Resources Lesson 1: Models of Healthcare for Settled Refugees
Models of healthcare
Note: many of the resources here talk about 'resettlement'. This is in fact a technical term related to settlement in a third country as defined by UNHCR "Resettlement is the transfer of refugees from an asylum country to another State that has agreed to admit them and ultimately grant them permanent settlement." The information in the resources below apply to refugees in their original country of refuge as well as to those resettled in a third country.
Mental health interventions.
The papers below discuss interventions on mental health. It worth starting with a quote from the paper How well do refugees adapt after resettlement in Western Countries? By Silove and Ekblad:
"Providing effective and humane resettlement services, clarifying refugee claims in a timely manner, encouraging family reunion, countering tendencies towards racism and xenophobia in the wider society, offering opportunities for work and education, and providing targeted mental health interventions for the most psychologically needy, together will ensure that most refugees regain their capacity for self-sufficiency and productivity, an outcome that will benefit refugees themselves as well as the receiving societies."
Abstract: In refugee resettlement, positive psychosocial outcomes for youth and adults depend to a great extent on their families. Yet refugee families find few empirically based services geared toward them. Preventive mental health interventions that aim to stop, lessen, or delay possible negative individual mental health and behavioral sequelae through improving family and community protective resources in resettled refugee families are needed. This paper describes 8 characteristics that preventive mental health interventions should address to meet the needs of refugee families, including: Feasibility, Acceptability, Culturally Tailored, Multilevel, Time Focused, Prosaicness, Effectiveness, and Adaptability. To address these 8 characteristics in the complex environment of refugee resettlement requires modifying the process of developmental research through incorporating innovative mental health services research strategies, including: resilience framework, community collaboration, mixed methods with focused ethnography, and the comprehensive dynamic trial. A preventive intervention development cycle for refugee families is proposed based on a program of research on refugees and migrants using these services research strategies. Furthering preventive mental health for refugee families also requires new policy directives, multisystemic partnerships, and research training.
"The resettlement interventions found to be most effective typically target culturally homogeneous client samples and demonstrate moderate to large outcome effects on aspects of traumatic stress and anxiety reduction. Further evaluations of the array of psychotherapeutic, psychosocial, pharmacological, and other therapeutic approaches, including psychoeducational and community-based interventions that facilitate personal and community growth and change, are encouraged. There is a need for increased awareness, training and funding to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement."
"The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration"
A paper A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination reviewed the evidence "...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" in a systematic way. Here is a summary of the results: "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." and they conclude: "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."
A review by the Canadian Collaboration for Immigrant and Refugee Health: Evidence-based clinical guidelines for immigrants and refugees "explicitly aims to improve patients' health using an evidence-based clinical preventive approach to complement existing public health approaches. In selecting topics, primary care practitioners considered not just the burden of illness but also health inequities and gaps in current knowledge". The report has identified the problem: "There are more than 200 million international migrants worldwide, and this movement of people has implications for individual and population health. The 2009 United Nations Human Development Report suggested that migration benefits people who move, through increased economic and education opportunities, but migrants frequently face barriers to local health and social services." The details of the recommendations can be seen here (as well as a very clear summary) and the report stresses that "Our recommendations differ from other guidelines because of our insistence on finding evidence for clear benefits before recommending routine interventions. For example, in our guidelines for post-traumatic stress disorder, intimate partner violence and social isolation in pregnancy, we recommend not conducting routine screening, but rather remaining alert. With regard to screening for asymptomatic intestinal parasites, we recommend focusing on serologic testing for high burden of disease parasites, rather than traditional testing of stool for ova and parasites."
The two documents quoted above provide good evidence based guidelines - to what extent they are being followed is a question for us to consider.
Meanwhile in the US, the CDC has issued its Health Assessment for refugees (without quoting the evidence base for the recommendations). US health assessment programs often include some or all of the following components: