Skip to main content

Table 2 Summary of included articles

From: Psychological trauma and access to primary healthcare for people from refugee and asylum-seeker backgrounds: a mixed methods systematic review


Aim/study focus

Study design


Outcome focus/measures

Main findings relevant to PTSD and service access

Asgary et al. (2011)

To examine the experience of refugee asylum seekers accessing health care

Qualitative: focus groups and interviews

Purposive sampling from specific health clinic

Experiences of accessing healthcare

Asylum seekers did not make link between experiences of trauma and ongoing medical sequelae (or mental health) nor see psychological issues as appropriate for/requiring medical intervention

Final sample of 50 (35 asylum seekers and 15 service providers)

Semi-structured interview schedule

Heavy burden of shame and stigma about sharing psychological trauma and histories of abuse

85% male and mostly from African countries

Service providers identified mental illness and particularly experiences of trauma as a major obstacle to obtaining care

Medical professionals may lack adequate training in recognizing the signs and symptoms of trauma

Bean et al. (2006)

To explore need for mental health care and patterns of utilization for unaccompanied minors

Quantitative: cross sectional survey

Purposive sampling from database for unaccompanied humanitarian minors

Patterns of service utilization

60% of the unaccompanied minors reported need for mental health care, but only 11.7% had received services

Mixed sample (N = 3032): unaccompanied minors (n = 920), their legal guardians (n = 557), and their teachers (n = 496)

Stressful Life Events scale; Hopkins Symptom Checklist-37 (Adolescents); Reactions of Adolescents to Traumatic Stress; Child Behaviour Checklist; Teachers Report Form

Adolescent traumatic stress was a predictor for variables of ‘perceived need’ and ‘unmet need’, but not for ‘self-reported service use’

Compared with a representative Dutch adolescent sample (n = 1059)

Number of stressful life events was the most crucial predictor for ‘perceived need’ and ‘unmet need’

Blair (2001)

To examine the extent and manifestation of mental health problems among Cambodian refugees in the USA, their rates of utilization of health and mental health services, and any barriers which may be preventing their access to these services

Quantitative: cross sectional survey

N = 124 randomly selected Cambodian refugees living in Utah

Mental health measured using the NIMH Diagnostic Interview Schedule (DIS)

Only 6% of participants had received medical care for PTSD

PTSD measured using the Diagnostic Interview for Children and Adolescents (DICA-R)

Participants with a diagnosis of PTSD perceived a greater number of barriers that limited their ability to access health and /or mental health services compared to those without PTSD

Questions concerning practical and cultural barriers to service use

Colucci (2015)

To explore barriers and facilitators to mental health service delivery for refugee young people

Qualitative: focus groups and interviews

Purposive sampling. N = 115 service providers participated in focus groups plus five key informant interviews

Key facilitators and barriers to accessing and maintaining engagement with services

Using a trauma informed approach was identified as a key facilitator, while bring up trauma in mental healthcare too early was considered a barrier to ongoing maintenance of access

Trauma was seen to impact on trust which can in turn impact service access

Geltman (2008)

To assess whether mental health counselling and other health services were associated with functional health outcomes of unaccompanied Sudanese refugee minors in the US

Quantitative: cross sectional survey

304 Sudanese refugee minors in foster care through the US Unaccompanied Refugee Minors Program (URMP)

Child Health Questionnaire

High prevalence of seeking care for somatic complaints (76%)

Harvard Trauma Questionnaire

Those with PTSD were no more likely to have seen a mental health counsellor than those without PTSD, but were more likely to have seen any healthcare professional. However, authors note that treating patients with somatization may be challenging for those practitioners with limited experience

Health services questionnaire developed by authors and based on questions adapted from the Health Care Access and Utilization section of the National Health Interview Survey (NHIS)

Lack of successful identification, diagnosis and treatment of the Sudanese refugees with worse functional and behavioural health, particularly PTSD

Jensen (2013)

To investigate how general practitioners experience providing care to refugees with mental health problems

Qualitative: interviews

15 service providers purposively sampled from areas with high proportions of migrants

Practitioners’ experiences of providing care

Participants felt that refugee patients with psychological trauma were too complicated for them to see on their own and were likely to refer to specialised services

This paper focuses on 9 of the 15 interviews which were done with general practitioners specifically

Semi-structured interview schedule based around vignette

Only some participants expressed awareness of considering backgrounds of trauma when working with refugee clients

Lamkaddem (2014)

How to explain the persistently high prevalence of PTSD among resettled refugees despite the fact that various PTSD treatments are known to be effective?

Quantitative: longitudinal study design

Sampling unclear (described elsewhere)

Part IV of Harvard Trauma Questionnaire

21% of respondents with PTSD had contact with a mental health care provider at T1. This increased at T2 to 54%. However, at T1 those who reported using mental healthcare had greater PTSD symptom severity

At T1: 410 refugees from Iran, Afghanistan and Somalia both with and without residence permits (178 asylum seekers and 232 residence permit holders)

In refugees who had used mental health care, PTSD symptoms generally improved

At T2: 172 (all permit holders)

Low use of mental healthcare partly argued to explain steady PTSD rates across time in resettlement countries

Maier (2010)

To determine the current mental health status and patterns of healthcare utilisation

Quantitative: descriptive

Convenience sample from list supplied by Swiss Federal Office for Migration

Standardised Neuropsychiatric interview (MINI)

Asylum seeker participants incurred significantly higher healthcare costs than the comparable resident population and consult doctors more frequently but rarely receive specific treatment for their mental health problems

78 adult asylum seekers

Records from Helsana health insurance company

Participants with a psychiatric disorder reported significantly more appointments than those without a psychiatric disorder

After their first year of residence

Sanchez-Cao (2013)

To describe the levels of psychological distress and mental health service contact among a group of unaccompanied asylum seeker children living in London

Quantitative: descriptive

Convenience sample

Harvard Trauma Questionnaire

High levels of psychological distress on self-report, with 66% at high risk of PTSD and 12% at high risk for depressive disorder. However, only 17% were in contact with mental health services, and this was predicted by depressive symptoms and time spent in the UK (not PTSD)

71 unaccompanied minors

Impact of Event Scale

Depressive symptoms rather than post-traumatic symptoms best predicted service contact

Birleson Depression Self-Rating Scale for children

Strengths and Difficulties Questionnaire self-report version

Attitudes to Health and Services Questionnaire

Silove (2007)

To investigate the contribution of trauma and PTSD to the overall prevalence of mental disorders amongst Vietnamese refugees and the host Australian-born population

Quantitative: cross sectional with comparisons with Australian-born sample

Probabilistic sampling of Vietnamese refugees (n = 1161) resettled in Australia for 11 years (drawing on census data)

Composite International Diagnostic Interview (CIDI 2.0) with trauma events schedule expanded from the Harvard Trauma Questionnaire

In comparison to Australian non-refugees, Vietnamese refugees were more likely to focus on the somatic symptoms of PTSD

To gauge patterns of service utilization for PTSD across the two populations

Australian-born sample (n = 7961) drawn from ABS Survey of Mental Health and Wellbeing

Australians and Vietnamese refugees with PTSD had high rates of general health consultations overall and specifically with primary care physicians. However, Australians with PTSD were almost twice as likely as Vietnamese refugees to indicate that these primary care consultations were for a mental health problem

Approximately one in 10 Vietnamese refugees compared to one in three Australians with PTSD had consulted a specialist mental health professional

Slewa-Younan (2015)

To examine levels of psychological distress and help-seeking behaviour in resettled refugees attending English tuition classes in Australia, and their associations with participants demographic characteristics

Quantitative: cross sectional survey

N = 225 Iraqi refugees resettled in Western Sydney

Kessler Psychological Distress Scale (K-10)

Participants had high levels of distress and PTSD symptomatology and low uptake of mental health care

Harvard Trauma Questionnaire

Of those with probable PTSD, the most common type of help sought was from a family member (23.1%), followed by GP (21.5%), psychiatrist (13.8%), psychologist (12.3%) and religious leader (10.8%)

Weine (2000)

To profile trauma related psychiatric symptoms in a group of refugees not seeking mental health services and to consider the service implications

Quantitative: descriptive

Two groups of Bosnian refugees:

Development of an 18 item Trauma Exposure questionnaire

Participants who had accessed services had higher PTSD symptom severity

1) Those who had not presented for mental health services, recruited from Bosnian Refugee Center and two other contacts (N = 40)

PTSD Symptoms Scale

Participants who has not sought services also had substantial trauma-related symptom levels: of 40 participants not presenting for services, 28 (70%) met symptom criteria for PTSD diagnosis

2) 29 Bosnian clients who had received services, access through a clinic

Center for Epidemiological Studies Depression Scale (CES-D)

MOS 36-Item Short-Form (SF-36)

Wong (2015)

To examine US-based Cambodian refugees’ utilization of mental health services across provider types, levels of minimally adequate care, and mode of communication with providers

Quantitative: descriptive

Probabilistic sampling (further details not provided)

Composite International Diagnostic Interview v2.1 (CIDI)

More than half of the participants who met criteria for PTSD or major depression or both (52%, n = 127) obtained mental health services from at least one provider in the past 12 months, however this was typically for medication

227 Cambodian refugees who met the past 12 month criteria for posttraumatic stress disorder (PTSD) or major depressive disorder or both

Wright (2016)

To examine changes in institutional resource needs and utilization over 2 years in a newly arrived refugee sample, and to investigate the role of institutional resource need and utilization on mental health in the post-arrival period

Quantitative: longitudinal

298 adult Iraqi refugees randomly selected

Harvard Trauma Questionnaire

Participants reported a significant increase in PTSD symptoms between the 1 and 2 year interviews

Refugees were interviewed three times. Baseline very soon after arrival, at 1 year and at 2 years

PTSD Checklist (PCL)—civilian version

Higher utilization of psychological services predicted an increase in PTSD symptoms

Hospital Anxiety and Depression Scale (HADS)

A 14-item checklist was developed for assessing refugees needs for and utilization of institutional resources