Refugee experiences of general practice in countries of resettlement: a literature review

Background

Refugees and asylum seekers often struggle to use general practice services in resettlement countries.

Aim

To describe and analyse the literature on the experiences of refugees and asylum seekers using general practice services in countries of resettlement.

Design and setting

Literature review using systematic search and narrative data extraction and synthesis methodologies. International, peer-reviewed literature published in English language between 1990 and 2013.

Method

Embase, Ovid MEDLINE, PsycINFO, CSA Sociological Abstracts, and CINAHL databases were searched using the terms: refugee, asylum seeker, experience, perception, doctor, physician, and general practitioner. Titles, abstracts and full texts were reviewed and were critically appraised. Narrative themes describing the refugee or asylum seeker’s personal experiences of general practice services were identified, coded, and analysed.

Results

From 8722 papers, 85 were fully reviewed and 23 included. These represented the experiences of approximately 864 individuals using general practice services across 11 countries. Common narrative themes that emerged were: difficulties accessing general practice services, language barriers, poor doctor–patient relationships, and problems with the cultural acceptability of medical care.

Conclusion

The difficulties refugees and asylum seekers experience accessing and using general practice services could be addressed by providing practical support for patients to register, make appointments, and attend services, and through using interpreters. Clinicians should look beyond refugee stereotypes to focus on the needs and expectations of the individual. They should provide clear explanations about unfamiliar clinical processes and treatments while offering timely management.     

Which psychological characteristics influence therapists' readiness to work with refugees?

Refugee populations show considerably high rates of mental health problems. Yet many mental health professionals may have reservations to work with refugees due to suspected cultural differences, language barriers and the need to provide additional services. However, little is known about psychotherapists' readiness to work with refugees. In a sample of German psychotherapists (N = 111), we explored therapeutic style (neutrality, supportiveness and self-doubt), therapists' basic assumptions (pessimism, rationality and therapy as art), experiences, private and work-related contact with refugees, political interests, openness and practical barriers as potential predictors of readiness to work with refugees. Therapeutic styles of self-doubt and neutrality, rationality as basic assumption, former experiences with refugees in a therapeutic setting, feeling comfortable working with an interpreter in therapy and perceived language barriers emerged as most important predictors of psychotherapists' readiness to work with refugees. Future directions and potential interventions to promote therapists' readiness to work with refugees are discussed.     

What works? Lessons from a pretrial qualitative study to inform a multi-component intervention for refugees and asylum seekers: Learning Through Play and EMDR Group Traumatic Episode Protocol

Almost half of the trials failed to recruit their targeted sample size of which 89% could be preventable. Successful implementation of mental health trials in a context of forcibly displaced individuals can be even more challenging. Mental health difficulties have the potential to impact parenting skills, which are linked to poor development in children, while parenting interventions can improve parents' mental health and parenting behaviors. However, the evidence on parenting interventions for refugees is limited. A parenting intervention, Learning Through Play Plus Eye Movement Desensitization and Reprocessing Group Treatment Protocol, has been designed to address parental mental health. This pretrial qualitative study, conducted with refugees, asylum seekers and professionals, aimed to explore their perceptions of the intervention and to identify barriers and recommendations for better engagement, recruitment, and delivery. Three themes were generated from thematic analysis: the content of the intervention, suggestions for improvement and implementation, and understanding the role of the facilitator. These themes provided insights into the issues that might predict the barriers for delivery of the intervention and offered several changes, including destigmatization strategies to improve engagement.     

Asylum seekers' expectations of and trust in general practice: a qualitative study

Background

The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems.

Aim

This study explored how migrants'' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role.

Design of study

Two qualitative methods.

Setting

Glasgow, UK.

Method

Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders'' accounts with World Health Organization statistics.

Results

Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders'' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience.

Conclusion

GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals'' expectations in a GPled system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.     

Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

Background

No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: 'non-English-speaking', 'ethnic', 'migrant', 'immigrant', 'refugee' and 'multicultural'.

Results

In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention.

Conclusions

The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy.

     

Parental PTSD,adverse parenting and child attachment in a refugee sample

In contrast with traumatic experiences, there is a dearth of studies on the link between trauma symptoms, disconnected (frightened, threatening and dissociative) parenting behavior, extremely insensitive parenting behavior and child attachment. This study extends previous work on the impact of posttraumatic stress disorder (PTSD) on families by studying the unique contribution of disconnected and extremely insensitive parenting behavior on child attachment in a highly traumatized sample of 68 asylum seekers and refugees and their children (18–42 months). The results show that parental symptoms of PTSD are directly related to children’s insecure attachment and disorganized attachment. The greatest proportion of the risk could be attributed to factors related to the dyad and not the family. A mediation effect of adverse parenting behavior was not confirmed. On the one hand the results indicate the need for an effective treatment of PTSD symptomatology while on the other hand the results indicate the need for clinical attention to insecure attachment relationships.     

The emerging evidence for Narrative Exposure Therapy: A review

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low-income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.     

Interpersonal physiological regulation during couple support interactions: Examining the role of respiratory sinus arrhythmia and emotional support

In times of need, people seek comfort and support from close others. Support provision is an integral component of attachment relationships, one that is linked with physical and psychological well‐being. Successful support provision is believed to be grounded in transactions of sensitive, caring behavior between caregivers and support seekers and to serve a profound regulatory function. However, physiological processes underlying support transactions have not been previously studied. We assessed autonomic vagal regulation and coded spontaneous emotional support behaviors in N = 100 heterosexual couples involved in a support interaction. We focused on cardiac vagal activation, operationalized as the increase in respiratory sinus arrhythmia (RSA) from baseline to interaction, as an indicator of regulatory efforts. Analyses revealed a negative association between caregivers' and support seekers' regulatory efforts, which was mediated by emotional support behaviors. We found that caregivers with greater increases in RSA from baseline to interaction provided more emotional support to their partners. Such emotional support was associated with smaller increases in support seekers' RSA and with support seekers' perceptions of their partners as being more sensitive to their needs. Finally, these links were only significant among dyads in which caregivers reported lower levels of attachment anxiety. We interpret these results in the framework of interpersonal regulatory processes, suggesting that provision of support may impose regulatory demands on the side of the caregivers, which in turn could result in attenuated regulatory efforts and positive partner perceptions for the support seekers.     

Depressive and anxiety symptoms in refugees: Insights from classical test theory,item response theory and network analysis

Screening tools developed for Western populations have produced heterogeneous prevalence estimates for depression and anxiety disorders among refugees. The use of these instruments assumes that psychopathological symptoms are manifested similarly across different cultural groups. Here, we scrutinized whether depressive and anxiety symptoms are manifested similarly between German residents and refugees in Germany. We tested measurement invariance, test information and specifics of symptom interrelations in 200 refugees and 202 German residents with classical test theory (CTT), item response theory (IRT) and network analysis. Participants completed the Patient Health Questionnaire regarding depressive and anxiety symptoms in either Arabic or German. Measurement invariance was only present to a certain extent. Questionnaires were most informative on different spectrums of the latent traits for the two groups. Network analysis demonstrated that symptom interrelations of depressive and anxiety symptoms differed across residents and refugees. This was especially true for core symptoms of common nosological systems, such as losing interest or feeling depressed. Surprisingly, traumatic events in the past were not central in refugees' anxiety networks. Core symptoms of nosological systems seem to be differently pronounced in refugees and residents, which has important implications for our understanding of mental health symptoms in refugees.     

Experiences of Kurdish war-wounded refugees in communication with Swedish authorities through interpreter

Objective

To study experiences of war-wounded Kurdish refugees with respect to cross-cultural communication through interpreters.

Method

Semi-structured interviews were conducted with ten men, aged 31–42. Content analysis was used for analysis and interpretation of data.

Result

War-wounded Kurdish refugees experienced a number of difficulties regarding communication through interpreters, mainly related to the insufficient language link to the Swedish authorities, particularly health care personnel. In many instances, interpreters were selected based on the immigrant's citizenship rather than mother tongue, leading to a more complex, tri-lingual interpretation situation. Differences in cultural background, fear, suspicion and lack of confidence in interpreters were addressed as other problems by the participants.

Conclusion

Interpreter competence and patient confidence in the interpreter are essential for an adequate cross-cultural health communication. Assignment of interpreters should be based on knowledge of the patient's/client's mother tongue, rather than citizenship, and the outcome is improved by a common ethnic and cultural background of interpreter and patient/client. Our study should be considered as a pilot study, and the results should be validated in larger cohorts as well as in other ethnic and language groups.

Practice implications

In order to minimize communication misunderstandings, complicated tri-lingual interpretation situations should be avoided. Interpreters should ideally be assigned according to patient's/client's mother tongue rather than citizenship. Interpreters’ competence and patient's/client's confidence in interpreter may have significant impact on communication outcome.     

Integrating diversity and fostering interdependence: Ecological lessons learned about refugee participation in multiethnic communities

Communities in the United States are becoming increasingly diverse, in part, because of the continual resettlement of refugees and immigrants from around the world. The promotion of refugees' well‐being and integration depends upon how our communities value diversity and provide opportunities for meaningful involvement. However, refugees often face challenges to such involvement. An ecological perspective suggests that it is important to consider not only the characteristics of individuals but also to examine the extent to which particular settings are able to facilitate the participation of community members. The purpose of this study was to understand the participation experiences of 54 Hmong refugees living in multiethnic housing developments. Interviews revealed that while Hmong residents valued participation highly, most were excluded from meaningful avenues of participation because of multiple barriers, including language differences, time constraints, and discrimination. No supports to address these barriers existed in their communities. It is important to understand and build individuals' capacities to participate and communities' capacities to promote involvement, integrate diversity, and foster interdependence. Participation is fundamental to the process of enabling refugees to become an integral part of their new communities and is a potential way for them to regain a sense of control over their lives and the decisions that affect them. © 2002 Wiley Periodicals, Inc.     

Louse‐borne relapsing fever in Finland in two asylum seekers from Somalia

We report two cases of louse‐borne relapsing fever (LBRF) in young Somali asylum seekers having recently arrived to Finland. They had sought medical attention for a febrile illness. Blood smears were examined for suspected malaria, but instead, spirochete shaped bacteria were observed. The bacteria were confirmed as Borrelia recurrentis by PCR and sequencing. The patients survived, but their treatment was complicated by Jarisch–Herxheimer reaction. We conclude that LBRF must be considered as a diagnostic option in febrile refugees also in the northernmost parts of Europe.     

Attitudes about depression and its treatment among mental health professionals, lay persons and immigrants and refugees in Norway

Background

Internationally, depression is a common psychological disorder whose treatment depends upon its identification by treating professionals as well as patient utilization of mental health care systems; the latter often being hampered by cultural differences between patients and health professionals.

Method

The current study used vignettes of depressed patients which varied the culture and/or social circumstances of the patient to assess whether these variables influenced the conceptualization of depression and its treatment. Participants (N = 722) included mental health professionals, lay people, immigrants, and refugees in Norway.

Results

We found that immigrants and refugees, particularly those of non-western origin, endorsed different types of depression treatments from native Norwegians and mental health professionals, and judged who deserved treatment and who was overreacting based on the patient's culture and social circumstances, while native Norwegians did not.

Limitations

While widely used cross-culturally, vignette methodology is limited in its generalizability to real clinical situations. Acculturation was not evaluated, which may have influenced the results.

Conclusions

Findings support the integration of cultural competency ideals not only into treatment, but also into public health promotions of mental health services for lay people.     

Development and evaluation of a cultural competency training curriculum

Background  

Increasing the cultural competence of physicians and other health care providers has been suggested as one mechanism for reducing health disparities by improving the quality of care across racial/ethnic groups. While cultural competency training for physicians is increasingly promoted, relatively few studies evaluating the impact of training have been published.     

Acceptability of a novel suicide prevention psychological therapy for people who experience non-affective psychosis

Objectives

Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability.

Design

Qualitative interview study.

Methods

Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non-affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi-structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability.

Results

Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self-efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy.

Conclusions

Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).     

Factors influencing European GPs' engagement in smoking cessation: a multi-country literature review

Background

Smoking cessation advice by GPs is an effective and cost-effective intervention, but is not implemented as widely as it could be.

Aim

This wide-ranging Europe-wide literature review, part of the European Union (EU) PESCE (General Practitioners and the Economics of Smoking Cessation in Europe) project, explored the extent of GPs'' engagement in smoking cessation and the factors that influence their engagement.

Method

Two searches were conducted, one for grey literature, across all European countries, and one for academic studies. Data from eligible studies published from 1990 onwards were synthesised and reported under four categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills.

Results

The literature showed that most GPs in Europe question the smoking status of all new patients but fewer routinely ask this of regular patients, or advise smokers to quit. The proportion offering intensive interventions or prescribing treatments is lower still. Factors influencing GPs'' engagement in smoking cessation include GPs'' own smoking status and their attitudes towards giving smoking cessation advice; whether patients present with smoking-related symptoms, are pregnant, or heavy smokers; time, training, and reimbursement are important structural factors; and some GPs lack knowledge and skills regarding the use of specific cessation methods and treatments, or have limited awareness of specialist cessation services. No single factor or category of factors explains the variations in GPs'' engagement in smoking cessation.

Conclusion

Strategies to improve the frequency and quality of GPs'' engagement in smoking cessation need to address the multifaceted influences on GPs'' practice and to reflect the widely differing contexts across Europe.     

Developing a web-based LGBT cultural competency training for oncologists: The COLORS training

Objective

Despite substantial LGBT cancer health disparities, there are no LGBT cultural competency trainings tailored for oncologists. Here we describe the systematic development of a web-based, oncology-focused LGBT cultural competency training.

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of ‘unsuccessful’ psychotherapy

Objectives

This paper aimed to explore the experiences of depressed adolescents who completed but did not ‘respond’ to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores.

Design

This was a qualitative study employing interpretative phenomenological analysis (IPA).

Method

Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA.

Results

Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements.

Conclusions

Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects.