Refugee health is an important global health policy and practice issue. New Zealand (NZ) currently resettles over 1000 refugees annually. A NZ Refugee Settlement Strategy was implemented in 2013 to improve resettlement outcomes and better support refugees with social and economic integration to their new community and to NZ more broadly. The NZ refugee community is diverse with respect to country of origin, faith, immigration status, social class and education, both within and between ethnic groups. Refugees are considered a vulnerable group with high and complex health care needs.1 They often have suffered extreme mental and physical trauma, coming from countries in situations of long-term war or conflict. These traumatic experiences combine with deprivation, unhealthy environmental conditions and disrupted access to health care, leading to important disparities in health.2 Refugees are also more likely to have increased morbidity, poor health habits and a decreased life expectancy. Although other vulnerable groups also face access barriers and complex health problems, the diverse and complex health care needs of refugees require specific attention.
The primary health care (PHC) sector is pivotal in assessing health needs, managing care and facilitating referrals to appropriate services for refugees. PHC providers are faced with the challenging task of endeavouring to meet these needs, both on refugees’ arrival and in their transition to long-term health care, often with limited professional and organisational support, and within limited funding environments.3 They also report increased pressure of working with refugee patients who cannot speak English and who may manifest multiple problems, with health generally representing part of the broader social challenges that they face. PHC professionals are often unsure about refugees’ entitlements to health care, how to deal with refugees’ mental health problems and where to make appropriate referrals.4 Evidence suggests that while health professionals seek to offer appropriate care, they have to deal with considerable uncertainty and apprehension in responding to the needs of refugees, which can be disempowering, create a disabling hesitancy and inertia in their practice, to the potential detriment of patient care, including stigmatisation. Despite policy initiatives and legislation, robust evidence informing strategies to enhance access, coordination of care and quality of care and reduce inequities in day-to-day NZ PHC practice remains limited. Furthermore, there is little published research examining the health services refugees receive in practice from the viewpoint of service providers.5 For PHC to be more responsive to the distinctive needs of refugees living in NZ, rigorous context-specific refugee health services research examining PHC delivery for this group is critical. The proposed research will be instrumental in addressing the gaps in evidence to foster best practice PHC for refugees in NZ.
This study is the initial phase of a wider qualitative inquiry exploring PHC professionals’ accounts of providing care to refugees in NZ’s Southern region. We seek to systematically review NZ refugee health literature and policy documents, with a particular focus on processes of refugees’ integration, resettlement and access to and engagement with PHC. The specific objectives are to: a. map and synthesise the extent, range and nature of the NZ literature on refugee health policy and practice; b. identify key concepts, dominant views and discourse trends within the selected documents; c. advise on practical and theoretical implications of the findings for refugee health promotion, nursing practice and PHC delivery more broadly. This presentation will specifically describe the innovative methodological approach used to assess current scientific and policy evidence around refugee health delivery in NZ. Preliminary findings from the critical interpretive analysis will be discussed.
Methods:
Design: We use a critical interpretive synthesis (CIS) approach6 to systematically review NZ literature with relevance to PHC refugee health policy and practice. CIS is an established evidence synthesis method which has been widely used in a range of highly relevant health care settings, including access to health care by vulnerable groups. Search strategy: The review will follow an iterative process. Eligibility criteria: NZ literature, with relevance to PHC refugee health policy and practice, published from 2013 (implementation of the NZ Refugee Resettlement Strategy). Systematic review methodology7 will be used to examine both published (MEDLINE, EMBASE, CINAHL) and NZ Grey literature. It will include consultation with experts (e.g. representatives from Immigration NZ, NZ Red Cross). Eligible documents will include original research articles and literature reviews, Government reports, strategic health plans, programme evaluation studies, policy briefs, clinical practice guidelines, educational material and needs assessments. Data analysis: A critical interpretive analysis approach will be used to qualitatively examine the content of the documents6. The interpretive process will draw particular attention to inequity, discrimination and stigma processes (relational, structural, symbolic).
Results:
This study utilises an innovative approach for reviewing different forms of evidence on PHC delivery for refugees in NZ, including scientific evidence, grey literature and refugee health policies. The consultation process inherent to our review provides an opportunity to critically reflect on emerging interpretive trends to further our analysis of the literature by discussing with local experts from the field. The findings will provide insight to researchers examining PHC delivery for refugees in NZ and will contribute to the wider international evidence base on refugee health delivery. The findings will likely have an impact at service delivery level by a. identifying aspects of PHC for refugees that need to be improved, and b. pinpointing strategies on how to best support PHC professionals in providing responsive, high-quality and culturally appropriate care to this group - including reducing health disparities, discrimination and stigma. We also anticipate that this critical review of evidence will shed light on key concepts worth further exploration to foster theory development in the field. Finally, the findings from this study will provide a rich knowledge base to situate the narratives derived from the qualitative interviews with PHC nurses and general practitioners in the subsequent phase of the wider qualitative exploratory study.
Conclusion:
The critical interpretive synthesis method used for reviewing scientific and contextual evidence around refugee health was instrumental in developing a thorough understanding of refugee health delivery and policies in the NZ PHC setting. The explicit focus on equity is a significant contribution to the field and allows for a critical examination of processes of refugees’ integration, resettlement pathways and experiences of access to and engagement with PHC, with the ultimate goal of shedding light on promising strategies for discrimination and stigma reduction.