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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

Author/date Aim/study focus Study design Sampling 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