This study was approved by one of the French Research Ethics committees (N°IRB: IORG0009855) under the authority of the Ministry of Research on November 27, 2020 (Approval number 20.10.09.57715). All methods were performed in accordance with the Declaration of Helsinki regarding ethical aspects, information and consent of subjects to participate and data publication. Written informed consent was obtained from all subjects and/or their legal guardian(s). Its registration number on ClinicalTrials.gov is NCT05423782 (Registration 21/06/2022).
We conducted a single-center, cross-sectional, observational epidemiological study.
People wishing to apply for asylum in France must register at the reception platform for asylum seekers (RPAS) in their region of arrival. Our study was conducted in Marseille during this initial registration process for asylum seekers. Participants were screened. The investigators of our study were positioned inside the reception platform (RPAS) in a confidential space, on the days when the RPAS was open, i.e. 4 and a half days a week between March 1, 2021 and August 31, 2021. We consecutively included all individuals who met our inclusion criteria and consented to participate in this study. Inclusion criteria took into account people who were over the age of 18, registering with the Marseille RPAS and had an initial asylum application receipt (within the past 21 days or an appointment at the prefecture to obtain this initial receipt). Individuals with cognitive (dementia) or mental (mental retardation) impairments limiting comprehension or oral expression (dysphasia, aphasia) were excluded. Professional telephone interpretation was used for each non-native speaker to ensure that the lack of French language skills did not limit the understanding and informed consent of the study. With the help of these interpreting services, all subjects consented to participate in the study by signing a form following the delivery of clear, fair and appropriate information in their language of use.
A face-to-face questionnaire was filled in using Redcap software (www.project-redcap.org). This questionnaire included data about age, sex, education level, marital status (single, children, spouse), country of origin, type of asylum procedure (Regular, accelerated or Dublin ) and housing status. 5 categories of housing status were initially collected (public space, squat, acquaintance's house, self-catering hotel with charge, state accommodation scheme). We chose these 5 categories to reflect French situation about the most common types of housing of asylum seekers. Their correspondence to the European ETHOS Typology on Homelessness and Housing Exclusion  is as follows: Public space (ETHOS 1.1), Squat (ETHOS 8.2 or 8.3 or 11), acquaintance’ house (ETHOS 8.1), State accommodation scheme (ETHOS 2 or 3 or 4 or 5 or 7).
To assess participants' somatic health, we administered the Cumulative Illness Rating Scale (CIRS) used to assess comorbidity, collected data regarding tobacco use (Pack years-number), performed a standardized biological assessment and proposed a chest X-ray for TB screening at the anti-tuberculosis center (CLAT).
The CIRS is a comprehensive measure of multimorbidity previously validated on homeless people [19,20,21]. Each item is assigned a severity score by means of assessing the impact on the patient: 1 (no problem), 2 (current mild problem or past significant problem), 3 (moderate disability or morbidity), 4 (severe problem), 5 (extremely severe or life-threatening problem). The CIRS classifies all items into 14 body systems (including one for mental disorders) to obtain a final cumulative score. Information regarding treatments taken according to the reported problems was also collected. To describe the disorders by system, we merged the following CIRS diseases categories together: cardiac and hypertension, hepatic and gastrointestinal, renal and urological.
Our standardized biological work-up included screening for the main infectious diseases: HIV (confirmed by 2 samples including a western blot), hepatitis B and C (viral loads), syphilis (TPIE and VDRL serology), strongyloidiasis or bilharzia parasitosis (serologies), gonococcal or chlamydial urethritis (detected by urinary PCR). Concerning vaccinations, we looked for protection against tetanus (immunization if tetanus antibody > 1 IU/ml) and hepatitis B (Serology with HBsAb, HBsAg, HBcAb). In addition, the biological work-up screened for the following non-infectious diseases: diabetes (fasting blood glucose level > 2 g/l), renal dysfunction (creatinine > 104umol/l) and dysthyroidism (hyperthyroidism if thyroid stimulating hormone (TSH) < 0.270 mIU/L, hypothyroidism if TSH > 4.20 mIU/L). Finally, we looked for pregnancy in women of childbearing age (Blood HCG > 5 IU/l).
People were considered to have a metabolic disease if they were identified with the CIRS or if they had diabetes or dysthyroidism identified by a blood test. People with a urinary tract disease were those for whom this type of disease was identified with the CIRS or those for whom renal dysfunction was detected by a blood test.
People were considered to have a morbidity if they had at least one CIRS item scored at 2 or higher and/or if they had a disease detected with a blood test and/or x-ray.
Mental health status was assessed by the Refugee Health Screener (RHS-15) and by the CIRS item that detects a mental disorder.
The RHS-15 is a valid [22, 23] 15-item instrument to detect Post-traumatic stress disorder (PTSD), anxiety or depression symptoms in asylum seekers and refugees. 14 items are rated on a 5-point Likert scale (0 = not at all to 4 = extremely). The last item assesses the general ability to handle stress on a 5-point Likert scale and a distress thermometer (DT) ranging from 0 to 10. A screening result is positive if the sum of the first 14 items ≥ 12 or if the DT is ≥ 5. The RHS-15 is not disorder specific and does not provide a diagnosis. In case of a positive result, we can conclude that there is a symptomatology that could correlate to anxiety, depressive or post-traumatic stress disorders.
In order to identify patients with a psychiatric disorder not included in those detected by the RHS-15, we also identified those for whom the CIRS Psychiatric Disorder item reached a 2 or higher mark.
People were considered to have a mental disorder if they had a positive RHS-15 screening and/or for whom the CIRS Psychiatric Disorder item reached a 2 or higher mark.
Patients were considered sick if they had at least one somatic or mental disorder.
Statistical analysis was performed using IBM SPSS Statistics version 20 (IBM SPSS Inc., Chicago, IL, USA). Results were expressed as proportions with 95% confidence intervals (CI) or ± SD means (standard deviation) in order to estimate from the results of our sample the corresponding figures for all asylum seekers living in France. The association of outcomes with categorical variables was evaluated using the Chi square or Fisher’s exact test, and the student t-test or Mann–Whitney U test for continuous ones, as appropriate. A multivariate analysis was performed using a logistic regression model to predict health status. Factors taken into account were those significantly associated with outcome (level < 0.05) in univariate analysis. Calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test to evaluate the discrepancy between observed and expected values. A two-sided P value of less than 0.05 was considered statistically significant.