Post-migration Social Determinants of Health in Asylum Seekers: A Retrospective Qualitative Study

In the United States (U.S.), the number of asylum seekers has increased sixfold in the past decade. Limited research has explored the impact of social determinants of health on asylum seekers. To document evidence of torture and trauma, clinicians in medical-legal asylum clinics conduct Forensic Medical Evaluations (FMEs) according to the standardized United Nations Istanbul Protocol. These evaluations represent an uncommon encounter with the U.S. health system during the multi-year asylum process, during which applicants may not otherwise engage with health systems. This study aimed to determine post-migration factors that influence risk for negative health outcomes in U.S. asylum applicants and to categorize risk factors within the U.S. Department of Health and Human Services' social determinants of health framework. We performed a qualitative, retrospective study of a representative, purposive sample of forensic medical evaluations from 2010 to 2020 from the Weill Cornell Center for Human Rights' database. We identified major themes pertaining to post-migration risk and protective factors organized across social determinant domains. The 58 FMEs represented 29 asylum seekers in the U.S. The mean age was 30 years. Of the participants, 55% were female and 45% were male. The sample represented a global population, with origins from the Americas (41%), Africa (45%), and Asia (14%). Our analysis additionally identified the prolonged asylum process as a novel, unique structural barrier and identified protective factors, including community support. Given numerous barriers to accessing care experienced during the asylum process, this study identified a unique opportunity to utilize forensic medical evaluations to screen for social determinants of health.