Authors' objectives: For those displaced across borders, significant adversity before, during and after displacement journeys, including attitudes and structures in countries of transit and arrival, contributes to considerable risk of poor physical and mental health, and poor and exclusionary experiences of health care. We aimed to understand the opportunities and practices that can support better healthcare responses for forced migrants. During 2022, a record 103 million people were forcibly displaced inside or across borders worldwide. In the UK, although numbers are low in relation to other comparable economies, in the 12 months to September 2022, 85,902 people sought asylum, 143,377 people were awaiting an initial decision, 17,378 people received refugee or alternative forms of humanitarian protection, 213,307 Ukrainian refugees were granted visas under the Ukraine Family and Ukraine Sponsorship schemes, and an estimated half a million undocumented migrants were living in the UK. For those seeking and receiving asylum, a complex set of interconnecting adversities, before, during and after arrival in receiving countries produce significant risks to poor health. Beginning with the original persecution or exposure to war and violence that typically drive displacement, adversities include risks of trafficking, precarity and trauma throughout the displacement journey, isolation and difficult experiences adapting to a new dominant culture, and the prevailing attitudes and structures in transit and receiving countries. These factors are often paid limited attention in the settlement context, despite heavy evidence that compared with native-born populations, forced migrants typically face a greater risk of diverse and comorbid health conditions, including infectious, cardiovascular and chronic respiratory diseases, cancers, and diabetes, and an increased risk of developing poor mental health. Postmigration stressors are complex and intersecting, and when it comes to navigating and negotiating access to health care in settlement or receiving country contexts, studies increasingly highlight poor experiences and substantial barriers. This aligns with broader evidence that public systems rely heavily on individual agency, provide best for those with minimal needs and are in a position to shape, frame and reproduce inequalities. While international human rights law provides us with an ethical framework in which to recognise rights to health care and to the social and material conditions for good health, health and care practices are often neither sufficiently responsive nor adequately equipped to ensure quality care for forced-migrant communities.

Authors' results and conclusions: The review identified 108 studies. We identified six domains of impact: (1) benefit from and creation of community, including linkages with formal (health) services; (2) the formation of networks of care that included traditional and non-traditional providers; (3) proactive engagement, including conducting care in familiar spaces; (4) considered communication; (5) informed providers and enhanced attitudes; and (6) a right to knowledge (respecting the need of new arrivals for information, knowledge and confidence in local systems). The case examples drew attention to the benefits of a willingness to innovate and work outside existing structures, ‘micro-flexibility’ in interactions with patients, and the creation of safe spaces to encourage trust in providers. Other positive behaviours included engaging in intercultural exchange, facilitating the connection of people with their cultural sphere (e.g. nationality, language) and a reflexive attitude to the individual and their broader circumstances. Social and political structures can diminish these efforts. We found that environments that enable good health and enable people to live lives of meaning are vital. We found that these environments require flexibility and reflexivity in practice, intercultural exchange, humility and a commitment to communication. We suggest that a broader range of caring practitioners can, and should, through intentional and interconnected practice, contribute to the health care of forced migrants. Opening up healthcare systems to include other state actors (e.g. teachers and settlement workers) and a range of non-state actors, who should include community leaders and peers and private players, is a key step in this process. Our study showed that health care must be flexible, be interested in individuals and culture, committed to communication and learning, and support people to live meaningful lives. We recommend that a wide range of traditional and non-traditional health providers, such as community leaders, peers, schools and settlement services, work together to improve care. A total 108 studies were selected for inclusion. Most (72) were judged to be of high quality. Forced-migrant participants were drawn from most continents of the world. Most interventions related to mental health. There was substantial heterogeneity in the design of interventions and practices, the health and institutional contexts of interventions, the participant groups and reported outcomes. Outcomes fell into a number of distinct domains, including acceptability, awareness and health agency. Direct measures of access were reported in 64 studies, proxy measures in 48, and 15 studies reported no measure of access. Consistent with our focus on responsive care, we sought within the descriptions of the interventions or service practices to identify any actions that might foster a responsiveness to the needs and contexts of the study population. We identified that programmes of care were overwhelmingly informed by multiple knowledges and perspectives (collaboration, published evidence, experts). The majority of studies also described practices that had recognised language and communication, displacement (and settlement) experiences, potential disconnects between the cultural traditions, values and expectations of arriving and local societies, the broader systems in which participants or services were located, and a set of resource practices and mechanisms for reaching people, namely engaging with, and seeking representation from, communities. We further identified six domains of impact of interventions: (1) the benefit from and creation of community, including linkages with formal (health) services; (2) the formation of networks of care that included traditional and non-traditional healthcare providers; (3) proactive engagement, including conducting care in familiar spaces; (4) considered communication, particularly relating to the benefits of bilingual workers; (5) informed providers and attitudes that saw improved knowledge and compassion; and (6) a right to knowledge that identified the importance of respecting the need of new arrivals for information, knowledge and confidence in local systems, including normalising and understanding the impacts of experiences of war. Five sites were identified from a ‘long list’ of more than 80. Three were in the UK: (1) a non-clinical outreach advocacy, education and support service helping to improve access to state healthcare systems; (2) a community-based, holistic health screening and care planning service; and (3) an inclusion health general practitioner and well-being service that includes holistic health screening. One was in Belgium (a stepped-care mental health service taking a human rights, transcultural and community approach to mental health care) and one in Victoria, Australia (a nurse-led service providing holistic health assessments and care co-ordination for patients with complex needs). Our exploration of these services provides a resource of contrasting services that each demonstrates what is possible in the health care of forced migrants. Taken together, however, the services show a willingness to innovate and work outside existing structures, a complementary ‘micro-flexibility’ in their interactions with patients and clients, and the creation of safe spaces to encourage trust in providers. A further subset of active behaviours was identified: engaging in intercultural exchange (navigating with humility, interest and reflexivity different perceptions); facilitating the connection of people within their cultural sphere (faith, nationality, experiences, language, gender); a focus on the individual; and a reflexive attitude to the individual and their broader circumstances. Our study poses important questions around local and national capacity to dismantle some of the structures, institutional behaviours and ideas that affirm the current experience of healthcare contexts for forced migrants. At the same time, we have shown that it is feasible within a range of organisational contexts for healthcare practice to do this. To our knowledge, it has not previously been recognised how broad a range of caring practitioners and agencies can, and should, through intentional and interconnected practice, contribute to the health care of forced migrants. Opening up healthcare systems to include other state actors, such as teachers and settlement workers, and a range of non-state actors, who should include religious and ethnic community leaders, is a key step in this process. We argue that community is and should be prioritised as a conduit for engagement in a range of healthcare provision, benefiting important social connections and bridging access to statutory care. Refugee patients and communities should be seen as partners in their care deserving of knowledge, skills and confidence in healthcare navigation and psychoeducation, particularly as it relates to normalising responses to war and settlement stressors. An appetite for a networked community of knowledgeable healthcare providers should be recognised and enabled through broad, reflexive and considered programmes of collaborative and informed practice.

Authors' recommendations: Our key research recommendations are as follows. At policy level, we suggest a rapid, cross-sector review of the health and health service implications of existing and proposed immigration practices and their implications in the short, medium and longer terms. For refugee communities, we suggest that there should be further exploration of the role and training of non-specialist peers in healthcare practice in a range of facilitative and delivery roles, including translation. For practitioners, we suggest that research is conducted to better understand: (1) how we motivate, engage and leverage alliance-building relationships across a broad constituency of caring practitioners; and (2) the models and possibilities for embedding intercultural exchange, competencies and reflexivities in both professional education and professional practice.

Authors' methods: We integrated (1) local stakeholder perspectives, from workshops and dialogue; (2) evidence and knowledge from a mixed-methods systematic review; and (3) learning from five case examples from current international practice. We ran database searches (American Psychological Association PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, National Institute for Health and Care Research Journals Library) in February 2022, searched relevant agency websites and conducted backward and forward citation searches, extracted data, assessed methodological quality and integrated qualitative and quantitative findings. Review: wide heterogeneity in study characteristics presented challenges in drawing clear associations from the data. Case examples: we engaged only a small numbers of service users and only with service users from some services. We conducted a mixed-methods convergent integrated systematic review. We included experimental and observational studies, qualitative studies and primary mixed-method studies allowing us to draw on the strength of the different constituent research approaches to produce a broad conceptualisation of evidence, deemed especially useful in the case of complex interventions or complex systems. We included studies conducted in any country and in any language. We included studies with two types of participant: (1) adults or children who are forced migrants; and (2) participants who are relevant to a healthcare ‘moment of opportunity’ for a forced migrant; this included any worker (voluntary or paid, professional or lay) who could play an instrumental role in supporting healthcare access and healthcare experiences. We included studies that aimed to deliver responsive health care for forced migrants. We included studies only where this aim was clearly captured within the stated aims and objectives of the study (not intervention). We included studies regardless of outcome measures, but considered outcomes based on three criteria, namely whether they reported a direct measure of access (e.g. quality of communication, acceptability or appropriateness), a proxy measure of access (e.g. knowledge gain from a practice improvement training programme, such as on cultural awareness as reported by workers) or no measure of access (e.g. a clinical/psychosocial measure only). We searched the American Psychological Association PsycINFO (OVID Technologies 1967–), EMBASE (OVID), the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (EBSCO Publishing 1994–), MEDLINE (Ovid Technologies Inc. 1996–), applying no restrictions on language or publication status, from inception to 28 February 2022. This was supplemented by a grey literature search of relevant material, and forward and backward citation searches. We assessed methodological quality using the study design-specific tools from the Joanna Briggs Institute and developed an additional assessment tool to allow the explicit consideration of appropriateness of interventions for cross-cultural settings. We ‘qualitised’ relevant quantitative data by translating these findings into textual descriptions. These findings were pooled with the textual summaries of qualitative findings and examined and categorised through a framework synthesis approach to data analysis. We conducted a thematic synthesis of intervention and practice designs, in what we saw as their critical features as they related to aspects of access. Maintaining our broad view of evidence we concurrently identified examples of relevant interventions and models of care in current practice, globally, that were taking active steps to improve access to care for forced migrants. We intentionally sought variability through different contexts, characteristics and models of care. We used case study methodology to understand possibilities and practices in responsive care and located these within the different local knowledges, experiences, skills and attributes of workers alongside the experiences of those engaging in services. We also took into account the broader institutional and political contexts in which this all takes place. We conducted semistructured interviews with providers, collaborators and service users, face to face or remotely, and one to one or as part of a small group interview. For UK settings, we made site visits and conducted short-term observation of clinics, where appropriate, and provider settings. Visits and observations served to broaden our understanding of the local contexts, providing the opportunity to acquire the tacit knowledge that can be drawn from observing workers’ personal qualities, the range of interactions taking place within any given space, the informal reflexive perceptions and insights between participants and researchers, bringing a vital aspect to our enquiry. We reviewed service information and evaluations where available. Qualitative evidence, including field notes and documents, was combined in a broad thematic analysis.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR132961

Year Published: 2025

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/MRWK3419

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/MRWK3419

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk