Empathy and journey mapping the healthcare experience: a community-based participatory approach to exploring women's access to primary health services within Melbourne's Arabic-speaking refugee communities

Access and use of sexual and reproductive health services among asylum-seeking and refugee women in high-income countries: A scoping review

BACKGROUND

Refugee and asylum-seeking women are known to experience a myriad of intersecting sociocultural, institutional, and systemic barriers when accessing healthcare services after resettlement in high-income countries. Barriers can negatively affect service uptake and engagement, contributing to health inequities and forgone care. Access to sexual and reproductive healthcare (e.g., family planning, cervical cancer prevention) has largely been understudied. This scoping review sought to: i) examine the use of sexual and reproductive health services among refugee and asylum-seeking women in high-income countries; and ii) identify barriers and facilitators influencing access to sexual and reproductive healthcare for refugee and asylum-seeking women in high-income countries.

METHODS

This review was conducted in accordance with Joanna Briggs Institute Methodology for Scoping Reviews. Ten databases (e.g., CINAHL, MEDLINE, Embase) were searched for qualitative, quantitative, mixed method studies, and gray literature published anytime before February 2024 across high-income countries (defined by the World Bank). The Health Behaviour Model was used to examine and understand factors influencing service use and access.

RESULTS

3,997 titles and abstracts were screened, with 66 empirical studies included. Most were conducted in the United States (44%), Australia (25%), Europe (18%) and elsewhere and were qualitative (68%). Papers largely addressed contraception, abortion, cervical cancer screening, gender-based violence, and sexual health education. Included studies indicated that refugee and asylum-seeking women in high-income countries face a greater unmet need for contraception, higher use of abortion care, and lower engagement with cervical cancer screening, all when compared to women born in the resettlement country. Frequently reported barriers included differences in health literacy, shame and stigma around sexual health, language and communication challenges, racial or xenophobic interactions with healthcare providers, and healthcare/medication costs.

CONCLUSIONS

Studies across the globe identified consistent empirical evidence demonstrating health inequities facing refugee and asylum-seeking and myriad intersecting barriers contributing to underuse of essential sexual and reproductive health services. Facilitators included multilingual healthcare provider, use of interpreters and interpretation services, community health promotion work shops, and financial aid/Medicare.

'If I'm not sick, I'm not going to see the doctor': Access to preventive sexual and reproductive health care for Karen women from refugee backgrounds living in Melbourne, Australia-A qualitative study

ISSUE ADDRESSED

Women from refugee backgrounds have poorer health outcomes than host country populations. People from Myanmar, most of whom are from the Karen ethnic minority constitute one of the largest groups of humanitarian visa entrants to Australia since 2015. Barriers to and enablers of preventive sexual and reproductive health (SRH) for this group of women are poorly understood. The objective is to establish the preventive SRH care needs and experiences of Karen women from refugee backgrounds living in Australia.

METHODS

A qualitative study using semi-structured interviews was conducted with a purposive sample of Karen women. A bi-cultural worker assisted in recruitment and interpreting during data collection. All interviews were conducted in Karen language with a bi-cultural worker interpreting into English during the interview. Audio recordings of English dialogue were transcribed verbatim. Thematic analysis was used to analyse and report data.

RESULTS

Thirteen women were interviewed. Five major themes were identified: (1) prevention awareness including lack of access to education and knowledge of services pre-arrival; appreciation of the new health system; limited vaccination knowledge, (2) perceived need for prevention including consequences of not screening; health care provider (HCP) attendance, (3) health information seeking including providing a comprehensive approach to information delivery; trusted sources of information, (4) barriers including missed opportunities; communication, language, illiteracy; lack of continuity of care and, (5) enablers including HCP' characteristics; peer support and individual responsibility.

CONCLUSION

Findings from this study indicate that to improve access to preventive SRH services a multi-component strategy is needed. Provision of preventive SRH information using a multi-pronged approach; peer and community support interventions; and HCPs offering services and information opportunistically would benefit Karen women unfamiliar with preventive SRH care. SO WHAT?: Primary prevention services and education codesigned with community members may be effective in improving Karen women's access to SRH care.

Qualitative Systematic Literature Review: Participatory Visual Methods in Community Health Interventions With Migrants

This systematic review investigates how participatory visual methods (PVMs) (1) are applied in community health interventions (CHIs) with adult migrant populations and (2) identify potentials for participation. The search was performed in PubMed in 2021 and 2023. Eighteen articles fulfilled inclusion criteria as they investigated a CHI targeting migrants and used a visual method. We excluded articles that used quantitative methods, articles written in languages other than English, Danish, Swedish, or Norwegian, and the formats reviews, protocols, and theoretical articles. As a framework to graduate the degree of participation, we applied Arnstein's 'A Ladder of Citizen Participation'. Most of the studies took place in the United States, and the most frequent method used was photovoice. We categorize an equal number of articles as 'degrees of citizen power' or 'degrees of tokenism'. We identify the capacity to accommodate the needs of specific target groups to be a strength in PVMs, which has potential to engage migrants in several parts of the research process. Additionally, PVMs can be used to support a change in the participants' lives by facilitating a reflexive process concerning their life situation. However, utilization of PVMs also include a risk of tensions, they can be resource-demanding and potentially exclude certain groups.

What do women want? Migrant and refugee women's preferences for the delivery of sexual and reproductive healthcare and information

OBJECTIVE

Migrant and refugee women experience inequities in sexual and reproductive health (SRH) care, reflected in the low uptake of SRH services. It is essential for healthcare providers and educators to be aware of women's preferences for SRH information and service delivery, to provide culturally responsive care. Identifying migrant and refugee women's preferences for SRH information and service delivery is the objective of this study.

DESIGN

This study investigated this issue, in communities of migrant and refugee women living in Australia and Canada. Eighty-four individual interviews and 16 focus groups comprising 85 participants were conducted (total n = 169), with migrant and refugee women aged 18 years and over from Afghanistan, India (Punjab), Iraq, Somalia, South Sudan, Sri-Lanka (Tamil), Sudan and various South American (Latina) backgrounds. Nine individual interviews were also undertaken with community interviewers, who were migrant or refugee women themselves.

RESULTS

Thematic analyses identified that migrant and refugee women are enthusiastic to learn about SRH across the lifespan, using a variety of modalities including group education delivered by community leaders; online and written material; and information provided by general practitioners. Participants emphasised the need for empathetic SRH care, which encompassed longer times for consultations, being seen as experts of their own bodies, privacy and healthcare provided by women practitioners. Greater engagement with migrant and refugee men was positioned as an additional solution to addressing SRH concerns of women.

CONCLUSION

Insights from this study can help facilitate the co-design and evaluation of acceptable and sustainable programs to address inequities in SRH experienced by migrant and refugee women.

Access to health services among culturally and linguistically diverse populations in the Australian universal health care system: issues and challenges

Background

About half of first- or second-generation Australians are born overseas, and one-in-five speak English as their second language at home which often are referred to as Culturally and Linguistically Diverse (CALD) populations. These people have varied health needs and face several barriers in accessing health services. Nevertheless, there are limited studies that synthesised these challenges. This study aimed to explore issues and challenges in accessing health services among CALD populations in Australia.

Methods

We conducted a scoping review of the literature published from 1^st January 1970 to 30^th October 2021 in four databases: PubMed, Scopus, Embase, and the Web of Science. The search strategy was developed around CALD populations and the health services within the Australian context. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for selection and Arksey and O’Malley framework for analysis of relevant articles. A narrative synthesis of data was conducted using inductive thematic analysis approach. Identified issues and challenges were described using an adapted socioecological model.

Results

A total of 64 studies were included in the final review. Several challenges at various levels were identified to influence access to health services utilisation. Individual and family level challenges were related to interacting social and health conditions, poor health literacy, multimorbidity, diminishing healthy migrants’ effect. Community and organisational level challenges were acculturation leading to unhealthy food behaviours and lifestyles, language and communication problems, inadequate interpretation services, and poor cultural competency of providers. Finally, challenges at systems and policy levels included multiple structural disadvantages and vulnerabilities, inadequate health systems and services to address the needs of CALD populations.

Conclusions

People from CALD backgrounds have multiple interacting social factors and diseases, low access to health services, and face challenges in the multilevel health and social systems. Health systems and services need to focus on treating multimorbidity through culturally appropriate health interventions that can effectively prevent and control diseases. Existing health services can be strengthened by ensuring multilingual health resources and onsite interpreters. Addressing structural challenges needs a holistic policy intervention such as improving social determinants of health (e.g., improving living and working conditions and reducing socioeconomic disparities) of CALD populations, which requires a high level political commitment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13256-z.

Research methods from human-centered design: Potential applications in pharmacy and health services research

Challenges faced by health systems have become increasingly complex, and expanding the range of methodological options available via interdisciplinary collaboration is important to enable researchers to address them. As complexity increases, it can be more difficult to ensure solutions remain patient-centered. Human-centered design is an approach that focuses on engaging with and understanding the needs of all services users while retaining a systems perspective. Therefore, design professionals skilled in these approaches are increasingly collaborating within health systems in pharmacy and health research teams. This methodological paper considers the potential contribution of human-centered design approaches to optimising development, implementation, and sustainability of patient-centered interventions in pharmacy and health services research. It provides an overview of human-centered design principles and their application, and outlines the emerging roles of design professionals in pharmacy and health services research. It focuses on three key human-centered design methods that can most readily be used by pharmacy and health services researchers. Journey mapping, prototyping, and user testing are discussed in detail. Journey mapping enables holistic visualisation of patient experience from practical and emotional perspectives. It may be used to visualize current practice or model potential future services, and can be informed by quantitative and qualitative data derived from both primary and secondary research. Prototyping facilitates exploration of interventions such as new services quickly and at low-cost. Health services researchers can utilize prototypes for services, processes, experiences, physical objects, environments, spaces, or digital tools for example. Formative evaluation and user testing supports rapid iteration of prototypes to ensure that they meet patient and healthcare professional needs. Finally, challenges with interdisciplinary collaboration and strategies to maximize the potential of using human-centered design approaches in pharmacy and health services research to address complex challenges, enhance practice and deliver benefits for service users, patients, and health systems are discussed.

Engaging Citizens Via Journey Maps to Address Urban Health Issues

Effectively addressing urban health challenges requires engagement of citizens. However, citizens often face barriers providing feedback, and city officials likewise face difficulties incorporating feedback in a meaningful and systematic way. This paper shares one innovative approach to capturing citizens' stories about urban health concerns, developed by the Building Healthy Cities (BHC) project in 2 Asian cities (Indore, India, and Makassar, Indonesia). Using ethnographic methods, BHC developed "journey maps" as a monitoring tool to follow key service issues over time. Several urban health-related issues were identified in each city. For this paper, we focus on wastewater management, which was a serious health issue in both cities. Qualitative data were collected from citizens in one neighborhood and city officials quarterly starting in early 2018; these data were supplemented by city spending data, usage statistics, photos and news articles. In both cities, the journey maps captured notable changes during the first 2 years of the project. At the start of the journeys (2018), informal settlement citizens in Indore reported poor drainage which was compounded by trash, narrow roads blocking vehicular removal of waste, and unsafe infrastructure leading to waterborne diseases and injuries (including several child deaths). Likewise in Makassar, dirty water overflowed from open drains due to frequent flooding and garbage. Citizens reported exposure to diarrhea, dengue and skin symptoms due to the drains, which was confirmed by the local health post. By the end of Year 2 (2019), these journeys captured increasing dialogue between citizens and the city, which resulted in several improvements. In Indore, changes included garbage vans built for narrow streets and construction of a safer bridge. In Makassar, while they still suffer from seasonal flooding, the city has increased garbage pickup, included drainage activities in the village-level budgeting process, and a slum improvement project has pledged funding to improve drainage and street issues in 41 neighborhoods. Journey maps work on the premise that capturing a community's experience and relaying it to government officials can bring about positive change. They also provide crucial grassroots level evidence to support more traditional research findings, which can lead to effective urban health solutions. As this work continues, BHC is training citizens to collect and share their own journeys.