**1. Introduction**

In recent years, there has been an unprecedented increase in the numbers of individuals experiencing forced migration, with many seeking refuge in countries throughout Europe [1].

**Karsten Klingberg <sup>1</sup> , Adrian Stoller <sup>1</sup> , Martin Müller <sup>1</sup> , Sabrina Jegerlehner 1,2 , Adam D. Brown <sup>3</sup> , Aristomenis Exadaktylos <sup>1</sup> , Anne Jachmann 1,**† **and David Srivastava 1,**†**, \***

In particular, Switzerland has witnessed a sharp rise in persons seeking asylum [2]. The net population growth from AS and refugees in countries such as Switzerland has important public health implications since there will be a greater health care demand [3]. Research on hospital-based emergency department (ED) utilization in Norway has shown that immigrants use emergency health care services significantly more often than nationals [4]. These findings are consistent with other studies in Europe that show that recent immigrants are more likely than local nationals to seek care from EDs and out-of-hours GP services [5–8]. During the asylum process in Switzerland, every individual is granted with universal health care coverage and a GP-based model of care, which gives the asylum seekers access to a GP including regular consultations in the asylum center. Additional ED visits are possible without prior GP consultation and there are no co-payments necessary.

General trends showing that hospital-based EDs face increasing levels of visits throughout the world [9–13]. This means that EDs are confronting growing pressure to meet the needs of patients with insufficient resources, resulting in a variety of "supply" problems such as overcrowding, boarding, higher morbidity, and staff burn out [9,14].

Patients seeking care for non-acute medical issues appear to make up a large percentage of ED visits, ranging up to 62%, with a mean of 37% [15]. Triage data from a study of North African patients who had recently migrated to Switzerland showed that they were less likely to need highly urgent care [16]. In a recent interview-based study of low-acuity ED patients in Germany, two factors were identified [17]: firstly, patients felt it would be more convenient to present in the ED, as this did not require an appointment and was not restricted to office hours. Secondly, patients believed they would receive more specialized advice. In addition, poor health and socioeconomic status have been shown to be important factors that influence the threshold of ED use for non-urgent complaints [18]. These findings are supported by Kraaijvanger et al., who showed that health concerns, access to medical tests (e.g., X-rays, blood tests, etc.) and convenience are strongly associated with ED visits for non-acute issues [19].

Identifying the underlying factors contributing to consultations for non-urgent complaints could guide stakeholders and policy makers in implementing measures for equal and effective health care—especially for this vulnerable population. To understand and manage the influencing factors that force AS to seek help in the ED for non-urgent complaints will help to improve services and quality of care for those who may be unable to navigate in a new health care system and have to use the ED as an entry point to the health care system. Therefore, the purpose of this study was to conduct interviews with AS and SN patients, in order to understand the different factors that influence consultations in the ED for non-urgent conditions.

#### **2. Materials and Methods**

#### *2.1. Study Design, Setting and Participants*

We conducted a prospective cross-sectional, controlled, single-center study. Data were collected from 01/12/2016 to 31/07/2017 among patients attending the ED of the University Hospital Bern (Inselspital) in Switzerland. The Inselspital is one of the largest hospitals in Switzerland, with a catchment area of 1.8 million people. More than 45,000 patients are treated in the ED each year [20]. Eligible AS were matched for a predefined period with a group of SN as controls. The two groups were matched by sex, age and triage category. The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guideline for cross-sectional studies was employed [21].

Walk-in AS patients attending the ED during the study period and of 16 years of age or older were asked to participate in the survey. Their asylum status was defined by the official Swiss identification card ("F": provisionally admitted foreigners, "N": permit for asylum seekers, or "S" people in need of protection). The study was restricted to patients who had no life-threatening or highly urgent problem as defined by the category in the Swiss Emergency Triage Scale (STS) (Range from 1: acute life-threating to 5: non-urgent problem [22]).

The criteria for eligibility in the SN control group included registration with Swiss citizenship, together with the same triage category, age +/−10 years as well as same sex as the matching AS. Efforts were made to obtain a close temporal match, e.g., recruiting a successive control patient shortly after successfully recruiting an AS study patient. The control group was recruited in a predefined, reduced period. Exclusion criteria for both groups were critically ill patients by the STS (STS < 3), the need for expedited diagnostic testing as judged by the attending consultant, transport by ambulance or patient's refusal to participate in the study.

We designed a survey with questions regarding prior and current health-seeking behavior based on current literature and with the help of a psychologist (YB). The survey was available both as a printed and as a protected web-based version on a tablet.

Trained medical students acted as interviewers and conducted the survey in the waiting area or the treatment area without interfering with medical care. The students received an allowance per questionnaire but were not involved in the treatment.

In cases, where communication between the participant and the interviewer was not possible due to language barriers, accompanying persons or professional interpreters were consulted by phone or in person, to ensure that the participant understood the consent form and the survey questions. These interpreters then also facilitated the medical care (not part of the study).
