Health Care Access for Displaced Persons

Original Editor - Vidya Acharya and Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson and Carin Hunter  

Introduction[edit | edit source]

The right to health is embodied in numerous human rights instruments. Despite this, migrants are often met with restrictive access to health services. This is particularly a problem for migrants without resident permits, and displaced persons. However, it can also be a challenge accessing health services which one is entitled to. There are possible barriers at each stage of the health care service from identifying a health problem to getting access to a proper service. Such barriers could be information and health understanding, economic challenges, communication and biases from health professionals. It is important to be aware that these barriers do not occur in isolation, but that they are often multifactorial and clustered. This makes it even harder because many new barriers and challenges can arise even when one is solved.

Barriers to Accessing Health Care[edit | edit source]

Accessing health care and social care support and services becomes a challenge for many displaced persons. Barriers or difficulties in accessing health care include:[1]

  • Language barriers
  • Excessive paperwork
  • Lack of information on how to access services
  • Types of services available
  • Lack of cultural competency
  • Fear of persecution
  • Systemic issues associated with being ‘status less’ (i.e., the transitioning process from an asylum seeker to a refugee)

Immigration Status[edit | edit source]

Immigration status often plays a role in a lack of access to health services due to the fear of deportation and discrimination, resulting in reduced utilisation of health care services.[2]

Lack of Familiarity with the Health Care System[edit | edit source]

The limited information on accessing primary health care services and not knowing whom to ask or where to go for health care, can result in frustration. It can also prompt people to seek help from inappropriate sources. The displaced person may experience difficulties; for example, immediate access to GP (General Practitioner) in the host countries follows a protocol that involves an appointment and wait-listed approach. It is contrasting to their homeland, where they get to see the GP immediately. It can be confusing as the displaced person may think conditions might resolve by the time they get an appointment. The problem with this approach is that it may prevent individuals with more severe illnesses from acquiring medical attention early in the disease process.[3]

Lack of Resources[edit | edit source]

Lack of availability of adequate resources to screen and provide specialised treatment programs for traumatised displaced persons. [4]

Financial Costs[edit | edit source]

Access to healthcare becomes an arduous task in the presence of financial constraints. Multiple factors like lack of livelihood, health insurance, transportation costs affect access to health care for new refugees. The financial capability of the displaced person and lack of medical coverage for services that are chargeable presents as a barrier in seeking medical help.[5]

Trust Issues[edit | edit source]

When working with different cultural groups, external intervention can be seen as obtrusive, meddling into personal space. They may distrust the health care provider. It may be based on the fear of sharing sensitive information, divulging visa status or the fear of deportation. [6]

Language Barriers[edit | edit source]

Research suggests that communication difficulties with service providers act as a critical barrier for displaced persons seeking health and social services.[1] The majority of displaced persons may not speak the language of the host country and have fear of and difficulty in expressing their medical symptoms in a second language.[7] Therefore, people with a language barrier are unable to seek medical attention without an interpreter or translator, which are not always widely available depending on the language of the person.

An interpreter helps in transferring the message from the health provider to the displaced person and vice-versa. The role of interpreter is to hear concerns from both sides and provide accurate interpretation.[8] Even with interpreters, miscommunication can occur between doctors and patients due to the lack of proficient medical interpreters. This leads to inappropriate diagnosis, and devastating outcomes such as adverse drug effects, permanent disability, or even death.[1] Confusion might arise during a medical consultation with the use of complex medical terms providing information.[1] The feelings of alienation and mistrust may continue to grow and may prevent the patient from seeking out future medical care.[9]

Problems Associated with Interpreters[edit | edit source]

  • Family or individual refuses
  • Male interpreter is present for a female client
  • Interpreter imposes own view
  • Family does not want to disclose sensitive information
  • Availability of a suitable interpreter
  • Interpreter is not efficient
  • Added financial costs[8]

Health Literacy[edit | edit source]

Health literacy is the ability of an individual to obtain, process, and understand necessary health information.[10] Low reading skills and poor English language comprehension make it challenging for the displaced person to navigate in the new environment. A stuby by Boateng[11] shows that displaced persons with limited English proficiency are more affected by the health literacy barrier than native English speakers. Displaced persons with low health literacy are less likely to understand written or verbal information from their health care providers, to follow medications or appointment schedules, or navigate the health care system to obtain medical care.[12] This can lead to non-adherence to treatment. Low health literacy can have serious health consequences and puts additional demands on the healthcare system. It has been found that lack of health literacy resulted in difficulty in filling and refilling prescription medications, reading medicine labels, understanding the right dose, and taking medications at the right time.[12]

Overcoming Barriers[edit | edit source]

It is important to try to overcome barriers to accessing care and provide guidance for navigating the healthcare system. Understanding the displaced persons’ expectations of the health care system and challenges faced by them is essential to improve and provide necessary health care services to refugees. New roles should be developed for health care staff that address the diverse needs of displaced persons groups who have dealt with exceptional life situations like war, separation, and death.[1] There is a need to improve language and information services and create close links with community-based organisations. Health services should engage in community-level interventions focusing on more culturally congruent services with the communities’ health constructions.[1]

Providing Culturally Sensitive Care[edit | edit source]

Cultural sensitivity is essential in cross-cultural medical treatment. There is a need for more cultural health service providers. Strategies to support displaced persons should be developed. Increasing cultural awareness, cultural sensitivity, cultural education, and cultural competence among health professionals is essential to provide quality care to culturally diverse patients. [5]

Formalising training to health care staff about understanding the health care needs of displaced persons is a must along with providing special treatment programmes to traumatised displaced persons.[14] Health care providers should address cultural factors during initial assessments and investigations including:[5][8]

  • Taking a detailed medical history and conducting a physical exam. Cultural values inform the patients’ definition of health, the body and its functions, and the perception of the problem and cause
  • Inquiring about traditional treatments practised. Alternative approaches exist in various cultures (like for reducing fever, hygiene, and beautification) and a wide range of practices and customs are practised during major life events (childbirth and death)
  • Assessing care needs that often require the provider to view illness in a broad social context, rather than as an individual concern
  • Differentiating between cure and treatment, sharing information on health and wellness, and involving the patient's family and community in care and medical decisions


In the area of mental health, a broad continuum of mental health services including psychosocial assessments, advocacy, home visits, case management, counselling, psychopharmacology, and asylum evaluations need to be provided to refugees. Agencies should encourage all of their staff to consider social adjustment issues from intake and throughout the refugee experience. Social adjustments and mental health issues must be included in the thinking of support staff working with displaced persons in order to serve them better. Employment counsellors should be trained to observe clients over a longer period to note difficulties that may arise and refer the candidates for counselling and other social services.[8]

There is a need to engage in more community-level interventions with a focus on cultural congruence with the communities’ health constructions. Culture-blaming issues is another area that needs attention. It should be avoided and focus should be kept on developing strategies to support marginalised groups. Cultural safety requires genuine efforts to understand cultural barriers through community engagement and working with community members in addressing these barriers. [1]

Providing Legal Status[edit | edit source]

Migrants with legal documents have better access to health care. It is important to invest and develop effective strategies that allow the provision of primary and preventive health services such as screenings, health promotion, and disease prevention for the vulnerable groups of migrants.[15] Increasing medical insurance coverage for displaced persons can help in getting access to health care facilities.

Access to Health Care Service[edit | edit source]

Lack of knowledge about how to navigate the complex health care system results in poor access to healthcare services.

  • Providing education about navigating the healthcare system[8]
  • Increasing eligibility for Health Insurance may provide assistance[8]


Fast track schemes to integrate displaced persons:

  • New public-private partnership for health surveillance
  • Delivering information about health promotion
  • Phone-based incentives
  • Sign-posting of essential health services

Language and Information Services[edit | edit source]

In the absence of linguistically and culturally accessible care, displaced persons and immigrants may have difficulty developing trust and respect for physicians and western medicine. There is a need to improve language and information services. Access to language services, cultural awareness, and education of both provider and patient will remove misunderstandings among the patient and the health care provider. The following should be implemented:

  • Language-assistance services should be provided at no cost to the patient, at all points of contact, promptly, and during all hours of operation;
  • Verbal and written notices informing patients of their right to receive language assistance should be made available, where possible in a wide range of languages;
  • Unless requested by the patient, family members or friends should not serve as interpreters; and,
  • Patient-related materials and signage must be provided in the commonly encountered patient language group(s).[8]


Confusion that arises during a medical consultation due to the use of complex medical terminology needs to be corrected. There is a need to address cultural differences concerning diagnoses, and medical terminology.[1]

Role of the Interpreter[edit | edit source]

The interpreter facilitates communication during the consultation and builds interpersonal trust. As discussed earlier, interpreters accompanying displaced persons need to be competent in interpreting medical language to prevent any errors. Interpreters should be trained to work with culturally diverse groups. In some cases, interpreters from the same community may fear leaking of personal information in their society; so, the interpreter should assist on request. In the absence of an interpreter, health providers can make use of non-verbal communication skills to express themselves adequately. Hand signals, visual cues, gestures, simple words slow speech, friendliness (approaching with smile/being calm/humour) can be used to communicate better.[5]

The use of telephone interpreters increases the availability of interpreters at any time of the day.[16] Remote telephone interpreting services provide rapid access to various languages, and patients feel comfortable about confidentiality with a remote interpreter. [17]

According to a pilot study evaluating the quality of care available to displaced persons, four themes reflected a ‘good doctor visit’. They were:

  1. Ability to communicate without language barriers;
  2. Open reciprocal dialogue with providers;
  3. Provider professionalism; and
  4. Accurate diagnosis and treatment. [14]

Translational Services[edit | edit source]

Providing qualified translational services will assist newly arrived displaced persons to access health care services.[8] Providing written cross-cultural health promotion material is required. Speech-to speech translation systems that convert speech in the source language to another speech in the target language can be developed and used for communication.

Cultural Competence in Rehabilitation[edit | edit source]

Rehabilitation professionals should be aware of their own cultural identity. They should have cultural knowledge of common health beliefs and behaviours and should display culturally-sensitive behaviours (e.g., empathy, trust, acceptance, respect). They are required to use this knowledge and skills to modify their approach to meet the culturally-diverse needs of their clientele. Therefore, the ability to work with clients from diverse cultures is considered as a skill for improving clinical outcomes.[18]

Brief Interventions for Rehabilitation Professionals working with Displaced Persons[edit | edit source]

Rehabilitation professionals should identify the functional capacity of the client along with the functional deficits. The main focus should be on resources and current situations and future life opportunities.[19]

Building a Therapeutic Relationship[edit | edit source]

The rehabilitation professional should create a working relationship with the client and establish trust and rapport. They should show an attitude of understanding and interest to the client. They should listen with empathy and face the emotions that the client wishes to express. Confidentiality of the client's information must be assured. Pay attention to how the client feels: whether they need a break, or are okay to continue the sessions.[19]

Education and Information[edit | edit source]

Rehabilitation professionals should educate the client about their condition and treatment options.[19]

Create a Safe Environment[edit | edit source]

A safe environment, so the client feels comfortable enough to express themselves should be provided. The therapist should acknowledge the client’s present situation and past experiences. The rehabilitation professional should adapt to a pace that is tolerable for the client. Anything which triggers traumatic memories should be addressed immediately.[19]

Boundaries[edit | edit source]

Respect should be given for the client's boundaries during rehabilitation. For example, body positioning between the client and therapist - consider what distance the client feels comfortable? Rehabilitation professionals should ask for permission from the client and explain the necessity of touch to the client before conducting any physical examination. A respectful contact, such as a firm handshake, establishes excellent rapport with the client. [19]

Facilitating Access to Rehabilitation Centre[edit | edit source]

Many displaced persons may not be aware of rehabilitation management options. Providing information about the services available through posters, images can be beneficial.

Summary[edit | edit source]

The development of cultural competence is a learning process. Teamwork and collaboration among health care providers is essential. Displaced persons will benefit more from a culturally competent interaction.[21]

Resources[edit | edit source]

Translation Cards

  • "Designed for humanitarian response, Translation Cards is an app for Android devices that allows for tap-and-play audio translations, even in the most remote bandwidth-constrained locations. Each card contains an audio translation, optional text translation, and works across multiple languages. Any organisation can rapidly create a deck of cards catered to their own specific use cases. Translation Cards are available on the Google Play Store for free. The app comes bundled with a default deck designed by UNHCR Innovation for humanitarian refugee crisis response in Europe."[22]
  • https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Fang ML, Sixsmith J, Lawthom R, Mountian I, Shahrin A. Experiencing ‘pathologized presence and normalized absence’; understanding health related experiences and access to health care among Iraqi and Somali asylum seekers, refugees and persons without legal status. BMC public health. 2015 Dec;15(1):923.
  2. Rangel Gomez MG, López Jaramillo AM, Svarch A, Tonda J, Lara J, Anderson EJ, Rosales CB. Together for Health: an initiative to access health services for the Hispanic/Mexican population living in the United States. Frontiers in public health. 2019;7:273. https://www.frontiersin.org/articles/10.3389/fpubh.2019.00273/full
  3. Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, Hassan G, Rousseau C, Pottie K. Common mental health problems in immigrants and refugees: general approach in primary care. Cmaj. 2011 Sep 6;183(12):E959-67.
  4. Kiselev N, Pfaltz M, Haas F, Schick M, Kappen M, Sijbrandij M, De Graaff AM, Bird M, Hansen P, Ventevogel P, Fuhr DC. Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. European journal of psychotraumatology. 2020 Dec 31;11(1):1717825. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034440/#CIT0047
  5. 5.0 5.1 5.2 5.3 Chuah FL, Tan ST, Yeo J, Legido-Quigley H. The health needs and access barriers among refugees and asylum-seekers in Malaysia: a qualitative study. International journal for equity in health. 2018 Dec 1;17(1):120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6094870/
  6. Keys to Cultural Competency: A Literature Review for Evaluators of Recent Immigrant and Refugee Service Programs in Colorado, REFT Institute, Inc. March 2002.
  7. Carta MG, Bernal M, Hardoy MC, Haro-Abad JM. Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clinical practice and epidemiology in mental health. 2005 Dec 1;1(1):13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1236945/
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Quickfall J. Cross-cultural promotion of health: a partnership process? Principles and factors involved in the culturally competent community based nursing care of asylum applicants in Scotland.https://era.ed.ac.uk/handle/1842/4466
  9. Health Challenges for Refugees and Immigrants by Ariel Burgess, VOLUME 25, NUMBER 2 https://reliefweb.int/sites/reliefweb.int/files/resources/ACB7A9B4B95ED39A8525723D006D6047-irsa-refugee-health-apr04.pdf
  10. Baker DW. The meaning and the measure of health literacy. Journal of general internal medicine. 2006 Aug 1;21(8):878-83. https://pubmed.ncbi.nlm.nih.gov/16881951/
  11. Development, Implementation, and Evaluation of Refugee Health Literacy Program (R-HeLP) Cecilia A. Boateng University of Kentucky
  12. 12.0 12.1 Schloman B. Information Resources Column:" Health Literacy: A Key Ingredient for Managing Personal Health.". Online Journal of Issues in Nursing. 2004 Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No2May04/HealthLiteracyAKeyIngredientforManagingPersonalHealth.aspx
  13. PFontJr. Health Literacy and Cultural Competency. Available from: http://www.youtube.com/watch?v=ZsX0ha_rIBg[last accessed 30/08/20]
  14. 14.0 14.1 Patient Experience Journal Refugees' perceptions of primary care: What makes a good doctor's visit? Volume 6 Issue 3 Article 5 https://pxjournal.org/cgi/viewcontent.cgi?article=1382&context=journal
  15. Rangel Gomez MG, López Jaramillo AM, Svarch A, Tonda J, Lara J, Anderson EJ, Rosales CB. Together for Health: an initiative to access health services for the Hispanic/Mexican population living in the United States. Frontiers in public health. 2019;7:(273). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6769102/
  16. Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ open. 2017 Aug 1;7(8):e015981. https://bmjopen.bmj.com/content/7/8/e015981
  17. Phillips C. Remote telephone interpretation in medical consultations with refugees: meta-communications about care, survival and selfhood. Journal of Refugee Studies. 2013 Dec 1;26(4):505-23. https://www.researchgate.net/publication/243056385_Remote_Telephone_Interpretation_in_Medical_Consultations_with_Refugees_Meta-communications_about_Care_Survival_and_Selfhood
  18. Bialocerkowski A, Wells C, Grimmer-Somers K. Teaching physiotherapy skills in culturally-diverse classes. BMC medical education. 2011 Dec;11(1):34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146421/
  19. 19.0 19.1 19.2 19.3 19.4 Interventions for Physiotherapists Working with Torture Survivors; With special focus on chronic pain, PTSD, and sleep disturbances By Hanne Frank Nielsen DIGNITY Publication Series 6.
  20. American Physical Therapy Association. Developing Diversity in Physical Therapy: The Importance of Cultural Competence. Available from: https://youtu.be/dMJ1VYtFIB8[last accessed 30/08/20]
  21. Black JD, Purnell LD. Cultural competence for the physical therapy professional. Journal of Physical Therapy Education. 2002 Apr 1;16(1):3.
  22. Translation Cards. Available from: http://translation-cards.com/ (accessed 6 July 2022).