The perceptions of general practice among Central and Eastern Europeans in the United Kingdom: A systematic scoping review

Abstract Background Around 2 million people have migrated from Central and Eastern Europe to the UK since 2004. The UK Central and Eastern European Community (UK‐CEE) are disproportionately exposed to the social determinants of poor physical and mental health. Their health and healthcare beliefs remain under‐researched, particularly regarding primary care. Objective This review explores UK‐CEE community members' use and perceptions of UK general practice. Methods A systematic search of nine bibliographic databases identified 2094 publications that fulfilled the search criteria. Grey literature searches identified 16 additional relevant publications. Screening by title and abstract identified 201 publications of relevance, decreasing to 65 after full‐text screening. Publications were critically appraised, with data extracted and coded. Thematic analysis using constant comparison allowed generation of higher‐order thematic constructs. Results Full UK‐CEE national representation was achieved. Comparatively low levels of GP registration were described, with ability, desire and need to engage with GP services shaped by the interconnected nature of individual community members' cultural and sociodemographic factors. Difficulties overcoming access and in‐consultation barriers are common, with health expectations frequently unmet. Distrust and dissatisfaction with general practice often persist, promoting alternative health‐seeking approaches including transnational healthcare. Marginalized UK‐CEE community subgroups including Roma, trafficked and homeless individuals have particularly poor GP engagement and outcomes. Limited data on the impact of Brexit and COVID‐19 could be identified. Conclusions Review findings demonstrate the need for codesigned approaches to remove barriers to engagement, culturally adapt and develop trust in GP care for UK‐CEE individuals. Community Involvement Community members and stakeholders shaped the conceptualisation of the review question and validation of emergent themes.


| INTRODUCTION
The past century has witnessed unprecedented global population migration. 1 Migrants are typically younger and physically fit individuals. 2,3 Longitudinal exposure to socially determined risks factors for poor health can erode this health premium. [4][5][6][7][8][9][10] The United Kingdom provides health coverage for all permanent residents and certain economic migrants. 11 UK healthcare providers' awareness of migrants' motivations and challenges in using healthcare services varies, affecting the degree of inclusion of migrant perspectives in service design, 12-15 communication [16][17][18] and levels of general practice registration. 19 20 continuing throughout the implementation of Brexit. 21 CEEs within the UK (UK-CEE) are heterogeneous in terms of nationality, language, age and socioeconomic status. They are, however, united by shared home nation political and socioeconomic histories, alongside migration and integration experiences within UK society. 22 Similar health system reforms across CEE counties over the past 30 years have included the introduction of public health insurance, greater emphasis on primary healthcare (including general practice), increased formal and informal out-of-pocket healthcare payments and market entry of privately owned outpatient specialist clinics. 23 UK census and healthcare data classify CEEs as 'White Other'. 24,25 In contrast to many other 'white' migrant communities, there is evidence of poor physical and mental health outcomes at a locality level, particularly for common mental health disorders including anxiety, suicide and alcohol overuse. [26][27][28][29] A review of UK-CEE healthcare access found commonalities in dissatisfaction with UK healthcare, stemming from language barriers and a mismatch between healthcare expectations and service provision. 30 Dissatisfaction with GP care has been cited as a reason for low UK-CEE rates of GP registration and inappropriate emergency department (ED) use. 30,31 Patterns of primary care and private healthcare service use may also be influenced by shared UK-CEE help-seeking behaviours, service knowledge and perceptions of GP accessibility. 16,[32][33][34] To date, no systematic review has explored the frequency and variability in factors influencing UK-CEEs' registration, use and perceptions of UK general practice. As such, it is unclear where research gaps exist, including the particular needs and experiences of people from distinct countries within our definition of CEE. Primary care 2 | METHODS A systematic literature search was undertaken using established scoping review methodology. 40,43,44 The search strategy comprised (1) defining the research question; (2) identification of relevant research publications; (3) data abstraction and charting; (4) summary, synthesis and reporting of results; and (5) stakeholder consultation.

| Inclusion criteria
Inclusion and exclusion criteria are presented (Table 2), with justification (

| Quality assessment
Publication quality does not typically influence scoping review inclusion or weighting. 40,57 Critical appraisal was undertaken using design-specific quality assessment checklists to aid interpretation, with colour-coded numerical scoring indicating the degree of fulfilment (Appendix SD). 58 Publication quality was generally good, with included publications having high (n = 50), moderate (n = 12) or low (n = 3) critical appraisal scores.
A data abstraction chart was developed, piloted on three shortlisted publications, discussed within the team and refined. Concise text-based information was extracted from included publications and uploaded to NVivo. 59

| Summary, synthesis and reporting of results
A representative sample of three transcripts was reread and coded independently by team members. Discussion of the emerging codes formed the basis of a coding scheme for the remaining transcripts.
Tabulated coded data were used to explore relationships between study outcomes, enabling inductive and iterative generation of emergent themes, followed by thematic analysis with constant comparison, rather than prior theory, to clarify higher-order constructs. 60 Specific attention was paid to the applicability of findings to population subgroups. 61 The lead author discussed emergent review

| Outcome measures
The most commonly identified study forms were peer-reviewed research publications (n = 45) and local government or third-sector organisation reports (n = 11), with smaller numbers of academic theses, conference abstracts, magazine articles, oral presentation summaries and letters also fulfilling inclusion criteria (Table 4). Study methodologies included qualitative (n = 28), quantitative (n = 10), mixed methods (qualitative and quantitative) and smaller numbers of case reports, case series, audits and other study designs (Table 5).

| Emergent themes
Three emergent themes were identified based on UK-CEEs' degree of engagement with general practice services, their encounters with general practice services and the impact of unmet expectations on future general practice engagement ( Figure 2).

| Theme 1: General practice engagement is shaped by UK-CEE community members' ability, desire and need to engage with UK healthcare
Rates of general practice registration ranged between 12% 62 and 87.9%, 63 with no significant variation able to be discerned between the devolved UK nations. At an individual level, UK-CEE community members' ability, desire and perceived or actual need to engage with general practice and navigate facilitators or barriers were shaped by an interaction of personal, social and cultural factors (Table 9). 32

| Structural barriers to registration
GP registration was not perceived as straightforward, with community members often lacking knowledge and guidance on the process and requirements, including personal documentation. 32,67,72 In areas of recent migration, some practices were at full capacity, necessitating out of area registration. 79,80 The ability to gain and maintain practice registration was affected by uncertainty around healthcare entitlements, lack of clarity on GP role and accommodation transiency (UK and transnational). 80 Transiency was most pronounced in those with unofficial residency, 33,81 casual or undocumented employment, 33 Roma, 75 3. Medical information: Limited availability or supply of non-Englishlanguage medical information 39,67 or interpreters. 16,87 4. Appointment availability: Both on inquiry and timing in light of other commitments, particularly work. 32,39,67,71,80,88 Structural barriers were reduced through informal co-national support networks that provided service knowledge, encouraged healthcare review, supported GP registration and provided translation (in-consultation, health correspondence, health information). 16,27,33,67,81,89 Peer disinformation, negative perceptions and use of transnational healthcare could, however, also normalize GP nonattendance, particularly where personal barriers to engagement already existed. 33

| Increased perceived need for primary care services
An increased need for care was seen in: 1. Non-Polish individuals and those living away from urban centres who had fewer culturally familiar health options. 33,63 2. Individuals with children, where more frequent contact stemmed from health visitor, immunisation and childhood illness appointments (which were perceived as urgent). 32,33,62,65,80 3. Limited finances for example, individuals without social security coverage to access state or personal finances for private home nation healthcare. 33 4. Acute or perceived severe health needs: Initial health engagement could be tortuous and have avoided general practice. 33

| Lack or deprioritization of perceived GP need
In a number of instances, registration and use of GP services were delayed or not attempted due to a lack of desire or perceived need. 33,62,64,[68][69][70][71][72] Deprioritization against more urgent life pressures was common for example, attainment of accommodation, employment (long or unsociable shift patterns) and financial stability (particularly in London). 33,67 A lack of perceived healthcare need was most common in younger adults, men, recent arrivals and those intending to stay in the United Kingdom for a short period. 27,33,62,[67][68][69][70][71]81 Perceived need for UK general practice was shaped by perceptions of self-care and transnational healthcare use. 33,90 Reasons for UK GP attendance showed only partial overlap with healthcare attendance in an individual's nation of origin. 85 Conditions deprioritized for GP attendance included: 1. Mental health symptoms, despite a high prevalence, rarely led to GP presentation. 27,87,92 Previous help-seeking, greater National Health Service (NHS) knowledge and poorer mental health increased the likelihood of attendance. 93 Less than 25% attended a GP in the 6 months preceding suicide, often for physical concerns, including chronic disease. 27 Relationships and social connectedness were protective mental health factors. 27,93 2. Screening. Accommodation transiency, cyclical migration and requirement for GP registration impacted upon receiving appointment and screening letters. 39,46,88,94 GP invitations for childhood immunisations, health checks, cervical, breast and colorectal screening, when received, understood and convenient, were commonly accepted. 39,70,89 Understanding of screening indications was limited, with concerns around frequency, quality or inconvenience leading some to pursue additional screening in home nations. 39,70 Many personal barriers to screening attendance were similar to UK nationals. 39 3. Health promotion. GP health promotion strategies were not actively sought out due to more urgent life pressures, 33

| UK-CEE community members' expectations of general practitioners
Individuals often delayed presentation until they felt that their needs were serious. GP expertize was sought for specific 'strong' treatment or specialist referral. 33 Management decisions using shared decision-making, nonspecific medication, limited antibiotic prescription, promotion of selfcare and lifestyle advice and 'watchful waiting' did not meet these health expectations. 33,65,70 The short duration of GP or nurse assessment and frequent absence of physical examination were perceived as unthorough and thus incomplete. 32,68,71,77,96 This mismatch in expectations was compounded by language, cultural and system barriers.

| Medication prescription
Antibiotics were felt to be required rapidly for infections, particularly in children. Recommendation of 'low-strength' 'nonspecific' over-thecounter medications (particularly paracetamol) and antibiotic nonprescription were frequent points of contention. 32

| Understanding GP care
The reason for perceived denial of care was often not explained to or understood by UK-CEEs. Some individuals reported being told their requests were not safe, indicated or evidence based. [65][66][67]97 This failed to address health concerns or validate efforts taken to obtain a GP appointment. Individuals felt that they had not been taken seriously, had been 'failed' by their GP and had lost control over their health. 80 UK-CEEs desired to know GPs' treatment rationale, 32 proposing factors including: 1. The system: To limit resource expenditure due to underfunding. 32

| Longitudinal consideration
An initial emphasis on immigration-related service pressures 31,79 transitioned to more specific aspects of general practice access and engagement. Despite long-term intentions to remain in the United Kingdom, 62 nonacculturation to UK health norms, GP services and healthcare entitlements often persisted over time. 33 (2) deteriorating mental health and wellbeing (mood, anxiety and stress) 107 ; and (3) increased perceived or actual discrimination. 62 This was pronounced for UK-CEE Roma, with financial benefit ineligibility due to 'immigration status'. 77,95 The direct effect of COVID-19 on UK-CEE GP perceptions and engagement was not described.

| Barriers to GP registration and engagement
Low levels of GP registration and barriers to service engagement have been reported within other UK migrant and marginalized groups. [116][117][118][119] While some barriers such as inadequate documentation are shared with these groups, 120 the current review finding of a lack of desire to register or engage with GP services seems more specific to the UK-CEEs. Unofficial employment and accommodation increases the likelihood of registration rejection for UK-CEE nationals, including homeless, trafficked or Roma individuals. 33,73,74,76,77 The absence of residency means that individuals' concerns about healthcare charges or deportation are not unfounded. 76,77 Rather than being a 'hard to reach community', 67

| Strengths and limitations of the review
The review provides a comprehensive exploration of academic and grey literature, 40,44,57 demonstrating a model for identifying service development requirements, 163 future research and intervention development. 164 Critical appraisal aids interpretation of findings, 40 informing subsequent research into the effect and transferability of outcomes. 35,80 Findings were validated by CEE community members (Romanian, Polish and Lithuanian). We recognize that certain subgroups (e.g., trafficked individuals), 73 stigmatized conditions (e.g., mental health, alcohol or substance misuse) 27