Barriers and facilitators to refugees and asylum seekers accessing non-hospital-based care: a mixed methods systematic review

Barriers and facilitators to refugees and asylum seekers accessing non-hospital-based care: a mixed methods systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Barriers and facilitators to refugees and asylum seekers accessing non-hospital-based care: a mixed methods systematic review Laura Fitzharris, Julie Broderick, Emer McGowan, Rikke Siersbaek This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5699124/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Asylum seekers and refugees have complex healthcare needs but often face barriers in accessing health services, particularly in non-hospital settings. This mixed methods systematic review aims to identify the facilitators and barriers to accessing non-hospital-based care among these groups. Methods A search of Medline, PubMed, EMBASE, PsycINFO, and the Cochrane Library identified qualitative and quantitative studies on this topic, utilizing the Joanna Briggs Institute methodology for data synthesis. Results Twenty-one studies were included (17 qualitative, 3 quantitative, 1 mixed method). Key barriers identified were language issues, pre-migration experiences, and the health system's structure. Key facilitators included refugee centres and social support. These factors were grouped into four themes: (i) health system structure, (ii) healthcare encounters, (iii) pre-migration experiences, and (iv) language/communication. Conclusion The findings illustrate the links between language, cultural sensitivity, and healthcare access. While qualitative evidence is strong, quantitative support is limited, suggesting healthcare systems could improve to better serve this diverse population. Health Economics & Outcomes Research Refugees asylum seekers non-hospital-based care primary care barriers facilitators Figures Figure 1 Figure 2 Introduction Rates of forced migration continue to increase globally [ 1 ]. Recent figures show that refugees (35.3 million) and asylum seekers (5.4 million) make up nearly 38 percent of the 108.4 million people worldwide who are forcibly displaced due to conflict, persecution, war, and human rights violations [ 2 ]. Almost four hundred thousand (n = 384,245) asylum seekers were granted protection status in the European Union (EU) in 2022, of whom 44% received refugee status, 31% subsidiary protection, and 25% humanitarian status. Germany, the UK, France, and Spain were the main countries of destination for first-time asylum applicants in the EU in 2022 [ 3 ]. It is widely recognised that asylum seekers and refugees are a socially excluded group due to the trauma experienced when migrating, state of liminality, societal stigma, and prejudice [ 4 , 5 ], with many likely to have complex healthcare needs [ 6 ]. Refugees are at an increased risk for diabetes, communicable diseases, and health issues affecting women and children, as well as facing common challenges like malnutrition and anaemia [ 7 ]. Additionally, many experience mental health issues, including depression, anxiety, and PTSD [ 8 ]. It is essential to understand how refugees utilise health services and the barriers they face, particularly those related to language and culture. Satinsky et al. (2019) indicated that asylum seekers and refugees often underutilize mental healthcare, primarily due to these culturally specific obstacles [ 9 ]. While access to healthcare among migrants varies widely, there are common factors that influence their experiences, including adversity, trauma, displacement, migration, and resettlement. Numerous systematic reviews indicate that migrants are disproportionately represented in acute hospital settings while often underutilizing non-hospital-based services like primary care for lower acuity conditions [ 10 , 11 ]. The reasons for this disparity are complex, involving challenges related to communication and cultural understanding [ 12 ]. The healthcare system and the resettlement process, which often requires multiple moves, complicate the establishment of trust and ongoing relationships with healthcare providers. Levesque's access model offers a framework to explore barriers to healthcare engagement from both migrant and provider perspectives [ 13 ]. Refugees and asylum seekers frequently encounter difficulties in accessing primary care services, which often do not address their specific needs [ 14 ]. The barriers they face in obtaining non-hospital-based care have not been adequately defined. Gathering evidence on these challenges and facilitators from both patient and practitioner perspectives would be valuable in enhancing future healthcare services. Aims i) Synthesise quantitative and qualitative data on the experiences and perceptions of migrants (defined specifically as refugees and asylum seekers) and stakeholders (general practitioners (GPs), healthcare workers, and voluntary sector workers) of accessing non-hospital-based care. ii) Describe and summarise barriers and facilitators to accessing non-hospital-based care for refugees and asylum seekers using a tailored conceptual model of access to healthcare. Methods Design The paper is structured and conducted in concordance with the PRISMA guidelines for systematic reviews and reported per the updated Prisma P Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 guidelines and checklist [ 15 ]. The full protocol for this review has been published on HRB Open Research [ 16 ]. Eligibility criteria The inclusion and exclusion criteria are shown in Table 1 . Table 1 I nclusion Criteria a) Qualitative, quantitative, and mixed methods studies that investigated access of specified marginalised groups (limited to refugees and asylum seekers) to non-hospital-based care for a physical and/or mental health condition were included. b) Nonhospital-based care means not relating to, associated with, or occurring within a hospital, so eligible studies will relate to primary care (PC), community care (CC), or other non-hospital-based setting such as GP practices, pharmacies, dental surgeries, ophthalmic services, and screening and immunisation services. c) Age group included adults > 18 years and adolescent groups aged 13–18 years. d) Studies containing mixed age groups, for instance, children 80% of the population must be the population of interest to this review. e) Studies based in European countries only. Member states of Council of Europe as of 16th of March 2022. f) Full-text articles, grey literature including academic papers, research and committee reports, government reports, and conference papers in English were included. g) No restriction regarding the year of publication of studies. Exclusion Criteria (a)Abstracts, editorial letters, commentaries, conference proceedings, systematic reviews, secondary studies (risk bias and error), method papers or protocols (b) Studies on children under the age of 13, family studies where 80% of included participants were children (c) Non-English language studies (d) Studies that have no health-related function (e) Studies that reported no evaluation of the barriers and facilitators in accessing health care such as case studies, (g) literature that did not contain original data or analysis of acute hospital-based care for example those that presented to accident and emergency services (f)Individuals who were not asylum seekers, refugees (g) Any services provided in hospital settings and tertiary settings (h) Studies of low methodological quality through performing sensitivity analyses, exerting undue influence (i) Studies whereby countries not ‘Member states of Council of Europe’ Information sources, searches, and study selection From January to May 2023, we searched the following databases: Medline/PubMed, EMBASE, CINAHL, PsycINFO, and the Cochrane Library. A medical librarian assisted in developing search terms related to "asylum seeker," "refugee," "migrant health," "primary care," and "community care" in connection with access to non-hospital-based care and services. The full search strategy is in Appendix 1. In July 2023, we conducted a grey literature search and hand searches using reference lists from the included studies. Only European countries that were member states of the Council of Europe as of March 16, 2022, were included; a complete list of these countries can be found in Appendix II. Title and abstract screening Upon completing the identification process, all report titles and abstracts were uploaded to the online systematic review management system, Covidence. Two pairs of reviewers independently performed two tasks: (a) screening the titles and abstracts and (b) conducting full-text screenings based on predetermined protocol criteria. The entire identification, screening, and inclusion process is illustrated in a PRISMA diagram (Fig. 1 ). If any disagreements arose, the studies were retained by consensus and subsequently subjected to a full-text review. Population: A strict definition of the included population using 2 frameworks (the P in PICO) and (S in SPIDER) was employed due to the broad definition of ‘migrant’ found in research and policy documents [ 17 ]. The definition from the International Organization for Migration (IOM), which is also used in World Health Assembly (WHA) resolutions 61.17 and 70.15, was utilised [ 18 ]. References to ‘refugees’ and ‘asylum seekers’ are made following the definition from the United Nations High Commissioner for Refugees (UNHCR). As a result of employing these definitions, we excluded all ‘undocumented migrants’, ‘economic migrants’, and ‘labour migrants’. Conditions/Domains: Primary care provides integrated, accessible healthcare services by physicians and their teams, addressing a wide range of personal healthcare needs, as defined by the Alma Ata Declaration [ 19 ]. In this review, 'non-hospital-based care' includes primary care, mobile health clinics, stand-alone clinics, GPs, day centres, and voluntary agencies. Outcomes: Beliefs, attitudes, opinions, views, experiences, perceptions, facilitators, and barriers to accessing non-hospital-based care, as well as tools used in quantitative studies. Phenomenon of Interest : Facilitators and barriers to accessing non-hospital based care. Study types: This review considered quantitative, qualitative, and mixed methods studies. Risk of Bias Assessment To recognize the diverse study designs in this review, the JBI critical appraisal tool portfolio was essential for evaluating quality and risk of bias [ 20 ]. These tools provided a consistent checklist to assess the presence (yes), absence (no), lack of clarity (unclear), or lack of applicability (not applicable) of quality across various methods. For qualitative studies, ConQual ratings were calculated to determine dependability and credibility. While Munn et al. (2020) advise against strict cut-off values for quality in quantitative research, the authors chose pragmatic thresholds for this mixed-methods review: less than 25% (very low), 25%-49% (low), 50%-74% (moderate), and above 75% (high) [ 21 ]. A summary of quality assessments for all studies can be found. (Supplementary File 1). Data extraction One author extracted study characteristics—such as aims, settings, country of origin, participants' race and ethnicity, methodology, and results—using an Excel spreadsheet, which another reviewed. Separate tables were created for qualitative and quantitative studies, with qualitative findings and discussions analysed using NVivo V.11 software. Strategy for mixed methods data synthesis: Qualitative data were analysed using NVivo software with inductive coding for thematic narrative synthesis [ 22 ]. A subjective approach guided the coding process to identify facilitators and barriers to accessing care, focusing on previously overlooked information. The authors followed the mixed methods review methodology of JBI. We coded primary quotations, key findings, and interpretations, with sections marked for facilitators and/or barriers. Codes were developed iteratively from the data and refined as new insights emerged. Details of the themes and subthemes are presented in Fig. 2. A conceptual model was created to illustrate the factors influencing access to non-hospital-based care. The convergent integrated approach from the JBI methodology for mixed methods systematic reviews (MMSR) was used for evidence synthesis [ 23 ]. This involved integrating quantitative and qualitative data through data transformation. For example, quantitative data from three papers and a mixed methods study were converted into qualitative descriptions. This "qualitised" data was combined with qualitative data from other studies and organized into tables showing themes and subthemes. Results Study selection A systematic database search found 3,003 articles, from which 600 studies were excluded. Seventeen records were selected for quality appraisal, along with four additional articles found through hand searches. In total, 21 papers were evaluated for quality. Quality assessment: Seventeen papers utilised a qualitative study design and four a quantitative study design. Six qualitative studies were rated as high quality, and 11 rated as moderate. (Supplementary file 1). Of the quantitative/mixed-methods studies (n = 4), three were of high quality. One quantitative study was rated as moderate quality. Description of included studies and Study populations Details of the populations studied in the included papers are displayed in Table 2 . Study Outcomes Table 3 summarises findings on healthcare access from both qualitative and quantitative studies, including confidence levels (Supplementary File 2). Quantitative-only results are detailed in Table 5, while qualitative-only findings are in Table 6 (Supplementary File 3). There was no quantitative data to support qualitative evidence for certain vulnerable groups, like those related to pregnancy and postpartum care. Additionally, minimal quantitative support was found for factors such as psychological trauma and navigating the healthcare system, even though qualitative data strongly highlighted these issues. Language barriers, cultural sensitivity, and healthcare system structure were mainly reported in qualitative data, with moderate quantitative support. Access to mental healthcare did have available quantitative data. Quotations reflecting the themes and subthemes from qualitative studies can be found in Supplementary File 4. Figure 2 summarizes these themes, showing multiple dimensions that influence access. Figure 2 Theme 1) Knowledge and functioning of healthcare systems : A lack of understanding of the healthcare system significantly hindered access to care (Table 4). Factors such as difficulties with GP registration and uncertainty about accessing services contributed to this issue. Health literacy, which includes knowledge about health and healthcare systems, is crucial. Individuals with lower health literacy struggled to find and evaluate health information, making it difficult for them to make informed decisions about vaccinations and cancer screenings. (Subtheme) Capacity, resources, socio-economic factors Evidence showed that GP registration challenges, healthcare system capacity, available resources, and migrants' socio-economic status significantly affect healthcare access. Limited healthcare facilities led to difficulties in obtaining timely medical treatment, often linked to individuals' socio-economic circumstances. Financial constraints also hindered access to necessary medical services. Furthermore, uncertainties about legal status restricted job opportunities, impacting both integration and timely healthcare access. Moderate evidence supported these findings (Supplementary File 2). Theme 2) Healthcare encounter : This text addressed migrants' experiences in navigating services and their attitudes toward them. Key factors included staff attitudes and training, which were moderately supported by two quantitative studies (see Supplementary file 2). (Subtheme) Fear/Discrimination : Social support, especially among younger males, had been shown to positively impact both physical and mental health, serving as a mediator between discrimination and health outcomes. While there was some agreement between qualitative and quantitative studies regarding the relationship between discrimination and health, the direction and extent of these associations were still under-researched. Fear and discrimination hindered access. Younger male refugees living in temporary camps had reported fear, perceived discrimination, and incivility negatively affected their mental and physical health. These factors can obstruct access to mental health support due to a deep-seated lack of trust and fear associated with their uncertain legal status. (Table 4) Pregnant refugee women living in temporary accommodation reported feelings of fear and discrimination, which hindered their willingness to access mental health services. Their reluctance was closely tied to their experiences during the migration process, particularly their time in temporary transit centres, due to lack of trust. These feelings were prominently highlighted in qualitative studies, although they were not reflected in quantitative studies. Overall, this fear served as a significant barrier to seeking necessary services, as it prevented these women from trusting the care they might receive. Theme 3) Pre-migration experience: Asylum seekers and refugees had previous experience with a different healthcare system, most notably characterised by direct access to hospital-based specialists in their native country. The UK-based studies (n = 7) reported areas where they experienced difficulties namely, difficulties with GP registration and interpreter services. (Table 2 ). Challenges were reported in the qualitative studies relating to the clinical encounter when expectations were not adequately articulated by GPs. Migrants' previous knowledge and experience of healthcare influenced their current expectations in a healthcare system relying on GPs performing a gatekeeping role. Pre-migration experiences included past trauma and psychological effects of war and torture. (Subtheme) Expectations The perceptions of pregnancy and childhood among migrant women were deeply influenced by their expectations for prenatal care. These include the desire for a female doctor, access to regular ultrasounds, and comprehensive postpartum follow-up. Two studies showed that the experiences these women encountered with obstetrical care before migration significantly shaped their healthcare needs and expectations in their new country. (Table 2 ) Three qualitative studies reported positive experiences in migrants’ interactions with voluntary workers, especially during pregnancy and post-natal care. (Table 4). These studies identified the supportive role of nurses and support voluntary workers in specific refugee camps. The qualitative studies relating to this setting strongly highlighted the positive impact of building trusting relationships as a strong facilitator. However, synthesised findings showed this was not supported in any of the quantitative papers. (Supplementary file 2). Theme 4) Language and communication To the theme of language, the understanding of language significantly influenced the ability to effectively express thoughts, feelings, and reasons for attending the GP, particularly through translation. The synthesized findings, backed by moderate to high-quality quantitative evidence, indicated that language served as a major barrier to access. (Supplementary file 2) (Subtheme) Use of interpreter services and cultural sensitivity The use of interpreter services and the cultural sensitivity of healthcare providers impacted access. Additionally, the level of cultural sensitivity influenced interactions with GPs and the broader healthcare system. Conceptual model A conceptual model - ‘the migrant experience’, was created to represent the interwoven nature of factors that underpin access to healthcare. (Fig. 2). Discussion This review draws on international literature, synthesising the breadth of the available qualitative and quantitative literature on access to non-hospital-based care. The findings reveal the complex interplay between language, social support, fear, stigma, and pre-migration experiences, all of which significantly impact access to healthcare for this population. Furthermore, the healthcare system's role is critical in shaping these dynamics. The conceptual model developed effectively categorizes barriers and facilitators into attitudinal, situational, and perceptual factors, offering valuable insights for improving access. Access to healthcare services for migrant populations is a complex and contextually varied issue. This review builds upon and reinforces the research published in the Harvard Public Health Review in 2016 [ 24 ]. The authors highlighted the numerous challenges faced in delivering care to newly arriving refugees, including the competing demands associated with public health, mental health, primary care, and specialty care that refugees encounter upon their arrival in the host country. One of the key barriers identified in this review was language, which includes both communication challenges and the importance of cross-cultural sensitivity. Cross-cultural barriers arise from language and cultural differences, affecting culturally based explanatory models of disease—essentially, how individuals perceive, interpret, and respond to illness. This can significantly influence the patient-practitioner relationship. Although the review did not provide an in-depth analysis of this issue, it is reasonable to suggest that language barriers exist at multiple levels, including individual, clinician, and systemic levels. Individual barriers highlighted in the review include low health literacy and limited English proficiency. Clinical barriers involve the limited use of interpreters, while systemic barriers consist of a shortage of professional interpreters and a lack of clinical care professionals. Three qualitative studies highlighted the negative perspectives of refugees in transit, largely due to socio-economic factors (financial and legal) and the stigma surrounding mental health difficulties, particularly in temporary accommodation centres. Limited research on the relationship between access to healthcare, incivility, and perceived discrimination can have harmful effects, as fear of seeking healthcare services may indirectly impact health. These findings align with a large-scale study conducted in 'hotspots' and 'transit centres’ for migrant refugees [ 25 ]. Migrants often hesitate to discuss their psychological support needs due to time constraints, the nature of being in transit, and the stigma attached to mental health during the asylum-seeking process. These results are not surprising and are echoed in a systematic review from 2022 that examined barriers to migrants accessing mental health services in high-income countries [ 26 ]. The stigmatisation of poor mental health, combined with language as a social construct, poses significant barriers to accessing care. Based on these findings, it is essential to further explore primary mental health care needs within this group. Additionally, cultural beliefs rooted in migrants’ pre-migration experiences must be taken into account. This review reveals that barriers to accessing mental health services are prevalent, with stigmatization of perceived mental health issues being the most common barrier. Stigma and fear, frequently mentioned by participants during interviews, are closely linked to their understanding of how both individuals and society perceive mental health. The role of gender in accessing healthcare is a significant consideration in this review. Women encounter various barriers as well as facilitators within the qualitative studies, particularly concerning maternity care services. The support provided by experienced voluntary workers has been instrumental in establishing caring and trusting relationships with pregnant refugee women. This finding is consistent with the recent EU policy review focused on maternity care for migrant women across Europe [ 27 ]. For women seeking asylum, inclusive access to maternity care necessitates culturally appropriate and respectful practices, along with reliable language services. The concept of the "maternal migrant effect" highlights the experiences of pregnant women migrating from countries with high maternal mortality rates, such as Syria and Afghanistan, to those with lower rates, like the UK and Germany [ 28 ]. Nevertheless, when interviewed, refugee women expressed fears about seeking help or discussing mental health concerns, particularly in contexts like refugee camps. The stigma and discrimination they face are multifaceted, shaped by various intersecting social identities. There may be a gendered dimension to these challenges, as women can experience barriers specific to biological factors, including a higher susceptibility to postpartum depression. This underscores the need for comprehensive pre- and post-natal mental health support for migrant women. General practice has played a key role in efforts to tackle health inequalities among migrant populations. Primary care policy on migrant health is not consistent across Europe [ 29 ]. Many European countries have a strongly embedded GP-led health service whereby the GP is the ‘gatekeeper’ to access other primary and secondary care services, which is often in contrast to the country of origin of migrants who have a stronger link to specialist services [ 30 ]. Access to GP services for asylum seekers and refugees is reasonable, however, primary care is wider than GP practice. Lack of understanding of healthcare systems affects access to information and thus access to services promptly. Access is central to the performance of healthcare systems around the world [ 31 ]. This paper suggests a conceptualization of access to health care describing broad dimensions of factors such as language, cultural competency, and function of the healthcare system and how this enables the operationalization of access to health care for migrants concerning the Levesque model of access to healthcare framework [ 32 ]. It is reasonable to consider access as the interface to the healthcare system and the migrant population. Gkiouleka et al. (2023) identified key principles for reducing health inequalities: the coordination of interconnected services, recognition of cultural differences among patient groups, accommodation of diverse patient needs, and integration of cultural references [ 33 ]. These principles are particularly pertinent to the role of primary care for migrant populations. Furthermore, the contextual factors discussed in this review can inform national policy planning aimed at developing a resilient healthcare system that effectively addresses the challenges of forced migration in Europe. Strengths and limitations This review has several notable strengths. It is the first mixed methods systematic review to identify and synthesize both qualitative and quantitative data regarding the challenges and facilitators faced by stakeholders. The qualitative synthesis generated key themes related to culturally competent care and the need for increased capacity and resources to address the demands of rising migration. By incorporating the perspectives of migrants, the studies added depth to the findings, effectively illustrated in the conceptual model. However, there are limitations. While European countries are geographically close, their distinct migration policies were not considered. We believe the findings will broadly resonate across Europe. Although we aimed to include only EU countries, we also included the UK and Turkey for applicability due to their significant migrant populations. We did not account for how the duration since leaving their country of origin impacts access to non-hospital-based care, as this information was often unavailable. Additionally, the review only included articles published in English, which limited the data collected. Conclusion/Future recommendations A systematic review of 21 studies reveals a pressing issue: asylum seekers and refugees encounter numerous barriers when trying to access non-hospital-based care. Key obstacles include language difficulties, navigating the complex healthcare system, and the necessity to possess cross-cultural competency. This situation underscores the need for a robust primary healthcare system tailored to marginalized groups. There is a clear opportunity to enhance healthcare access for these individuals, as significant barriers related to language and communication persist, often exacerbated by fear and stigma that lead to social exclusion. Such challenges can delay healthcare-seeking behaviour, particularly for those in transit suffering from mental health conditions. These delays not only impact immediate health outcomes but can also lead to long-lasting consequences for untreated medical issues. To address these critical barriers, future research must investigate current healthcare utilisation patterns and obstacles faced by asylum seekers and refugees, particularly in countries recently affected by conflict. Given the findings, it is imperative to re-evaluate mental health service policies and ensure the availability of culturally sensitive services across the EU, ultimately fostering an inclusive healthcare environment for all. 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Lancet Public Health 8(6):e463–e472 Tables Table 2 is available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Supplementaryfile1JBI.docx Supplementaryfile2synthesisedfindings.docx Supplementaryfile3qualandquantonly.docx Supplementaryfile4Illustrativequotations.docx AppendicesMMSR.docx Table2.docx Cite Share Download PDF Status: Posted Version 1 posted 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5699124","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":393685222,"identity":"7e069c2b-43f5-4936-bfe6-00822051ba9c","order_by":0,"name":"Laura Fitzharris","email":"","orcid":"https://orcid.org/0000-0002-9496-1958","institution":"Trinity College, Dublin","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Fitzharris","suffix":""},{"id":393685428,"identity":"a138fa1b-92b0-4330-9449-d6f9d8225df7","order_by":1,"name":"Julie Broderick","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYBACe/nDxx///COX2A/kSDAYEKHFcEZamjFjG1vizDZitRjcyDGTBmnZcAykhRhgOAOqZfP95oc3GApsCGuxlz9jJv3xD1vitmNsxhYMBmlE2DKfB2jLB5AWHjagXw4T1mJwsweoZQbQYW1gLf+J0HID6DDGHrfEDWxgLQeIcBgkkHOMJY6lGVskGCQT1mIvkQyMyjYLOf7mww9vfPhjR1gLKkggVcMoGAWjYBSMAuwAAIQiOtVpJuvxAAAAAElFTkSuQmCC","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":true,"prefix":"","firstName":"Julie","middleName":"","lastName":"Broderick","suffix":""},{"id":393685429,"identity":"e90e0bba-cd17-4579-bf36-0b0ad7592b39","order_by":2,"name":"Emer McGowan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYBACg+OHHz7mMfiX2A/kSDAYEKHF8kyasTFPxYHimW3EarG/ocMmzXPmQP2GYyAtxACzGzxs0rxtB3I3329+eIOhwIZILbltf3K3HWMztmAwSCNKSxlQywGgFh42oF8OE9ZicIPHTDr334HEzW1gLf+J0aJjJv237UDiBjawlgNEaAEF8lyglhnH0owtEgySidACikreNmBUNh9+eOPDHzvCWlBBAqkaRsEoGAWjYBRgBwDwHEMO0+zeBAAAAABJRU5ErkJggg==","orcid":"","institution":"Trinity College, Dublin","correspondingAuthor":true,"prefix":"","firstName":"Emer","middleName":"","lastName":"McGowan","suffix":""},{"id":393685430,"identity":"1b5794c6-f598-4aa7-a0bf-016168c7c48e","order_by":3,"name":"Rikke Siersbaek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYDACZiBmbGBg4AfSEgwGpGiRbCNaCwNUi8ExkBZigHw787GPP3fY5Rvfb354g6HAhrAWg8NsybN5zyRbbjvGZmzBYJBGhBZmHmNmxjZmA7NjPGxAvxwmwmHN/J8Zf7bVGxi3gbX8J6yF4TAPMwNv22EDAzawlgNEOOwwmzEz75njBhLH0owtEgySiXBY/+HHjD93VBvwNx9+eOPDHzsiHIYCEkjVMApGwSgYBaMAOwAAnN8vPIRHQloAAAAASUVORK5CYII=","orcid":"","institution":"Trinity College Dublin","correspondingAuthor":true,"prefix":"","firstName":"Rikke","middleName":"","lastName":"Siersbaek","suffix":""}],"badges":[],"createdAt":"2024-12-23 11:13:02","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5699124/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5699124/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72261824,"identity":"e27a6565-9928-4790-aca1-8a597c74228b","added_by":"auto","created_at":"2024-12-24 11:01:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49224,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/4d1273c418fbbfd9726d80b8.png"},{"id":72263018,"identity":"d39fb92c-1f90-4aa1-8abc-6e6d44aeff95","added_by":"auto","created_at":"2024-12-24 11:09:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38024,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/d134c6ef59e283deceed6140.png"},{"id":72264093,"identity":"e6a49391-ede7-4a35-90b8-2ad24df69f3e","added_by":"auto","created_at":"2024-12-24 11:25:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":609184,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/79e52c75-3e5b-4906-a1dd-0eb10d683ec0.pdf"},{"id":72261820,"identity":"f1aa00cd-d273-42e6-997e-fc4778ec67bb","added_by":"auto","created_at":"2024-12-24 11:01:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30194,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1JBI.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/a291ce3b22eeb2dd40026e48.docx"},{"id":72262878,"identity":"f150afc9-af0c-4682-bf63-8673357ccc55","added_by":"auto","created_at":"2024-12-24 11:09:43","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":16903,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2synthesisedfindings.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/97db4b6bfecff9d85a370231.docx"},{"id":72263219,"identity":"e189200a-506d-451f-9d23-58775c7331d1","added_by":"auto","created_at":"2024-12-24 11:17:43","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16456,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile3qualandquantonly.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/ed8cce8acd0d3528a4195612.docx"},{"id":72261835,"identity":"d53a921b-0ec2-4d5c-a3cd-bef9c0ce01e5","added_by":"auto","created_at":"2024-12-24 11:01:43","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":30759,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile4Illustrativequotations.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/3f3ce4d1b09fa54f592c88f0.docx"},{"id":72263034,"identity":"2d84e864-e515-42a5-8a65-6d29f9580183","added_by":"auto","created_at":"2024-12-24 11:09:45","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":13732,"visible":true,"origin":"","legend":"","description":"","filename":"AppendicesMMSR.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/e81b4971c0cdd5fbda1262a2.docx"},{"id":72261826,"identity":"9af67ea4-20ba-4c53-a59b-3a77eff70a2a","added_by":"auto","created_at":"2024-12-24 11:01:43","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":31000,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5699124/v1/e241ad56e434b471ca0d0c08.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eBarriers and facilitators to refugees and asylum seekers accessing non-hospital-based care: a mixed methods systematic review \u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRates of forced migration continue to increase globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Recent figures show that refugees (35.3\u0026nbsp;million) and asylum seekers (5.4\u0026nbsp;million) make up nearly 38 percent of the 108.4\u0026nbsp;million people worldwide who are forcibly displaced due to conflict, persecution, war, and human rights violations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Almost four hundred thousand (n\u0026thinsp;=\u0026thinsp;384,245) asylum seekers were granted protection status in the European Union (EU) in 2022, of whom 44% received refugee status, 31% subsidiary protection, and 25% humanitarian status. Germany, the UK, France, and Spain were the main countries of destination for first-time asylum applicants in the EU in 2022 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is widely recognised that asylum seekers and refugees are a socially excluded group due to the trauma experienced when migrating, state of liminality, societal stigma, and prejudice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], with many likely to have complex healthcare needs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRefugees are at an increased risk for diabetes, communicable diseases, and health issues affecting women and children, as well as facing common challenges like malnutrition and anaemia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, many experience mental health issues, including depression, anxiety, and PTSD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is essential to understand how refugees utilise health services and the barriers they face, particularly those related to language and culture. Satinsky et al. (2019) indicated that asylum seekers and refugees often underutilize mental healthcare, primarily due to these culturally specific obstacles [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While access to healthcare among migrants varies widely, there are common factors that influence their experiences, including adversity, trauma, displacement, migration, and resettlement.\u003c/p\u003e \u003cp\u003eNumerous systematic reviews indicate that migrants are disproportionately represented in acute hospital settings while often underutilizing non-hospital-based services like primary care for lower acuity conditions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The reasons for this disparity are complex, involving challenges related to communication and cultural understanding [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The healthcare system and the resettlement process, which often requires multiple moves, complicate the establishment of trust and ongoing relationships with healthcare providers. Levesque's access model offers a framework to explore barriers to healthcare engagement from both migrant and provider perspectives [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRefugees and asylum seekers frequently encounter difficulties in accessing primary care services, which often do not address their specific needs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The barriers they face in obtaining non-hospital-based care have not been adequately defined. Gathering evidence on these challenges and facilitators from both patient and practitioner perspectives would be valuable in enhancing future healthcare services.\u003c/p\u003e\n\u003ch3\u003eAims\u003c/h3\u003e\n\u003cp\u003ei) Synthesise quantitative and qualitative data on the experiences and perceptions of migrants (defined specifically as refugees and asylum seekers) and stakeholders (general practitioners (GPs), healthcare workers, and voluntary sector workers) of accessing non-hospital-based care.\u003c/p\u003e \u003cp\u003eii) Describe and summarise barriers and facilitators to accessing non-hospital-based care for refugees and asylum seekers using a tailored conceptual model of access to healthcare.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThe paper is structured and conducted in concordance with the PRISMA guidelines for systematic reviews and reported per the updated Prisma P Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 guidelines and checklist [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The full protocol for this review has been published on HRB Open Research [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion and exclusion criteria are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003cb\u003enclusion Criteria\u003c/b\u003e\u003c/p\u003e \u003cp\u003ea) Qualitative, quantitative, and mixed methods studies that investigated access of specified marginalised groups (limited to refugees and asylum seekers) to non-hospital-based care for a physical and/or mental health condition were included.\u003c/p\u003e \u003cp\u003eb) Nonhospital-based care means not relating to, associated with, or occurring within a hospital, so eligible studies will relate to primary care (PC), community care (CC), or other non-hospital-based setting such as GP practices, pharmacies, dental surgeries, ophthalmic services, and screening and immunisation services.\u003c/p\u003e \u003cp\u003ec) Age group included adults\u0026thinsp;\u0026gt;\u0026thinsp;18 years and adolescent groups aged 13\u0026ndash;18 years.\u003c/p\u003e \u003cp\u003ed) Studies containing mixed age groups, for instance, children\u0026thinsp;\u0026lt;\u0026thinsp;13 years or marginalised groups other than those included in this review- data was made available separately for the populations of interest, or if mixed, then \u0026gt;\u0026thinsp;80% of the population must be the population of interest to this review.\u003c/p\u003e \u003cp\u003ee) Studies based in European countries only. Member states of Council\u0026nbsp;of\u0026nbsp;Europe\u0026nbsp;as of 16th of March 2022.\u003c/p\u003e \u003cp\u003ef) Full-text articles, grey literature including academic papers, research and committee reports, government reports, and conference papers in English were included.\u003c/p\u003e \u003cp\u003eg) No restriction regarding the year of publication of studies.\u003c/p\u003e \u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(a)Abstracts, editorial letters, commentaries, conference proceedings, systematic reviews, secondary studies (risk bias and error), method papers or protocols\u003c/p\u003e \u003cp\u003e(b) Studies on children under the age of 13, family studies where 80% of included participants were children\u003c/p\u003e \u003cp\u003e(c) Non-English language studies\u003c/p\u003e \u003cp\u003e(d) Studies that have no health-related function\u003c/p\u003e \u003cp\u003e(e) Studies that reported no evaluation of the barriers and facilitators in accessing health care such as case studies, (g) literature that did not contain original data or analysis of acute hospital-based care for example those that presented to accident and emergency services\u003c/p\u003e \u003cp\u003e(f)Individuals who were not asylum seekers, refugees\u003c/p\u003e \u003cp\u003e(g) Any services provided in hospital settings and tertiary settings\u003c/p\u003e \u003cp\u003e(h) Studies of low methodological quality through performing sensitivity analyses, exerting undue influence\u003c/p\u003e \u003cp\u003e(i) Studies whereby countries not \u0026lsquo;Member states of Council of Europe\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eInformation sources, searches, and study selection\u003c/h3\u003e\n\u003cp\u003eFrom January to May 2023, we searched the following databases: Medline/PubMed, EMBASE, CINAHL, PsycINFO, and the Cochrane Library. A medical librarian assisted in developing search terms related to \"asylum seeker,\" \"refugee,\" \"migrant health,\" \"primary care,\" and \"community care\" in connection with access to non-hospital-based care and services. The full search strategy is in Appendix 1.\u003c/p\u003e \u003cp\u003eIn July 2023, we conducted a grey literature search and hand searches using reference lists from the included studies. Only European countries that were member states of the Council of Europe as of March 16, 2022, were included; a complete list of these countries can be found in Appendix II.\u003c/p\u003e\n\u003ch3\u003eTitle and abstract screening\u003c/h3\u003e\n\u003cp\u003eUpon completing the identification process, all report titles and abstracts were uploaded to the online systematic review management system, Covidence. Two pairs of reviewers independently performed two tasks: (a) screening the titles and abstracts and (b) conducting full-text screenings based on predetermined protocol criteria. The entire identification, screening, and inclusion process is illustrated in a PRISMA diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). If any disagreements arose, the studies were retained by consensus and subsequently subjected to a full-text review.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePopulation:\u003c/h2\u003e \u003cp\u003eA strict definition of the included population using 2 frameworks (the P in PICO) and (S in SPIDER) was employed due to the broad definition of \u0026lsquo;migrant\u0026rsquo; found in research and policy documents [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The definition from the International Organization for Migration (IOM), which is also used in World Health Assembly (WHA) resolutions 61.17 and 70.15, was utilised [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. References to \u0026lsquo;refugees\u0026rsquo; and \u0026lsquo;asylum seekers\u0026rsquo; are made following the definition from the United Nations High Commissioner for Refugees (UNHCR). As a result of employing these definitions, we excluded all \u0026lsquo;undocumented migrants\u0026rsquo;, \u0026lsquo;economic migrants\u0026rsquo;, and \u0026lsquo;labour migrants\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eConditions/Domains:\u003c/h3\u003e\n\u003cp\u003ePrimary care provides integrated, accessible healthcare services by physicians and their teams, addressing a wide range of personal healthcare needs, as defined by the Alma Ata Declaration [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In this review, 'non-hospital-based care' includes primary care, mobile health clinics, stand-alone clinics, GPs, day centres, and voluntary agencies.\u003c/p\u003e\n\u003ch3\u003eOutcomes:\u003c/h3\u003e\n\u003cp\u003eBeliefs, attitudes, opinions, views, experiences, perceptions, facilitators, and barriers to accessing non-hospital-based care, as well as tools used in quantitative studies.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003ePhenomenon of Interest\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eFacilitators and barriers to accessing non-hospital based care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy types:\u003c/h2\u003e \u003cp\u003eThis review considered quantitative, qualitative, and mixed methods studies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRisk of Bias Assessment\u003c/h2\u003e \u003cp\u003eTo recognize the diverse study designs in this review, the JBI critical appraisal tool portfolio was essential for evaluating quality and risk of bias [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These tools provided a consistent checklist to assess the presence (yes), absence (no), lack of clarity (unclear), or lack of applicability (not applicable) of quality across various methods. For qualitative studies, ConQual ratings were calculated to determine dependability and credibility. While Munn et al. (2020) advise against strict cut-off values for quality in quantitative research, the authors chose pragmatic thresholds for this mixed-methods review: less than 25% (very low), 25%-49% (low), 50%-74% (moderate), and above 75% (high) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A summary of quality assessments for all studies can be found. (Supplementary File 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData extraction\u003c/h2\u003e \u003cp\u003eOne author extracted study characteristics\u0026mdash;such as aims, settings, country of origin, participants' race and ethnicity, methodology, and results\u0026mdash;using an Excel spreadsheet, which another reviewed. Separate tables were created for qualitative and quantitative studies, with qualitative findings and discussions analysed using NVivo V.11 software.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrategy for mixed methods data synthesis:\u003c/h2\u003e \u003cp\u003eQualitative data were analysed using NVivo software with inductive coding for thematic narrative synthesis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A subjective approach guided the coding process to identify facilitators and barriers to accessing care, focusing on previously overlooked information.\u003c/p\u003e \u003cp\u003eThe authors followed the mixed methods review methodology of JBI. We coded primary quotations, key findings, and interpretations, with sections marked for facilitators and/or barriers. Codes were developed iteratively from the data and refined as new insights emerged. Details of the themes and subthemes are presented in Fig.\u0026nbsp;2. A conceptual model was created to illustrate the factors influencing access to non-hospital-based care.\u003c/p\u003e \u003cp\u003eThe convergent integrated approach from the JBI methodology for mixed methods systematic reviews (MMSR) was used for evidence synthesis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This involved integrating quantitative and qualitative data through data transformation. For example, quantitative data from three papers and a mixed methods study were converted into qualitative descriptions. This \"qualitised\" data was combined with qualitative data from other studies and organized into tables showing themes and subthemes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy selection\u003c/h2\u003e\n \u003cp\u003eA systematic database search found 3,003 articles, from which 600 studies were excluded. Seventeen records were selected for quality appraisal, along with four additional articles found through hand searches. In total, 21 papers were evaluated for quality.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eQuality assessment:\u003c/h2\u003e\n \u003cp\u003eSeventeen papers utilised a qualitative study design and four a quantitative study design. Six qualitative studies were rated as high quality, and 11 rated as moderate. (Supplementary file 1). Of the quantitative/mixed-methods studies (n\u0026thinsp;=\u0026thinsp;4), three were of high quality. One quantitative study was rated as moderate quality.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eDescription of included studies and Study populations\u003c/h2\u003e\n \u003cp\u003eDetails of the populations studied in the included papers are displayed in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003ch2\u003eStudy Outcomes \u003c/h2\u003e\n \u003cp\u003eTable\u0026nbsp;3 summarises findings on healthcare access from both qualitative and quantitative studies, including confidence levels (Supplementary File 2).\u003c/p\u003e\n \u003cp\u003eQuantitative-only results are detailed in Table\u0026nbsp;5, while qualitative-only findings are in Table\u0026nbsp;6 (Supplementary File 3). There was no quantitative data to support qualitative evidence for certain vulnerable groups, like those related to pregnancy and postpartum care. Additionally, minimal quantitative support was found for factors such as psychological trauma and navigating the healthcare system, even though qualitative data strongly highlighted these issues.\u003c/p\u003e\n \u003cp\u003eLanguage barriers, cultural sensitivity, and healthcare system structure were mainly reported in qualitative data, with moderate quantitative support. Access to mental healthcare did have available quantitative data.\u003c/p\u003e\n \u003cp\u003eQuotations reflecting the themes and subthemes from qualitative studies can be found in Supplementary File 4. Figure\u0026nbsp;2 summarizes these themes, showing multiple dimensions that influence access.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1) Knowledge and functioning of healthcare systems\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eA lack of understanding of the healthcare system significantly hindered access to care (Table\u0026nbsp;4). Factors such as difficulties with GP registration and uncertainty about accessing services contributed to this issue. Health literacy, which includes knowledge about health and healthcare systems, is crucial. Individuals with lower health literacy struggled to find and evaluate health information, making it difficult for them to make informed decisions about vaccinations and cancer screenings.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Subtheme) Capacity, resources, socio-economic factors\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEvidence showed that GP registration challenges, healthcare system capacity, available resources, and migrants\u0026apos; socio-economic status significantly affect healthcare access. Limited healthcare facilities led to difficulties in obtaining timely medical treatment, often linked to individuals\u0026apos; socio-economic circumstances. Financial constraints also hindered access to necessary medical services. Furthermore, uncertainties about legal status restricted job opportunities, impacting both integration and timely healthcare access. Moderate evidence supported these findings (Supplementary File 2).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2) Healthcare encounter\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eThis text addressed migrants\u0026apos; experiences in navigating services and their attitudes toward them. Key factors included staff attitudes and training, which were moderately supported by two quantitative studies (see Supplementary file 2).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Subtheme) Fear/Discrimination\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eSocial support, especially among younger males, had been shown to positively impact both physical and mental health, serving as a mediator between discrimination and health outcomes. While there was some agreement between qualitative and quantitative studies regarding the relationship between discrimination and health, the direction and extent of these associations were still under-researched. Fear and discrimination hindered access. Younger male refugees living in temporary camps had reported fear, perceived discrimination, and incivility negatively affected their mental and physical health. These factors can obstruct access to mental health support due to a deep-seated lack of trust and fear associated with their uncertain legal status. (Table\u0026nbsp;4)\u003c/p\u003e\n \u003cp\u003ePregnant refugee women living in temporary accommodation reported feelings of fear and discrimination, which hindered their willingness to access mental health services. Their reluctance was closely tied to their experiences during the migration process, particularly their time in temporary transit centres, due to lack of trust. These feelings were prominently highlighted in qualitative studies, although they were not reflected in quantitative studies. Overall, this fear served as a significant barrier to seeking necessary services, as it prevented these women from trusting the care they might receive.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 3) Pre-migration experience:\u003c/h2\u003e\n \u003cp\u003eAsylum seekers and refugees had previous experience with a different healthcare system, most notably characterised by direct access to hospital-based specialists in their native country. The UK-based studies (n\u0026thinsp;=\u0026thinsp;7) reported areas where they experienced difficulties namely, difficulties with GP registration and interpreter services. (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Challenges were reported in the qualitative studies relating to the clinical encounter when expectations were not adequately articulated by GPs. Migrants\u0026apos; previous knowledge and experience of healthcare influenced their current expectations in a healthcare system relying on GPs performing a gatekeeping role. Pre-migration experiences included past trauma and psychological effects of war and torture.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e(Subtheme) Expectations\u003c/h2\u003e\n \u003cp\u003eThe perceptions of pregnancy and childhood among migrant women were deeply influenced by their expectations for prenatal care. These include the desire for a female doctor, access to regular ultrasounds, and comprehensive postpartum follow-up. Two studies showed that the experiences these women encountered with obstetrical care before migration significantly shaped their healthcare needs and expectations in their new country. (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eThree qualitative studies reported positive experiences in migrants\u0026rsquo; interactions with voluntary workers, especially during pregnancy and post-natal care. (Table\u0026nbsp;4). These studies identified the supportive role of nurses and support voluntary workers in specific refugee camps. The qualitative studies relating to this setting strongly highlighted the positive impact of building trusting relationships as a strong facilitator. However, synthesised findings showed this was not supported in any of the quantitative papers. (Supplementary file 2).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme 4) Language and communication\u003c/h2\u003e\n \u003cp\u003eTo the theme of language, the understanding of language significantly influenced the ability to effectively express thoughts, feelings, and reasons for attending the GP, particularly through translation. The synthesized findings, backed by moderate to high-quality quantitative evidence, indicated that language served as a major barrier to access. (Supplementary file 2)\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003e(Subtheme) Use of interpreter services and cultural sensitivity\u003c/h2\u003e\n \u003cp\u003eThe use of interpreter services and the cultural sensitivity of healthcare providers impacted access. Additionally, the level of cultural sensitivity influenced interactions with GPs and the broader healthcare system.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eConceptual model\u003c/h2\u003e\n \u003cp\u003eA conceptual model - \u0026lsquo;the migrant experience\u0026rsquo;, was created to represent the interwoven nature of factors that underpin access to healthcare. (Fig.\u0026nbsp;2).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review draws on international literature, synthesising the breadth of the available qualitative and quantitative literature on access to non-hospital-based care. The findings reveal the complex interplay between language, social support, fear, stigma, and pre-migration experiences, all of which significantly impact access to healthcare for this population. Furthermore, the healthcare system's role is critical in shaping these dynamics. The conceptual model developed effectively categorizes barriers and facilitators into attitudinal, situational, and perceptual factors, offering valuable insights for improving access.\u003c/p\u003e \u003cp\u003eAccess to healthcare services for migrant populations is a complex and contextually varied issue. This review builds upon and reinforces the research published in the Harvard Public Health Review in 2016 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The authors highlighted the numerous challenges faced in delivering care to newly arriving refugees, including the competing demands associated with public health, mental health, primary care, and specialty care that refugees encounter upon their arrival in the host country.\u003c/p\u003e \u003cp\u003eOne of the key barriers identified in this review was language, which includes both communication challenges and the importance of cross-cultural sensitivity. Cross-cultural barriers arise from language and cultural differences, affecting culturally based explanatory models of disease\u0026mdash;essentially, how individuals perceive, interpret, and respond to illness. This can significantly influence the patient-practitioner relationship. Although the review did not provide an in-depth analysis of this issue, it is reasonable to suggest that language barriers exist at multiple levels, including individual, clinician, and systemic levels. Individual barriers highlighted in the review include low health literacy and limited English proficiency. Clinical barriers involve the limited use of interpreters, while systemic barriers consist of a shortage of professional interpreters and a lack of clinical care professionals.\u003c/p\u003e \u003cp\u003eThree qualitative studies highlighted the negative perspectives of refugees in transit, largely due to socio-economic factors (financial and legal) and the stigma surrounding mental health difficulties, particularly in temporary accommodation centres. Limited research on the relationship between access to healthcare, incivility, and perceived discrimination can have harmful effects, as fear of seeking healthcare services may indirectly impact health. These findings align with a large-scale study conducted in 'hotspots' and 'transit centres\u0026rsquo; for migrant refugees [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Migrants often hesitate to discuss their psychological support needs due to time constraints, the nature of being in transit, and the stigma attached to mental health during the asylum-seeking process. These results are not surprising and are echoed in a systematic review from 2022 that examined barriers to migrants accessing mental health services in high-income countries [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The stigmatisation of poor mental health, combined with language as a social construct, poses significant barriers to accessing care. Based on these findings, it is essential to further explore primary mental health care needs within this group. Additionally, cultural beliefs rooted in migrants\u0026rsquo; pre-migration experiences must be taken into account. This review reveals that barriers to accessing mental health services are prevalent, with stigmatization of perceived mental health issues being the most common barrier. Stigma and fear, frequently mentioned by participants during interviews, are closely linked to their understanding of how both individuals and society perceive mental health.\u003c/p\u003e \u003cp\u003eThe role of gender in accessing healthcare is a significant consideration in this review. Women encounter various barriers as well as facilitators within the qualitative studies, particularly concerning maternity care services. The support provided by experienced voluntary workers has been instrumental in establishing caring and trusting relationships with pregnant refugee women. This finding is consistent with the recent EU policy review focused on maternity care for migrant women across Europe [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For women seeking asylum, inclusive access to maternity care necessitates culturally appropriate and respectful practices, along with reliable language services. The concept of the \"maternal migrant effect\" highlights the experiences of pregnant women migrating from countries with high maternal mortality rates, such as Syria and Afghanistan, to those with lower rates, like the UK and Germany [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Nevertheless, when interviewed, refugee women expressed fears about seeking help or discussing mental health concerns, particularly in contexts like refugee camps. The stigma and discrimination they face are multifaceted, shaped by various intersecting social identities. There may be a gendered dimension to these challenges, as women can experience barriers specific to biological factors, including a higher susceptibility to postpartum depression. This underscores the need for comprehensive pre- and post-natal mental health support for migrant women.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGeneral practice has played a key role in efforts to tackle health inequalities among migrant populations. Primary care policy on migrant health is not consistent across Europe [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Many European countries have a strongly embedded GP-led health service whereby the GP is the \u0026lsquo;gatekeeper\u0026rsquo; to access other primary and secondary care services, which is often in contrast to the country of origin of migrants who have a stronger link to specialist services [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccess to GP services for asylum seekers and refugees is reasonable, however, primary care is wider than GP practice. Lack of understanding of healthcare systems affects access to information and thus access to services promptly. Access is central to the performance of healthcare systems around the world [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This paper suggests a conceptualization of access to health care describing broad dimensions of factors such as language, cultural competency, and function of the healthcare system and how this enables the operationalization of access to health care for migrants concerning the Levesque model of access to healthcare framework [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It is reasonable to consider access as the interface to the healthcare system and the migrant population.\u003c/p\u003e \u003cp\u003eGkiouleka et al. (2023) identified key principles for reducing health inequalities: the coordination of interconnected services, recognition of cultural differences among patient groups, accommodation of diverse patient needs, and integration of cultural references [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These principles are particularly pertinent to the role of primary care for migrant populations. Furthermore, the contextual factors discussed in this review can inform national policy planning aimed at developing a resilient healthcare system that effectively addresses the challenges of forced migration in Europe.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis review has several notable strengths. It is the first mixed methods systematic review to identify and synthesize both qualitative and quantitative data regarding the challenges and facilitators faced by stakeholders. The qualitative synthesis generated key themes related to culturally competent care and the need for increased capacity and resources to address the demands of rising migration. By incorporating the perspectives of migrants, the studies added depth to the findings, effectively illustrated in the conceptual model.\u003c/p\u003e \u003cp\u003eHowever, there are limitations. While European countries are geographically close, their distinct migration policies were not considered. We believe the findings will broadly resonate across Europe. Although we aimed to include only EU countries, we also included the UK and Turkey for applicability due to their significant migrant populations. We did not account for how the duration since leaving their country of origin impacts access to non-hospital-based care, as this information was often unavailable. Additionally, the review only included articles published in English, which limited the data collected.\u003c/p\u003e "},{"header":"Conclusion/Future recommendations","content":"\u003cp\u003eA systematic review of 21 studies reveals a pressing issue: asylum seekers and refugees encounter numerous barriers when trying to access non-hospital-based care. Key obstacles include language difficulties, navigating the complex healthcare system, and the necessity to possess cross-cultural competency. This situation underscores the need for a robust primary healthcare system tailored to marginalized groups. There is a clear opportunity to enhance healthcare access for these individuals, as significant barriers related to language and communication persist, often exacerbated by fear and stigma that lead to social exclusion. Such challenges can delay healthcare-seeking behaviour, particularly for those in transit suffering from mental health conditions. These delays not only impact immediate health outcomes but can also lead to long-lasting consequences for untreated medical issues. To address these critical barriers, future research must investigate current healthcare utilisation patterns and obstacles faced by asylum seekers and refugees, particularly in countries recently affected by conflict. Given the findings, it is imperative to re-evaluate mental health service policies and ensure the availability of culturally sensitive services across the EU, ultimately fostering an inclusive healthcare environment for all.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHeaven Crawley F, Garba FN (2022) \u003cem\u003eZanj: The Journal of Critical Global South Studies\u003c/em\u003e, Vol. 5, No. 1/2, Special Issue: Migration and (In)Equality in the Global South pp. 1\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNHCR (2023) \u003cem\u003eMid-year trends report\u003c/em\u003e, published October 2023. Figure on refugees includes refugees under UNRWA and UNHCR mandate as well as statistical projections. 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Lancet Public Health 8(6):e463\u0026ndash;e472\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Trinity College Dublin","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Refugees, asylum seekers, non-hospital-based care, primary care, barriers, facilitators","lastPublishedDoi":"10.21203/rs.3.rs-5699124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5699124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAsylum seekers and refugees have complex healthcare needs but often face barriers in accessing health services, particularly in non-hospital settings. This mixed methods systematic review aims to identify the facilitators and barriers to accessing non-hospital-based care among these groups.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA search of Medline, PubMed, EMBASE, PsycINFO, and the Cochrane Library identified qualitative and quantitative studies on this topic, utilizing the Joanna Briggs Institute methodology for data synthesis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-one studies were included (17 qualitative, 3 quantitative, 1 mixed method). Key barriers identified were language issues, pre-migration experiences, and the health system's structure. Key facilitators included refugee centres and social support. These factors were grouped into four themes: (i) health system structure, (ii) healthcare encounters, (iii) pre-migration experiences, and (iv) language/communication.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings illustrate the links between language, cultural sensitivity, and healthcare access. While qualitative evidence is strong, quantitative support is limited, suggesting healthcare systems could improve to better serve this diverse population.\u003c/p\u003e","manuscriptTitle":"Barriers and facilitators to refugees and asylum seekers accessing non-hospital-based care: a mixed methods systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 11:01:37","doi":"10.21203/rs.3.rs-5699124/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d8a65b0-9624-4bb6-b435-8a9ccadc1890","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":41961904,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2024-12-24T11:01:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-24 11:01:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5699124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5699124","identity":"rs-5699124","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}