Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

Abstract Background It has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers. Methods A systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included. Results The interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them. Conclusion This review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health. Patient or Public Contribution Patient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.


| BACKGROUND
Globally, the number of humanitarian migrants, who include refugees and displaced people, has been consistently increasing, with an unprecedented 70.8 million people around the world being forced to leave their home country in 2019 due to conflict and persecution. 1 There are currently more displaced people who have left their current home or residence than at any point since reliable data have been recorded. 2 The United Nations High Commissioner for Refugees (UNHCR) defines a refugee as a person 'who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion' and an asylum-seeker is 'someone whose request for sanctuary has yet to be processed'. 3 Therefore, an asylum seeker is seeking international protection, but whose claim for refugee status is yet to be determined. The UNHCR was originally established in 1950 to help the refugees of the Second World War, 4

and developed the 1951 Refugee
Convention to safeguard the rights of refugees. Although the health and well-being of refugees were not specifically mentioned in the 1951 convention, the World Health Organization (WHO) Constitution 'envisages… the highest attainable standard of health as a fundamental right of every human being'. 5 As such, nation states that accept humanitarian migrants have a responsibility to ensure that the health and well-being of this group are maintained throughout their resettlement process.
It has been widely acknowledged that specifically refugees and asylum seekers may experience poorer health outcomes, spanning mental health and general well-being. This is due to a combination of factors including high burden of disease, poor health care, poverty and the hazards associated with migration. 6 The literature also highlights that many displaced people are reluctant to seek health care assistance when needed due to multiple reasons including, but not limited to, cultural beliefs and psychological trauma. The humanitarian migrants are at risk of poor health outcomes, which is further compounded by reluctance to seek health care assistance when needed due to a range of complex factors. 7,8 Timely access to highquality care during resettlement is commonly reported as a challenge amongst refugee populations. 9 The most commonly reported point of access to health care for migrants including refugees and asylum seekers is via the primary health care/community network in the country of resettlement. 10 A recent systematic review has identified a number of constraints that limit the provision of quality health care to refugee populations including access to health care services, provision of focused care and further resettlement. 11 Access to health care delivery is frequently identified as a barrier for effective health care for refugees and asylum seekers. Often, this is linked to the fragmented and difficultto-navigate health care systems in countries of resettlement 12 or the reluctance of refugees/asylum seekers to access health care for simple reasons like communication barriers. 13 The review also outlined a number of aspects of care quality that should be targets for improvement to enhance health care and outcomes amongst refugees and displaced people. Some of these aspects include building a trusting relationship between patients and practitioners; improving communication; ensuring cultural and social awareness by the practitioners; and ensuring that there is sufficient time to address the needs of refugees. 11 Promoting continuity of health care and ensuring adequate resources to promote this are also a key part of resettlement processes. 11,13 The resettlement process is one component contributing to complex care needs amongst refugees and asylum seekers. Complex care needs describe a diverse population who experiences a combination of medical conditions and requirements for long-term care along with behavioural and/or social need. 14 In the context of refugees and asylum seekers, complex care needs may comprise resettlement, social acclimatization and health concerns. 15 Primary health care systems globally have explored and adopted numerous approaches to improve the quality of health care provided to refugees and asylum seekers, and yet, knowledge of the nature of the interventions used and their impacts is fragmented. 11 The primary health care system is the entry level into the health system via which the people can enter the health system, and it includes a broad range of activities and services from health promotion and prevention to the treatment and management of acute and chronic conditions. 16,17 The present review therefore aims to synthesize the evidence on primary health care interventions to improve the quality of health care provided to refugees and asylum seekers. This review focuses on the interventions exclusively developed in primary care delivery for refugees and asylum seekers in OECD (Organization for Economic Co-Operation and Development) countries of resettlement and to establish evidence of their impacts on care quality. These findings are valuable for health care providers and policy makers towards the systematic enhancement of the quality of health care provision to sustain the complex care needs of refugee and asylum seeker populations.

| METHODS
A systematic review [18][19][20] was undertaken and the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was used to guide the reporting of the review. 21

| Data sources and study strategy
The search strategy was developed in liaison with a medical information specialist (S. M.). A medical information specialist is a librarian (information specialist) who specializes in health and medical literature. This strategy was applied to the following five databases from inception till 2 September 2020 for relevant studies: CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science. Search terms were combined for primary health care, refugees and asylum seekers.
All searches were limited to studies published in the English language only, but no date limits were applied. The detailed search strategy for the databases is attached as File S1.

Inclusion criteria
The eligibility criteria were developed using the Population, Intervention, Comparison and Outcome (PICO) framework. 19 Articles that fulfilled the following criteria were included: (1) articles published in the English language; (2) empirical and original studies; (3) research conducted in the primary health care setting in countries of resettlement (OECD countries); and (4) articles reporting an intervention to enhance any of the six outcomes that meet the definition of health care quality: health care safety, effectiveness of care, timeliness of care, efficiency of care, equitable and person-centred care. Quality of care was defined as that aligned with the six pillars of quality identified in the WHO's definition of quality of care: 'the extent to which health care services provided to individuals and patient populations improve desired health outcomes'. To achieve this, health care must be 'safe, effective, timely, efficient, equitable and people-centred'. 22

Exclusion criteria
Articles that reported interventions that did not occur in a primary care setting or include a component that occurred within a primary care setting were excluded, along with those that were not focused on the target population of refugees and/or asylum seekers. Articles that were commentary, opinion pieces, editorials and non-peerreviewed were also excluded.

| Study selection and data extraction
Articles were managed using a reference-management software (Covidence), and duplicates were removed. The process of title and abstract screening was undertaken independently by two reviewers The data extraction proforma was developed by the research team to address the review questions. The following study characteristics were extracted using the finalized proforma: investigators, year, country, setting, sample and background, design and health care professional involved in the delivery of the intervention and the intervention.

| Assessment of quality
All the included articles were assessed and evaluated using the comprehensive Quality Appraisal for Diverse Studies (QuADS) tool, which is specifically designed to appraise qualitative, mixed and multimethod studies in health services research 23 (see File   S2). The nature of health services research involves diverse study designs that can be in-depth qualitative studies, mixed methods and multimethod approaches of exploration and evaluation. 23 Each criterion was scored on a 4-point scale ranging from 0 to 3.
The QuADS tool was independently applied to the studies by two reviewers (M. P. I.; J. L.). Discrepancies were discussed and resolved by a third reviewer (R. H.).

| Data synthesis
The findings were analysed using a narrative empirical synthesis based on the aims of the systematic review. 24 Narrative synthesis in systematic reviews is particularly useful in understanding the effects of the interventions as well as the factors that impact the implementation of interventions. 24 The narrative approach was used to synthesize the qualitative and quantitative findings, which allowed indepth exploration and collective understanding from multiple studies that developed a broader perception of the phenomenon under study. The initial descriptions of eligible studies and results are tabulated in Table 1.

| Excluded studies
Studies (n = 101) were excluded at the full-text review stage because they did not fulfil the inclusion criteria and for the following reasons: n = 44 reported an intervention that is not focused on improving the quality of care for refugees and asylum seekers, and n = 24 did not report eligible outcomes relevant to the inclusion criteria. In addition to these, n = 19 were studies from non-OECD countries; n = 14 focused on the nonrefugee/asylum seeker population or the intervention was beyond the primary care context.

| Study quality
The studies rated highly on a clear statement of research aims and appropriate study design descriptions to address the stated aims, and yet, generally received an average or low score for description of the data collection methods. [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] The majority of the studies received low scores (0-1/3) on criteria related to sampling 25, and evidence of research stakeholders' involvement in the research F I G U R E 1 PRISMA flow diagram for a systematic review of the literature to explore interventions focusing on improving health care quality for refugees and asylum seekers in the context of primary health care. PRISMA, Preferred Reporting Items for Systematic Reviews design and conduct (0-1/3). We did not exclude studies based on the quality assessment; rather, the quality assessment data were used simply to indicate the strength of the available evidence.

| Characteristics of the included studies
Of the total of 55 studies included in the review, the majority n = 35 were from North America (United States and Canada) 25 Figure 2). Two interventions (2/55 studies) were organized to be included in more than one category outlined above. 29,78 The majority of the studies (29/55 studies) identified in this review discussed the involvement of doctors engaging with the interventions. [25][26][27][28][29]31,32,[34][35][36][37]41,43,46,47,50,53,56,58,67,69,70,74,[76][77][78][79] Health care professionals involved in the interventions also included nurses or nurse practitioners (11/55 studies), 26,28,29,31,35,36,48,50,58,77,78 undergraduate students (6/55 studies), 29,30,36,40,57,78 patient navigator roles/community health workers (4/55 studies), 39,42,44,46 clinical psychologists (4/55 studies), 35,47,54,74 pharmacists (3/55 studies), 38,62,71 physiotherapists and/or exercise specialists (3/55 studies), 28  F I G U R E 2 Interventions present within the primary care network that aim to improve the health care quality of refugees and asylum seekers in countries of resettlement A substantial group of studies (n = 14) described health promotion interventions 28,36,39,42,44,46,51,52,56,57,63,64,66,73 for refugees/asylum seekers and their families and these were predominantly aimed at promoting access to the services available (five studies), 36,46,51,52,57 improving engagement with and adherence to health regimes for better health care outcomes (seven studies). 28,39,42,56,63,66,73 Two studies in this category were also designed to promote information about physical health and well-being especially related to cardiovascular health like healthy diet, sleep and exercise. 44,64 Six studies sought to advance the skills and ability of refugees and asylum seekers to talk about their health and health care with health professionals and broader health and social care workers. 29,45,47,48,54,62 The studies tackled a range of issues addressing mental health concerns (2/6 studies) 47,54 and trauma care related to past experiences and/or migration to a new country (3/6 studies). 45,48,54 One intervention was more broadly seeking to improve individual patients' ability to speak with health care workers in the host country's health care system. 29 Interventions often focused on a specific cultural and ethnic group. to online modules to upskill GPs about cross-cultural considerations for specific refugee populations. 32,37 Another study on promoting equitable health care delivery was in the format of face-to-face teaching, discussion groups and implementation of organizational structures to promote equity in care delivery. 70 Posttraining surveys reported that health care professionals felt more confident in clinical encounters and were more likely to involve patients in future care discussions. 70 One study discussed the role of a refugee health fellow in building the capacity of primary health care professionals, including GPs and practice nurses, in providing effective health care for refugees and asylum seekers in an Australian context. 79 The role of the facilitator was to identify and contact general practices involved in providing care to refugees and asylum seekers. Visits to the general practices aided in providing health resources, tools and frameworks to promote provision of safe and patient-focused health care for refugees and asylum seekers. 79 Moreover, multiple subsequent visits were arranged to discuss practice-specific issues in relation to providing ongoing assistance. Tailored educational strategies were collaboratively developed by the fellow along with the GPs and practice nurses to deal with health care issues pertinent to refugees and asylum seekers. This targeted approach of developing skills of the IQBAL ET AL. Three interventions promoting person-centred care targeted impact in distinct groups of refugees and asylum seekers. Two interventions were designed for a specific refugee/asylum seeker cultural group 49,69 and/or a specific health condition. 49,69 The effectiveness of these interventions was reported through patient self-reported outcomes such as patient satisfaction in the overall quality of their mental health care, satisfaction with the primary care provider and the degree of patient-centredness. 49,69 A statistical increase in the number of clinic visits for age-appropriate child checks was reported, and increased health care professional satisfaction and confidence was measured in relation to providing care for a specific health condition like failure to thrive in refugee children. 49 Another unique initiative promoting person-centred care and improved access to health care involved upskilling refugees who were doctors themselves to become effective members of the National Health Service team, in the primary care delivery context, of the host country, that is, United Kingdom, and involve them in care delivery of the refugee population. 61 Participating refugee doctors became familiar with the health care delivery standards of the host country and over 50% continued to work as doctors, providing care in the community.
Seven interventions focused on specifically enhancing access to health care services amongst refugees by upskilling health care professionals. 29,30,32,40,67,70 Interventions (n = 2 studies) in this category were designed to upskill primary health care professionals in terms of the legal aspects for refugee health and approaches that orient refugees to a new health system to promote cultural safety and access to care in the host country. 32,67 For example, specific modules were designed with information on the different aspects of health care delivery and legal aspects such as the involvement of interpreters, translators and cultural mediators in care provision. 32 A further study reported conducting face-to-face workshops on specific topics (such as trauma-and violence-informed care) with general group discussions about issues raised by primary care professionals and online education modules to support harm reduction. 70 30 presented a more interprofessional model involving nursing and dental students in addition to medical students. This approach of involving students in refugee care provision was reported to be an effective approach of developing the students' skills and knowledge of sensitive issues in providing care to refugees. The involvement and mentoring of students were rewarding experiences for the entire team including the senior health care professionals. 30 Interprofessional models of care discussed have initiated holistic and accessible health care for the refugees.
(3) System and/or service integration models and structures: Seventeen interventions (17/55 studies) were designed to promote health system integration and continuity of care arrangements.
Interventions in this subcategory were designed to improve different facets of health care delivery. However, all 17 studies focused on the delivery of safe health care. [25][26][27]34,35,38,41,50,58,59,68,71,72,74,[76][77][78] Some studies were designed to improve more than one health care outcome: Fourteen studies (14/17 studies) sought to enhance or enable delivery of person-centred care, 26,27,[33][34][35]41,43,47,[58][59][60]74,[76][77][78] nine studies (9/17 studies) focused on promoting efficient care delivery 38,41,50,58,59,68,71,76,77 and two studies (2/17 studies) enhanced equitable health care delivery. 25,72 Six studies were designed to be in close proximity to the residences of refugees and asylum seekers, which promoted better engagement with them and aided in providing them timely access to care. 41,50,58,59,68,77 Collaborative models of care were also described that linked refugees and asylum seekers to appropriate health care facilities (n = 3 studies), such as patientcentred medical homes for provision of health care by collaborative, interprofessional health care staff. 25 Australia. 43,50 These interventions focused on enhanced patient access, provision of culturally oriented, family/person-focused collaborative care in primary care more generally 43,50,59,72,77,78 and, more specifically, antenatal/maternity care. 25 family-focused health care delivery (three studies). 43,77,78 In addition to these, Grigg-Saito et al. 59  This category included comprehensive care delivery models for mental health care (n = 6 studies) offered in accessible locations including homes, community centres and schools. 27,35,47,55,59,68,74 Two studies discussed a family care approach promoting the mental and psychological well-being of the entire family. 27,59 Four studies offered patients access to evidence-based, traumainformed mental health care in the primary care clinical context itself, and these care services offered integration with wider sustainable social support networks. 35,47,68,74 Patient access to care and person-centred care within existing health services was promoted via interventions offering client information in multiple languages, translation services and also various formats (11 studies) 26,27,[33][34][35]43,[58][59][60]74,77 or the involvement of cultural mediators in its delivery (five studies). 35,41,47,76,78 Some of the interventions highlighted the freeof-cost services, which again related to improved accessibility to care and equitable health care for refugees and asylum seekers (n = 4 studies). 38,71,76,77 Distinct, patient-focused and integrated clinics were also evaluated relative to specific diseases to enhance the provision of screening services, education and treatment for infectious diseases such as latent tuberculosis infections (two studies). 26,76 Some studies reported the involvement of allied health staff members (two studies) such as pharmacists in effectively leading these clinics for tuberculosis in particular 71 and for other minor ailments. 38 The studies reported on factors such as the importance of cultural mediators, language translators and cost-free services in improving safety, quality, equity and accessibility to care and provision of person-centred care. The complexities and challenges of conducting longitudinal studies with humanitarian migrants are identified in the literature. 83,84 Long-term and longitudinal research on refugee resettlement is valuable because it can provide an insight into the transformation of challenges and opportunities over time. 84 All education programmes discussed the importance of being culturally/linguistically relevant in promoting both the physical and psychological well-being of both receiving and providing care. Studies that explored refugees' experiences were useful in providing an in-depth understanding of client experiences with the intervention and these were explored in some studies on upskilling refugees/asylum seekers. 54,57,63,66 The in-depth understanding of participants' perspectives aided in identifying the subtle, yet critical aspects of care provision that impacted health and well-being. 54,57,63 Participants also explained why the positive impact of the intervention waned after the completion of the intervention. 57 An important aspect was communicating about the implementation of the intervention with the participants. 63 Research involving resettled refugees and asylum seekers raises methodological and ethical complexities. [84][85][86] This complex nature of conducting research with humanitarian migrants is reflected in the wider literature and some draw particular attention to methodological issues of sampling, translation and use of local assistants and using an open-minded approach to draw inferences. 85 Others have identified ethical considerations in relation to research, its application and policy, 87 and issues around informed consent, and the notion of do no harm in research. 86 The broader literature suggests that refugee health requires intersectoral and multidisciplinary work to promote effective health care delivery. 88,89 The WHO mandates this by advocating for enhanced coordination and collaboration to achieve the goal of universal health coverage for refugees and migrants. 82 However, this review identified that doctors were predominantly the group provided with the skill development opportunities. 32,37,53,67,69,70,79 This has implications for involving the wider health care team and interprofessional members in primary care delivery for refugees and asylum seekers. Very few interventions are targeted towards upskilling or encouraging the involvement of interprofessional teams in health care delivery. The potential for enhancing health care quality through interprofessional team involvement requires further exploration. The majority of studies focused on specific issues pertaining to refugee health, with a paucity of interventions that focused on holistic enculturation and adjustment of the displaced people in the new country of residence. Interventions of this nature involved a community approach with the physical-psychosocial-spiritual needs at the centre of focus. 50,59 There is also an emergence of online resources available for supporting refugee health care that are designed both for primary care doctors and for refugees, but these were often focused on physicians only. 52,67 The challenge is in managing information available via online resources for refugees and asylum seekers in multiple languages, especially in terms of maintaining its quality and authenticity. 52 The is an opportunity to explore the role of digital platforms in managing the health of humanitarian migrants and refugees. 90,91

| Implications
The review findings suggest that there is value in involving multidisciplinary health care professionals when exploring models of health care delivery for refugees and asylum seekers, and yet, there is a paucity of interventions involving other members of health care teams beyond doctors. Coordination and integration of health care across different health and nonhealth services have been associated with improved communication and coordination between service providers to meet the needs of migrant patients. 92 Moreover, the role of the health sector in working across organizations on issues not limited to health but to wider aspects related to migration, social, welfare, education, interior and development sectors is a priority in promoting the health of refugees and migrants. 93 Refugees are identified to have complex care needs; therefore, a multidisciplinary team is an important mechanism for organizing and coordinating health and care services to meet the needs of individuals with complex care needs. 94 Papers discussing upskilling of health care professionals highlighted the importance of cultural competence as underpinning quality care for humanitarian migrants. 32,37,53,70,78,79,95 Time constraints faced by primary health care providers in participating in such activities were identified as a key challenge. 32,37 Addressing health care professionals' cultural competence is a common approach to improving the quality of health services for culturally and ethnically diverse groups, such as refugees and asylum seekers. 96 status. 98,99 The identified interventions in the primary care setting were designed for both refugees and asylum seekers, and no differentiated intervention specifically for asylum seekers was recognized. A lack of distinction was identified in studies between different types of humanitarian migrants and this identifies a need for more rigorous evaluations, especially those focused on the impact of innovative models on different groups of humanitarian migrants.

| CONCLUSION
This review has identified 55 studies that report on interventions in primary care that were developed to promote effective health care delivery for refugees, asylum seekers and their families. Interventions were designed with a focus on delivering effective, efficient, timely, equitable and person-centred health care for important issues pertinent to the health of refugees and their resettlement in the host country. Interventions were focused on upskilling humanitarian migrants, their families and health professionals and on models and systems of care to improve health care quality communication and care arrangements. It is identified that there is a paucity of studies that have explored the involvement of a multidisciplinary team and community-focused and intersectorial approaches that may be important in contributing to quality care provision for this population.

ACKNOWLEDGEMENTS
This systematic review was conducted as part of the wider research project titled Refugee Health facilitator Program: Evaluating scope, scalability and outcomes in collaboration with the WentWest organization. We acknowledge their role in assisting with this study. This study was supported by the School of population health, University of New South Wales Grant Building Scheme.

CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from thecorresponding author upon reasonable request.