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Principal Health Issues that Migrants/Refugees face in Australia

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Principal Health Issues that Migrants/Refugees face in Australia

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Refugees arriving in Australia often grapple with several health challenges, including malaria, mental health issues, and anaemia.

1. Malaria: Many refugees come from regions where malaria is endemic, making them susceptible to the disease upon arrival in Australia. Prevention through the provision of bed nets, insect repellents, and education on malaria transmission is crucial. Treatment should include early diagnosis through blood tests and the administration of antimalarial drugs, such as artemisinin-based combination therapies.

2. Mental Health: Refugees frequently endure traumatic experiences in their home countries and during their journey to Australia, leading to high rates of mental health issues like PTSD, anxiety, and depression. Access to culturally sensitive mental health services and psychosocial support is essential. Cognitive-behavioral therapy, trauma-informed care, and community-based interventions can be effective treatments.

3. Anaemia: Refugees may face anaemia due to poor nutrition, previous health conditions, or blood disorders. Iron supplementation, dietary education, and access to culturally appropriate foods can help manage anaemia. Regular blood tests can monitor progress and adjust treatment as needed.

Mental health and forced displacement.

(2021, August 31). WHO. https://www.who.int/news-room/fact-sheets/detail/mental-health-and-forced-displacement

Phillips, C. & Francis, J. Malaria. Australian Refugee Health Practice Guide. https://refugeehealthguide.org.au/malaria/

Aoun, M. (2022, Dec 15). Iron deficiency, anemia and association with refugee camp exposure among recently resettled refugees: A Canadian retrospective cohort study. National Libraray of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9754286/

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Problems and stressors facing migrants and refugees

Migrants and refugees often face various problems and stressors which can take place at various stages of the migration process:

Pre-migration: lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.

Migration travel and transit: exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.

Post-migration: barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.

Integration and settlement: poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.

Risk and protective factors for mental health conditions

All of the above-mentioned stressors can increase the risk of developing mental health conditions.For example, unemployment, poor socioeconomic conditions, and lack of social integration among migrants and refugees are risk factors for mental health conditions such as depression. At the same time, these stressors can also exacerbate pre-existing social and mental health problems.

Factors that negatively impact the mental health and well-being of migrant and refugee children include socioeconomic deprivation, discrimination, racism, low family cohesion, and frequent school changes. Children who have been separated from migrating parents are at heightened risk of developing depression, anxiety, suicidal ideation, conduct disorder, and substance use problems.

On the other hand, the impact of stressors can be buffered by protective factors such as access to employment and services, social support, proficiency in the language of the host country, and family reunification. Among resettled refugee children, protective factors include better socioeconomic status, access to education, a perceived sense of safety, contacts with family, living and socialising alongside other people of the same ethnic origin, a stable and cohesive family structure and good parental mental health.

Prevalence of mental health conditions

Many migrants and refugees will experience distress (e.g. feelings of anxiety and sadness, hopelessness, difficulty sleeping, fatigue, irritability, anger and/or aches and pains).For most people, these reactions will improve over time.

Some studies show that the prevalence of common mental disorders (e.g. depression, anxiety and post-traumatic stress disorder (PTSD)) is higher among migrants and refugees than among host populations. Asylum seekers tend to be at elevated risk of suicide. There is also consistent evidence that the incidence of psychoses is higher among migrant populations in a number of countries, and this has been linked with the cumulative effect of social disadvantages before, during and after migration.

Responding to the mental health needs of migrants and refugees

A comprehensive, multi-disciplinary and inclusive approach is needed to address the mental health needs of migrants and refugees.
Overcoming barriers to receiving mental health care
Addressing barriers to receiving mental health care should include:

provision of clear information on mental health care entitlements and how to receive services (e.g. through reception centers, community outreach, schools, religious or cultural settings);

outreach to at-risk groups (e.g. unaccompanied minors, persons with disabilities, persons who identify as LGBTIQ+);

facilitation of affordable and non-discriminatory access to care regardless of legal status, ensuring financial coverage of mental health services and care provided;

facilitation of communication (e.g. through engaging interpreters and cultural mediators);

providing person-centred care that is respectful of cultural differences; and

facilitating the engagement of multiple sectors and systems (e.g. law enforcement, protection, social services and education) to integrate mental health considerations and support and ensure referral and access to mental health services.

Integrating mental health in primary health care
Making mental health care available through general health care can help identify migrants and refugees with mental health conditions and can make care more accessible and cost effective (e.g. see WHO mhGAP intervention guides mhGAP-HIG and mhGAP-IG). The delivery of interventions may require adaptation to migrant and refugee populations to take into account language and cultural considerations. Interventions provided should be consistent with the national guidelines and policies on mental health of the host country.
Ensuring continuity of care
When providing mental health care, an important consideration is related to the length of stay of the migrant or refugee in the host country. The continuity and quality of mental health care of migrants and refugees on the move can be improved by creating international protocols for assuring continuity of care, improving communication among different social and mental health service providers and providing key written information tailored to their needs that migrants and refugees can take with them and share with different providers.
Addressing social determinants and promoting social integration and inclusion
Migration management policies and provision that have proved to have a negative effect on the mental well-being of migrants (e.g. separation of families and children) should be avoided. The social integration of migrants and refugees can be facilitated by equal access to employment opportunities and decent work, vocational training, financial support, social protection services, and legal and law enforcement agencies, as well as mental health care and psychosocial support. The recognition of skills and qualifications acquired pre-migration can also help their integration into the employment sector. Activities and events that promote the social inclusion of migrants and refugees include community forums or peer-mentorship programmes organized by members of the same refugee or migrant group who are already well-integrated into the local community. Special attention is required to support asylum seekers.

WHO response

WHO is the lead International agency in providing technical advice on mental health.

WHO developed a Global Action Plan (2019-2023) to promote the health of migrants and refugees, approved by the World Health Assembly in May 2019. The Global Action Plan describes overarching priorities and guiding principles to promote the health of migrants and refugees and to contribute to achieving the aim of the 2030 Agenda for Sustainable Development - to leave no one behind. The Global Action Plan highlights how the many barriers that migrants and refugees experience in accessing health-care services can precipitate negative mental health outcomes.

The plan recommends priorities and options for action by the Secretariat in coordination and collaboration with the International Organization for Migration (IOM), the United Nations High Commissioner for Refugees (UNHCR) and other relevant partners.

In May 2021, the World Health Assembly endorsed an update of the Comprehensive Mental Health Action Plan (2013-2030), with the overall goal to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability of persons with mental disorders.

WHO is committed to supporting Member States in promoting the physical and mental health of migrants and refugees by strengthening health care services, as appropriate and acceptable to country contexts and financial situations, and in line with their national priorities and legal frameworks and competence. WHO is also committed to ensuring that essential components are addressed, including the provision of treatment and care for mental and behavioural disorders.

In line with the Global Action Plan, WHO is operational on mental health in a range of countries and territories that host large numbers of migrants and refugees. These include Bangladesh, Colombia, Pakistan, Iraq, Jordan, Lebanon, Libya, Pakistan, South Sudan, Sudan, Turkey and Uganda.

WHO has close working relationship with other UN partners, including IOM and UNHCR to meet the mental health needs of migrants and refugees.

WHO co-chairs the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings that provides advice and support to organizations working in emergencies and helps ensure that the mental health response is coordinated and effective. Emergency situations often cause displacement and may lead to people becoming refugees or internally displaced.

WHO's advice and tools are used by most large international humanitarian organizations active in mental health. WHO and partners have published a range of practical tools and guidelines to meet the mental health needs of people affected by emergencies, including migrants and refugees.

(1) World Migration Report 2020. International Organization for Migration, Geneva.

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Migrants and refugees often face various problems and stressors which can take place at various stages of the migration process: Pre-migration: lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.

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Australia is undoubtedly a multicultural tapestry, and experiencing it firsthand has been an eye-opening journey. It's impossible not to feel a deep connection with migrants and refugees daily struggles. Language barriers, cultural disparities, and healthcare system unfamiliarity create a challenging environment for those seeking better lives here. The weight of these determinants on their health is evident.

After coming to Australia, I'm humbled and enlightened. The diversity is enriching, but it also highlights the importance of culturally sensitive, accessible, and affordable healthcare services. I can't help but empathize with the hardships migrants and refugees face due to inadequate health literacy, transportation difficulties, and financial constraints. It's a big reminder that improving healthcare access and understanding is not just a matter of policy but a moral obligation. Australia's multiculturalism is a treasure, and ensuring the health and well-being of all its inhabitants, irrespective of their backgrounds, should be a shared mission.

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Social Determinants which impact migrants/refugees in Australia

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Social Determinants which impact migrants/refugees in Australia

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Migrants and refugees in Australia often face a myriad of challenges related to social determinants of health, which significantly impact their well-being. Language barriers, cultural differences, and health system unfamiliarity hinder their access to healthcare. Poor health literacy, stemming from language issues, results in difficulty understanding medical interventions, disease, and the health system, which can lead to inadequate care and health disparities. Additionally, differences between the healthcare systems in their countries of origin and Australia can create confusion, concern, and isolation.

Cultural disparities also contribute to the unfamiliar environment migrants and refugees encounter. Incompatibility of services with their cultural practices and a lack of cultural sensitivity further alienate them. Some healthcare staff may not understand their backgrounds, making incorrect assumptions and being dismissive of their cultural or traditional health practices.

Access to healthcare is another challenge, with difficulties in transport, remote service locations, and associated costs. Affordability is a significant concern, as costs of services and pharmaceuticals can be prohibitive, leading to delayed or avoided healthcare seeking.

The impact of these social determinants on migrant and refugee health can result in poorer health outcomes, compounding existing vulnerabilities. Addressing these issues through culturally sensitive, affordable, and accessible healthcare services is essential to improving the health and well-being of these populations and reducing health disparities in Australia.

Au, M., Anandakumar, A.D., Preston, R. et al. (2019, July 18). A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions. BMC Int Health Hum Rights.  https://doi.org/10.1186/s12914-019-0206-6

Arora, A. (2022, July 21). Migrants and refugees can struggle to access healthcare in Australia. This is why. SBS News. https://www.sbs.com.au/news/article/migrants-and-refugees-can-struggle-to-access-healthcare-in-australia-this-is-why/vko0lzq1e

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BMC International Health and Human Rights 19, Article number: 22 (2019) Cite this article

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Abstract

Background

Refugees have significant unmet health needs. Delivering services to refugees continues to be problematic in the Australian healthcare system. A systematic review and thematic synthesis of the literature exploring refugee perceptions of the Australian healthcare system was performed.

Methods

Titles and abstracts of 1610 articles published between 2006 and 2019 were screened, and 147 articles were read in full text. Depending on the type of study, articles were appraised using the Modified Critical Appraisal Tool (developed by authors), the Mixed Methods Appraisal Tool, or the JBI Appraisal Checklist for Systematic Reviews. Using QSR NVivo 11, articles were coded into descriptive themes and synthesised into analytical themes. An explanatory model was used to synthesise these findings. Confidence in the review findings were assessed with GRADE-CERQual approach.

Results

The final synthesis included 35 articles consisting of one systematic review, 7 mixed methods studies, and 27 qualitative studies. Only one study was from a regional or rural area. A model incorporating aspects of engagement, access, trust, and privacy can be used to explain the experiences of refugees in using the Australian healthcare system. Refugees struggled to engage with health services due to their unfamiliarity with the health system. Information sharing is needed but this is not always delivered effectively, resulting in disempowerment and loss of autonomy. In response, refugees resorted to familiar means, such as family members and their pre-existing cultural knowledge. At times, this perpetuated their unfamiliarity with the broader health system. Access barriers were also encountered. Trust and privacy are pervasive issues that influenced access and engagement.

Conclusions

Refugees face significant barriers in accessing and engaging with healthcare services and often resorted to familiar means to overcome what is unfamiliar. This has implications across all areas of service provision. Health administrators and educators need to consider improving the cultural competency of staff and students. Policymakers need to consider engaging communities and upscale the availability and accessibility of professional language and cultural supports. Research is needed on how these measures can be effectively delivered. There is limited research in remote areas and further evidence is needed in these settings.

Peer Review reports

Background

Refugees in Australia are consistently recognised as an underserved population with higher rates of mental health and infectious diseases [ 1, 2, 3]. This is compounded by pre-arrival and post-arrival factors including poor care in their country of origin, trauma, prolonged detention, and barriers to appropriate care on arrival [ 4].

Seeking refugee status in Australia is tightly controlled. In the year 2016-2017, 21,968 visas were granted under the Refugee and Humanitarian Assistance Programme including 8208 places for displaced Syrian and Iraqi refugees. Those who arrive in Australia without a visa are subject to mandatory detention [ 5]. The evidence indicates a clear detrimental effect of indefinite detention, especially on mental health, and the morbidity is transferred into settlement [ 6, 7, 8, 9]. Given these health issues, most States or Territories have their own policies with different targets and objectives towards improving refugee health [ 10, 11, 12]. However, to date, there is still no coordinated national policy.

Once in the community, refugees have access to Medicare Benefit Schedule item numbers that allows a general practitioner to complete a refugee health assessment within the first 12 months [ 13]. Refugees are also linked with resettlement agencies that provide some assistance in navigating the health system for six to 18 months upon arrival [ 14]. These services shape refugees' initial experiences with the healthcare system.

Current literature exploring some of the challenges and facilitators faced by health professionals in delivering primary healthcare for refugees and asylum seekers in high-income countries can be conceptualised into three broad themes: the healthcare encounter, working within the healthcare system, and asylum and resettlement [ 15]. However, research is needed to understand the experiences of refugees as an integral part of a framework to provide effective solutions to address these barriers. Furthermore, studies that collectively group high-income countries together do not adequately address the unique geographical profile, health system characteristics and social profile of Australia. These all play a role in health, particularly, rural and remoteness. This is of significance as there have been efforts made by the Australian Government to resettle refugees in regional areas [ 16].

From the best available knowledge, no other systematic review has examined refugee perceptions of using Australian healthcare services. A scoping review of refugee perceptions in their host country only included two Australian studies with other international data [ 17]. A similar review examined refugee experiences of general practice in their countries of resettlement. However, the article was restricted to general practice [ 18]. Other primary research have considered refugee experiences of healthcare services but this is often limited to one particular service or setting [ 19, 20]. Examining the experiences of Australian refugees may be beneficial in an international context for nations that resettle refugees in regional and remote areas as well as those countries that offer universal primary healthcare. Considering the current state of the literature, the aim of this study was to explore the perceptions of refugees in using Australian healthcare services. Articles published from 2006 to 2019 were selected to capture the current refugee demographics that occurred post-Iraq and Afghanistan conflicts. It also reflects Australia's most recent refugee intake after the end of the Pacific Solution policy in 2007.

Methods

Protocol and registration

This review adopted a thematic synthesis approach and adhered to ENTREQ and PRISMA guidelines [ 21, 22, 23]. The review was registered with PROSPERO (registration number: CRD42018088364).

Eligibility criteria

Time frame: Studies published between the years 2006 to 2019 were included to capture Australia's most recent refugee demographics after the Iraq and Afghanistan conflicts.

Population: Refugees in Australia. Asylum seekers, immigrants, migrants, and displaced persons were excluded. Studies that had refugees as part of a heterogenous population were included if it clearly stated that some participants were refugees.

Language: English language only.

Intervention: Articles had to relate to refugee interaction with a specific health service or health intervention. Health seeking behaviours or service utilisation were insufficient to judge perceptions of using a health service and therefore excluded.

Outcomes: Data related to the perception of refugees using health services. Studies that included the perceptions of refugees and health service providers were considered but only data relating to refugees were reviewed.

Types of articles: Qualitative, quantitative, mixed methods, systematic reviews, and grey literature were included. Letters, commentaries and case studies were excluded. For systematic reviews, only the findings from studies relating to refugees were considered.

Information sources

Studies were identified through electronic databases including Scopus, CINHAL, PubMed, MEDLINE, Cochrane, and Informit. Hand searching was also used to select studies. Geographical limits to Australia were applied to all the databases where available. The last search was ran on the 2nd of April 2019.

Search

The search strategy is presented in Additional file 2. Maintaining close adherence to the search terms for multiple databases was ensured. As there is some variability in the definition of refugees, asylum seekers, migrants, and immigrants, all these terms were included in the search strategy to avoid any missed articles.

Study selection

Duplicates were first removed, and articles published outside 2006 to 2019 were excluded. Two researchers (MA and AA) independently screened the articles, first by title, then abstract. Full text articles were screened. One author had to be contacted to retrieve full text. At each stage of the process, eligibility was negotiated by consensus. When consensus was not met, a third researcher (RP) was involved to decide its selection.

Data collection process, data items, and analysis

Two researchers (MA and AA) were involved in the data extraction process using QSR NVivo 11 software. Coding was regularly reviewed by authors to improve inter-coder reliability. Disagreements were resolved through consensus. For studies that had a heterogenous population involving participants other than just refugees, only the data that was related to refugees was coded. Where it was not clear to assessors if certain data related to refugees, data was included for analysis, but this affected its appraisal performance and the confidence in the review findings.

Both first order and second order constructs were included in the extraction process to capture the author's interpretation [ 24, 25]. Line-by-line coding relating to refugee perceptions developed the descriptive themes [ 21]. All authors interpreted the descriptive themes to develop the analytical themes that went beyond the primary studies. An interpretative approach was taken on the collective data whilst ensuring the author's original interpretation was captured in individual studies [ 26].

Two researchers (MA and AA) also independently extracted the study characteristics including the aim, methodologies used, study setting, number of refugee participants, gender of participants, country of origin, and services explored.

Appraisal of articles

Given the lack of consensus over a standardised qualitative appraisal tool, a Modified Critical Appraisal Tool (MCAT) was developed using components of Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research, Critical Appraisal Skills Programme Qualitative Appraisal Checklists, and McMaster University Critical Review Form, in order to capture the breadth and depth of assessment made by different tools (Additional file 1) [ 27]. The tool assessed for theoretical congruity, fundamentals, credibility, dependability, reporting, and utility. Reporting was assessed using Standards for Reporting Qualitative Research. The MCAT was not assigned a scoring system and a judgment was applied to each component.

The Mixed Methods Appraisal Tool (MMAT) was used for quantitative and mixed methods studies. The qualitative component of mixed methods studies were additionally appraised with the MCAT. Systematic reviews were appraised with the JBI Appraisal Checklist for Systematic Reviews. Consistency across tools was maintained as judgments were applied on components rather than assigning scores or grades. Two researchers (MA and AA) independently appraised the articles and consensus was met on all the articles.

Assessment of confidence in the review findings

The Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) method was used to assess the confidence of review findings despite the review included quantitative, mixed methods and other systematic reviews. Fidelity to the GRADE-CERQual approach was maintained by adhering to definitions and using the four categories of grading. However, the authors acknowledge potential for this to distort the findings, which GRADE-CERQual assessment cannot assess. However, given the small number of these articles, the degree of alteration is minimal. Two researchers (MA and AA) performed this assessment under the supervision of other authors. Disagreements were resolved through consensus.

Results

Study selection

A total of 35 studies were included comprising of one systematic review, seven mixed methods studies, and 27 qualitative studies (see Fig. 1).

Adapted PRISMA 2009 Flow Diagram

The initial search strategy generated 3349 articles with an additional seven articles identified from the reference lists of included articles. A total of 147 articles were read in full text excluding a further 112 articles.

Study characteristics

Study characteristics and results of individual studies are detailed in Table 1.

Table 1 Table of Results. Number of refugees marked witha indicate that it is a mixed population

Methods and study design

Study settings

Participants

Country of origin

Refugees came from over 39 countries or regions. The most investigated country of origin was Afghanistan; others were the African continent, countries from the Middle East, Vietnam, Sri Lanka, and South-East Asia.

Health services explored

Risk of bias within studies

The results of the qualitative appraisal are summarised in Table 2. Quantitative, mixed methods, and systematic review appraisals are summarised in Table 3. Seven articles were of high quality, 9 articles were of acceptable quality and 19 articles were low quality. For all qualitative and mixed methods studies, theoretical appraisal was omitted from assessment as only 8 articles stated their methodology and paradigm [ 20, 35, 38, 39, 42, 45, 50, 59].

Table 2 Appraisal of Qualitative Articles using the Modified Critical Appraisal Tool (MCAT). Theoretical appraisal was omitted from assessment as only 8 articles clearly stated their methodology and paradigm [20, 35, 38, 39, 42, 45, 50, 59].

Table 3 Quantitative and Mixed Methods Appraisals

Synthesis of results

Three major concepts that are inter-related emerged from the review: personal engagement, service and system issues with access, and trust and privacy.

Engagement: refugees' struggle to engage with health services

As the Centre for Advancing Health defines, engagement is the actions individuals must take to obtain the greatest benefit from the healthcare services available to them [ 61]. The struggle that refugees experience to engage with healthcare services in Australia was evident. Refugees must take certain actions to negotiate care, which can be conceptualised as a three-step process.

Refugees are in an unfamiliar environment

Refugees perceive many differences in the Australian healthcare system including language, health system, and culture. This unfamiliarity hinders their engagement with services.

Healthcare differences between the country of origin and Australia also contributed to a lack of understanding, concern, isolation, or distress [ 29, 39, 44].

Refugees also held different expectations about the Australian healthcare system [ 28, 33].

Refugees reported that some healthcare staff did not understand their past trauma, gave insensitive advice, or caused distress by reminding them of their past [ 55]. Healthcare staff often probed problems or sensitive issues refugees regarded were inappropriate to discuss in their culture or religion [ 19, 55].

The importance of health information sharing

The importance of providing and understanding health information needs of refugees was captured through the concept of information sharing. To ameliorate the unfamiliarity and misunderstanding, refugees require high quality information sharing practices to help them navigate a complex health system to overcome difficulty [ 28, 33, 39, 40, 44]. Information about the availability of services was scarce or insufficient [ 40, 56, 59].

In contrast, some refugees were overloaded with information during the settlement process [ 33].

Furthermore, refugees felt that healthcare staff were challenged by time constraints and commonly attributed this as a barrier to information sharing [ 45, 53, 59].

Contrary to the experience of "not knowing" was a sense of deeply valuing information when it was available. Where information was understood by participants, they felt more in control, relaxed, and comfortable [ 39].

For women with little social support, being informed about their pregnancy and able to ask questions may contribute to them feeling empowered, and a positive perception of their pregnancy [ 45].

On the contrary, a lack of information or understanding resulted in disempowerment, distress, and fear [ 33, 39, 42, 51]. Some refugees were not provided with adequate information or explanation about their condition, treatment, or process of care. This was often compounded by a language barrier, or a lack of use of interpreters [ 31, 32, 33, 34, 39, 41, 42, 53, 59].

Disempowerment was particularly prominent when care was related to children of refugees. A study exploring maternal and child health services identified that refugees were cautious to question the plan of treatment, fearing that it would make them appear neglectful and result in legal repercussions [ 47].

Reclaiming power and autonomy through familiar means

When refugees were not able to overcome the challenges of information sharing, they resorted to familiar means to reclaim their power and autonomy to exercise their own agency. Family, friends, interpreters, support workers, past experiences, and own cultural knowledge were familiar avenues that were often resorted to.

Support from family promoted refugees' engagement with health services through language, transport and navigating the health system. Husbands played an important role in these areas [ 45, 48, 49, 50, 53, 58, 59, 60]. Men took on new roles that were not traditionally practiced in their country of origin [ 44, 45, 48, 50, 53].

While family members are often required to assist, refugees felt they were often excluded from their clinical care [ 32, 33, 42, 48, 49, 57]. However, reliance on family members was evident and potentially disempowering as it removed their opportunity to engage with services themselves. This was perpetuated by healthcare staff when refugees were told to bring family members to translate [ 37, 45, 58].

Family and friends could equally be discouraging and act as barriers to appropriate healthcare [ 19, 55].

Cultural and religious stigma perpetuated by family, friends, and religious leaders were barriers to accessing services, particularly mental health services [ 19, 20, 38, 56].

Access: system and service issues

A predominant part of refugees' experiences in the Australian healthcare system were barriers and enablers faced in accessing healthcare services. Access issues interacted with the way refugees engaged with services. These experiences can be conceptualised using Penchansky and Thomas' definition of access, which is a broad concept describing the fit between the patient and the health care under the dimensions of acceptability, accommodation, accessibility, affordability, and availability [ 63].

Acceptability of services

Acceptability relates the attitudes that refugees have towards a health service as well as the attitudes that providers have to refugees [ 63].

Accommodation of services

Accommodation, which describes how supply services are organised to accept patients, as well as the ability for patients to accommodate to these factors and their perceived appropriateness, influenced the degree of access that refugees had with services [ 63].

Accessibility of services

Affordability of services

Availability of services

Availability identifies the relationship between the volume supplied and type of services made available, in relation to the volume of patient demand and types of need [ 63]. Access is influenced by this and refugees reported unmet health needs in rural and regional towns where there were a lack of specialist services [ 54].

Trust and privacy: influencing all aspects of access and engagement

Trust and privacy are issues that influence engagement and access. It is a pervasive issue that influences the degree of familiarity refugees can have with the health system, the amount of information that they can share with healthcare staff and the degree of power and autonomy that they can exercise.

Discussion

Summary of evidence

The findings from this synthesis suggest that refugees face major barriers in their engagement and access of healthcare services in Australia which they must take action to overcome. These barriers are complex and inter-related as shown in the model used to explain the findings (Fig. 2). Refugees are in an unfamiliar environment due to perceived differences in language, culture, and health systems. This results in a need for effective information sharing to promote power and autonomy to navigate the health system. However, this is often done ineffectively, resulting in disempowerment and loss of autonomy. To exercise their agency, refugees reclaim their power and autonomy through familiar means such as family, friends and interpreters. At times, they may be successful, but reliance on family and friends may perpetuate their unfamiliarity with the health system. These factors collectively influence the degree of engagement that they have with the health system. Interacting with this, refugees face access issues which can be conceptualised using Penchansky and Thomas' concept of access [ 63]. Trust and privacy ultimately affects all aspects of access and engagement. The links between access and engagement were through effective information sharing and successful reclamation of power and autonomy, which may be promoted or hindered by family or services.

Explanatory Model for the Experiences of Refugees in Using Healthcare Services in Australia

The model describes a response that refugees use to make the best of their means in a foreign country (Fig. 2). It reflects the harsh realities of their circumstances, which must be negotiated to engage with health services.

The findings relating to individual barriers and enablers faced in the clinical setting is consistent with international literature. A literature review of refugee experiences of general practice involving papers from 12 resettlement countries noted prominent barriers to access, language barriers, issues with the doctor-patient relationship, and the cultural acceptability of medical care [ 18]. In another scoping review of refugee experiences of healthcare in nine host countries, communication and information, language barriers, access barriers, continuity of care, discrimination, cultural competency, and knowledge about the healthcare system were all raised as issues [ 17].

This systematic review adds to the body of evidence by providing an Australian context of the health system. The findings emphasise the importance of information sharing and noting the familiar avenues that refugees resort to maintain power and autonomy. It clusters their experiences into the dynamic categories of engagement, access, and trust and privacy. This has not been previously captured as an interacting process and may be an oversight of previous literature which was captured in the present thematic synthesis and systematic review. An explanatory model is presented to explain how refugees negotiate a complex health system (Fig. 2). These findings may be transferrable to other settings as previous systematic reviews of refugee experiences in general practice and scoping reviews of refugee experiences in their host countries identified aspects of these interacting processes [ 17, 18].

Overall, the evidence supporting these review findings is highly robust with high confidence in four review findings and moderate confidence in one review finding, as assessed by the GRADE-CERQual approach (Table 4). Despite the high number of low-quality studies, findings were coherent and adequate across studies. There were a satisfactory number of high-quality studies supporting each review finding.

Table 4 GRADE-CERQual Evidence Profile (EP)

The authors are not confident that the review findings represent Australia as a whole. Half of all the primary studies were performed in Melbourne. Research is largely concentrated in metropolitan areas of Victoria, New South Wales, and South-East Queensland. Only one study investigated rural or regional areas [ 54]. There currently exists a gap in the available literature in rural and regional areas. Further research is needed in these settings, particularly in Northern Australia (Northern Territory and North Queensland), as refugee services and their community contexts will be considerably different compared to their metropolitan counterparts.

Almost all the included studies did not report reflexivity, research paradigm, or theoretical perspective. This risks inaccurate interpretation of the data by third parties or potential biases authors may have onto their own interpretations and methodologies [ 64]. As such, this affected the credibility of articles and was reflected in their appraisal (Table 2).

Implications

For health administrators, training of healthcare staff as part of continuing professional development is essential to promote cultural competency and sensitivity. A systematic review examining interventions improving cultural competency noted that training had positive impacts on provider outcomes [ 69]. However, the study had difficulty determining which types of training had the best outcomes. Further research is required in this area to examine effective means of delivering cultural competency training.

Health educators also play a role in influencing the cultural competency and sensitivity of future healthcare staff. Different models of delivering this education have been used overseas [ 70, 71]. Education on refugee health in an Australian context will need to prepare graduates with cultural sensitivity and confidence in approaching patients of refugee backgrounds. This includes reflective skills to understand their pre-existing prejudices and attitudes, as well as empathy for the refugee context. Further research is required to establish best method of delivering this curriculum in an Australian setting.

For policy makers, promoting refugee health nurses or bilingual support staff can help refugees navigate the health system. Research evaluating the role of refugee health nurses has shown success in providing clinical support, advocacy, and education [ 36]. However, their roles are challenged by the workload, communication, and tension between services [ 72]. Their roles can range from assisting refugees to navigate the health system, carrying out cultural sensitive assessments, to improving the clinical capacity of health services. Upscaling their availability in the community to ensure greater access should be a priority.

Incentives that allow general practitioners adequate time to provide health information to refugees may be another viable avenue to overcome information sharing barriers. Interviews involving general practitioners providing care to refugees identified remuneration as a barrier [ 73].

Specialist refugee clinics that offer multiple services and on-site interpreting may be a possible solution to overcome barriers that refugees face. However, removing refugees out from primary care into specialist clinics may pose challenges such as reliance and follow-up issues. Although some specialist refugee clinics already operate in New South Wales and Victoria, further research investigating models of care is necessary [ 74].

The novel finding in our review identified that refugee experiences can be considered under the broad dynamic categories of engagement, access, and trust and privacy which has not been previously captured as an interacting process. Further research is required to examine the transferability of the present review findings in an international context. The authors believe that this may be possible as past reviews have identified aspects of the present model [ 17, 18].

This review did not capture the experiences of asylum seekers and health service providers which is integral to understanding the broader experience of this population group. All refugees would have previously been asylum seekers and data from this population group may be able to inform the early settlement health needs of this vulnerable population. Data from health service providers would be able to provide another perspective on the needs and concerns of refugees, as well as the quality of care, how care can be more appropriately delivered, and how refugees are able to negotiate their care [ 75]. The research team is currently undertaking a systematic review on the experiences of Australian healthcare staff working in refugee health which can potentially complement this study.

Limitations

Synthesis of qualitative data removes the data from its context and generalises the results into different contexts. It risks inaccurately representing or interpreting the data from the original research [ 21, 76]. Close adherence to interpretations of the original authors as well as making available the aims, settings, methods and sample characteristics of each study (Table 1) allows readers to judge for themselves whether or not the contexts of the studies reviewed are similar to their own [ 21].

The reporting restrictions of journals may have affected adequate assessment of the methodological credibility of articles. This unfairly disadvantages qualitative researchers from adequately reporting their methodological rigour. However, the PRISMA Explanation and Elaboration notes that this should not be an excuse for omission [ 22]. As such, most articles were of low quality when appraised as strict adherence to the appraisal tools were made. Articles were not provided the benefit of the doubt.

Conclusions

Through the synthesis of literature documenting the experiences of refugees in the Australian healthcare system, the major concepts of engagement, access, and trust and privacy encapsulated their narratives. The access barriers identified were largely consistent with other literature. However, this study emphasised the importance of information sharing, and noting the familiar avenues that refugees resort to maintain power and autonomy. This has not been previously captured as an interacting process. However, there continues to be a lack of available data from rural and regional areas and further research is needed in these settings which are vastly different to metropolitan areas. Implications of this study can be applied to clinical practice, health administration, health education, and health policy, by addressing service provider attitudes and the availability of services. Further research is required to examine how these recommendations can be delivered effectively.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

ENTREQ:

Enhancing transparency in reporting the synthesis of qualitative research

GRADE-CERQual:

Confidence in the Evidence from Reviews of Qualitative Research

JBI:

Joanna Briggs Institute

MCAT:

Modified critical appraisal tool

MMAT:

Mixed methods appraisal tool

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

References

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Funding

The Amuthan Medical Research Bursary, administered by James Cook University College of Medicine and Dentistry, was awarded to MA for this project. James Cook University played no role in the design, collection, analysis, data interpretation, or writing of the manuscript.

Author information

Authors and Affiliations

1. College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia

Michael Au, Athire Debbie Anandakumar, Robyn Preston & Robin A. Ray

2. School of Health, Medical and Applied Sciences, CQUniversity, Townsville, Queensland, Australia

Robyn Preston

3. Townsville Multicultural Support Group Incorporated, Townsville, Queensland, Australia

Meg Davis

Contributions

MA conceptualised the study. MA defined the aims, research question, and methods of study in consultation with RP, RR, and MD. MA and AA collected, appraised, extracted and analysed the data under the supervision of RP, RR and MD. RP and RR were also involved in the quality assessment and appraisal. MA compiled and wrote the manuscript under the supervision of RP, RR and MD. All authors read and approved the final manuscript.

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Corresponding author

Correspondence to Michael Au.

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The authors declare that they have no competing interests.

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Au, M., Anandakumar, A.D., Preston, R. et al. A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions. BMC Int Health Hum Rights 19, 22 (2019). https://doi.org/10.1186/s12914-019-0206-6
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Keywords

Refugees

Perception

Access

Engagement

Qualitative

Health services

Trust

Power

Health information

Autonomy

Cultural competency

Public health

# data[].attributes.attachment_link.title
A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions - BMC International Health and Human Rights

# data[].attributes.attachment_link.description
Background Refugees have significant unmet health needs. Delivering services to refugees continues to be problematic in the Australian healthcare system. A systematic review and thematic synthesis of the literature exploring refugee perceptions of the Australian healthcare system was performed. Methods Titles and abstracts of 1610 articles published between 2006 and 2019 were screened, and 147 articles were read in full text.

# data[].attributes.body
Punjabi, an Indo-Aryan language, is predominantly spoken in the Indian state of Punjab and the Pakistani province of Punjab. With a rich literary heritage, Gurmukhi script is used in India, while Shahmukhi is prevalent in Pakistan. Punjabi is celebrated for its lyrical poetry, music, and cultural significance.
About 154.5 million people worlwide speak Punjabi as their mother tongue.

(https://www.worlddata.info/languages/punjabi.php)

# data[].attributes.body
Punjabi music is a lively and diverse genre that fuses traditional folk tunes with contemporary beats. Bhangra, a prominent style, is characterized by energetic rhythms and vibrant lyrics, often celebrating Punjabi culture. It has gained international popularity, shaping modern Indian music and captivating audiences with its infectious melodies and dance-inducing tunes.
Key Punjabi musical instruments include the dhol, harmonium, tabla, tumbi, sarangi, and flute. They create the rhythmic and melodious foundation of Bhangra and other Punjabi music genres.

# data[].attributes.body
Punjabi people, primarily from the Indian state of Punjab, are known for their warm hospitality, vibrant culture, and love for music and dance. They have a rich history and are famous for their agricultural prowess. Punjabis worldwide celebrate festivals like Vaisakhi with enthusiasm, and Punjabi cuisine is renowned for its flavorful dishes, including roti, dal, and tandoori specialties.

# data[].attributes.body
Traditional Punjabi medicine, often rooted in Ayurveda and local wisdom, relies on natural remedies and holistic approaches. It incorporates herbs, yoga, meditation, and dietary practices to maintain health and treat ailments. Balancing the body's doshas (Vata, Pitta, Kapha) is central to traditional Punjabi medicine, emphasizing prevention and overall well-being.
One such medicine is Chirchitta(achyranthes aspera) which has astringent, emetic, diuretic, larvicidal, immunostimulant, anti-anasacra, analgesic, antiasthmatic, and antihepatitis properties.

Sharma, M; Khattra, A. (2018, Aug). Medicinal herbs of Punjab (India). Research Gate. https://www.researchgate.net/publication/327318842_Medicinal_herbs_of_Punjab_India

# data[].attributes.body
Punjab is considered the breadbasket of India. As its vibrant culture, its cuisine is also very rich. One such dish is Sarson da Saag. Beacuse of the extremely fertile land, Sarson(mustard leaves) grow in large quanities. This dish is a blend of sarson and bathua which is cultivated on a large scale in winters.

Ingredients

For the Greens:

1 tablespoon ghee

4 bunches (400g) of sarson (mustard leaves), washed, spun, and finely chopped

1 bunch (100g) spinach leaves, washed, spun, and finely chopped

For the Tadka:

2 tablespoons ghee

1 tablespoon neutral-flavored oil, such as sunflower

2 dried red chiles

2 garlic cloves, peeled and minced

1/2-inch piece of ginger, peeled and minced

1 hot green chile, minced

1 teaspoon (3g) Diamond Crystal kosher salt; if using table salt, use half as much by volume or same weight

1/2 teaspoon chile powder

2 tablespoons salted butter, for serving

Nutrition Facts
Servings: 4Amount per serving
Calories | 209
% Daily Value*
Total Fat 19g | 25%
Saturated Fat 10g | 50%
Cholesterol 40mg | 13%
Sodium 385mg | 17%
Total Carbohydrate 8g | 3%
Dietary Fiber 5g | 16%
Total Sugars 2g
Protein 4gVitamin C 74mg | 369%
Calcium 163mg | 13%
Iron 3mg | 16%
Potassium 553mg | 12%
*The % Daily Value (DV) tells you how much a nutrient in a food serving contributes to a daily diet. 2,000 calories a day is used for general nutrition advice.

(Nutrition information is calculated using an ingredient database and should be considered an estimate.)

https://www.tarladalal.com/calories-for-sarson-ka-saag-punjabi-sarson-ka-saag-recipe-32800

Makan, C. (2022, July 22). Sarson Ka Saag (Braised Mustard Greens and Spinach) Recipe. Serious Eats. https://www.seriouseats.com/sarson-ka-saag-recipe-5705197

# data[].attributes.body
Modern Punjabi art showcases a vibrant fusion of tradition and innovation. Contemporary Punjabi artists blend bold colors and intricate patterns with new mediums and global influences. This art captures the rich cultural heritage, struggles, and aspirations of the Punjabi people while reflecting the evolving landscape of Punjab today.

(Zoay, F. (2016, Oct 14). Canvas 1 by Faryal Azhar Zoay. Uddari Art. https://uddariart.wordpress.com/2016/10/14/canvas-1-by-faryal-azhar-zoay/https://uddariart.wordpress.com/2016/10/14/canvas-1-by-faryal-azhar-zoay/)

# data[].attributes.body
Health to me means holistic well-being which encompasses physical vitality, emotional balance, mental strength and familial harmony. Strong family bonds and traditional values and principles give me a sense of fulfillment and happiness. I prioritise an active lifestyle and having balanced-nutritious diet to stay healthy and fit.

(TNN. (2019, Aug, 17). Is Punjabi food good or bad for weight watchers? E-Times. https://timesofindia.indiatimes.com/life-style/health-fitness/diet/is-punjabi-food-good-or-bad-for-weight-watchers/articleshow/61846449.cms)

Read more at:
http://timesofindia.indiatimes.com/articleshow/61846449.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst