A Qualitative study of language barriers between South African health care providers and cross-border migrants

Factors affecting antenatal care attendance in Soweto, Johannesburg: The three-delay model

BACKGROUND

 Antenatal care remains critical for identifying and managing complications contributing to maternal and infant mortality, yet attendance among women in South Africa persists as a challenge.

AIM

 This study aimed to understand the challenges faced by women attending antenatal care in Soweto, Johannesburg, using the three-delay model.

SETTING

 This study was conducted in Soweto, Johannesburg.

METHODS

 An exploratory, descriptive and qualitative research design was used, and in-depth interviews were conducted with 10 pregnant women and four women who had recently given birth.

RESULTS

 Findings indicate delays in seeking care due to factors such as pregnancy unawareness, waiting for visible signs, and fear of human immunodeficiency virus (HIV) testing. Challenges such as transportation difficulties, distance to clinics, and facility conditions further impeded the initiation of antenatal care. Late initiation often occurred to avoid long waits, inadequate facilities, language barriers and nurse mistreatment.

CONCLUSION

 From this study, we learn that challenges such as unawareness of pregnancy, cultural notions of keeping pregnancy a secret, fear of HIV testing, long waiting lines, high cost of transportation fees, clinic demarcation, shortage of essential medicines, broken toilets and verbal abuse from nurses have delayed women from initiating antenatal care early in Soweto, Johannesburg.Contribution: Challenges of women with antenatal care attendance in South Africa must be addressed by implementing community-based health education interventions, institutionalising HIV psycho-social support services and improving quality of antenatal care services in public health facilities.

Uncovering multi-level mental healthcare barriers for migrants: a qualitative analysis across China, Germany, Netherlands, Romania, and South Africa

BACKGROUND

Forced displacement is a significant issue globally, and it affected 112 million people in 2022. Many of these people have found refuge in low- and middle-income countries. Migrants and refugees face complex and specialized health challenges, particularly in the area of mental health. This study aims to provide an in-depth qualitative assessment of the multi-level barriers that migrants face in accessing mental health services in Germany, Macao (Special Administrative Region of China), the Netherlands, Romania, and South Africa. The ultimate objective is to inform tailored health policy and management practices for this vulnerable population.

METHODS

Adhering to a qualitative research paradigm, the study centers on stakeholders' perspectives spanning microsystems, mesosystems, and macrosystems of healthcare. Utilizing a purposive sampling methodology, key informants from the aforementioned geographical locations were engaged in semi-structured interviews. Data underwent thematic content analysis guided by a deductive-inductive approach.

RESULTS

The study unveiled three pivotal thematic barriers: language and communication obstacles, cultural impediments, and systemic constraints. The unavailability of professional interpreters universally exacerbated language barriers across all countries. Cultural barriers, stigmatization, and discrimination, specifically within the mental health sector, were found to limit access to healthcare further. Systemic barriers encompassed bureaucratic intricacies and a conspicuous lack of resources, including a failure to recognize the urgency of mental healthcare needs for migrants.

CONCLUSIONS

This research elucidates the multifaceted, systemic challenges hindering equitable mental healthcare provision for migrants. It posits that sweeping policy reforms are imperative, advocating for the implementation of strategies, such as increasing the availability of language services, enhancing healthcare providers' capacity, and legal framework and policy change to be more inclusive. The findings substantially contribute to scholarly discourse by providing an interdisciplinary and international lens on the barriers to mental healthcare access for displaced populations.

Community interpreting in Germany: results of a nationwide cross-sectional study among interpreters

BACKGROUND

Community interpreters (CIPs) play a crucial role in various community services, including healthcare, when service providers and users do not share a common language. However, there is a lack of evidence-based data on this population globally. This explorative cross-sectional study aims to gain a better understanding of CIPs and their work in Germany.

METHODS

A nationwide online survey was conducted among CIPs in Germany to collect data on their qualification background, working conditions, mental health, interpreting-related psychosocial distress and sociodemographics. Participants were recruited through interpreting pools, training institutions and migrant organizations. Data were analyzed descriptively, dependent t-test, multiple logistic and hierarchical stepwise regression analyses were performed to predict participation in interpreting-specific training, interpreting competence and interpreting-related psychosocial distress.

RESULTS

Across all 16 federal states, N = 873 responses were used for analysis. Most participants are female (74%), born abroad (77%) and have a high level of education (69%). The vast majority interpret occasionally in their leisure time (44%) and are self-employed/freelance (51%). 34% interpret solely or additional on a voluntary basis (unpaid). The median hours of interpreting per month are 10 h, 75% do not exceed 30 h. On average interpreters work in four different settings. 69% attended any kind of interpreting training with a median of 25 h in total. Interpreting in more settings emerged as an associated factor with participation in training. Of those who have never attended any training, 69% consider themselves as rather/very competent in interpreting. Interpreting more frequently, having less severe anxiety symptoms, getting higher and more often paid and being less satisfied with the payment is associated with self-reported interpreting competence. In total, 36% reported moderate or severe psychosocial distress regarding interpreting. Higher general psychosocial distress and depressive symptoms, higher interpreting frequency and lower payment satisfaction were found to be associated with higher distress regarding interpreting. Additionally, factors such as precarious work conditions, lack of recognition and discrimination (e.g. racism and sexism) were reported as distressing.

CONCLUSION

This study provides a first comprehensive evidence-based national database on CIPs in Germany. The findings can be valuable for the development of qualifications, guidelines, policies and the process of professionalizing the field of CIPs.

Scoping Review of Health Economics Research on Refugee Health in Sub-Saharan Africa

OBJECTIVES

Most refugees and internally displaced people (IDP) stay in low- and middle-income settings. A substantial proportion are hosted by countries in sub-Saharan African (SSA), which puts significant pressure on limited government healthcare budgets. As health economics may guide more optimal healthcare decision making, we scope the health economics literature on forcibly displaced populations in SSA to identify the nature and range of health economics evidence.

METHODS

We conducted a scoping review of peer-reviewed and gray literature in English published from 2000 to 2021. Our search terms comprised a combination of keywords related to refugees, SSA, and health economics. We followed a stepwise methodology consisting of the identification and selection of studies, extraction and charting of data.

RESULTS

We identified 29 health economics studies on refugees and IDPs in SSA covering different providers, interventions, and delivery platforms. Twenty-one articles studied the determinants of health, followed by 5 on the supply of healthcare and 2 concerned with economic evaluation and the demand for healthcare, respectively. We found an equal division of articles focusing on refugees and IDPs, as well as by settlement type. Mental health was the most frequently studied health area and Uganda was the most studied destination country.

CONCLUSIONS

The health economics literature on refugees in SSA remains limited. Our scoping review encourages future research to study a larger variety of healthcare systems and health economic topics such as economic evaluations, health financing and whole health systems to support resource allocation decisions and sustainable long-term solutions.

Cross-border simulation training for German and Polish emergency medical teams is feasible: conception and evaluation of a bilingual simulation training

BACKGROUND

Cross-border cooperation of emergency medical services, institutions and hospitals helps to reduce negative impact of national borders and consecutive discrimination of persons living and working in border regions. This study aims to explore the feasibility and effectiveness of a cross-border bilingual simulation training for emergency medical services within an INTERREG-VA-funded project.

METHODS

Five days of simulation training for German and Polish paramedics in mixed groups were planned. Effectiveness of training and main learning objectives were evaluated as pre-post-comparisons and self-assessment by participants.

RESULTS

Due to COVID-19 pandemic, only three of nine training modules with n = 16 participants could be realised. Cross-border-simulation training was ranked more positively and was perceived as more useful after the training compared to pretraining. Primary survey has been performed using ABCDE scheme in 18 of 21 scenarios, whereas schemes to obtain medical history have been applied incompletely. However, participants stated to be able to communicate with patients and relatives in 10 of 21 scenarios.

CONCLUSION

This study demonstrates feasibility of a bilingual cross-border simulation training for German and Polish rescue teams. Further research is highly needed to evaluate communication processes and intra-team interaction during bilingual simulation training and in cross-border emergency medical services rescue operations.

Navigating language discordance in public health care in rural South Africa: a qualitative descriptive study of occupational therapists' perspectives

BACKGROUND

Language discordance occurs in healthcare when staff and service users do not share proficiency in the same language. It is a global phenomenon impacting on the quality of health services, as person-centred practice requires communication to establish partnerships and rapport. In a country as linguistically diverse as South Africa, effective ways to navigate language discordance in health care are urgently required, yet there is limited research. This study aimed to describe how occupational therapists navigated language discordance when working in the public health sector in KwaZulu-Natal.

METHODS

A qualitative descriptive design involved using purposive sampling to recruit occupational therapists as participants (n = 8) for 15 semi-structured interviews. Thematic analysis was used to analyse the data, which included reflective journal entries from all participants.

RESULTS

The four emergent themes were: (1) concurrent use of strategies, (2) I'm doing as much I can, what more can I do? (3) Language definitely impacts that therapy process and lastly, (4) systemic oppression perpetuating language discordance.

CONCLUSION

Language discordance is a complex context-specific phenomenon, therefore insight into concurrent use of strategies is important to practitioners to enable them to navigate language discordance and ensure provision of quality services. These insights are significant for healthcare professionals and resource allocators as they shed light on the shortcomings of advocating for a single strategy such as providing trained interpreters. Successful navigation is characterised by determination, being kind to oneself, willingness to learn and use of pragmatic and flexible approaches. To prepare to navigate language discordance in a low-resource context, education should extend in time and scope, to include multiple strategies, culture and relevant languages.

From 'no problem' to 'a lot of difficulties': barriers to health service utilization among migrants in Rakai, Uganda

Migration is increasingly common in Africa, especially for employment. Migrants may face additional barriers to accessing health care, including human immunodeficiency virus (HIV) prevention and treatment, compared with long-term residents. Exploring migrants' experiences with health services can provide insights to inform the design of health programmes. In this study, we used qualitative methods to understand migrants' barriers to health service utilization in south-central Uganda. This secondary data analysis used data from in-depth semi-structured interviews with 35 migrants and 25 key informants between 2017 and 2021. Interviews were analysed thematically through team debriefings and memos. We constructed three representative migrant journeys to illustrate barriers to accessing health services, reflecting experiences of migrant personas with differing HIV status and wealth. Migrants reported experiencing a range of barriers, which largely depended on the resources they could access, their existing health needs and their ability to form connections and relationships at their destination. Migrants were less familiar with local health services, and sometimes needed more time and resources to access care. Migrants living with HIV faced additional barriers to accessing health services due to anticipated discrimination from community members or health workers and difficulties in continuing antiretroviral therapy when switching health facilities. Despite these barriers, social networks and local connections facilitated access. However, for some migrants, such as those who were poorer or living with HIV, these barriers were more pronounced. Our work highlights how local connections with community members and health workers help migrants access health services. In practice, reducing barriers to health services is likely to benefit both migrants and long-term residents.

Do not lose your patient in translation: Using interpreters effectively in primary care

South Africa is a multicultural society characterised by a rich diversity of languages. As a result, many healthcare providers and their patients often do not speak the same language, which makes communication challenging. The language barriers, when present, require an interpreter to ensure accurate and effective communication between the parties. In addition to assisting in a clear exchange of information, a trained medical interpreter also acts as a cultural liaison. This is especially true when the provider and the patient come from different cultural backgrounds. Based on the patient's needs, preferences, and available resources, clinicians should select and engage with the most appropriate interpreter. The effective use of an interpreter requires knowledge and skill. Patients and healthcare providers can benefit from several specific behaviours during interpreter-mediated consultations. This review article provides practical tips on when and how to use an interpreter effectively during clinical encounters in primary healthcare settings in South Africa.

Impacts of language barriers on healthcare access and quality among Afaan Oromoo-speaking patients in Addis Ababa, Ethiopia

BACKGROUND

Ethiopia is a multilingual and multinational federation with Addis Ababa serving as both the capital city of Oromia regional state and the seat of the Ethiopian federal government. Nevertheless, only Amharic is considered as the working language of the city and federal offices, including hospitals. As a result, Afaan Oromoo-speaking patients may be facing language barriers in the healthcare settings in Addis Ababa. Language barriers have the capacity to affect patients' experience of care and treatment outcomes. This study, hence, examined the impacts of language barriers on the healthcare access and quality for the Afaan Oromoo-speaking patients in public hospitals in Addis Ababa.

METHODS

In-depth interviews with patients (N = 27) and key informant interviews with healthcare providers (N = 9) were conducted in six public hospitals found in Addis Ababa. All the interviews were audio-taped and transcribed verbatim. A thematic analysis technique was employed to address the study objectives.

RESULTS

The study participants indicated the widely existing problem of language discordance between patients and healthcare providers. The impacts of language barriers on the patients include preventable medical errors, low treatment adherence, low health-seeking behavior, additional treatment cost, increased length of hospital stays, weak therapeutic relation, social desirability bias, less confidence, and dissatisfaction with the healthcare. For the healthcare providers, language barriers are affecting their ability to take patient history, perform diagnoses and provide treatment, and have also increased their work burden. The use of ad hoc interpreters sourced from bilingual/multilingual patients, patient attendants, volunteer healthcare providers, and other casual people has been reported to deal with the problem of language barriers.

CONCLUSION

A significant number of Afaan Oromoo-speaking patients are facing language barriers in accessing quality healthcare in public hospitals in Addis Ababa, and this constitutes structural violence. As a way out, making Afaan Oromoo an additional working language of the public hospitals in Addis Ababa, the assignment of professional interpreters, and a hiring system that promotes the recruitment of qualified multi-lingual healthcare providers are suggested.

Care preferences of older migrants and minority ethnic groups with various care needs: a protocol for a scoping review

INTRODUCTION

Worldwide, our societies are characterised by increasing diversity, which is greatly contributed to by people who have migrated from one country to another. To provide person-centred care, healthcare staff need to consider the personal background, biography and preferences of people with care needs. Little is known about the care preferences of older migrants and minority ethnic groups. The purpose of this planned scoping review is to explore and systematically investigate current research addressing the care preferences of older migrants and minority ethnic groups. In addition, gaps requiring further research will be identified. To the best of our knowledge, this scoping review will be the first to synthesise the literature regarding the preferences in nursing care of older migrants and minority ethnic groups.

METHODS

A scoping review will be conducted to identify and analyse the care preferences of older migrants and minority ethnic groups (population 60 years or older with various care needs). Based on the research aim, we will systematically search the electronic databases MEDLINE (via PubMed), CINAHL (via EBSCO) and PsycINFO (via EBSCO). We will include literature published in English and German with no restrictions regarding the publication date. The identified records will be independently screened (title/abstract and full text) by two reviewers. Data from the included studies will be extracted by one and verified by a second researcher. We will analyse the identified preferences with an inductive content analysis and will narratively present the review results in the form of tables.

ETHICS AND DISSEMINATION

There are no ethical concerns related to conducting this study. We will discuss our results with practitioners in the field of nursing care of older people with migration backgrounds. We will present our results and make them available to the public at (inter)national conferences and in the form of peer-reviewed and practice articles.

"We Learn and Teach Each Other": Interactive Training for Cross-Cultural Trauma-Informed Care in the Refugee Community

This paper introduces culturally responsive and trauma-informed mental health training modules to build and enhance competences and partnerships among mental health professionals and refugee community leaders, while facilitating intercultural, mutual learning between participants from various cultural and professional backgrounds. Focus group interviews and participant self-reflections with the training participants (N = 54) were analyzed using thematic analysis. Findings revealed an enhanced understanding of culturally unique as well as universal trauma responses and coping in the refugee community, which led to the building and strengthening of a sense of community and an expansion of social networks and support systems. This study highlights the effectiveness of interactive learning and knowledge transference among participants with various cultural and professional backgrounds, showing that face-to-face interactions and mutual learning reportedly facilitated building relationships and trust among participants and especially those between refugee/immigrant community leaders and service providers.

Experiences and Expectations of Ethnic Minorities and Majorities towards Community Pharmacy Medicines-Related Services in Estonia

The unique professional competence of pharmacists can support the safe and effective use of medicines by patients. Additionally, it is important to acknowledge and incorporate the needs of patients with various cultural and social backgrounds. The objective of this study was to assess and compare the experiences and expectations of Russian- and Estonian-speaking pharmacy customers about medicines-related services in Estonian community pharmacies. Cross-sectional study among pharmacy customers was conducted in Estonia 2018−2020. For data analysis, an Independent t-Test was used to compare experiences and expectations of respondents towards medicines-related services. The study involved 552 pharmacy customers: 58.5% (n = 323) Estonians and 41.5% (n = 229) Russians. The majority of the total sample (78.3%) considered the pharmacist competent to help. Medicines-related concerns were more common among Russians (p = 0.037), however, they sought less contact to consult a pharmacist than Estonians (p < 0.001). Furthermore, expectations about different medicines-related services in the future were higher among Estonians than among Russians (p < 0.001). Community pharmacists in Estonia should focus more on person-centered care to better meet the expectations and needs of different ethnic groups about medicines-related services. It is also important to reduce the language barrier and to increase the recognition of cultural traditions by health professionals.

Experiences of seeking healthcare across the border: lessons to inform upstream policies and system developments on cross-border health in East Africa

OBJECTIVES

This study explored the experiences of accessing care across the border in East Africa.

PARTICIPANTS

From February to June 2018, a cross-sectional study using qualitative and quantitative methods was conducted among 279 household adults residing along selected national border sites of Uganda, Kenya and Rwanda and had accessed care from the opposite side of the border 5 years prior to this study.

SETTING

Access to HIV treatment, maternal delivery and childhood immunisation services was explored. We applied the health access framework and an appreciative inquiry approach to identify factors that enabled access to the services.

MEASURES

Exploratory factor analysis and linear regression were used for quantitative data, while deductive content analysis was done for the qualitative data on respondent's experiences navigating health access barriers.

RESULTS

The majority of respondents (83.9%; 234/279) had accessed care from public health facilities. Nearly one-third (77/279) had sought care across the border more than a year ago and 22.9% (64/279) less than a month ago. From the linear regression, the main predictor for ease of access for healthcare were ''ease of border crossing' (regression coefficient (RegCoef) 0.381); 'services being free' (RegCoef 0.478); 'services and medicines availability' (RegCoef 0.274) and 'acceptable quality of services' (RegCoef 0.364). The key facilitators for successful navigation of access barriers were related to the presence of informal routes, speaking a similar language and the ability to pay for the services.

CONCLUSION

Communities resident near national borders were able to cross borders to seek healthcare. There is need for a policy environment to enable East Africa invest better and realise synergies for these communities. This will advance Universal Health Coverage goals for communities along the border who represent the far fang areas of the health system with multiple barriers to healthcare access.

Policy exclusion or confusion? Perspectives on universal health coverage for migrants and refugees in South Africa

Notwithstanding the promise of the inclusivity of universal health coverage (UHC), the integration of migrants and refugees into host countries' health systems remains elusive and contested. In South Africa, there is insufficient scholarly attention on UHC, migrants and refugees, given the country's strategic importance in Africa and the envisaged implementation of the National Health Insurance (NHI) system. In this paper, a social exclusion conceptual framework is used to explore whether South African legislation, health policies and perspectives or actions of health policy actors facilitate UHC for migrants and refugees or exacerbate their exclusion. We combined a review of legislation and policies since 1994, with semi-structured interviews with 18 key informants from government, academia, civil society organizations and a United Nations organization. We used thematic analysis to identify themes and sub-themes from the qualitative data. The South African Constitution and the National Health Act facilitate UHC, while the Immigration Act and the 2019 NHI Bill make the legal status of migrants the most significant determinant of healthcare access. This legislative disjuncture is exacerbated by variations in content, interpretation and/or implementation of policies at the provincial level. Resource constraints in the public health sector contribute to the perceived dysfunctionality of the public healthcare system, which affects the financial classification, quality of care and access for all public sector patients. However, migrants and refugees bear the brunt of the reported dysfunctionality, in addition to experiences of medical xenophobia. These issues need to be addressed to ensure that South Africa's quest for UHC expressed through the NHI system is realized.

The role of pharmacy personnel in promoting adherence to antiretroviral therapy in the Eastern Cape: communication barriers and breakthroughs

Background: Many people living with HIV struggle to adhere to their antiretroviral therapy, leading to suboptimal health outcomes and increased costs to the healthcare system. Due to their unique training and position in the health care system, South African pharmacists and pharmacy support personnel have the potential to improve adherence through effective patient counselling. However, they are often underutilised and face multiple barriers to providing these services. The aim of this study was to examine how pharmacists and pharmacy personnel view their impact upon the medication adherence behaviours of people living with and receiving medication therapy for HIV.Methods: The study used an exploratory qualitative research design. Our research team conducted in-depth interviews with 24 pharmacy personnel working in public health clinics in the Eastern Cape of South Africa, then used thematic analysis of the qualitative research data to determine the results.Results: Pharmacy personnel identified three key sets of communication challenges that limited effective patient counselling on antiretroviral therapy. These included environmental barriers presented by clinic design, language barriers between patients and pharmacy personnel, and varying communication styles and education levels of pharmacy staff and patients. Additionally, pharmacy personnel described innovative strategies they use to improve patient-provider communication and address adherence issues.Conclusions: Pharmacy personnel working in public health clinics face daily communication challenges as they attempt to provide counselling to patients with HIV. Both the clinic environment and the complex nature of HIV treatment serve as barriers to patient comprehension. In the face of these challenges, pharmacy personnel do their best to implement strategies that enhance patient counselling and address concerns about adherence. Increased attention should be paid to reducing the barriers to pharmacy-based patient counselling and utilising pharmacy personnel to enhance patient understanding and adherence to antiretroviral therapy.

"The system has to be health literate, too" - perspectives among healthcare professionals on health literacy in transcultural treatment settings

BACKGROUND

Effective communication is a central aspect of organizational health literacy. Healthcare professionals are expected to ensure an effective and satisfactory flow of information and to support their patients in accessing, understanding, appraising, and applying health information. This qualitative study aimed to examine the health literacy-related challenges, needs, and applied solutions of healthcare professionals when engaging with persons with a migrant background. Based on the integrated model of health literacy (Sørensen et al., BMC Public Health 12:80, 2012), we focused on environmental, personal, and situational factors that shape health literacy in transcultural treatment settings.

METHODS

We conducted five focus group discussions with healthcare professionals (N = 31) who are in regular contact with persons with a migrant background. Discussions were transcribed verbatim and analyzed using qualitative content analysis by applying a deductive-inductive categorization procedure. Deductive categories were derived from the integrated model of health literacy.

RESULTS

Challenges included a mismatch in the provision and use of health services. Participants regarded easily accessible services and outreach counselling as helpful solutions. Further challenges were the migrant patients' distrust in healthcare professionals and the German healthcare system, the participants' uncertainty in dealing with patients' expectations and needs, and the patients' non-compliance with appointments. Environmental factors included systemic lack of time and economic pressure. Both were reported as impeding the flow of information in all treatment settings. Participants with a migrant background themselves (n = 16) regarded this personal factor as an opportunity that increased patients' trust in them. They also reported challenges such as high levels of responsibility felt when ad hoc interpreting for colleagues.

CONCLUSIONS

Known issues observed in the delivery of healthcare for the majority population (i.e., systemic lack of time, economic pressure) appear to be intensified in the context of migration. An increasingly diverse patient clientele indicates a growing need for culture-sensitive, health-literate healthcare organizations. A corresponding diversity of the health workforce is desirable and should be strengthened by national finance and educational programs. Healthcare professionals who interpret for colleagues should be given the necessary time. Further studies are needed to develop appropriate interventions for improving health literacy at individual and organizational levels. Funding for interpreting services should be expanded.

Patient Empowerment During the COVID-19 Pandemic by Ensuring Safe and Fast Communication of Test Results: Implementation and Performance of a Tracking System

Background

Overcoming the COVID-19 crisis requires new ideas and strategies for online communication of personal medical information and patient empowerment. Rapid testing of a large number of subjects is essential for monitoring and delaying the spread of SARS-CoV-2 in order to mitigate the pandemic’s consequences. People who do not know that they are infected may not stay in quarantine and, thus, risk infecting others. Unfortunately, the massive number of COVID-19 tests performed is challenging for both laboratories and the units that conduct throat swabs and communicate the results.

Objective

The goal of this study was to reduce the communication burden for health care professionals. We developed a secure and easy-to-use tracking system to report COVID-19 test results online that is simple to understand for the tested subjects as soon as these results become available. Instead of personal calls, the system updates the status and the results of the tests automatically. This aims to reduce the delay when informing testees about their results and, consequently, to slow down the virus spread.

Methods

The application in this study draws on an existing tracking tool. With this open-source and browser-based online tracking system, we aim to minimize the time required to inform the tested person and the testing units (eg, hospitals or the public health care system). The system can be integrated into the clinical workflow with very modest effort and avoids excessive load to telephone hotlines.

Results

The test statuses and results are published on a secured webpage, enabling regular status checks by patients; status checks are performed without the use of smartphones, which has some importance, as smartphone usage diminishes with age. Stress tests and statistics show the performance of our software. CTest is currently running at two university hospitals in Germany—University Hospital Ulm and University Hospital Tübingen—with thousands of tests being performed each week. Results show a mean number of 10 (SD 2.8) views per testee.

Conclusions

CTest runs independently of existing infrastructures, aims at straightforward integration, and aims for the safe transmission of information. The system is easy to use for testees. QR (Quick Response) code links allow for quick access to the test results. The mean number of views per entry indicates a reduced amount of time for both health care professionals and testees. The system is quite generic and can be extended and adapted to other communication tasks.

Being heard - Supporting person-centred communication in paediatric care using augmentative and alternative communication as universal design: A position paper

Person-centred care, with its central focus on the patient in partnership with healthcare practitioners, is considered to be the contemporary gold standard of care. This type of care implies effective communication from and by both the patient and the healthcare practitioner. This is often problematic in the case of the paediatric population, because of the many communicative challenges that may arise due to the child's developmental level, illness and distress, linguistic competency and disabilities. The principle of universal design put forth in conventions and legislation means that the design of products and services should be usable by all people, to the greatest extent possible. Augmentative and alternative communication encompasses strategies, for example pictures and apps, that are typically used with people with communication disability. In this position paper, we argue for the universal use of augmentative and alternative communication to support person-centred communication and care for children, regardless of age or potential disability. Clinical examples are shared from three different paediatric care settings where pictorial supports were applied universally. Interviews were conducted with children and adolescents (with and without disabilities), parents and healthcare practitioners, and the principles of universal design were used as a framework to demonstrate how person-centred communication is supported in paediatric care.

Migrants' perceptions of health system responsiveness and satisfaction with health workers in a South African Province

Background: There is global emphasis on quality universal health coverage (UHC) that is responsive to the needs of vulnerable communities, such as migrants.

Objective: Examine the perceptions of migrants on health system responsiveness (HSR) and their satisfaction with health workers in public health facilities of a South African Province.

Method: We conducted a cross-sectional study in 13 public health facilities. Following informed consent, we used a semi-structured questionnaire to collect sociodemographic information, patient perceptions of HSR and their satisfaction with health workers. Two open-ended questions gave patients the opportunity to comment on the health facility visit. We applied descriptive and multivariate analyses to our data, and thematic analysis to the qualitative responses.

Results: A total of 251 migrant patients participated in the study, giving a response rate of 80.7%. The majority of patients were female (81.1%), and the mean age was 31.4 years. 30.0% of patients reported that they waited too long; 94.3% that the consulting nurse or doctor listened to them; and 89.4% that they received information about their condition. However, 81.7% said they did not know the name of the consulting nurse or doctor. The mean scores on patients’ satisfaction with health workers ranged from 7.0 (95% CI 6.42–7.63) for clerks, 7.7 (95% CI 7.4–8.0) for security guards, 7.4 (95% CI 7.1–7.6) for nurses and 8.3 (95% CI 7.93–8.63) for doctors. The predictors of patient satisfaction with nurses were being given information about their condition; polite treatment, time spent in facility, whether they received prescribed medicines; and stating that they would refer the health facility to family/friends. Four overlapping themes emerged: health workers’ attitudes; time waited at the health facility, communication difficulties; and sub-optimal procedures in the health facility.

Conclusion: UHC policies should incorporate migrant patients’ perceptions of HSR and the determinants of their satisfaction with health workers.

Quality in crisis: a systematic review of the quality of health systems in humanitarian settings

Background

There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings.

Methods

This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain.

Results

We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety.

Conclusion

The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00342-z.

In Pursuit of Preventive Audiology in South Africa: Scoping the Context for Ototoxicity Assessment and Management

Aim

The study explored the South African healthcare context for ototoxicity assessment and management from the audiologists' perspectives.

Materials and Methods

This was done through a survey research methodology that adopted a cross-sectional research design. South African audiologists were recruited from professional associations databases using specific inclusion criteria; and 31 audiologists from across the country participated. The study used an 18-item web-based survey guided by the Health Professions Council of South Africa (HPCSA) (2018) guidelines. Data were analyzed through both descriptive and inferential statistics.

Results

Findings revealed serious contextual challenges influencing the implementation of assessment and management programs within the South African context. Over two-thirds of the participants engage with ototoxicity monitoring and management, but the practices adopted are not aligned to international standards nor the national HPCSA guidelines on assessment and management of patients on ototoxic medications. Findings speak to the frequency of practice; the referral pathways audiologists use; prevention and promotion methods used; availability of resources for the implementation of ototoxicity assessment and management; barriers to ototoxicity assessment and management; the influence of language and culture in ototoxicity assessment and management; as well as information management practices within this context. No relationship could be established between knowledge regarding ototoxicity, communication, caseload, and ototoxicity assessment and management on the chi-square.

Conclusion

Implications for strategic planning, budget allocation, collaborative multidisciplinary within the same institution approaches; training; policy formulation; and translation of policies and guidelines into practice are raised by these findings.

Ad hoc interpreters in South African psychiatric services: service provider perspectives

Background: Language and communication lie at the heart of good quality mental health care and are a vital, yet complex, part of the diagnostic and treatment process. In South African mental health care, ad hoc interpreting arrangements are the status quo. However, these can cause both clinician and patient shame and distress.

Objective: Though this issue has been researched from the point of view of informal interpreters, relatively little is known about psychiatrists’ experiences of working with ad hoc interpreters. This study is part of an attempt to bridge that gap.

Methods: We made use of a cross-sectional qualitative interview design. We interviewed seven psychiatrists working at a psychiatric hospital in the Western Cape of South Africa. Data were analysed manually using thematic analysis.

Results:Five main themes can be identified from the data: miscommunication and other difficulties associated with the language barrier; the language barrier between clinicians and patients and a need for language services; participants’ views on interpreting; the role of age, culture and gender; and the use of trained and untrained interpreters and using staff as interpreters.

Conclusions: Psychiatrists experience numerous difficulties in conducting their work due to the language barrier. This has an impact on their ability to provide adequate mental health care to patients. There is a need for better language services to ensure that everyone that seeks mental health care can receive the same level of care. Currently, one’s ability to speak a certain language will have a significant impact on the quality of care received.

[Healthcare experiences of primary care workers with Bengalese immigrants in Paraná State, Brazil]

The aim of this study was to analyze the experiences of primary care workers with Bengalese immigrants in Paraná State, Brazil. This was a qualitative study in a primary care unit with approximately 700 Bengalese immigrants living in its coverage area. The study was conducted in a medium-sized city in northern Paraná State. Data were obtained through semi-structured interviews with the health workers. The data were analyzed adopting proper compliance with all ethical aspects. The results showed that the immigrants' physical appearance and language affected the way the health workers treated them. It was thus possible to identify a series of implications in the actions and services offered to this immigrant population: adherence to a protocol, even though it did not take the immigrants' specific needs into account; presumption of the immigrant population's reasons and needs for seeking the health services; and the omission of some specific health interventions. The Bengalese immigrant population thus accesses the primary healthcare services much more through their adaptive skills than by the health workers' capacity to offer care according to the patients' needs. It is thus necessary to take a special look at the health workers in this situation and design forms of support that can be offered to healthcare teams that deal with immigrant populations on a daily basis.

Barriers to accessing health care services: a qualitative study of migrant construction workers in a southwestern Indian city

BACKGROUND

This study examined access to health care in an occupational context in an urban city of India. Many people migrate from rural areas to cities, often across Indian states, for employment prospects. The purpose of the study is to explore the barriers to accessing health care among a vulnerable group - internal migrants working in the construction sector in Manipal, Karnataka. Understanding the lay workers' accounts of access to health services can help to comprehend the diversity of factors that hinder access to health care.

METHODS

Individual semi-structured interviews involving 15 migrant construction workers were conducted. The study applied theory-guided content analysis to investigate access to health services among the construction workers. The adductive analysis combined deductive and inductive approaches with the aim of verifying the existing barrier theory in a vulnerable context and further developing the health care access barrier theory.

RESULTS

This study's result is a revised version of the health care access barriers model, including the dimension of trust. Three known health care access barriers - financial, cognitive and structural, as well as the new barrier (distrust in public health care services), were identified among migrant construction workers in a city context in Karnataka, India.

CONCLUSIONS

Further qualitative research on vulnerable groups would produce a more comprehensive account of access to health care. The socioeconomic status behind access to health care, as well as distrust in public health services, forms focal challenges for any policymaker hoping to improve health services to match people's needs.

Global Reach of an Online COVID-19 Course in Multiple Languages on OpenWHO in the First Quarter of 2020: Analysis of Platform Use Data

Background

At the onset of the coronavirus outbreak, the World Health Organization’s (WHO) Health Emergencies Learning and Capacity Development Unit, together with the WHO’s health technical lead on coronaviruses, developed a massive open online course within 3 weeks as part of the global response to the emergency. The introductory coronavirus disease (COVID‑19) course was launched on January 26, 2020, on the health emergencies learning platform OpenWHO.org.

Objective

The aim of this paper is to investigate the geographic reach of different language courses accessed by a worldwide audience seeking information on COVID-19. Users’ professional identities and backgrounds were explored to inform course owners on the use case. The course was developed and delivered via the open-access learning platform OpenWHO.org. The self-paced resources are available in a total of 13 languages and were produced between January 26 and March 25, 2020.

Methods

Data were collected from the online courses’ statistical data and metrics reporting system on the OpenWHO platform. User patterns and locations were analyzed based on Google Analytics and the platform’s own statistics capabilities, and data sets were overlaid. This analysis was conducted based on user location, with the data disaggregated according to the six WHO regions, the top 10 countries, and the proportion of use for each language version. Data included affiliation, gender, age, and other parameters for 32.43% (52,214/161,007) of the users who indicated their background.

Results

As of March 25, 2020, the introductory COVID-19 course totaled 232,890 enrollments across all languages. The Spanish language course was comprised of more than half (n=118,754, 50.99%) of all course enrollments, and the English language course was comprised of 38.21% (n=88,988) of enrollments. The WHO’s Region of the Americas accounted for most of the course enrollments, with more than 72.47% (138,503/191,130) enrollment across all languages. Other regions were more evenly distributed with less than 10% enrollment for each. A total of 32.43% (52,214/161,007) of users specified a professional affiliation by choosing from the 12 most common backgrounds in the OpenWHO user profiles. Before the COVID-19 pandemic, users were spread over the 11 distinct affiliations, with a small fraction of users identifying themselves as “Other.” With the COVID-19 introductory course, the largest number of users selected “Other” (16,527/52,214, 31.65%), suggesting a large number of users who were not health professionals or academics. The top 10 countries with the most users across all languages were Argentina, Chile, Colombia, Ecuador, India, Mexico, Peru, Spain, the United Kingdom, and the United States.

Conclusions

The online course has addressed a worldwide learning need by providing WHO’s technical guidance packaged in simple formats for access and use. The learning material development was expedited to meet the onset of the epidemic. Initial data suggest that the various language versions of the course, in particular Spanish, have reached new user groups, fulfilling the platform’s aim of providing learning everywhere to anyone that is interested. User surveys will be carried out to measure the real impact.

Barriers to health care services in migrants and potential strategies to improve accessibility: A qualitative analysis

BACKGROUND

While migrants in Taiwan are entitled to universal health care, barriers to health care services exist. We aimed to explore challenges encountered by migrants when accessing health care services and potential strategies to overcome these barriers.

METHODS

Invitations to participate in the study were sent to all hospitals, 12 migrant organizations, one language school, and one language service company in Taiwan, and convenience sampling was used to recruit study participants. Focus group interviews were held with 111 migrants, clinicians, migrant organization coordinators, and representatives from the medical institutions, language school and language service company. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using a thematic approach.

RESULTS

The study participants acknowledged that the current support system for migrants in the health care sector is inadequate. Barriers to health care services were noted in three areas - language and information, sociocultural and economic, and policy and resources. Potential strategies to overcome these barriers included the provision of on-site or distant interpreting services, provision of multilingual instruction notes and forms, and establishing a multilingual medical assistance hotline.

CONCLUSION

While migrants benefit from the current support and welfare system, our study found substantial gaps that need to be filled including a lack of professional medical interpreters and training programs, a lack of legal framework for medical interpreting, and inadequacy in the dispersal of information on existing resources that may facilitate the integration of migrants into society and the health care system. Overcoming these barriers may improve migrants' access to health services.

Utilization of healthcare services among Chinese migrants in Kenya: a qualitative study

Background

The number of Chinese migrants in Sub-Saharan Africa (SSA) is increasing, which is part of the south-south migration. The healthcare seeking challenges for Chinese migrants in Africa are different from local people and other global migrants. The aim of this study is to explore utilization of local health services and barriers to health services access among Chinese migrants in Kenya.

Methods

Thirteen in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among Chinese migrants (n = 32) and healthcare-related stakeholders (n = 3) in Nairobi and Kisumu, Kenya. Data was collected, transcribed, translated, and analyzed for themes.

Results

Chinese migrants in Kenya preferred self-treatment by taking medicines from China. When ailments did not improve, they then sought care at clinics providing Traditional Chinese Medicine (TCM) or received treatment at Kenyan private healthcare facilities. Returning to China for care was also an option depending on the perceived severity of disease. The main supply-side barriers to local healthcare utilization by Chinese migrants were language and lack of health insurance. The main demand-side barriers included ignorance of available healthcare services and distrust of local medical care.

Conclusions

Providing information on quality healthcare services in Kenya, which includes Chinese language translation assistance, may improve utilization of local healthcare facilities by Chinese migrants in the country.

'When they come, we don't send them back': counter-narratives of 'medical xenophobia' in South Africa's public health care system

Relying on the experiences of migrant patients, research on migration and health in South Africa has documented a particular concern with public health care providers as indiscriminately practicing 'medical xenophobia'. This article argues that there is more complexity, ambivalence, and a range of possible experiences of non-nationals in South Africa's public health care system than the current extant literature on 'medical xenophobia' has suggested. Based upon in-depth interviews with frontline health care providers and participant observation at a public health care clinic in Musina sub-District, this article demonstrates how discretion may play a crucial role in inclusive health care delivery to migrants in a country marred by high xenophobic sentiment. It finds that in spite of several institutional and policy-related challenges, frontline health care providers in Musina provided public health care services and HIV treatment to black African migrants who are often at the receiving end of xenophobic sentiment and violence. The article concludes that citizenship, nationality or legal status alone do not appear to tell us much as 'bureaucratic incorporation' and 'therapeutic citizenship' are some of the modalities through which migrants are constantly being (re)defined by some of South Africa's health care providers.

Malaria among foreign migrant workers in Savannakhet Province, Lao People's Democratic Republic

Background

Although mobile and migrant populations are considered an important group in malaria elimination settings, there is currently a lack of understanding about foreign migrant workers in the Lao People's Democratic Republic (Lao PDR). The present study aimed to document the migration characteristics, positive rate of malaria infection, and preventive and treatment-seeking behavior for malaria among foreign migrant workers in the malaria-endemic districts of Savannakhet province, Lao PDR.

Methods

A community-based survey was undertaken in four districts of Savannakhet province between February and June, 2015. Questionnaire-based interviews and blood examinations, including rapid diagnostic tests and PCR assays, were conducted with 391 migrant workers who were registered at local police departments.

Results

Most of the study participants were men (75.7%) and Vietnamese (92.6%). The median age (interquartile range) was 31 (25 to 41) years old. Most common occupation was factory worker (47.6%), followed by trader/shopkeeper (21.5%) and plantation worker/farmer (16.4%). The median length of stay (interquartile range) in the districts was 405 (183 to 1207) days. The majority of the participants (85.9%) had not worked in a province other than the study province, nor had the majority (92.6%) worked in a foreign country other than the Lao PDR. Although most of the participants (62.7%) reportedly used a bed net daily, these nets were mostly conventional untreated ones. No one tested positive for malaria. However, 10.0% of the participants reported a malaria-like illness episode that had occurred in the Lao PDR. The most common measure taken for the episode was to visit a hospital/health center in the Lao PDR, followed by conducting self-medication alone. Forty-one participants reported an experience of working in the forest while living in the Lao PDR.

Conclusions

Foreign migrant workers who are registered at local police departments are unlikely to play a major role in maintaining local transmissions and spreading drug-resistant malaria in the study province. However, some of them were involved in forest-related activities, suggesting that these workers are potentially at risk of malaria. The Lao National Malaria Control Program should educate foreign migrant workers about the risk of malaria when living in Lao PDR.

Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017

BackgroundMigrants within the European Union and European Economic Area (EU/EEA) may be underimmunised and lack documentation on previous vaccinations. We investigated approaches to vaccination in recently arrived adult and child migrants, and guideline availability and implementation. Methods: Between March and May 2017, a national vaccination expert from every EU/EEA country and Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: We approached 32 countries (response rate 100%). Although 28 experts reported vaccination guidance at national level, specific guidelines for recently arrived migrants were only available in six countries and not consistently implemented. Twenty-three countries administered vaccinations during on-arrival health checks. Most experts recommended multiple vaccination opportunities be made available: at point of entry (n = 13) or at holding level (reception centres, migrant camps, detention centres) (n = 21). In 30 countries, child migrants without evidence of previous vaccination were re-vaccinated according to the national schedule. Diphtheria-pertussis-tetanus and polio vaccinations were given to migrant children in all countries, measles-mumps-rubella (MMR) in 31 countries, hepatitis B vaccination in 25. Low levels of catch-up vaccination were reported in adult migrants, with only 13 countries offering MMR and 10 countries charging fees. Conclusion: Existing guidance is often not migrant-specific and may not be applied in practice; clarification is needed on which vaccines should be given. Strategies are needed specifically for catch-up vaccination in adult migrants. Vaccinations should be offered in multiple settings, free of charge, with sufficient guidance and training provided to front-line healthcare professionals.

Migrants’ and refugees’ health: towards an agenda of solutions

Despite the greatly increased numbers of migrants and refugees worldwide in recent years, insufficient attention has been paid to addressing their health needs. While a variety of international instruments assert the right to health, in practice, migrants and refugees—especially those awaiting clarification of their status, such as asylum seekers and those without documentation—often fall in cracks between service providers and humanitarian relief programmes at national and regional levels.

This report provides a summary of the current state of knowledge regarding the health issues of migrants and refugees and of the extent to which they are being met. It highlights, through a series of case studies, the diverse approaches to policies, entitlements and services provided in different jurisdictions, ranging from regional (Europe) and country (Germany, Iran, Italy, Turkey, South Africa) levels to provinces and cities (Quebec/Montreal, Berlin). These provide evidence of successes and challenges and highlight areas requiring further effort, including in the domains of policy, service design and delivery, education and training, research and communication. They also underscore the challenges of highly neglected aspects such as mental health and the critical importance of developing cultural/transnational competence in the health professional individuals and institutions working with migrants and refugees.

Results from discussions taking place in an M8 Alliance Expert Group Meeting (Rome, 23–24 June 2017) and from the literature are synthesised to develop an ‘agenda of solutions’. This agenda aims to provide a comprehensive framework, which bridges humanitarian, ethical and rights-based imperatives to provide a framework for action to tackle this crucial area.

Accessing ART in Malawi while living in South Africa - a thematic analysis of qualitative data from undocumented Malawian migrants

The majority of international migrants from Malawi to South Africa are undocumented, and some of them are on ART. This study explored how these migrants manage to access ART. Qualitative data were collected using open-ended questions in semi-structured interviews. 23 returned undocumented Malawian migrants from South Africa participated in the study. Also, key informant discussions were held with three health workers. Data collection took place in April and May 2015 at a rural village of Namwera in Mangochi district in southern Malawi. Interviews were audio-recorded, transcribed and translated into English for thematic analysis. The guardians collected ART from health facilities in Malawi on behalf of the migrants. The guardians sent ART through truck and bus drivers to the migrants in South Africa. The migrants shared their ART. Others bought ART from the 'street pharmacies'. Others accessed ART from South African health facilities through the help of their South African friends. There are risks to dispensing ART to the migrants who do not themselves present at health facilities. There is value to more regular contacts between clients and health service system that is compromised by alternative strategies. It is better to deliver ART services in South Africa to the undocumented migrants.

Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort

BACKGROUND

Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa.

METHODS

The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, ≈7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome.

DISCUSSION

Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.

"The needs have clearly evolved as time has gone on.": A qualitative study to explore stakeholders' perspectives on the health needs of Syrian refugees in Greece following the 2016 European Union-Turkey agreement

Background

By 2017, more than 500,000 Syrian refugees had passed through Greece seeking safety and asylum. Understanding how their health needs evolved over the refugee crisis in Greece and in relation to changing migration policy, and exploring the challenges involved in delivering their healthcare is timely as non-governmental organizations (NGOs) transition health service provision to the Greek health authorities.

Methods

We conducted a qualitative study to explore stakeholders' perspectives on delivering health services to Syrian refugees over the course of the humanitarian response in Greece from 2015 to 2017. Twenty-five in-depth interviews were conducted face-to-face or by Skype with healthcare providers, NGO staff, and organizational and government representatives involved in coordinating and managing healthcare for the Syrian refugee population in Greece. Following informed consent, interviews were audio-recorded or detailed summaries were manually recorded. Data were coded inductively to identify emerging themes.

Results

Following the implementation of the European Union-Turkey agreement in 2016, healthcare providers in refugee camps reported a shift from acute physical health issues to mental health disorders, and heightened risks of gender-based violence among Syrian refugees. Key challenges to service delivery included a narrow model of healthcare provision and insufficient referral mechanisms for social support and mental health services. Language and gender differences between refugees and healthcare providers, and a lack of privacy and space in clinics impeded the quality of care. Stakeholders observed deterioration in refugees' mental health in relation to longer periods spent in the camps. Many also emphasized that services for gender-based violence and mental health should be prioritized.

Conclusion

This study provides stakeholders' perspectives on changes in refugee health needs over the course of the humanitarian response in Greece. With protracted encampment resulting from migration policy, addressing mental health disorders and gender-based violence should be prioritized, including psychosocial training for healthcare providers and strengthening referral mechanisms for specialized care. The findings also emphasize the importance of providing human-centered care and gender concordant services by incorporating female healthcare providers and interpreters into medical teams. Strategic communication and coordination is needed between NGOs and Greek health authorities to facilitate the transition of health service delivery to the Greek healthcare system and to improve access and quality of care for refugees.