Design and setting

We had the collaboration of several organizations to perform this study: A religious Non-Governmental Organization (NGO) Fundación Ayuda Social de las Iglesias Cristianas (FASIC), the academic organization Universidad Diego Portales (UDP), the international agency The United Nations High Commissioner for Refugees (UNHCR) and a number of municipalities in the Metropolitan Region of Santiago, Chile. Municipalities located in the Metropolitan Region were chosen because this region concentrates 63% of international immigrants in Chile, including refugees [17]. The study was conducted over six months, from August 2018 to January 2019.

Sampling and recruitment procedures

The sampling strategy was intentional and reasoned, looking for criteria of representativeness of discourse, experience and meaning of the case study [18,19]. Recruitment criteria were established based on the characteristics of the qualitative paradigm [20], which aimed to cover the heterogeneity of the asylum experience and its relationship with healthcare scenarios, based on differentiated criteria for the three populations or perspectives of interest: A) population of asylum seekers, B) Public healthcare teams with experience in caring for this population, C) Staff of institutions responsible for recognition of international protection (Table 1).

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Table 1. General socio-demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0241153.t001

For asylum seekers, the sample was selected based on theoretical and practical criteria. The theoretical criterion was the time spent as a refugee or asylum seeker in Chile, considering two persons in the process of asylum seeker´s status assessment, 2 with recent refugee status approved and 4 with long-term (more than 1 year) status of refugee.

It was not possible to access cases in which the refugee or asylum seeker request had been rejected. On the other hand, the practical criterion considered the feasibility of contacts and mediated recruitment from contact with NGO FASIC. This non-probabilistic sampling was selected given the unique study group and potential sensible topics to be discussed with them during data collection [21]. All participants could refuse to be involved or quit during the research process. The general criteria for inclusion in the study were: i) being a refugee or asylum seeker immigrant; ii) being at least 18 years old; iii) being of Latin American nationality; iv) having had a previous experience with the Chilean healthcare system.

For healthcare teams, a selective sampling strategy was also used, through a theoretical criterion that they provided healthcare treatment for asylum seekers. The teams were contacted directly by the researchers. The criteria for inclusion in the study were: i) belonging to a public healthcare team and ii) having experience working with refugee or asylum populations. Participants in this group regularly attended immigrant population, including refugees and asylum seekers. It must be noted that there is no mechanism available in the country for healthcare providers to distinguish between general migrants and refugees or asylum seekers, except for self-report. Hence, based on their testimonies, all healthcare workers selected in this study declared having experience attending migrants who defined themselves as refugees and asylum seekers. All participants included in this sub-group belonged to the primary healthcare system and had worked there for at least two years at the time of the study.

The members of organizations in charge of protecting this type of population were also selected based on a selective sample criterion and the theoretical criteria that were part of any of the institutions dedicated to the advice and recognition of the condition of asylum. Recruitment was made based on contacts established with the academic, social and healthcare institutions involved in the study. The two organizations that contributed to the recruitment of participants (FASIC and UDP) are the most experienced ones in supporting and accompanying refugees in Chile. The criteria for inclusion in the study were: i) belonging to a team of organizations linked to the international protection process ii) having experience working with asylum populations. Respondents included in this sub-group had been working for more than a year in social and legal orientation of people in a situation of refuge or asylum seeking in Chile. The study finally included a total of 14 participants, all adults from the Santiago Metropolitan region.

Data collection, processing, and analysis

All semi-structured interviews were conducted by the principal investigator (AC) and a research assistant in Spanish. The interviews were audio-recorded, transcribed into Spanish and a thematic analysis of the information was carried out. All quotes were translated from Spanish into English by the authors (BC) and translated back into Spanish in order to check language and cultural consistency.

Ethical considerations

The study was approved by the Ethics Committee at Universidad del Desarrollo on 23 July 2018 (#23/10-2018). Written informed consent, including for audio recording, was obtained from all participants. Confidentiality was safeguarded by the first author. Names and other personal details were removed from transcripts before analysis. Participants who were refugees or asylum seekers were reimbursed a US$5 bus fare.

Refugees’ poor knowledge of healthcare system and rights

Overall, refugees and asylum seekers were completely unaware of how the healthcare system in Chile works and did not have access to it until such time as a specific need arose, such as a health condition or a health emergency. “I used to feel very worried about the idea that the girls could get sick (…). However, we came with pending orthodontic treatments (…) and a lady offered us a plan of attention to all and we were happy. But of course, then we realized that it was very expensive. (…). When I started working, I found out that as refugees we had the right to FONASA [public system] and that they [private system] had practically robbed us.” (W1, Refugee, woman).

In terms of healthcare, information on migrants' access to health had partially reached the healthcare teams, and although many of them had been trained, they still faced obstacles to providing care to these migrants. “We do a lot of training with the [healthcare] teams but they always tell you that there was a case that they could not enter into the formal system, because they did not have Chilean ID card (…)” (W3, Nurse, woman).

Nearly all refugees or asylum seekers reported having sought healthcare in primary care structures and having been denied their right to healthcare due to submitting expired identity documents or documents related to the request for refuge. Although refugee applicants have the right to access health, many of them report not knowing how to become formal beneficiaries of the healthcare system in Chile. “At the beginning, because of our health issue, we did it through FONASA (…). But about two months ago, my daughter had a backache, went to the healthcare center but was not treated. They said she was un-registered or that the document was expired. I did not understand well, but they did not attend her, (…) then we paid, in pharmacy we asked them to give us something and that was what we did until the pain disappeared.” (M1, refugee, man).

Most respondents were unaware that access to healthcare is guaranteed as a human right in Chile, regardless of the situation in which their asylum application is found. For this reason, they generally did not complain when they were rejected from the public healthcare system and often went to private centers with direct out-of-pocket payments for health attention.

Disregard of the Refugee Law by Chilean stakeholders

On the other hand, the two NGO employees identified difficulties in providing information both regarding the refugee and asylum application process, and regarding healthcare access. Although the Refugee Law was approved in 2010, the most critical issue that interviewees seemed to agree on was that there had not been a systematic implementation process for this law, and highlighted some barriers. These barriers included but were not limited to meeting specific conditions to apply or giving the wrong information. “I believe that the situation today is very complex (…) at least from our perspective, which is the legal perspective, there are a number of obstacles in the asylum procedure that occur from the beginning, right? (…) and that has repercussions on everything, on the ability of the person to find work, to access health, (…) the basic rights.” (W2, Lawyer, woman).

Lack of appropriate mental health services

Although in Chile the mental healthcare system has been integrated into primary care since 1993, mental healthcare needs of this specific population were reportedly hardly covered by public services, registering a loss of referrals in the case where the problems had been investigated in primary care, or simply lacking care due to the lack of Information and trust. In contrast to what happens with respect to healthcare in the period preceding forced migration, the majority of respondents reported having felt needs not covered under mental healthcare in Chile, which were related to episodes of distress, sleep disorders, emotional crises, despair, loneliness and even suicidal ideation.

“That is all for us who are here, at first one is afraid, you will know that a person is Colombian because they are always afraid. Then the fear passes and the longing remains, not being able to return… and there we must know how to endure no more, pray, don't let crying beat you.” (W1, refugee, woman).

The lack of mental healthcare, or access to specialists through the referral system gave rise to a search for alternatives that could not been maintained over time, such as university-based psychology clinics, or sporadic care in the private system. These types of interventions rather point at the treatment of symptoms or controlling the crisis, but they have little chance of becoming a long-term therapeutic process. This was explained by the testimonies of respondents who were in psychiatric treatment in either a university clinic that closed its care facilities or one foundation's psychologist. “I treated myself with a psychiatrist, because I was in treatment for depression, for the problem of post-traumatic stress. There were some psychiatrists from the University (…). They treated me super well, excellent, but then they closed and I was left with nothing”. (W1, refugee, woman).

Another respondent stated: “I’ve never looked for a psychologist or any other kind of support. Just FASIC provides us with yoga and the opportunity to talk to other people like us”(W5 applicant, woman). Yet another respondent maintained: We are depressed, we are longing. The longing I think has more to do with the stability one had before. I have here a partner and colleague, a friend and colleague, who told me: I am eating badly, I did not eat badly. Of course, she is longing for the stability she had… but it is the longing, it is longing to be calm. That is, I have had, say an emotional carousel because, precisely, one is not there [in his country]. (W6 applicant, woman).