotic resistance in the region is high and resistance to sexual health promotion exists at a societal level.5 A culture of homemade drug use and needle sharing exists in some parts; in Estonia the HIV prevalence is more than 1% of the adult population, predominantly due to the exceptionally high rates of intravenous drug use (1.2% of the population).9 Relatively few data exist on the reproductive health of CEE nationals. The World Health Organization found that less than 50% of women in five of the CEE accession countries utilised a modern form of contraception, with oral contraceptive use less than 10% in four countries for which data are available.10
Migration differentially favours those who are younger, economically productive and healthier.11 Migration is also associated with the rupture and re-establishment of sexual relationships, particularly as many individuals initially migrate without their primary partners. Migration has been identified as a critical factor in high-risk sexual behaviour independent of marital and cohabitation status or social milieu.12 All of these factors suggest that migrants from central and eastern Europe are at risk of sexual ill health and reproductive morbidity.
Our study has two main limitations: first, the inability to link behaviour with diagnoses and second, missing data. Identifying whether the population at need is captured within the study is difficult with KC60 data. The high proportion of CEE women attending FSW sessions and the higher proportion of men recorded as bi or homosexual from central and eastern Europe suggests that at least two high-risk populations are reflected in the clinic attendance. Self-reported data, such as country of birth, may be more likely to be incomplete for individuals with English as a second language, possibly biasing these results. If this were the case then the proportion of attendances by people born in central and eastern Europe could be even higher. Finally KC60 data are unable to provide descriptive detail for the more generic codes. “Family planning” captures contraception (women only), including prescribing and family planning advice and excluding condom provision.3 Emergency contraception and termination of pregnancy referral would also be recorded under this code; however, differentiating between these different aspects is not possible with KC60 data.
Homosexuality, although no longer a crime in CEE states, remains highly stigmatised.13 The stigmatisation and discrimination that many CEE men who have sex with men experience makes it likely they would favour emigration. Similarly, other high-risk populations in terms of sexual health, such as young people and the unemployed,5 14 are likely to favour emigration for economic and lifestyle reasons.
This study shows that CEE migrants are already having a substantial impact on GUM services in London and probably the UK. If attendance rates continue to rise at the current level, women born in central and eastern Europe will soon account for over 10% of all new attendances. Whereas the majority of CEE migrants are male, proportionately fewer CEE men accessed GUM services than women. The demographic profile of the CEE migrant population indicates that they are likely to be sexually active and to have reproductive ambitions; there is a high background prevalence of STI and HIV in their countries of origin14 and their uptake of risk reduction strategies such as safer sex and needle exchange are unknown. This, coupled with the higher rate of syphilis seen among CEE men in this study, would suggest that services need to adapt quickly to ensure the sexual and reproductive health needs of this population are met.
The authors would like to thank P Pearson for help extracting the data.
Funding: FMB was supported by a Wellcome training fellowship (grant 066866/Z/02). CHM is funded by a Department of Health/NCCRCD postdoctoral fellowship. ARE is funded by an MRC grant (G0601703).
Competing interests: None.
Contributors: FMB led the writing of the paper, with contributions from all authors. CHM prepared the data for analyses and led the statistical analyses with support from ARE.
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