Mapping Refugee Primary Care Access in Newfoundland and Labrador: A Retrospective Functional Resonance Analysis of the Initial Medical Intake Process

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While dedicated refugee clinics have emerged to address these gaps, there remains limited understanding of how care processes unfold within these settings. This study applies the Functional Resonance Analysis Method (FRAM) to examine how the initial medical intake process for government-assisted refugees (GARs) is operationalized at a refugee health clinic in St John’s, Newfoundland and Labrador. Method: Using FRAM, we mapped the intake journey of adult GARs for their first medical intake between January 2023 and March 2024. Data collection involved stakeholder workshops with clinicians, researchers, and settlement staff, supplemented by document review. A combination of thematic analysis and network mapping was used to identify functional interdependencies and sources of variability. Findings: Thirteen core functions were identified and analyzed using FRAM’s six-aspect schema (Input, Output, Preconditions, Resources, Control, and Time). The intake process followed a structured but flexible sequence, beginning with receipt of arrival lists and proceeding through appointment booking, triage, clinical assessment, and follow-up actions including lab work, prescriptions, and referrals. Findings revealed a tightly coupled administrative tasks, a central clinical hub anchored by the intake assessment, and a cross-cutting reliance on interpretation services. Key variability hotspots included interpreter availability, appointment wait times, and transport logistics. Conclusion: FRAM enabled a detailed, systems-level view of refugee healthcare access in a regional setting, highlighting both vulnerabilities and adaptive strengths. The method is valuable in visualizing how interdependent tasks align to support care delivery. Refugees newcomers primary care access initial medical intake systems thinking FRAM Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction As the World Health Organization (WHO) writes in the 2022 Global Report on Refugee and Migrant Health , migration is a social determinant of health – impacting all aspects of a person’s health and wellbeing [ 1 ]. Globally, refugees and migrants have poorer health outcomes than the populations of their host countries, both on arrival, and post-settlement. Migration significantly influences access to healthcare services, affecting individuals both during their journey to safety and upon arrival in their country of asylum. In Canada, refugees experience many barriers to accessing the publicly-funded healthcare services to which they are entitled through the Interim Federal Health Program (IFHP) [ 2 ]. The mainstream primary care system is not designed to meet the specific healthcare needs of refugees. Studies have shown that refugees often struggle to build trusting relationships within the healthcare system [ 3 ] and that providers feel ill-equipped or under-resourced to address these needs [ 4 , 5 ]. Refugee clinics have been established across the country to overcome these barriers and address the specific healthcare needs of refugees [ 3 , 5 – 7 ]. These clinics vary in scope and services. As Feldman described, these range from “gateway” clinics that connect refugees to primary care, to facilities that provide primary care alongside ancillary services, such as interpretation, social supports and specialized mental health services that support healthcare providers’ ability to provide healthcare to refugees [ 8 ]. Refugee clinics are often designed as temporary or transitional spaces (gateway clinics), yet in practice, they evolve to accommodate long-standing care needs and address systemic shortcomings [ 3 ]. The literature suggests that refugee healthcare needs are better met in refugee clinics, in both routine and preventative interventions [ 7 , 9 – 11 ]. The relationship between refugee clinics and mainstream healthcare can be challenging; to ensure that refugee healthcare needs are met beyond the clinic, some refugee clinic staff work to educate their colleagues in the mainstream primary healthcare system [ 5 , 12 ], and to coordinate appointments and ancillary services [ 3 , 13 ]. As outlined above, there has been some exploration of refugee health clinic in Canada, this study aims to understand the initial visit of the new arrivals to a refugee health clinic through a systematic approach. Methodological approach To address this gap, this study uses the Functional Resonance Analysis Method (FRAM), a systems-based qualitative approach developed to analyze complex processes within socio-technical systems like healthcare [ 14 ]. FRAM focuses on mapping everyday work practices—what Hollnagel describes as "work-as-done"—rather than relying solely on policies or protocols that reflect "work-as-imagined." [ 15 ] This practice enables the identification of essential healthcare functions, their interdependencies, and the variability that arises in daily practice, allowing researchers to understand both sources of resilience and points of vulnerability within a system [ 14 ]. While FRAM has been used effectively in various healthcare settings to explore transitions of care, risk management, and process improvements, its application to healthcare delivery remains limited in the Canadian context [ 14 ]. Given the fragmented, adaptive, and multi-actor nature of refugee care processes, FRAM provides a novel methodological approach to capturing the complexity of how refugee clinics in Canada deliver and sustain care under conditions of uncertainty and resource constraints. By applying FRAM, this study seeks to illuminate the internal dynamics of refugee clinics—mapping not only what these clinics do, but how they do it. In doing so, the research aims to generate insights that can inform policy and practice interventions to improve the equity, efficiency, and resilience of refugee healthcare delivery in Canada. Research objective and research question The objective of this exercise was to map and analyze the healthcare intake process for government-assisted refugees (GARs) in Newfoundland and Labrador (NL) using the Functional Resonance Analysis Method (FRAM). The research question is: How was the initial medical intake process for GARs operationalized in St John’s NL, and what functional variabilities and interdependencies can be identified using the FRAM. Method This study applied the Functional Resonance Analysis Method (FRAM) to map the care pathway of adult Government Assisted Refugees (GARs) who were seen in NL between January 2023 and March 2024. The map began with every step required to book the initial comprehensive appointment at the Local Health Authorities Eastern Health (Currently Known as NLHS)—which all GARs are expected to complete within 30 days of arrival—and ended with the follow-up actions triggered by that visit, including investigations, prescriptions, and referrals. To maintain a focus on this pathway, we excluded other categories of newcomers such as: All other classes of new arrivals (including claimant refugees) New arrivals without MCP (provincial) and IFHP (federal) health coverage New arrivals who require emergency services New arrivals who access primary care through other channels New arrivals with complex health needs We excluded pediatrics (new arrivals under 18 years of age) Data collection started with a series of virtual stakeholder workshops. Nine participants including clinicians, settlement workers, and researchers who had worked directly with the RHC during the study period—received a brief orientation to FRAM and then collaborated to identify key system functions, their six FRAM aspects, and sources of performance variability. A FRAM data gathering template (Appendix Table 1) was used during each workshop to record the functions and their interdependencies. The research assistant (MS) converted the workshop records into a draft FRAM model using the FRAM Model Visualizer (FMV) web application. The study investigators and RHC clinicians subsequently reviewed and iteratively refined this model to ensure it accurately represented day-to-day practice. In parallel, documentary analysis of relevant healthcare policies, service descriptions, and operational manuals provided an “official” picture of system functions. Together, the workshops and document review produced a detailed FRAM model of the healthcare journey experienced by GARs in NL After the draft FRAM model had been constructed and refined through several iterations, the analysis proceeded through two complementary stages. In the first stage, the research team examined the functions and their corresponding aspects using a network analysis approach. Each function’s six FRAM aspects—Input, Output, Precondition, Resource, Control, and Time—were systematically reviewed to catalogue sources of performance variability and to map the couplings linking one function to another. By tracing how a modified Output or absent Resource in one node became the Input or Precondition for downstream nodes, the analysis identified critical hubs where variability propagated across multiple pathways. In the second stage, a thematic analysis was undertaken to cluster individual functions into broader thematic groupings that captured the overarching trajectory of the patient journey. The integration of network and thematic analyses provided a comprehensive understanding of both the substantive content of care processes and the structural interdependencies that shaped their overall reliability. Findings This study found 13 distinct functions in the process of initial medical intake of GARs. In this section, we present the 13 functions and how they are interconnected. Examining each function’s six FRAM aspects then revealed the principal sources of performance variability and the tight interdependencies through which disturbances in one function could ripple across the entire pathway. Following, we present the thematic analysis of the functions and their aspects into three sequential themes that trace the patient journey. Descriptive Findings and Network Analysis We identified 13 distinct sequential and interrelated functions that comprised the initial medical intake process for GARs at the Refugee Health Collaborative in St. John’s, Newfoundland and Labrador (Table 1 ). The process began with the receipt of the GAR arrivals lists from Immigration, Refugees and Citizenship Canada and proceeded through administrative, logistical, and clinical steps such as demographic data sharing, appointment scheduling, patient notification, and prioritization or triage. Subsequent functions included patient travel to the clinic, initial medical assessments, and arrangements for laboratory work and diagnostic imaging. Interpretation services were engaged throughout the process, and the model also included the coordination of specialist appointments, medication access, and mental health service referrals when applicable. Each function was described using the six core FRAM aspects—Input, Output, Preconditions, Resources, Control, and Time—which provided a structured account of how the intake process was operationalized in practice. The functions reflected the collaborative work of multiple actors across health and settlement systems and illustrated the procedural components required to initiate and support healthcare access for newly arrived refugees. Table 1 List of Functions # Function Name 1 To send list of government assisted refugees to Association of New Canadians 2 To provide patient demographics to the Refugee Health Collaborative 3 To book an appointment with the Refugee Health Collaborative 4 To inform patients about their intake appointment details 5 To assess priority or triage 6 To travel to and from the Refugee Health Collaborative 7 To conduct an initial intake medical assessment 8 To arrange bloodwork 9 To arrange diagnostic imaging 10 To provide interpretation services 11 To coordinate specialist appointments 12 To obtain prescribed medications 13 To offer mental health services Each of the above functions had six aspects that are presented in the supplementary file. (Appendix Table 2) Network analysis The diagram below (Fig. 1 ) is a condensed FRAM network view. Each hexagon represents one of the 13 intake functions, but only those aspect or ports (small circles on the hexagons) that share an identical label with another function are shown and connected. Ports that are unique to a single function but contain entries are shown in red, while aspects with no entries remain white. This visual distinction offers a clear picture of where functional dependencies and information flows coincide across the system. This other four diagrams below (Fig. 2 – 5 ) shows how the interconnections between functions and their aspects get activated on the visualizer (FMV) when clicked on them, showing inter-dependencies. Figure 2 indicates how Function 2 (To provide patient demographics to the Refugee Health Collaborative) activates other linear functions. Function 5 (To assess priority or triage) feeds into one other important foreground function. Function 7 (To conduct an initial intake medical assessment) is a central node connected to as many as eight other functions. And Function 8 (to arrange bloodwork) is a result of Function 7 with support from Function 10 (to provide interpretation services). This network analysis shows three structural features 1. Linear administrative trunk (left) This segment represents the sequential flow of early-stage administrative tasks. It begins with the receipt of the refugee manifest and progresses through the sharing of demographic information, appointment booking, and notifying patients. Each function is connected through shared aspects like “Arrivals list & patient information” and “Appointment details,” showing how each task relies directly on the output of the one before it. This structure reflects a tightly coupled, step-by-step process necessary for initiating clinical care. 2. Central clinical hub (middle) The function “To conduct an initial intake medical assessment” forms the central node of the network. It connects to multiple downstream functions via outputs like “Completed health history and physical exam” and “Confirmed patient information in EMR.” These shared outputs link to bloodwork, imaging, specialist referral, medication, and mental-health services. This hub structure highlights the pivotal role of the initial assessment in activating subsequent care pathways. 3. Cross-cutting support node (bottom-left) The “To provide interpretation services” function links laterally to many other nodes across both the administrative and clinical arms of the system through the shared aspect “Interpreter services if needed.” This reveals interpretation as a foundational support function, essential to enabling communication at nearly every step in the intake process. Its cross-cutting nature emphasizes its systemic impact rather than linear placement. Thematic Analysis: Thematic analysis revealed a three-stage intake process supporting GARs: initiating access, navigating encounters, and facilitating continuity of care. Each stage reflects coordinated, culturally sensitive efforts to ensure timely and equitable healthcare. Initiating Access to Care The first stage of the patient journey involved initiating healthcare access through coordinated processes of booking appointments, communicating with patients, and assessing the urgency of healthcare needs. The intake process was triggered when the RHC received a weekly list of newly arrived GARs from Association for Newcomers (ANC) that included demographic details and any flagged medical concerns. Based on this information, RHC staff booked the initial intake appointments for eligible patients. This process was supported by an appointment-booking system, interpreter availability, and urgent-intake referral guidelines, and the first intake appointment was scheduled for one hour. After the booking, ANC staff contacted patients to provide appointment details including date, time, location, and any preparation instructions. Communication took place through telephone, email, or messaging systems, with attention to cultural sensitivity and interpreter support when necessary. Navigating Healthcare Encounters The second stage of the patient journey focused on the processes involved in navigating healthcare encounters, including travel logistics and clinical assessment within the RHC. Patients travelled to the clinic by walking, public transit, taxis, or private vehicles. Appointment details had been provided in advance, and extra assistance was available for anyone who needed help with transportation. Ongoing communication with patients about travel arrangements and potential disruptions remained an integral part of the process. Upon arrival, patients underwent a comprehensive medical assessment by a physician or nurse practitioner. This assessment included reviewing medical history, performing a physical examination, and identifying any new or existing conditions. Depending on the findings, patients received requisitions for bloodwork or diagnostic imaging, prescriptions, referrals to allied-health providers, or links to community supports. Interpreter services, clinical guidelines, and culturally sensitive practices supported the visit After the assessment, staff coordinated the necessary investigations. Bloodwork was arranged as promptly as possible, while diagnostic imaging was scheduled according to clinical urgency and service availability. Both processes relied on communication among healthcare staff, laboratory facilities, and imaging providers. Facilitating Continuity of Care The final stage of the intake process focused on facilitating continuity of care beyond the initial assessment. This stage involved interpretation services, specialist referrals, and access to prescribed medications. Interpretation services were provided both in person and by telephone, according to patients’ language needs. Scheduling protocols ensured that interpreters were available for appointments, and interpreter details were communicated to both patients and providers in advance. When further specialist care was required, healthcare providers completed referrals and RHC clerical staff co-ordinated specialist appointments. Scheduling varied with urgency and specialist availability, and patients were informed of their referral details and supported with transportation, and in-person interpretation by ANC throughout the process. If someone was referred to community allied health, there was no interpretation. ANC would provide in-person interpretation. Access to prescribed medications was facilitated through community pharmacies or, for patients facing language barriers, directly by ANC staff. Pharmacists provided instructions on medication use, side-effects, and dosage, with interpreter support when necessary. Medication access was further supported by verifying patient identity and confirming coverage under the Interim Federal Health Program (IFHP). Discussion This study provides a systems-level understanding of how GARs in Newfoundland and Labrador access primary healthcare during their initial medical intake. Using the Functional Resonance Analysis Method (FRAM), this research mapped the journey of newly arrived refugees from the point of arrival to the completion of their first medical assessment. The findings highlight the operational complexity of refugee health service delivery, emphasizing the need for coordination, flexibility, and system navigation supports. One key insight from this study is the centrality of structured processes in mitigating barriers to care. Functions such as appointment booking, patient communication, triage, interpretation services, and transportation supports were identified as essential mechanisms that collectively shaped the patient journey. These findings align with previous literature suggesting that refugees often face challenges in accessing mainstream primary care due to language barriers, limited health literacy, and unfamiliarity with the Canadian health system (16, 3]. The structured intake pathway described in this study mirrors the model of "refugee clinics" elsewhere in Canada, where tailored interventions — such as extended appointment times, integrated interpretation services, and social support — have been shown to improve access and quality of care [ 5 , 10 ]. Another important observation from this study is the role of triage in assessing priority and ensuring timely care. This resonates with findings from Winn et al. who observed that effective triage and intake systems were crucial in navigating the complex healthcare needs of Syrian refugees, particularly in prenatal and chronic disease management [ 12 ]. Similarly, Benjumea-Bedoya et al. emphasized that integrated care models, which include early assessment and clear care pathways, contributed to higher completion rates of treatments like latent tuberculosis infection therapy [ 9 ]. This study also draws attention to the importance of non-clinical functions, such as transportation and communication, which are often underemphasized in traditional healthcare models. As described by Darwish and Muldoon transportation challenges, appointment delays, and unclear communication have been persistent barriers to refugee healthcare access [ 6 ]. In the context of Newfoundland and Labrador — a province characterized by dispersed populations and limited public transit — the integration of transportation support into the healthcare intake process appears to be a particularly responsive adaptation to local needs. Moreover, the findings reflect a system that is responsive not only to clinical care needs but also to the socio-cultural context of refugee patients. The provision of both in-person and telephone interpretation services, for example, directly responds to concerns raised in other studies about the impact of language barriers on patient-provider communication and trust [ 3 , 5 ]. Policy implications The findings of this study have several policy implications for refugee health service delivery in Canada. First, the structured intake process described here illustrates the value of dedicated refugee health pathways, particularly during the early stages of resettlement. Policymakers should consider supporting the establishment or continuation of refugee-specific intake systems, especially in regions where mainstream primary care services may lack the capacity or expertise to address the complex needs of refugee populations. Second, the study highlights the need for sustained investments in system navigation supports, including interpretation services, transportation assistance, and culturally sensitive communication protocols. FRAM analysis revealed that these functions are not peripheral, but integral to the intake system’s effectiveness and resilience. Ensuring their availability and reliability should be considered core components of healthcare access, rather than optional add-ons. Third, this research underscores the importance of inter-sectoral collaboration between settlement agencies, public health, and primary care providers. Key intake functions relied on the transfer of information and coordination between organizations. Policies that foster integrated care planning, shared information systems, and collaborative funding models could enhance the efficiency and responsiveness of refugee healthcare services across Canada. Limitations This study was limited to the intake process for government-assisted refugees in a specific regional context (Newfoundland and Labrador), which may limit the generalizability of the findings to other provinces or refugee populations, such as privately sponsored or refugee claimants. While FRAM allowed for a detailed systems-oriented mapping of healthcare functions and processes, this study did not capture patient perspectives directly. As a result, it may underrepresent lived experiences, satisfaction, or unmet patient needs. Future research could complement these findings with patient interviews or longitudinal follow-up to assess how these intake processes affect long-term health access and outcomes. Conclusion This study applied FRAM to systematically map and examine the intake process for GARs accessing primary healthcare at the Refugee Health Collaborative in Newfoundland and Labrador (NL). By modelling the actual work practices across 13 interdependent functions, the study revealed the coordinated efforts required to deliver care in a fragmented and resource-constrained system. The analysis uncovered the importance of administrative sequencing, the pivotal role of the initial medical assessment, and the cross-cutting reliance on interpretation services, transportation, and patient communication. FRAM enabled the identification of both functional variability and structural interdependencies, offering a clear picture of how routine disruptions—such as interpreter shortages or booking delays—can ripple through the system. The model also highlighted areas of system resilience, including collaborative scheduling, adaptive workflows, and the integration of settlement and clinical services. As one of the first applications of FRAM to refugee health care delivery in Canada, this study demonstrates the method’s utility for making complex care pathways visible and actionable. These insights can inform the design of more responsive, equitable, and resilient models of refugee health access, both within NL and across other Canadian jurisdictions. Declarations Funding This work was funded by Strategy for Patient-Oriented Research (NL-SPOR) Grant from Newfoundland and Labrador’s Support for People and Patient-Oriented Research and Trials Unit (NL SUPPORT), and the Summer Undergraduate Research Award (SURA) from the Faculty of Medicine at Memorial University. The funder had no role in the study design, data collection, analysis, interpretation, or writing of the manuscript. Author Contribution MN, MS, and CAB conceived and designed the study and, together with HH and EM, collected the data. NLA supported the document analysis and literature review. MN, MS, CAB and NLA conducted the analysis. MN drafted the first version of the manuscript. All authors critically revised it, approved the final version, and agree to be accountable for all aspects of the work. Data Availability The data consist of de-identified workshop notes and public documents. Study materials (e.g., workshop guides) are available from the corresponding author on reasonable request. References World Health Organization. World report on the health of refugees and migrants. Geneva: World Health Organization; 2022. Antonipillai V, Baumann A, Hunter A, Wahoush O, O’Shea T. Impacts of the Interim Federal Health Program reforms: A stakeholder analysis of barriers to health care access and provision for refugees. Can J Public Health. 2017;108(4):e435–41. 10.17269/CJPH.108.5553 . Reboe-Benjamin M, Brindamour M, Leis K, Hanson J, Verity-Anderson L, Gomez M, et al. Refugees’ care experiences, self-reported health outcomes and transition to mainstream health care after one year at the Refugee Engagement and Community Health (REACH) Clinic. J Immigr Minor Health. 2024;26(1):101–9. 10.1007/s10903-023-01534-w . Duke P, Brunger F. The MUN Med Gateway Project: Marrying medical education and social accountability. Can Fam Physician. 2015;61(2):e81. Kohler G, Holland T, Sharpe A, Irwin M, Sampalli T, MacDonell K, et al. The Newcomer Health Clinic in Nova Scotia: A beacon clinic to support the health needs of the refugee population. Int J Health Policy Manag. 2018;7(12):1085–9. 10.15171/ijhpm.2018.54 . Darwish W, Muldoon L. Acute primary health care needs of Syrian refugees immediately after arrival to Canada. Can Fam Physician. 2020;66(1):e30–8. Malebranche M, Norrie E, Hao S, Brown G, Talavlikar R, Hull A, et al. Antenatal care utilization and obstetric and newborn outcomes among pregnant refugees attending a specialized refugee clinic. J Immigr Minor Health. 2020;22(3):467–75. 10.1007/s10903-019-00961-y . Feldman R. Primary health care for refugees and asylum seekers: A review of the literature and a framework for services. Public Health. 2006;120(9):809–16. 10.1016/j.puhe.2006.05.014 . Benjumea-Bedoya D, Becker M, Haworth-Brockman M, Balakumar S, Hiebert K, Lutz J-A, et al. Integrated care for latent tuberculosis infection (LTBI) at a primary health care facility for refugees in Winnipeg, Canada: A mixed-methods evaluation. Front Public Health. 2019;7:57. 10.3389/fpubh.2019.00057 . McMurray J, Breward K, Breward M, Alder R, Arya N. Integrated primary care improves access to healthcare for newly arrived refugees in Canada. J Immigr Minor Health. 2014;16(4):576–85. 10.1007/s10903-013-9954-x . Whalen-Browne M, Talavlikar R, Brown G, McBrien K, Wiedmeyer M-L, Norrie E, et al. Cervical cancer screening by refugee category in a refugee health primary care clinic in Calgary, Canada, 2011–2016. J Immigr Minor Health. 2022;24(6):1534–42. 10.1007/s10903-022-01345-5 . Winn A, Hetherington E, Tough S. Caring for pregnant refugee women in a turbulent policy landscape: Perspectives of health care professionals in Calgary, Alberta. Int J Equity Health. 2018;17(1):91. 10.1186/s12939-018-0801-5 . Smith JA, Basabose JD, Brockett M, Browne DT, Shamon S, Stephenson M. Family medicine with refugee newcomers during the COVID-19 pandemic. J Am Board Fam Med. 2021;34(Suppl):S210–6. 10.3122/jabfm.2021.S1.200115 . McGill A, Smith D, McCloskey R, Morris P, Goudreau A, Veitch B. The Functional Resonance Analysis Method as a health care research methodology: A scoping review. JBI Evid Synth. 2022;20(4):1074–97. 10.11124/JBIES-21-00099 . Hollnagel EFRAM. The Functional Resonance Analysis Method—Modelling complex socio-technical systems. 1st ed. Boca Raton: CRC; 2012. 10.1201/9781315255071 . Pottie K, Gruner D, Magwood O. Canada’s response to refugees at the primary health care level. Public Health Res Pract. 2018;28(1):e2811803. 10.17061/phrp2811803 . Benjumea-Bedoya D, Becker M, Haworth-Brockman M, Balakumar S, Hiebert K, Lutz J-A, et al. Integrated care for latent tuberculosis infection at a primary health care facility for refugees in Winnipeg, Canada: A mixed-methods evaluation. Front Public Health. 2019;7:57. 10.3389/fpubh.2019.00057 . Appendices. Function. Tables with all aspects (csv file). Additional Declarations No competing interests reported. Supplementary Files FRAMCVSTableofFunctionswithAspects.csv Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 02 May, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 31 Dec, 2025 Submission checks completed at journal 31 Dec, 2025 First submitted to journal 29 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":106016,"visible":true,"origin":"","legend":"\u003cp\u003eFRAM Visualizer of GARs first medical intake – Standard Mode\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/7c8f208a2abec122e64d20e3.png"},{"id":100371295,"identity":"7df3e89c-e096-4572-90c3-dde3b7b5f668","added_by":"auto","created_at":"2026-01-16 08:09:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":113687,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFRAM Visualizer of GARs – Function 2\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/18550be652552e4276132cc9.png"},{"id":100247776,"identity":"aa857f83-6073-4ca6-bd39-f05a7e354dd3","added_by":"auto","created_at":"2026-01-14 14:29:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":113787,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFRAM Visualizer of GARs – Function 5\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/5bff630e0b43e4477e8d61da.png"},{"id":100371473,"identity":"c79f33fe-b91b-43ad-b61e-1a0a395ad897","added_by":"auto","created_at":"2026-01-16 08:10:18","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":118643,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFRAM Visualizer of GARs – Function 7\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/2f2788434c85671f8db82f10.png"},{"id":100247783,"identity":"7b2b9489-2255-459d-b951-22a53549dfb8","added_by":"auto","created_at":"2026-01-14 14:29:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":114745,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFRAM Visualizer of GARs – Function 8\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/6e42b27e3139d3a1e85e5e09.png"},{"id":100383773,"identity":"6989a8ea-0119-4cf1-8643-89574a5373df","added_by":"auto","created_at":"2026-01-16 10:48:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":965471,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/91110514-f12e-407b-88c4-4308766c564d.pdf"},{"id":100247785,"identity":"b387e7ea-4cfa-4579-8999-9b85e03fa3b0","added_by":"auto","created_at":"2026-01-14 14:29:36","extension":"csv","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":8596,"visible":true,"origin":"","legend":"","description":"","filename":"FRAMCVSTableofFunctionswithAspects.csv","url":"https://assets-eu.researchsquare.com/files/rs-8475197/v1/83f40d1f91d1ede0de08e987.csv"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMapping Refugee Primary Care Access in Newfoundland and Labrador: A Retrospective Functional Resonance Analysis of the Initial Medical Intake Process\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs the World Health Organization (WHO) writes in the 2022 \u003cem\u003eGlobal Report on Refugee and Migrant Health\u003c/em\u003e, migration is a social determinant of health \u0026ndash; impacting all aspects of a person\u0026rsquo;s health and wellbeing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, refugees and migrants have poorer health outcomes than the populations of their host countries, both on arrival, and post-settlement. Migration significantly influences access to healthcare services, affecting individuals both during their journey to safety and upon arrival in their country of asylum.\u003c/p\u003e \u003cp\u003eIn Canada, refugees experience many barriers to accessing the publicly-funded healthcare services to which they are entitled through the Interim Federal Health Program (IFHP) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The mainstream primary care system is not designed to meet the specific healthcare needs of refugees. Studies have shown that refugees often struggle to build trusting relationships within the healthcare system [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and that providers feel ill-equipped or under-resourced to address these needs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRefugee clinics have been established across the country to overcome these barriers and address the specific healthcare needs of refugees [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These clinics vary in scope and services. As Feldman described, these range from \u0026ldquo;gateway\u0026rdquo; clinics that connect refugees to primary care, to facilities that provide primary care alongside ancillary services, such as interpretation, social supports and specialized mental health services that support healthcare providers\u0026rsquo; ability to provide healthcare to refugees [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRefugee clinics are often designed as temporary or transitional spaces (gateway clinics), yet in practice, they evolve to accommodate long-standing care needs and address systemic shortcomings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The literature suggests that refugee healthcare needs are better met in refugee clinics, in both routine and preventative interventions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The relationship between refugee clinics and mainstream healthcare can be challenging; to ensure that refugee healthcare needs are met beyond the clinic, some refugee clinic staff work to educate their colleagues in the mainstream primary healthcare system [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and to coordinate appointments and ancillary services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs outlined above, there has been some exploration of refugee health clinic in Canada, this study aims to understand the initial visit of the new arrivals to a refugee health clinic through a systematic approach.\u003c/p\u003e\n\u003ch3\u003eMethodological approach\u003c/h3\u003e\n\u003cp\u003eTo address this gap, this study uses the Functional Resonance Analysis Method (FRAM), a systems-based qualitative approach developed to analyze complex processes within socio-technical systems like healthcare [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. FRAM focuses on mapping everyday work practices\u0026mdash;what Hollnagel describes as \"work-as-done\"\u0026mdash;rather than relying solely on policies or protocols that reflect \"work-as-imagined.\" [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This practice enables the identification of essential healthcare functions, their interdependencies, and the variability that arises in daily practice, allowing researchers to understand both sources of resilience and points of vulnerability within a system [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile FRAM has been used effectively in various healthcare settings to explore transitions of care, risk management, and process improvements, its application to healthcare delivery remains limited in the Canadian context [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Given the fragmented, adaptive, and multi-actor nature of refugee care processes, FRAM provides a novel methodological approach to capturing the complexity of how refugee clinics in Canada deliver and sustain care under conditions of uncertainty and resource constraints.\u003c/p\u003e \u003cp\u003eBy applying FRAM, this study seeks to illuminate the internal dynamics of refugee clinics\u0026mdash;mapping not only what these clinics do, but how they do it. In doing so, the research aims to generate insights that can inform policy and practice interventions to improve the equity, efficiency, and resilience of refugee healthcare delivery in Canada.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch objective and research question\u003c/h2\u003e \u003cp\u003eThe objective of this exercise was to map and analyze the healthcare intake process for government-assisted refugees (GARs) in Newfoundland and Labrador (NL) using the Functional Resonance Analysis Method (FRAM).\u003c/p\u003e \u003cp\u003eThe research question is: How was the initial medical intake process for GARs operationalized in St John\u0026rsquo;s NL, and what functional variabilities and interdependencies can be identified using the FRAM.\u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cp\u003eThis study applied the Functional Resonance Analysis Method (FRAM) to map the care pathway of adult Government Assisted Refugees (GARs) who were seen in NL between January 2023 and March 2024. The map began with every step required to book the initial comprehensive appointment at the Local Health Authorities Eastern Health (Currently Known as NLHS)\u0026mdash;which all GARs are expected to complete within 30 days of arrival\u0026mdash;and ended with the follow-up actions triggered by that visit, including investigations, prescriptions, and referrals.\u003c/p\u003e \u003cp\u003eTo maintain a focus on this pathway, we excluded other categories of newcomers such as:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAll other classes of new arrivals (including claimant refugees)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNew arrivals without MCP (provincial) and IFHP (federal) health coverage\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNew arrivals who require emergency services\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNew arrivals who access primary care through other channels\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNew arrivals with complex health needs\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWe excluded pediatrics (new arrivals under 18 years of age)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eData collection started with a series of virtual stakeholder workshops. Nine participants including clinicians, settlement workers, and researchers who had worked directly with the RHC during the study period\u0026mdash;received a brief orientation to FRAM and then collaborated to identify key system functions, their six FRAM aspects, and sources of performance variability. A FRAM data gathering template (Appendix Table\u0026nbsp;1) was used during each workshop to record the functions and their interdependencies.\u003c/p\u003e \u003cp\u003eThe research assistant (MS) converted the workshop records into a draft FRAM model using the FRAM Model Visualizer (FMV) web application. The study investigators and RHC clinicians subsequently reviewed and iteratively refined this model to ensure it accurately represented day-to-day practice. In parallel, documentary analysis of relevant healthcare policies, service descriptions, and operational manuals provided an \u0026ldquo;official\u0026rdquo; picture of system functions. Together, the workshops and document review produced a detailed FRAM model of the healthcare journey experienced by GARs in NL\u003c/p\u003e \u003cp\u003eAfter the draft FRAM model had been constructed and refined through several iterations, the analysis proceeded through two complementary stages. In the first stage, the research team examined the functions and their corresponding aspects using a network analysis approach. Each function\u0026rsquo;s six FRAM aspects\u0026mdash;Input, Output, Precondition, Resource, Control, and Time\u0026mdash;were systematically reviewed to catalogue sources of performance variability and to map the couplings linking one function to another. By tracing how a modified Output or absent Resource in one node became the Input or Precondition for downstream nodes, the analysis identified critical hubs where variability propagated across multiple pathways. In the second stage, a thematic analysis was undertaken to cluster individual functions into broader thematic groupings that captured the overarching trajectory of the patient journey. The integration of network and thematic analyses provided a comprehensive understanding of both the substantive content of care processes and the structural interdependencies that shaped their overall reliability.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eThis study found 13 distinct functions in the process of initial medical intake of GARs. In this section, we present the 13 functions and how they are interconnected. Examining each function\u0026rsquo;s six FRAM aspects then revealed the principal sources of performance variability and the tight interdependencies through which disturbances in one function could ripple across the entire pathway. Following, we present the thematic analysis of the functions and their aspects into three sequential themes that trace the patient journey.\u003c/p\u003e\n\u003ch3\u003eDescriptive Findings and Network Analysis\u003c/h3\u003e\n\u003cp\u003eWe identified 13 distinct sequential and interrelated functions that comprised the initial medical intake process for GARs at the Refugee Health Collaborative in St. John\u0026rsquo;s, Newfoundland and Labrador (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The process began with the receipt of the GAR arrivals lists from Immigration, Refugees and Citizenship Canada and proceeded through administrative, logistical, and clinical steps such as demographic data sharing, appointment scheduling, patient notification, and prioritization or triage. Subsequent functions included patient travel to the clinic, initial medical assessments, and arrangements for laboratory work and diagnostic imaging. Interpretation services were engaged throughout the process, and the model also included the coordination of specialist appointments, medication access, and mental health service referrals when applicable.\u003c/p\u003e\n\u003cp\u003eEach function was described using the six core FRAM aspects\u0026mdash;Input, Output, Preconditions, Resources, Control, and Time\u0026mdash;which provided a structured account of how the intake process was operationalized in practice. The functions reflected the collaborative work of multiple actors across health and settlement systems and illustrated the procedural components required to initiate and support healthcare access for newly arrived refugees.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eList of Functions\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e#\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFunction Name\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo send list of government assisted refugees to Association of New Canadians\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo provide patient demographics to the Refugee Health Collaborative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo book an appointment with the Refugee Health Collaborative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo inform patients about their intake appointment details\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo assess priority or triage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo travel to and from the Refugee Health Collaborative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo conduct an initial intake medical assessment\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo arrange bloodwork\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo arrange diagnostic imaging\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo provide interpretation services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo coordinate specialist appointments\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo obtain prescribed medications\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo offer mental health services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eEach of the above functions had six aspects that are presented in the supplementary file. (Appendix Table\u0026nbsp;2)\u003c/p\u003e\n\u003ch3\u003eNetwork analysis\u003c/h3\u003e\n\u003cp\u003eThe diagram below (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) is a condensed FRAM network view. Each hexagon represents one of the 13 intake functions, but only those aspect or ports (small circles on the hexagons) that share an identical label with another function are shown and connected. Ports that are unique to a single function but contain entries are shown in red, while aspects with no entries remain white. This visual distinction offers a clear picture of where functional dependencies and information flows coincide across the system.\u003c/p\u003e\n\u003cp\u003eThis other four diagrams below (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e) shows how the interconnections between functions and their aspects get activated on the visualizer (FMV) when clicked on them, showing inter-dependencies. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e indicates how Function 2 (To provide patient demographics to the Refugee Health Collaborative) activates other linear functions. Function 5 (To assess priority or triage) feeds into one other important foreground function. Function 7 (To conduct an initial intake medical assessment) is a central node connected to as many as eight other functions. And Function 8 (to arrange bloodwork) is a result of Function 7 with support from Function 10 (to provide interpretation services).\u003c/p\u003e\n\u003cp\u003eThis network analysis shows three structural features\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Linear administrative trunk (left)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis segment represents the sequential flow of early-stage administrative tasks. It begins with the receipt of the refugee manifest and progresses through the sharing of demographic information, appointment booking, and notifying patients. Each function is connected through shared aspects like \u003cem\u003e\u0026ldquo;Arrivals list \u0026amp; patient information\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;Appointment details,\u0026rdquo;\u003c/em\u003e showing how each task relies directly on the output of the one before it. This structure reflects a tightly coupled, step-by-step process necessary for initiating clinical care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Central clinical hub (middle)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe function \u003cem\u003e\u0026ldquo;To conduct an initial intake medical assessment\u0026rdquo;\u003c/em\u003e forms the central node of the network. It connects to multiple downstream functions via outputs like \u003cem\u003e\u0026ldquo;Completed health history and physical exam\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;Confirmed patient information in EMR.\u0026rdquo;\u003c/em\u003e These shared outputs link to bloodwork, imaging, specialist referral, medication, and mental-health services. This hub structure highlights the pivotal role of the initial assessment in activating subsequent care pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Cross-cutting support node (bottom-left)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003e\u0026ldquo;To provide interpretation services\u0026rdquo;\u003c/em\u003e function links laterally to many other nodes across both the administrative and clinical arms of the system through the shared aspect \u003cem\u003e\u0026ldquo;Interpreter services if needed.\u0026rdquo;\u003c/em\u003e This reveals interpretation as a foundational support function, essential to enabling communication at nearly every step in the intake process. Its cross-cutting nature emphasizes its systemic impact rather than linear placement.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eThematic Analysis:\u003c/h2\u003e\n\u003cp\u003eThematic analysis revealed a three-stage intake process supporting GARs: initiating access, navigating encounters, and facilitating continuity of care. Each stage reflects coordinated, culturally sensitive efforts to ensure timely and equitable healthcare.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eInitiating Access to Care\u003c/h3\u003e\n\u003cp\u003eThe first stage of the patient journey involved initiating healthcare access through coordinated processes of booking appointments, communicating with patients, and assessing the urgency of healthcare needs. The intake process was triggered when the RHC received a weekly list of newly arrived GARs from Association for Newcomers (ANC) that included demographic details and any flagged medical concerns. Based on this information, RHC staff booked the initial intake appointments for eligible patients. This process was supported by an appointment-booking system, interpreter availability, and urgent-intake referral guidelines, and the first intake appointment was scheduled for one hour.\u003c/p\u003e\n\u003cp\u003eAfter the booking, ANC staff contacted patients to provide appointment details including date, time, location, and any preparation instructions. Communication took place through telephone, email, or messaging systems, with attention to cultural sensitivity and interpreter support when necessary.\u003c/p\u003e\n\u003ch3\u003eNavigating Healthcare Encounters\u003c/h3\u003e\n\u003cp\u003eThe second stage of the patient journey focused on the processes involved in navigating healthcare encounters, including travel logistics and clinical assessment within the RHC. Patients travelled to the clinic by walking, public transit, taxis, or private vehicles. Appointment details had been provided in advance, and extra assistance was available for anyone who needed help with transportation. Ongoing communication with patients about travel arrangements and potential disruptions remained an integral part of the process.\u003c/p\u003e\n\u003cp\u003eUpon arrival, patients underwent a comprehensive medical assessment by a physician or nurse practitioner. This assessment included reviewing medical history, performing a physical examination, and identifying any new or existing conditions. Depending on the findings, patients received requisitions for bloodwork or diagnostic imaging, prescriptions, referrals to allied-health providers, or links to community supports. Interpreter services, clinical guidelines, and culturally sensitive practices supported the visit\u003c/p\u003e\n\u003cp\u003eAfter the assessment, staff coordinated the necessary investigations. Bloodwork was arranged as promptly as possible, while diagnostic imaging was scheduled according to clinical urgency and service availability. Both processes relied on communication among healthcare staff, laboratory facilities, and imaging providers.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eFacilitating Continuity of Care\u003c/h2\u003e\n\u003cp\u003eThe final stage of the intake process focused on facilitating continuity of care beyond the initial assessment. This stage involved interpretation services, specialist referrals, and access to prescribed medications. Interpretation services were provided both in person and by telephone, according to patients\u0026rsquo; language needs. Scheduling protocols ensured that interpreters were available for appointments, and interpreter details were communicated to both patients and providers in advance.\u003c/p\u003e\n\u003cp\u003eWhen further specialist care was required, healthcare providers completed referrals and RHC clerical staff co-ordinated specialist appointments. Scheduling varied with urgency and specialist availability, and patients were informed of their referral details and supported with transportation, and in-person interpretation by ANC throughout the process. If someone was referred to community allied health, there was no interpretation. ANC would provide in-person interpretation.\u003c/p\u003e\n\u003cp\u003eAccess to prescribed medications was facilitated through community pharmacies or, for patients facing language barriers, directly by ANC staff. Pharmacists provided instructions on medication use, side-effects, and dosage, with interpreter support when necessary. Medication access was further supported by verifying patient identity and confirming coverage under the Interim Federal Health Program (IFHP).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a systems-level understanding of how GARs in Newfoundland and Labrador access primary healthcare during their initial medical intake. Using the Functional Resonance Analysis Method (FRAM), this research mapped the journey of newly arrived refugees from the point of arrival to the completion of their first medical assessment. The findings highlight the operational complexity of refugee health service delivery, emphasizing the need for coordination, flexibility, and system navigation supports.\u003c/p\u003e \u003cp\u003eOne key insight from this study is the centrality of structured processes in mitigating barriers to care. Functions such as appointment booking, patient communication, triage, interpretation services, and transportation supports were identified as essential mechanisms that collectively shaped the patient journey. These findings align with previous literature suggesting that refugees often face challenges in accessing mainstream primary care due to language barriers, limited health literacy, and unfamiliarity with the Canadian health system (16, 3]. The structured intake pathway described in this study mirrors the model of \"refugee clinics\" elsewhere in Canada, where tailored interventions \u0026mdash; such as extended appointment times, integrated interpretation services, and social support \u0026mdash; have been shown to improve access and quality of care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother important observation from this study is the role of triage in assessing priority and ensuring timely care. This resonates with findings from Winn et al. who observed that effective triage and intake systems were crucial in navigating the complex healthcare needs of Syrian refugees, particularly in prenatal and chronic disease management [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, Benjumea-Bedoya et al. emphasized that integrated care models, which include early assessment and clear care pathways, contributed to higher completion rates of treatments like latent tuberculosis infection therapy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study also draws attention to the importance of non-clinical functions, such as transportation and communication, which are often underemphasized in traditional healthcare models. As described by Darwish and Muldoon transportation challenges, appointment delays, and unclear communication have been persistent barriers to refugee healthcare access [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the context of Newfoundland and Labrador \u0026mdash; a province characterized by dispersed populations and limited public transit \u0026mdash; the integration of transportation support into the healthcare intake process appears to be a particularly responsive adaptation to local needs.\u003c/p\u003e \u003cp\u003eMoreover, the findings reflect a system that is responsive not only to clinical care needs but also to the socio-cultural context of refugee patients. The provision of both in-person and telephone interpretation services, for example, directly responds to concerns raised in other studies about the impact of language barriers on patient-provider communication and trust [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePolicy implications\u003c/h2\u003e \u003cp\u003eThe findings of this study have several policy implications for refugee health service delivery in Canada. First, the structured intake process described here illustrates the value of dedicated refugee health pathways, particularly during the early stages of resettlement. Policymakers should consider supporting the establishment or continuation of refugee-specific intake systems, especially in regions where mainstream primary care services may lack the capacity or expertise to address the complex needs of refugee populations.\u003c/p\u003e \u003cp\u003eSecond, the study highlights the need for sustained investments in system navigation supports, including interpretation services, transportation assistance, and culturally sensitive communication protocols. FRAM analysis revealed that these functions are not peripheral, but integral to the intake system\u0026rsquo;s effectiveness and resilience. Ensuring their availability and reliability should be considered core components of healthcare access, rather than optional add-ons.\u003c/p\u003e \u003cp\u003eThird, this research underscores the importance of inter-sectoral collaboration between settlement agencies, public health, and primary care providers. Key intake functions relied on the transfer of information and coordination between organizations. Policies that foster integrated care planning, shared information systems, and collaborative funding models could enhance the efficiency and responsiveness of refugee healthcare services across Canada.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study was limited to the intake process for government-assisted refugees in a specific regional context (Newfoundland and Labrador), which may limit the generalizability of the findings to other provinces or refugee populations, such as privately sponsored or refugee claimants. While FRAM allowed for a detailed systems-oriented mapping of healthcare functions and processes, this study did not capture patient perspectives directly. As a result, it may underrepresent lived experiences, satisfaction, or unmet patient needs. Future research could complement these findings with patient interviews or longitudinal follow-up to assess how these intake processes affect long-term health access and outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study applied FRAM to systematically map and examine the intake process for GARs accessing primary healthcare at the Refugee Health Collaborative in Newfoundland and Labrador (NL). By modelling the actual work practices across 13 interdependent functions, the study revealed the coordinated efforts required to deliver care in a fragmented and resource-constrained system. The analysis uncovered the importance of administrative sequencing, the pivotal role of the initial medical assessment, and the cross-cutting reliance on interpretation services, transportation, and patient communication.\u003c/p\u003e \u003cp\u003eFRAM enabled the identification of both functional variability and structural interdependencies, offering a clear picture of how routine disruptions\u0026mdash;such as interpreter shortages or booking delays\u0026mdash;can ripple through the system. The model also highlighted areas of system resilience, including collaborative scheduling, adaptive workflows, and the integration of settlement and clinical services.\u003c/p\u003e \u003cp\u003eAs one of the first applications of FRAM to refugee health care delivery in Canada, this study demonstrates the method\u0026rsquo;s utility for making complex care pathways visible and actionable. These insights can inform the design of more responsive, equitable, and resilient models of refugee health access, both within NL and across other Canadian jurisdictions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was funded by Strategy for Patient-Oriented Research (NL-SPOR) Grant from Newfoundland and Labrador\u0026rsquo;s Support for People and Patient-Oriented Research and Trials Unit (NL SUPPORT), and the Summer Undergraduate Research Award (SURA) from the Faculty of Medicine at Memorial University. The funder had no role in the study design, data collection, analysis, interpretation, or writing of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMN, MS, and CAB conceived and designed the study and, together with HH and EM, collected the data. NLA supported the document analysis and literature review. MN, MS, CAB and NLA conducted the analysis. MN drafted the first version of the manuscript. All authors critically revised it, approved the final version, and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data consist of de-identified workshop notes and public documents. Study materials (e.g., workshop guides) are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World report on the health of refugees and migrants. Geneva: World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonipillai V, Baumann A, Hunter A, Wahoush O, O\u0026rsquo;Shea T. Impacts of the Interim Federal Health Program reforms: A stakeholder analysis of barriers to health care access and provision for refugees. 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Boca Raton: CRC; 2012. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1201/9781315255071\u003c/span\u003e\u003cspan address=\"10.1201/9781315255071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePottie K, Gruner D, Magwood O. Canada\u0026rsquo;s response to refugees at the primary health care level. Public Health Res Pract. 2018;28(1):e2811803. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17061/phrp2811803\u003c/span\u003e\u003cspan address=\"10.17061/phrp2811803\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjumea-Bedoya D, Becker M, Haworth-Brockman M, Balakumar S, Hiebert K, Lutz J-A, et al. Integrated care for latent tuberculosis infection at a primary health care facility for refugees in Winnipeg, Canada: A mixed-methods evaluation. Front Public Health. 2019;7:57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2019.00057\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2019.00057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAppendices.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFunction. Tables with all aspects (csv file).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Refugees, newcomers, primary care, access, initial medical intake, systems thinking, FRAM","lastPublishedDoi":"10.21203/rs.3.rs-8475197/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8475197/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNewcomer refugees often face significant barriers to accessing healthcare in Canada, including linguistic, logistical, and systemic. While dedicated refugee clinics have emerged to address these gaps, there remains limited understanding of how care processes unfold within these settings. This study applies the Functional Resonance Analysis Method (FRAM) to examine how the initial medical intake process for government-assisted refugees (GARs) is operationalized at a refugee health clinic in St John\u0026rsquo;s, Newfoundland and Labrador.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUsing FRAM, we mapped the intake journey of adult GARs for their first medical intake between January 2023 and March 2024. Data collection involved stakeholder workshops with clinicians, researchers, and settlement staff, supplemented by document review. A combination of thematic analysis and network mapping was used to identify functional interdependencies and sources of variability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFindings:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThirteen core functions were identified and analyzed using FRAM\u0026rsquo;s six-aspect schema (Input, Output, Preconditions, Resources, Control, and Time). The intake process followed a structured but flexible sequence, beginning with receipt of arrival lists and proceeding through appointment booking, triage, clinical assessment, and follow-up actions including lab work, prescriptions, and referrals. Findings revealed a tightly coupled administrative tasks, a central clinical hub anchored by the intake assessment, and a cross-cutting reliance on interpretation services. Key variability hotspots included interpreter availability, appointment wait times, and transport logistics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFRAM enabled a detailed, systems-level view of refugee healthcare access in a regional setting, highlighting both vulnerabilities and adaptive strengths. The method is valuable in visualizing how interdependent tasks align to support care delivery.\u003c/p\u003e","manuscriptTitle":"Mapping Refugee Primary Care Access in Newfoundland and Labrador: A Retrospective Functional Resonance Analysis of the Initial Medical Intake Process","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-14 14:29:31","doi":"10.21203/rs.3.rs-8475197/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"189902240125209923384430409859302622997","date":"2026-05-02T18:56:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130409559179025755114464518326586590431","date":"2026-04-30T18:06:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T16:10:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-31T12:17:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-31T12:16:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2025-12-29T17:58:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f1b17c60-cb4c-460a-9d36-636e62985fa8","owner":[],"postedDate":"January 14th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"189902240125209923384430409859302622997","date":"2026-05-02T18:56:40+00:00","index":40,"fulltext":""},{"type":"reviewerAgreed","content":"130409559179025755114464518326586590431","date":"2026-04-30T18:06:40+00:00","index":37,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-14T14:29:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-14 14:29:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8475197","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8475197","identity":"rs-8475197","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}