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1.  Asylum seekers, refugees, and the politics of access to health care: a UK perspective 
The UK government has recently consulted on proposals to prohibit access to health care for some asylum seekers. This discussion paper considers the wider ethical, moral, and political issues that may arise from this policy. In particular, it explores the relationship between immigration and health and examines the impact of forced migration on health inequalities. It will be argued that it is both unethical and iniquitous to use health policy as a means of enforcing immigration policy. Instead, the founding principle of the NHS of equal access on the basis of need should be borne in mind when considering how to meet the needs of this population.
PMCID: PMC2751919  PMID: 19732492
emigration and immigration; medical ethics; primary health care; refugees
2.  Somatisation: illness perspectives of asylum seeker and refugee patients from the former country of Yugoslavia 
BMC Family Practice  2006;7:10.
Somatisation is particularly challenging in multicultural contexts where patients and physicians often differ in terms of their illness-related beliefs and practices and health care expectations. This paper reports on a exploratory study aimed at better understanding how asylum seeker and refugee patients from the former country of Yugoslavia who were identified by their physicians as somatising make sense of their suffering.
We conducted semi-structured interviews with 26 asylum seeker and refugee patients from the former country of Yugoslavia who attended the general medicine outpatient clinic of a Swiss teaching Hospital and were identified as presenting with somatisation. Interviews explored patients' illness perspectives and health care expectations. Interviews were audio taped, transcribed verbatim and analyzed to identify key themes in patients' narratives.
Patients attributed the onset of symptoms to past traumatic experiences and tended to attribute their persistence to current living conditions and uncertain legal status. Patients formulated their suffering in both medical and social/legal terms, and sought help from physicians for both types of problems.
Awareness of how asylum seeker and refugee patients make sense of their suffering can help physicians to better understand patients' expectations of the clinical encounter, and the particular nature and constraints of the patient-provider relationship in the context of asylum.
PMCID: PMC1386680  PMID: 16480514
3.  Experiences of refugees and asylum seekers in general practice: a qualitative study 
BMC Family Practice  2007;8:48.
There has been much debate regarding the refugee health situation in the UK. However most of the existing literature fails to take account of the opinions of refugees themselves. This study was established to determine the views of asylum seekers and refugees on their overall experiences in primary care and to suggest improvements to their care.
Qualitative study of adult asylum seekers and refugees who had entered the UK in the last 10 years. The study was set in Barnet Refugee Walk in Service, London. 11 Semi structured interviews were conducted and analysed using framework analysis.
Access to GPs may be more difficult for failed asylum seekers and those without support from refugee agencies or family. There may be concerns amongst some in the refugee community regarding the access to and confidentiality of professional interpreters. Most participants stated their preference for GPs who offered advice rather than prescriptions. The stigma associated with refugee status in the UK may have led to some refugees altering their help seeking behaviour.
The problem of poor access for those with inadequate support may be improved by better education and support for GPs in how to provide for refugees. Primary Care Trusts could also supply information to newly arrived refugees on how to access services. GPs should be aware that, in some situations, professional interpreters may not always be desired and that instead, it may be advisable to reach a consensus as to who should be used as an interpreter. A better doctor-patient experience resulting from improvements in access and communication may help to reduce the stigma associated with refugee status and lead to more appropriate help seeking behaviour. Given the small nature of our investigation, larger studies need to be conducted to confirm and to quantify these results.
PMCID: PMC2001193  PMID: 17711587
4.  Health and health care utilisation among asylum seekers and refugees in the Netherlands: design of a study 
BMC Public Health  2004;4:7.
This article discusses the design of a study on the prevalence of health problems (both physical and mental) and the utilisation of health care services among asylum seekers and refugees in the Netherlands, including factors that may be related to their health and their utilisation of these services.
The study will include random samples of adult asylum seekers and refugees from Afghanistan, Iran and Somali (total planned sample of 600), as these are among the largest groups within the reception centres and municipalities in the Netherlands.
The questionnaire that will be used will include questions on physical health (chronic and acute diseases and somatization), mental health (Hopkins Symptoms Checklist-25 and Harvard Trauma Questionnaire), utilisation of health care services, pre- and post-migratory traumatic experiences, life-style, acculturation, social support and socio-demographic background. The questionnaire has gone through a translation process (translation and back-translation, several checks and a pilot-study) and cross-cultural adaptation. Respondents will be interviewed by bilingual and bicultural interviewers who will be specifically trained for this purpose.
This article discusses the selection of the study population, the chosen outcome measures, the translation and cross-cultural adaptation of the measurement instrument, the training of the interviewers and the practical execution of the study. The information provided may be useful for other researchers in this relatively new field of epidemiological research among various groups of asylum seekers and refugees.
PMCID: PMC385239  PMID: 15070416
5.  Comparison of self-reported health & healthcare utilisation between asylum seekers and refugees: an observational study 
BMC Public Health  2009;9:214.
Adult refugees and asylum seekers living in Western countries experience a high prevalence of mental health problems, especially post traumatic stress disorder (PTSD), depression and anxiety. This study compares and contrasts the prevalence of health problems, and potential risk factors as well as the utilisation of health services by asylum seekers and refugees in the Irish context.
Cross sectional study using validated self reported health status questionnaires of adult asylum seekers (n = 60) and refugees (n = 28) from 30 countries, living in Ireland. Outcome measures included: general health status (SF-36), presence of PTSD symptoms and anxiety/depression symptoms. Data on chronic conditions and pre or post migration stressors are also reported. The two groups are compared for utilisation of the health care system and the use of over the counter medications.
Asylum seekers were significantly more likely than refugees to report symptoms of PTSD (OR 6.3, 95% CI: 2.2–17.9) and depression/anxiety (OR 5.8, 95% CI: 2.2–15.4), while no significant difference was found in self-reported general health. When adjusted by multivariable regression, the presence of more than one chronic disease (OR 4.0, 95%CI: 1.3–12.7; OR 3.4, 95% CI: 1.2–10.1), high levels of pre migration stressors (OR 3.6, 95% CI: 1.1–11.9; OR 3.3, 95% CI: 1.0–10.4) or post migration stressors (OR 17.3, 95% CI: 4.9–60.8; OR 3.9, 95% CI: 1.2–12.3) were independent predictors of self reported PTSD or depression/anxiety symptoms respectively, however, residence status was no longer significantly associated with PTSD or depression/anxiety. Residence status may act as a marker for other explanatory variables; our results show it has a strong relationship with post migration stressors (χ2 = 19.74, df = 1, P < 0.001).
In terms of health care utilisation, asylum seekers use GP services more often than refugees, while no significant difference was found between these groups for use of dentists, medication, hospitalisation or mental health services.
Asylum seekers have a higher level of self reported PTSD and depression/anxiety symptoms compared to refugees. However, residence status appears to act as a marker for post migration stressors. Compared to refugees, asylum seekers utilise GP services more often, but not mental health services.
PMCID: PMC2711949  PMID: 19566954
6.  A group-based approach to stabilisation and symptom management in a phased treatment model for refugees and asylum seekers 
European Journal of Psychotraumatology  2013;4:10.3402/ejpt.v4i0.21407.
Traumatised asylum seekers and refugees may present with significant and complex mental health problems as a result of prolonged, extreme, and multiple traumatic events. This is further complicated by ongoing complex social circumstances.
In our work at the Traumatic Stress Clinic (TSC), the understanding afforded by the concept of complex posttraumatic stress disorder (PTSD) together with the related notion of a phased treatment model, provides a useful framework for organising our work with this population.
Clinical Applications
An explication of complex PTSD as it applies to our client group is presented, followed by a description of our phased treatment model and an outline of the core principles, which guide our clinical approach. Our symptom management and stabilisation groups have been developed and refined over time and draw on techniques from a variety of cognitive behavioural therapies. These are described in some detail with illustrative clinical case vignettes.
This paper concludes with some reflections on the challenges inherent to working with this complex client group.
PMCID: PMC3871835  PMID: 24371509
complex PTSD; refugees; phased treatment model; stabilisation
7.  Responses to language barriers in consultations with refugees and asylum seekers: a telephone survey of Irish general practitioners 
BMC Family Practice  2008;9:68.
Refugees and asylum seekers experience language barriers in general practice. Qualitative studies have found that responses to language barriers in general practice are ad hoc with use of both professional interpreters and informal interpreters (patients' relatives or friends). However, the scale of the issues involved is unknown. This study quantifies the need for language assistance in general practice consultations and examines the experience of, and satisfaction with, methods of language assistance utilized.
Data were collected by telephone survey with general practitioners in a regional health authority in Ireland between July-August 2004. Each respondent was asked a series of questions about consulting with refugees and asylum seekers, the need for language assistance and the kind of language assistance used.
There was a 70% (n = 56/80) response rate to the telephone survey. The majority of respondents (77%) said that they had experienced consultations with refugees and asylum seekers in which language assistance was required. Despite this, general practitioners in the majority of cases managed without an interpreter or used informal methods of interpretation. In fact, when given a choice general practitioners would more often choose informal over professional methods of interpretation despite the fact that confidentiality was a significant concern.
The need for language assistance in consultations with refugees and asylum seekers in Irish general practice is high. General practitioners rely on informal responses. It is necessary to improve knowledge about the organisational contexts that shape general practitioners responses. We also recommend dialogue between general practitioners, patients and interpreters about the relative merits of informal and professional methods of interpretation so that general practitioners' choices are responsive to the needs of patients with limited English.
PMCID: PMC2637872  PMID: 19102735
8.  Gender and offender status predicting treatment success in refugees and asylum seekers with PTSD 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.20803.
Current knowledge is limited regarding patient characteristics related to treatment outcome of posttraumatic stress disorders (PTSD) in refugees and asylum seekers.
Gender, torture status, offender status, level of anger, and level of depression were investigated for possible effects on the treatment outcome.
Patient characteristics were explored in 54 refugees and asylum seekers who had completed a treatment program for PTSD. Non-responders (10), those who had the same or higher levels of symptom severity after treatment, were compared with responders, those who had lower symptom severity after treatment (44). Symptom severity was measured by Clinician-Administered PTSD Scale. The non-responders and responders constituted the dichotomous, dependent variable. The independent variables were gender, torture status, offender status, level of anger, and level of depression. T-tests and Exact Unconditional Homogeneity/Independence Tests for 2×2 Tables were used to study the relationship to treatment outcome.
Being male and reporting to have been a violent offender were significantly more frequent characteristics among the non-responders compared to the responders. The levels of pretreatment anger, depression and torture status did not affect the treatment outcome.
The study adds support to findings that females benefit more from treatment of PTSD than males and that violent offenders are difficult to treat within the standard treatment programs.
PMCID: PMC3909238  PMID: 24494062
Treatment; patient characteristics; gender; offender; trauma; torture
9.  Access to mental health for asylum seekers in the European Union. An analysis of disparities between legal rights and reality 
Archives of Public Health  2009;67(1):30-44.
The article explores some of the issues surrounding access to mental health care for asylum seekers, using Belgium as a case in point. Asylum and immigration issues have become increasingly pressing in Europe, with member states seeking a common European Asylum System and establishing minimum standards for the reception of asylum seekers. The EU measures have fallen short of providing and implementing clear guidelines. Significant discrepancies continue to exist between member states, notably policies on health care for refugees, and in particular mental healthcare. Access to mental health care is identified as crucial, yet for many the right to access is theoretical only, and in reality care is often inaccessible. Access should refer not only to the availability, but also the quality and efficacy of care. Refugees are a particularly vulnerable population, and access in the fullest sense of the term should be an essential element in the reception of asylum seekers.
PMCID: PMC3436694
Asylum seeker; refugee; mental health; reception conditions
10.  Asylum seekers' expectations of and trust in general practice: a qualitative study 
The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems.
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.
Glasgow, UK.
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.
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.
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.
PMCID: PMC2593560  PMID: 19068152
asylum seekers; general practice; health care needs; trust
11.  Length of stay in asylum centres and mental health in asylum seekers: a retrospective study from Denmark 
BMC Public Health  2007;7:288.
The length of stay in asylum centres is generally mentioned as a possible health risk to asylum seekers. Medical staff working with asylum seekers has claimed that long lengths of stay in asylum centres might cause or aggravate mental disorders. We used records from a large, multiethnic group of asylum seekers to study if the incidence of mental disorders increased with length of stay.
The study population was asylum seekers in Danish asylum centres run by the Danish Red Cross. General medical care was provided by Red Cross staff who could refer selected cases to medical specialists. If an asylum seeker needed more than three specialist consultations for mental illness or five consultations for physical illness the referrals had to be approved by The Danish Immigration Service. Between July 2001 – December 2002 the Red Cross prospectively registered health related data on all new applications (n = 4516) to the Immigration Service regarding referrals to medical specialists. We used these records to analyse the association between length of stay in the asylum centres and overall rate of referral for mental disorders. Data was analysed using weighted linear regression.
We found that referrals for mental disorders increased with length of stay in asylum centres in a large, multiethnic population of asylum seekers. The association was found in all the categories of psychiatric illness studied and for a majority of the nationality groups studied.
Length of stay in asylum centres was associated with an increase in referrals for mental disorders in a large, multiethnic group of asylum seekers. The present study supports the view that prolonged length of stay in an asylum centre is a risk factor for mental health. The risk of psychiatric illness among asylum seekers should be addressed by political and humanitarian means, giving prevention of illness the highest priority.
PMCID: PMC2151767  PMID: 17931414
12.  Tuberculosis case finding based on symptom screening among immigrants, refugees and asylum seekers in Rome 
BMC Public Health  2013;13:872.
In Italy the proportion of cases of tuberculosis in persons originating from high-prevalence countries has been increasing in the last decade. We designed a study to assess adherence to and yield of a tuberculosis screening programme based on symptom screening conducted at primary care centres for regular and irregular immigrants and refugees/asylum seekers.
Presence of symptoms suggestive of active tuberculosis was investigated by verbal screening in migrants presenting for any medical condition to 3 free primary care centres in the province of Rome. Individuals reporting at least one symptom were referred to a tuberculosis clinic for diagnostic workup.
Among 2142 migrants enrolled, 254 (11.9%) reported at least one symptom suggestive of active tuberculosis and 176 were referred to the tuberculosis clinic. Of them, 80 (45.4%) did not present for diagnostic evaluation. Tuberculosis was diagnosed in 7 individuals representing 0.33% of those screened and 7.3% of those evaluated for tuberculosis.
The overall yield of this intervention was in the range reported for other tuberculosis screening programmes for migrants, although we recorded an unsatisfactory adherence to diagnostic workup. Possible advantages of this intervention include low cost and reduced burden of medical procedures for the screened population. Further evaluation of this approach appears to be warranted.
PMCID: PMC3852535  PMID: 24053349
Migrants; Tuberculosis; Active case finding; Adherence to screening; Access to care
13.  Measuring the health impact of human rights violations related to Australian asylum policies and practices: a mixed methods study 
Human rights violations have adverse consequences for health. However, to date, there remains little empirical evidence documenting this association, beyond the obvious physical and psychological effects of torture. The primary aim of this study was to investigate whether Australian asylum policies and practices, which arguably violate human rights, are associated with adverse health outcomes.
We designed a mixed methods study to address the study aim. A cross-sectional survey was conducted with 71 Iraqi Temporary Protection Visa (TPV) refugees and 60 Iraqi Permanent Humanitarian Visa (PHV) refugees, residing in Melbourne, Australia. Prior to a recent policy amendment, TPV refugees were only given temporary residency status and had restricted access to a range of government funded benefits and services that permanent refugees are automatically entitled to. The quantitative results were triangulated with semi-structured interviews with TPV refugees and service providers. The main outcome measures were self-reported physical and psychological health. Standardised self-report instruments, validated in an Arabic population, were used to measure health and wellbeing outcomes.
Forty-six percent of TPV refugees compared with 25% of PHV refugees reported symptoms consistent with a diagnosis of clinical depression (p = 0.003). After controlling for the effects of age, gender and marital status, TPV status made a statistically significant contribution to psychological distress (B = 0.5, 95% CI 0.3 to 0.71, p ≤ 0.001) amongst Iraqi refugees. Qualitative data revealed that TPV refugees generally felt socially isolated and lacking in control over their life circumstances, because of their experiences in detention and on a temporary visa. This sense of powerlessness and, for some, an implicit awareness they were being denied basic human rights, culminated in a strong sense of injustice.
Government asylum policies and practices violating human rights norms are associated with demonstrable psychological health impacts. This link between policy, rights violations and health outcomes offers a framework for addressing the impact of socio-political structures on health.
PMCID: PMC2649030  PMID: 19192307
14.  Is legal status impacting outcomes of group therapy for posttraumatic stress disorder with male asylum seekers and refugees from Iran and Afghanistan? 
BMC Psychiatry  2013;13:148.
Legal status and other resettlement stressors are known to impact mental health of asylum seekers and refugees. However, the ways in which they interact with treatment of posttraumatic stress disorder (PTSD) with these populations is still poorly understood. The aim of this study was to examine whether legal status and other resettlement stressors influence outcomes of a trauma-focused group PTSD treatment within a day-treatment setting with asylum seekers and refugees.
Sixty six male Iranian and Afghan patients with PTSD residing in the Netherlands were assessed with self-rated symptom checklists for PTSD, anxiety and depression, and a demographic questionnaire one week before and two weeks after the treatment. Multivariate linear regression analysis was used to examine the impact of legal status and living arrangements on the treatment outcomes per symptom domain.
The results suggest that both asylum seekers and refugees can be helped with their mental health complaints with a trauma-focused group therapy for PTSD regardless of their legal status. Obtaining a refugee status in a course of the treatment appears to improve the treatment outcomes.
Legal status is impacting outcomes of group therapy for PTSD with male asylum seekers and refugees. Asylum seekers may benefit from group treatment regardless of unstable living conditions.
PMCID: PMC3665450  PMID: 23705873
Post-traumatic stress disorder; Asylum seekers; Refugees; Group therapy; Resettlement stress; Iran; Afghanistan
15.  Hidden violence is silent rape: sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands 
Culture, Health & Sexuality  2012;14(5):505-520.
Although women, young people and refugees are vulnerable to sexual and gender-based violence (SGBV) worldwide, little evidence exists concerning SGBV against refugees in Europe. Using community-based participatory research, 223 in-depth interviews were conducted with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Responses were analysed using framework analysis. The majority of the respondents were either personally victimised or knew of a close peer being victimised since their arrival in the European Union. A total of 332 experiences of SGBV were reported, mostly afflicted on them by (ex-)partners or asylum professionals. More than half of the reported violent experiences comprised sexual violence, including rape and sexual exploitation. Results suggest that refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are extremely vulnerable to violence and, specifically, to sexual violence. Future SGBV preventive measures should consist of rights-based, desirable and participatory interventions, focusing on several socio-ecological levels concurrently.
PMCID: PMC3379780  PMID: 22468763
sexual violence; refugees; Europe; risk factors; prevention
16.  I don't think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia 
Many refugees arrive in Australia with complex health needs. In South Australia (SA), providing initial health care to refugees is the responsibility of General Practitioners (GPs) in private practice. Their capacity to perform this work effectively for current newly arrived refugees is uncertain. The aim of this study was to document the challenges faced by GPs in private practice in SA when providing initial care to refugees and to discuss the implications of this for policy relating to optimising health care services for refugees.
Semi-structured interviews with twelve GPs in private practice and three Medical Directors of Divisions of General Practice. Using a template analysis approach the interviews were coded and analysed thematically.
Multiple challenges providing care to refugees were found including those related to: (1) refugee health issues; (2) the GP-refugee interaction; and (3) the structure of general practice. The Divisions also reported challenges assisting GPs to provide effective care related to a lack of funding and awareness of which GPs required support. Although respondents suggested a number of ways that GPs could be assisted to provide better initial care to refugees, strong support was voiced for the initial care of refugees to be provided via a specialist refugee health service.
GPs in this study were under-resourced, at both an individual GP level as well as a structural level, to provide effective initial care for refugees. In SA, there are likely to be a number of challenges attempting to increase the capacity of GPs in private practice to provide initial care. An alternative model is for refugees with multiple and complex health care needs as well as those with significant resettlement challenges to receive initial health care via the existing specialist refugee health service in Adelaide.
PMCID: PMC2531177  PMID: 18687150
17.  "They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK 
The provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK.
Two qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method.
Most asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system.
Most asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate.
PMCID: PMC1892018  PMID: 17537258
18.  Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need 
With the increasing trend in refugee urbanisation, growing numbers of refugees are diagnosed with chronic noncommunicable diseases (NCDs). However, with few exceptions, the local and international communities prioritise communicable diseases. The aim of this study is to review the literature to determine the prevalence and distribution of chronic NCDs among urban refugees living in developing countries, to report refugee access to health care for NCDs and to compare the prevalence of NCDs among urban refugees with the prevalence in their home countries. Major search engines and refugee agency websites were systematically searched between June and July 2012 for articles and reports on NCD prevalence among urban refugees. Most studies were conducted in the Middle East and indicated a high prevalence of NCDs among urban refugees in this region, but in general, the prevalence varied by refugees’ region or country of origin. Hypertension, musculoskeletal disease, diabetes and chronic respiratory disease were the major diseases observed. In general, most urban refugees in developing countries have adequate access to primary health care services. Further investigations are needed to document the burden of NCDs among urban refugees and to identify their need for health care in developing countries.
PMCID: PMC3978000
Refugee; Asylum-seeker; Noncommunicable disease; Developing countries; Urban; Health care
19.  School and Community-Based Interventions for Refugee and Asylum Seeking Children: A Systematic Review 
PLoS ONE  2014;9(2):e89359.
Research for effective psychological interventions for refugee and asylum-seeking children has intensified. The need for interventions in environments more easily accessed by children and families is especially relevant for newly arrived populations. This paper reviews the literature on school and community-based interventions aimed at reducing psychological disorders in refugee and asylum-seeking children.
Methods and Findings
Comprehensive searches were conducted in seven databases and further information was obtained through searching reference lists, grey literature, and contacting experts in the field. Studies were included if they reported on the efficacy of a school or community-based mental health intervention for refugee or asylum-seeking children. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively. The marked heterogeneity of studies excluded conducting a meta-analysis but study effect-sizes were calculated where possible. Twenty one studies met inclusion criteria for the review reporting on interventions for approximately 1800 refugee children. Fourteen studies were carried out in high-income countries in either a school (n = 11) or community (n = 3) setting and seven studies were carried out in refugee camps. Interventions were either primarily focused on the verbal processing of past experiences (n = 9), or on an array of creative art techniques (n = 7) and others used a combination of these interventions (n = 5). While both intervention types reported significant changes in symptomatology, effect sizes ranged from 0.31 to 0.93 and could mainly be calculated for interventions focusing on the verbal processing of past experiences.
Only a small number of studies fulfilled inclusion criteria and the majority of these were in the school setting. The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration.
PMCID: PMC3933416  PMID: 24586715
20.  Medical care of asylum seekers: a descriptive study of the appropriateness of nurse practitioners' care compared to traditional physician-based care in a gatekeeping system 
BMC Public Health  2007;7:310.
Medical care for asylum seekers is a complex and critical issue worldwide. It is influenced by social, political, and economic pressures, as well as premigration conditions, the process of migration, and postmigration conditions in the host country. Increasing needs and healthcare costs have led public health authorities to put nurse practitioners in charge of the management of a gatekeeping system for asylum seekers. The quality of this system has never been evaluated. We assessed the competencies of nurses and physicians in identifying the medical needs of asylum seekers and providing them with appropriate treatment that reflects good clinical practice.
This cross-sectional descriptive study evaluated the appropriateness of care provided to asylum seekers by trained nurse practitioners in nursing healthcare centers and by physicians in private practices, an academic medical outpatient clinic, and the emergency unit of the university hospital in Lausanne, Switzerland. From 1687 asylum seeking patients who had consulted each setting between June and December 2003, 450 were randomly selected to participate. A panel of experts reviewed their medical records and assessed the appropriateness of medical care received according to three parameters: 1) use of appropriate procedures to identify medical needs (medical history, clinical examination, complementary investigations, and referral), 2) provision of access to treatment meeting medical needs, and 3) absence of unnecessary medical procedures.
In the nurse practitioner group, the procedures used to identify medical needs were less often appropriate (79% of reports vs. 92.4% of reports; p < 0.001). Nevertheless, access to treatment was judged satisfactory and was similar (p = 0.264) between nurse practitioners and physicians (99% and 97.6% of patients, respectively, received adequate care). Excessive care was observed in only 2 physician reports (0.8%) and 3 nurse reports (1.5%) (p = 0.481).
Although the nursing gatekeeping system provides appropriate treatment to asylum seekers, it might be improved with further training in recording medical history and performing targeted clinical examination.
PMCID: PMC2194697  PMID: 17974001
21.  What do language barriers cost? An exploratory study among asylum seekers in Switzerland 
Language barriers have a major impact on both the quality and the costs of health care. While there is a growing body of evidence demonstrating the detrimental effects of language barriers on the quality of health care provision, less is known about their impact on costs. This purpose of this study was to investigate the association between language barriers and the costs of health care.
The data source was a representative set of asylum seekers whose health care was provided by a Swiss Health Maintenance Organisation (HMO). A cross-sectional survey was conducted: data was collected on all the asylum seekers' health care costs including consultations, diagnostic examinations, medical interventions, stays in the clinic, medication, and interpreter services. The data were analysed using path analysis.
Asylum seekers showed higher health care costs if there were language barriers between them and the health professionals. Most of these increased costs were attributable to those patients who received interpreter services: they used more health care services and more material. However, these patients also had a lower number of visits to the HMO than patients who faced language barriers but did not receive interpreter services.
Language barriers impact health care costs. In line with the limited literature, the results of this study seem to show that interpreter services lead to more targeted health care, concentrating higher health care utilisation into a smaller number of visits. Although the initial costs are higher, it can be posited that the use of interpreter services prevents the escalation of long-term costs. A future study specially designed to examine this presumption is needed.
PMCID: PMC2939598  PMID: 20731818
22.  EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study 
European Journal of Psychotraumatology  2011;2:10.3402/ejpt.v2i0.5881.
Traumatised asylum seekers and refugees are clinically considered a complex population. Discussion exists on whether with this population treatment guidelines for post-traumatic stress disorder (PTSD) should be followed and Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) should be applied, or whether a phased model starting with stabilisation is preferable. Some clinicians fear that trauma-focused interventions may lead to unmanageable distress or may be ineffective. While cognitive-behavioural interventions have been found to be effective with traumatised refugees, no studies concerning the efficacy of EMDR with this population have been conducted as yet.
In preparation for a randomised trial comparing EMDR and stabilisation with traumatised refugees, a pilot study with 20 participants was conducted. The objective was to examine feasibility of participation in a randomised trial for this complex population and to examine acceptability and preliminary efficacy of EMDR.
Participants were randomly allocated to 11 sessions of either EMDR or stabilisation. Symptoms of PTSD (SCID-I, HTQ), depression and anxiety (HSCL-25), and quality of life (WHOQOL-BREF) were assessed at pre- and post-treatment and 3-month follow-up.
Participation of traumatised refugees in the study was found feasible, although issues associated with complex traumatisation led to a high pre-treatment attrition and challenges in assessments. Acceptability of EMDR was found equal to that of stabilisation with a high drop-out for both conditions. No participants dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilisation. Different symptom courses between the two conditions, with EMDR showing some improvement and stabilisation showing some deterioration between pre-treatment and post-treatment, justify the conduct of a full trial.
With some adaptations in study design, inclusion of a greater sample is justifiable to determine which treatment is more suitable for this complex population.
PMCID: PMC3402110  PMID: 22893808
Complex trauma; PTSD; feasibility; trauma-focused therapy; torture; cross-cultural psychiatry; randomised
23.  Effects on asylum seekers of ill treatment in Zaïre. 
BMJ : British Medical Journal  1996;312(7026):293-294.
To describe the health effects of the political system in Zaïre on asylum seekers seen at the Medical Foundation for the Care of Victims of Torture a retrospective study was performed of the records of 92 asylum seekers from Zaïre who were seen for medical reports at the medical foundation in 1993 and 1994. Eighty one had been imprisoned; the others had been severely treated at home by the security services. Sixty six had been detained for up to one year. Prison conditions were invariably unsanitary, and food of poor quality when provided. All had been beaten on arrest, and all but two had been beaten repeatedly in prison. Nearly all the women and some of the men described sexual abuse. Almost all left prison through bribery or because a guard had a similar background. Seventy two asylum seekers had scarring, consider to be consistent with the history, and 70 were considered to have suffered persistent psychological damage. Asylum seekers from Zaïre will have health effects from experiences unimaginable to the ordinary Briton. An understanding of the background will help clinicians manage them.
PMCID: PMC2349865  PMID: 8611788
24.  A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination 
Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care.
A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service – Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included.
Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters.
The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.
PMCID: PMC3835619  PMID: 24199588
Access; Coordination; Health care models; Primary health care; Quality of care; Refugee; Migrant; Immigrant; Health services evaluation
25.  The psychiatric profession and the Australian government: the debate over collective depression syndrome among asylum-seeking detainees 
Psychiatrists have long had involvement with the political process, both individually and as a profession. They have made valuable contributions to debate over such issues as war, conflict, terrorism, torture, human rights abuse, drug abuse, suicide and other public health issues. However, they have also been complicit in some gross atrocities. Over several years there has been debate over the Australian Government’s treatment of asylum seekers, and the Royal Australian and New Zealand College of Psychiatrists took the unusual step of publicly criticizing the Australian Government’s policy on grounds of its toxicity leading to a diagnosis of collective depression syndrome, particularly among child detainees, but also adult detainees. The official Ministerial response was to deny that collective depression exists and to assert that the concept is meaningless. Can this intervention by psychiatrists be interpreted as a product of earlier political behaviors by psychiatrists? The willingness of psychiatrists to cooperate with other professions, notably psychologists, pediatricians, physicians and lawyers, is noted, as is presence of minority voices within the Australian psychiatric profession. The significance of the debate over the mental condition of asylum-seeking detainees is that its outcome has implications for how Australia sees itself and is seen by the rest of the world, that is, its national identity.
PMCID: PMC3218771  PMID: 22110326
collective depression syndrome; psychiatric profession; political intervention; asylum seeker; Australian national identity

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