Opportunities and practices supporting responsive health care for forced migrants: lessons from transnational practice and a mixed-methods systematic review.

Background: For those displaced across borders, significant adversity before, during and after displacement journeys, including attitudes and structures in countries of transit and arrival, contributes to considerable risk of poor physical and mental health, and poor and exclusionary experiences of health care.

Objectives: We aimed to understand the opportunities and practices that can support better healthcare responses for forced migrants.

Design: We integrated (1) local stakeholder perspectives, from workshops and dialogue; (2) evidence and knowledge from a mixed-methods systematic review; and (3) learning from five case examples from current international practice.

Review methods and data sources: We ran database searches (American Psychological Association PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, National Institute for Health and Care Research Journals Library) in February 2022, searched relevant agency websites and conducted backward and forward citation searches, extracted data, assessed methodological quality and integrated qualitative and quantitative findings.

Case examples: We studied three services in the UK, one in Belgium and one in Australia, conducting semistructured interviews with providers, collaborators and service users, and making site visits and observations if possible.

Results: The review identified 108 studies. We identified six domains of impact: (1) benefit from and creation of community, including linkages with formal (health) services; (2) the formation of networks of care that included traditional and non-traditional providers; (3) proactive engagement, including conducting care in familiar spaces; (4) considered communication; (5) informed providers and enhanced attitudes; and (6) a right to knowledge (respecting the need of new arrivals for information, knowledge and confidence in local systems). The case examples drew attention to the benefits of a willingness to innovate and work outside existing structures, 'micro-flexibility' in interactions with patients, and the creation of safe spaces to encourage trust in providers. Other positive behaviours included engaging in intercultural exchange, facilitating the connection of people with their cultural sphere (e.g. nationality, language) and a reflexive attitude to the individual and their broader circumstances. Social and political structures can diminish these efforts.

Limitations: Review: wide heterogeneity in study characteristics presented challenges in drawing clear associations from the data. Case examples: we engaged only a small numbers of service users and only with service users from some services.

Conclusions: We found that environments that enable good health and enable people to live lives of meaning are vital. We found that these environments require flexibility and reflexivity in practice, intercultural exchange, humility and a commitment to communication. We suggest that a broader range of caring practitioners can, and should, through intentional and interconnected practice, contribute to the health care of forced migrants. Opening up healthcare systems to include other state actors (e.g. teachers and settlement workers) and a range of non-state actors, who should include community leaders and peers and private players, is a key step in this process.

Future work: Future work should focus on the health and health service implications of immigration practices, the inclusion of peers in a range of healthcare roles, alliance-building across unlikely collaborators and the embedding of intercultural exchange in practice.

Study registration: This study is registered as PROSPERO (CRD42021271464).

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132961) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 13. See the NIHR Funding and Awards website for further award information.