Skip to main content
Download PDF
Download ePub

Barriers and facilitators to primary healthcare utilization among immigrants and refugees of low and middle-income countries: a scoping review

Globalization and Health volume 20, Article number: 75 (2024) Cite this article

Abstract

Introduction

Primary health care (PHC) is the most common model for providing primary care, and PHC services are the most common points of care that immigrants and refugees attend as a first step. Most immigrants travel to low- and middle-income countries (LMICs), yet only a few studies have examined their health conditions and their access to PHC in these countries. We have attempted to identify the barriers and facilitators that immigrants and refugees encounter when using PHC in these countries.

Methods

We searched PubMed, Scopus, Web of Science, Embase, ProQuest, Google Scholar, Microsoft Academic, and OpenGrey in this scoping review from its inception to the end of October 2023. Moreover, we manually searched key journals, reference lists, and citations from included studies to identify any missed studies. We extracted data from each selected study using a predefined form. Finally, a thematic analysis approach was utilized to synthesize the collected data from the included qualitative studies.

Results

17 qualitative studies were included in this review, which were from Iran (n = 3), Brazil (n = 3), Kenya (n = 2), Jordan (n = 2), Eastern Sudan (n = 1), Lebanon (n = 1), Bangladesh (n = 1), India (n = 1), Turkey (n = 1), Thailand (n = 1), and Malaysia (n = 1). Among the most common and important reported barriers are language differences, insufficiency of trained carers, unemployment, inability to pay the costs of hospital and medicines, no insurance coverage for immigrants, no clear referral and care system for immigrants, discrimination against women, and improper residence locations. Insurance coverage, awareness programs, and the study of immigrants’ needs, along with their social and financial support from family, are among the most essential facilitators.

Conclusion

For LMICs, funding is always a limitation, and increasing PHC utilization is the best choice for improving health. Knowing the challenges and facilitators of PHC utilization from the point of view of each stakeholder is a promising way to decide and make policies that can improve the health of both immigrants and refugees, as well as society as a whole.

Introduction

Immigration is a world-changing phenomenon in our era, increasing about 3-fold since 2010 with 41 million immigrants to 2024 with more than 117 million immigrants [1, 2]. People flee from their own countries for various reasons, including war, violations, climate change, and the risk of persecution due to their race, ethnicity, gender, or religion [3]. Two main subpopulations of immigrants are “refugees,” who cross international borders in search of peace and security, and “asylum seekers,” who seek international protection without a defined status of their refuge [4]. The health status of immigrants is a global challenge because they arrive in their destination countries with complex physiological and psychological conditions and needs that require healthcare services. For instance, a 2000 retrospective study in Canada, a country that welcomes immigrants, revealed that the health condition of immigrants significantly deteriorates 10 years after their arrival compared to the day they arrived, highlighting the shortcomings in healthcare provision for immigrants [5, 6]. Afghan immigrants arrive in Iran with unknown health conditions; thalassaemia is common among them due to a lack of premarital medical tests; and pediculosis is prevalent among them, which is difficult to treat because they believe in not giving young girls a haircut. This contributes to the complexity of their health needs, which the Iranian healthcare system often fails to address [7].

To provide primary care, primary health care (PHC) is the most common model in low- and middle-income countries (LMICs), which focusses on the prevention and early detection of diseases (in comparison to primary medical care (PMC), which is usual in high-income countries and focusses on treatment) [8, 9]. PHC is defined by the World Health Organization (WHO) as a “whole-of-society approach to effectively organizing and strengthening national health systems to bring services for health and well-being closer to communities” [10]. PHC services in LMICs can address up to 80% of the population’s health needs at a lower cost than PMC, highlighting the significance of access to these services in enhancing overall health [11, 12]. The WHO has set Universal Health Coverage (UHC) as a 2030 goal, with PHC aiming to achieve 90% of it by educating resilient PHC workforces, establishing a people-centered health system, and digitalizing services [13, 14]. One of the main points of UHC is to include all people regardless of their immigration status [15].

PHC services are the most common points of care that immigrants attend in their initial steps [16, 17]. Research demonstrates that providing immigrants with optimal access to PHC can significantly reduce health inequalities [18]. Despite the documented lower use of PHC by immigrants compared to the native population, various factors significantly influence the accessibility of PHC services for immigrants [8]. The attitude of healthcare providers toward immigrants, their acquaintance with immigrants’ health needs, the ability to communicate with each other despite language and cultural differences, and the unfamiliarity of immigrants with the health system of the new country are among the previously distinguished challenges in the way of PHC access for immigrants [19, 20]. Some strategies, like the “migrant-friendly hospital project” or the “Amsterdam Declaration,” are in response to these challenges and emphasize training healthcare providers in cultural competence and understanding immigrants’ needs [1].

Despite the common belief that high-income and developed countries are the primary host of immigrants, the United Nations High Commissioner for Refugees (UNHCR) reports that low- and middle-income countries (LMICs) account for the majority of immigration, accounting for approximately 75% of all immigrants in 2024 [2]. However, only a limited number of studies have examined the health status of immigrants and their access to PHC in these countries [1]. Furthermore, the numerous limitations in these countries pose a challenge to their ability to provide health services to the growing immigrant population. Even for their own population, PHC implementation faces multiple barriers, such as a poor economic situation, insufficient policymaker-implementer interactions, insufficient coordination with the community, a lack of trained health staff, inadequate marketing, inappropriate caregiver remuneration, a lack of insurance coverage, and a suboptimal PHC network arrangement. Besides, some facilitators have been mentioned, such as having a legal policy for implementing healthcare packages, contracting out the delivery of health services, flexibility in the funding mechanisms, availability of female health staff, good carer-patient interaction, and defined benefits packages [12, 21].

In this context, providing PHC services for immigrants requires a precise investigation of challenges and facilitators. To our knowledge, no previous study has comprehensively reviewed the results of qualitative studies about PHC utilization for immigrants in LMICs. Therefore, in this scoping review, we focus on the obstacles and enablers of PHC utilization for immigrants and refugees in LMICs, derived from qualitative studies, to illuminate this path for decision-makers. Using qualitative studies enables us to understand the perceptions and insights of stakeholders more comprehensively than quantitative studies.

Methods

This scoping review is based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [22]. This methodology is beneficial for gathering a wide range of literature in a specific field. We can investigate key themes and concepts in the field using a review approach. We conducted this systematic scoping review based on Peters et al.‘s (2015) guidance [23].

Search strategy

We used the SPIDER (sample, phenomenon of interest, design, evaluation, and research type) search framework to develop search strings. The research team considered “Immigrants, refugees, and asylum seekers” as the sample, “PHC” as the phenomenon of interest, and “qualitative study” as the research type. Based on some evidence, this search framework is more sensitive and reliable than some other frameworks for searching qualitative research, such as PICO (Population, Intervention, Comparison, and Outcome) [24]. We also contacted to relevant experts and used the free text method to explore additional potential terms. We used keywords such as “primary health care,” “primary healthcare,” “immigrants,” “refugees,” “asylum seekers,” “qualitative study,” and other equivalent terms. We developed the initial search strategy for the PubMed database and then modified it for different databases such as Scopus, Web of Science, Embase, ProQuest, Google Scholar, Microsoft Academic, and OpenGrey (Additional file 1). We manually searched key journals like Primary Health Care Research & Development, Australian Journal of Primary Health, Journal of Primary Care & Community Health, Journal of Primary Health Care, Journal of Immigrant & Refugee Studies, and Journal of Immigrant and Minority Health, along with reference lists and citations from included studies, to identify any missed studies. The search strategy identified studies published from April 1973 to the end of October 2023. We conducted the last update for this search in September 2024.

Study selection

We entered all the search results into the Endnote X21 software (Thomson Reuters, New York, NY), removed duplicates, and screened the remaining studies based on their title and abstract to determine if their subject aligned with our aim. We then applied inclusion and exclusion criteria to determine the final sample of studies for the research. We set the following inclusion criteria: (1) scientific studies with a qualitative design; (2) publication in a peer-reviewed journal; (3) writing in English; (4) exploring the experiences of various stakeholders (such as immigrants, PHC providers, policymakers, etc.) regarding primary health care utilization by immigrants; (5) conducting research in low- and middle-income countries, based on World Bank data; and (6) the availability of full text. On the other hand, our exclusion criteria were: (1) quantitative studies; (2) protocol studies, letters to the editor, abstracts, and editorials; (3) non-English language studies; (4) studies without full text; (5) review studies; and (6) qualitative studies that did not focus on knowledge of experiences related to PHC utilization by immigrants and refugees. Two authors (S.M.I.M. AND S.SH) independently performed these steps, and resolved any disagreement through discussion and the participation of the third author (M.E.). Figure 1 displays the PRISMA flowchart of study selection.

Fig. 1
figure 1

The PRISMA flowchart of the included studies

Full size image

Data extraction

Two authors (S.M.I.M. and S.SH.) independently performed the data extraction process. Before starting this process, all team members contributed to the development of a data collection form. This form’s items were: (1) first author’s name; (2) publication year; (3) host country; (4) sampling approach; (5) country of origin of the immigrants; (6) data collection method; (7) interview format; (8) interviewees; (9) analysis approach; (10) challenges of integration; 11) facilitators of integration; 12) summary of findings; and 13) funding source (Table 1). Other authors checked this process to ensure the accuracy of the extracted data. At this stage, as in previous stages, we resolved any disagreement through discussion and, in some cases, the participation of the expert author (M.B.).

Table 1 An overview of included studies
Full size table

Data synthesis and analysis

We applied the thematic analysis approach to synthesize the collected data from the included qualitative studies [25]. After that, four authors (S.SH, M.E., M.B., and K.B.L.) reviewed and evaluated the similarities and differences among these summaries and identified the main themes, including barriers and facilitators, based on Yang et al.‘s proposed framework on the classification of immigrant health service utilization. The behavioural medical model serves as the foundation for this framework, which categorizes the disparities in immigrants’ health service utilization into two levels: immigrant-specific and general [26]. This framework gave us a pre-defined and established basis for categorising our findings into groups that demonstrate relevance to the health status of immigrants.

Results

This scoping review included 17 qualitative studies from LMIC countries (Fig. 1). The included studies spanned different continents, with 11 (64.7%) originating from Asia, three (17.6%) from Africa, and three (17.6%) from South America. These studies investigated the origins of immigrants from Asia (58.8%, n = 10), Africa (17.6, n = 3), and South America (17.6, n = 3). Additionally, one study ( [27], conducted in India) included immigrants from every country. The timeframe of these studies indicates that 5.8% (n = 1) took place in the 1980s, followed by 5.8% (n = 1) in the 1990s, 35.3% (n = 6) in the 2010s, and 52.9% (n = 9) in the 2020s. Table 1 presents an overview of these studies.

Barriers to PHC utilization

Based on Yang et al.‘s proposed classification of health service utilization for immigrants, we categorized the extracted barriers to PHC utilization (Table 2). The majority of the studies identified language differences [7, 28,29,30,31,32], insufficiency of trained caregivers [27, 29, 33, 34], economic problems such as unemployment and inability to pay the costs of hospital and medicines [35,36,37], and unhealthy social conditions such as discrimination against women [27, 35, 36, 38], improper residence locations [31, 38], and their isolation [35, 37] as the main barriers to PHC utilization.

Table 2 A summary of barriers for utilization of PHC for immigrants
Full size table

General factors that contribute to immigrants’ healthcare needs include increased anxiety during doctor visits for their children [35], difficulties in understanding prescribed drugs [35], the need for dental and antenatal care [30], living in unidentified slums [27], and mistreatment by caregivers [34]. There are also problems in the host countries, like immigrants not having the right to work [36], not being able to get free education and health services [36], not having insurance [7], not having a clear referral and care system for immigrants [27, 29], PHC centres’ hours not matching the needs of immigrants [7], staff working in areas with a lot of immigrants not getting enough help [7], doctors and other health professionals having too much work [30], and immigrants having a bad opinion of health staff [7, 34].

Facilitators of PHC utilization

The reviewed studies identified a few suggested or implemented conditions as facilitators of PHC utilization for immigrants (Table 3). These facilitators include insurance coverage [29], awareness programs, studies of immigrants’ needs [29, 32], social and financial support from family and friends [36], and the proximity of health centers in refugee camps [38].

Table 3 A summary of facilitators for utilization of PHC for immigrants
Full size table

Policymakers are primarily concerned with contextual factors, such as ensuring justice and equality [29], providing health services for refugees [29], providing distinct health instructions for immigrants [29], supplying medical social workers [36], and organizing conferences on immigrants’ needs that involve all stakeholders, including immigrants themselves [32].

Discussion

In this study, we reviewed qualitative studies concerning the barriers and facilitators of PHC utilization in LMICs for immigrants. We reviewed 17 studies, mainly conducted in Asia, and extracted challenges and facilitators in this field from different stakeholders’ points of view. In these countries, funding and financial problems are the main barriers to PHC usage for immigrants. Other barriers mentioned include language differences, the insufficiency of trained carers, discrimination against women, and inappropriate residence locations. Insurance coverage, awareness programs, and studying immigrants’ needs as well as their social and financial support from their families are among the most important facilitators.

The primary barriers involved gaining access to primary care services for refugees and immigrants, as well as identifying key facilitators to enhance their access within the context of LMICs. These countries host the majority of refugees (86%), who also bear the most significant burden of mortality and morbidity from non-communicable diseases (NCDs) [39]. Despite the increasing prevalence of NCDs, most LMICs’ healthcare systems prioritize treatment, allocating only modest funds to primary care [40]. However, migrants often get medical care through the primary care network in their new countries [41].

The vast influx of refugees from nations like Iran, Turkey, Jordan, and Lebanon put a significant strain on the national health care systems of the hosts. On the other hand, waiting a long time to seek the appropriate treatment has resulted from being unable to receive medical attention [42, 43]. In Jordan, 90% of Jordanian patients have faith in their physician; nonetheless, lengthy wait times keep them from consulting one, which dramatically raises the rate of self-medication. Individuals who thought that health center wait times were excessive were twice as likely to self-medicate, with 88% of patients doing so if they thought the wait times were excessive [44]. Financial barriers have impeded refugees’ access to primary care services in Jordan [45, 46] and Lebanon [47]. The cost of primary care still includes missed time, travel, and supplies [48]. Some exclusionary policies that restrict and bureaucratize access to PHC have been adopted, such as more stringent document requirements for acquiring housing and food subsidies, the end of gratuities, and the beginning of charging for PHC services [49]. Previous studies have mentioned cost barriers as one of the main obstacles to refugees accessing primary health services, as demonstrated in the current study [50].

Lack of knowledge of ‘Who’s Doing What, Where, and When’ is an impediment to effectively navigating the health system and is fundamental in addressing healthcare access barriers for refugees, particularly in early phases of displacement among new arrivals and those situated in urban settings [51]. Due to unfamiliarity with the health system or inadequate access to healthcare facilities, foreign migrants in Malaysia tend to initiate care at a later stage of pregnancy [52]. The language barrier Syrians faced, as well as the unavailability of patients’ medical records in Turkey, had a negative impact on the health staff. Doctors providing primary health care services did not feel they could effectively attend to the needs of migrants [53]. Due to the lack of formal interpretation services, primary care facilities dealing with Somali refugees in Kenya frequently use ad hoc interpreters. There have been reports of informal interpreters, such as friends, family members, or taxi drivers, misrepresenting terminologies and symptoms or even breaching patient confidentiality [28].

The barriers to accessing primary health services are more significant. For example, post-migration living difficulties can significantly increase immigrants’ risk of post-traumatic stress disorder [54]. When implementing mental health interventions for refugees and asylum seekers in LMICs, primary care doctors recognize the constrained primary care system and the low recognition rates of common mental disorders as particular challenges [55]. Given the limited resources for mental health in LMICs, most primary care clinics in refugee settings must make difficult choices about which capacities to prioritize [56]. Moreover, a lack of funding for migrant health, particularly for preventive care, leads to low levels of HIV testing among migrants from LMICs [57]. These services have been proven to be challenging to access by refugees and migrants in LMICs that we have reviewed in this study.

In Iran, a previous qualitative study divided the problems that refugees face in getting primary health care into three groups: problems that happen before they are referred to PHC centres include having a lot of children, high service costs, not having medical insurance, getting to health centres, and making appointments for services; problems that happen after they are referred to PHC centres include language barriers, the behaviour of health care providers, and delays in receiving services; and problems that happen after PHC delivery, such as referral patients and high costs of para-clinics [58]. This study backs up what that study said.

The current study illustrates that refugees and migrants encounter various obstacles when attempting to access and utilize primary health services within the context of LMICs they represent. Nevertheless, Amara and Aljunid have stated that most urban refugees in LMICs have adequate access to primary healthcare services [59]. Their study included some, but not all, of the countries we have reviewed in this study.

Healthcare professionals and primary healthcare providers have a significant role in ensuring refugees have adequate access to primary care services. On the other hand, several primary health care reforms have increased the accessibility of services migrants require. With the goal of both integrating Syrian professionals into the health system and guaranteeing that Syrian refugees can receive health care without running into language or cultural barriers—a significant facilitator not identified by this study—primary health care reform in Turkey permits Syrian health professionals to work in the Turkish health system [53]. On the other hand, Somalian refugees highlight the shortage of trained community health workers in rural areas of their host countries, Kenya and Ethiopia, where their simple messages and primary health care services could significantly impact the situation [60].

People view integrating affected refugees into national health systems by addressing the humanitarian-development nexus as a helpful approach. However, in Thailand, an integrated and evidence-based PHC, adequately funded and implemented by one health agency, is a practical and relevant approach to reduce the infectious disease burden in refugee camps [61]. Also, low-cost eHealth strategies like online scheduling and referrals made it easier for everyone to get the same access to PHC services. This meant that newly diagnosed and identified cases who didn’t have a regular provider could still get care in PHC for refugees [62].

Strategies include shifting resources for NCDs and other traditional hospital services to the primary level and creating vital health promotion programs emphasizing prevention and self-care. Additionally, we should prioritize encouraging refugees to use primary care facilities first and, when necessary, provide referral services to hospitals for more complex conditions [63]. Cross-cultural medicine can also improve the relationship between a doctor and a patient and help get past common barriers to care. These barriers can include communication problems caused by language and cultural differences as well as disease explanations that are based on culture [64].

Strengths and limitations

To our knowledge, this is the first study to review all qualitative studies regarding immigrants’ access to PHC services in LMICs, gathering stakeholders’ opinions about barriers and facilitators of PHC utilization. Drawing attention to the struggles of LMICs to improve the health of immigrants is a valuable goal that we tried to achieve in this study.

This study is not without its limitations. Firstly, our scope limited us to reviewing only qualitative studies, which may have resulted in missing data in this field and potentially contributed to further bias. Secondly, reviewing only English articles might be a source of bias for us, especially since most LMICs’ mother tongues are not English. Thirdly, the number of studies in LMICs is much lower than in high-income countries, which might be another source of bias. Therefore, it is crucial to promote more research in the area of immigrant PHC utilization in these countries, in order to generate more data that can serve as a foundation for future decision-making. Future studies must focus on finding solutions to challenges in PHC utilization for immigrants, particularly by identifying current facilitators.

The findings and conclusion of this review should be considered in light of the studies’ contexts and representative countries. We cannot generalize the findings to other countries or all LMICs because the 17 reviewed studies only represent 11 LMICs. Since qualitative research by design involves only specific settings, generalizations are not possible beyond the research population. The majority of studies were non-random, which limits generalization at this level. Therefore, it is best to interpret these insights as representative of the specific settings and populations under study, rather than suggesting broader trends across LMICs.

While some LMICs have a strong representation in the literature when it comes to the obstacles and enablers that refugees face in accessing primary care, there is an under-representation of LMICs with high migration rates. For instance, our review excludes countries like Ethiopia, the Philippines, and Somalia, which experience significant refugee movements due to the lack of primary research on this issue. Filling this gap would enable us to gauge the specific problems and opportunities for healthcare services in these contexts. Therefore, this is the foundation for future studies about how well refugees access primary care services within those regions. Filling the gap would provide a more representative picture of access to care for refugees at the global level.

Conclusion

Appropriate PHC access and utilization are effective strategies for increasing society’s health at the lowest possible cost. Immigrants are currently a growing population worldwide. Because of their specific circumstances, their health needs require special attention. For LMICs, money is always a limitation, and increasing PHC utilization is the best choice for health improvements. Knowing the challenges and facilitators of PHC utilization from the point of view of each stakeholder is a promising way to make decisions and policies that can improve the health of both immigrants and society as a whole. Among these barriers, the most common ones that need to be addressed are language differences, insufficiency of trained carers, unemployment, inability to pay hospital and medicine costs, mistreatment by carers, lack of access to free education and health services, lack of insurance coverage for immigrants, lack of a clear referral and care system for immigrants, discrimination against women, and incorrect residence locations. Facilitators such as insurance coverage, awareness programs, studying immigrants’ needs, social and financial support from family and friends, and the proximity of health centers in refugee camps could help overcome those barriers.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Brandenberger J, Tylleskär T, Sontag K, Peterhans B, Ritz N. A systematic literature review of reported challenges in health care delivery to migrants and refugees in high-income countries-the 3 C model. BMC Public Health. 2019;19(1):1–11.

    Article  Google Scholar 

  2. UNCHR. Figures at a glance, https://www.unhcr.org/us/about-unhcr/who-we-are/figures-glance, Aug 2024.

  3. Sakellari M. Communicating climate change induced migration: the role of NGOs. Open Res Europe. 2024;3:163.

    Article  Google Scholar 

  4. Patel P, Bernays S, Dolan H, Muscat DM, Trevena L. Communication experiences in primary healthcare with refugees and asylum seekers: a literature review and narrative synthesis. Int J Environ Res Public Health. 2021;18(4):1469.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Dunn JR, Dyck I. Social determinants of health in Canada’s immigrant population: results from the National Population Health Survey. Soc Sci Med. 2000;51(11):1573–93.

    Article  CAS  PubMed  Google Scholar 

  6. Ahmed S, Shommu NS, Rumana N, Barron GR, Wicklum S, Turin TC. Barriers to access of primary healthcare by immigrant populations in Canada: a literature review. J Immigr Minor Health. 2016;18:1522–40.

    Article  PubMed  Google Scholar 

  7. Takbiri A, Takian A, Foroushani AR, Jaafaripooyan E. The challenges of providing primary health care to Afghan immigrants in Tehran: a key global human right issue. Int J Hum Rights Health Care. 2020;13(3):259–73.

    Article  Google Scholar 

  8. Batista R, Pottie K, Bouchard L, Ng E, Tanuseputro P, Tugwell P. Primary health care models addressing health equity for immigrants: a systematic scoping review. J Immigr Minor Health. 2018;20:214–30.

    Article  PubMed  Google Scholar 

  9. Muldoon LK, Hogg WE, Levitt M. Primary care (PC) and primary health care (PHC) what is the difference? Can J Public Health. 2006;97:409–11.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Primary health care, World Health Organization. https://www.who.int/health-topics/primary-health-care#tab=tab_1

  11. Doherty J, Govender R. The cost-effectiveness of primary care services in developing countries: a review of the international literature. Washington: World Bank. World Health Organization, Fogarty International Centre of the US National Institutes of Health 2004.

  12. El-Jardali F, Fadlallah R, Daouk A, Rizk R, Hemadi N, El Kebbi O, Farha A, Akl EA. Barriers and facilitators to implementation of essential health benefits package within primary health care settings in low‐income and middle‐income countries: a systematic review. Int J Health Plann Manag. 2019;34(1):15–41.

    Article  Google Scholar 

  13. World Health Organization. Universal health coverage (UHC), https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc). Aug 2024.

  14. Health–Europe TLR. Strengthening primary health care to achieve universal health coverage. Lancet Reg Health-Europe. 2024;39.

  15. Stevenson K, Antia K, Burns R, Mosca D, Gencianos G, Rechel B, Norredam M, LeVoy M, Blanchet K. Universal health coverage for undocumented migrants in the WHO European region: a long way to go. Lancet Reg Health–Europe. 2024;41.

  16. Cheng I-H, Drillich A, Schattner P. Refugee experiences of general practice in countries of resettlement: a literature review. Br J Gen Pract. 2015;65(632):e171–6.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Yelland J, Riggs E, Wahidi S, Fouladi F, Casey S, Szwarc J, Duell-Piening P, Chesters D, Brown S. How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families? BMC Pregnancy Childbirth. 2014;14(1):1–12.

    Article  Google Scholar 

  18. Turin TC, Haque S, Chowdhury N, Ferdous M, Rumana N, Rahman A, Rahman N, Lasker M, Rashid R. Overcoming the challenges faced by immigrant populations while accessing primary care: potential solution-oriented actions advocated by the bangladeshi-canadian community. J Prim Care Community Health. 2021;12:21501327211010165.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ open. 2017;7(8).

  20. Harris MF. Integration of refugees into routine primary care in NSW, Australia. Public Health Res Pract. 2018;28(1).

  21. Etemadi M, Shahabi S, Lankarani KB, Heydari ST. Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions. Globalization Health. 2023;19(1):26.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MD, Horsley T, Weeks L. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

    Article  PubMed  Google Scholar 

  23. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. JBI Evid Implement. 2015;13(3):141–6.

    Google Scholar 

  24. Cooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435–43.

    Article  PubMed  Google Scholar 

  25. Lucas PJ, Baird J, Arai L, Law C, Roberts HM. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. BMC Med Res Methodol. 2007;7(1):1–7.

    Article  Google Scholar 

  26. Yang PQ, Hwang SH. Explaining immigrant health service utilization: a theoretical framework. Sage Open. 2016;6(2):2158244016648137.

    Article  Google Scholar 

  27. Gawde NC, Sivakami M, Babu BV. Utilization of maternal health services among internal migrants in Mumbai, India. J Biosoc Sci. 2016;48(6):767–96.

    Article  PubMed  Google Scholar 

  28. Mutiso V, Warsame AH, Bosire E, Musyimi C, Musau A, Isse MM, Ndetei DM. Intrigues of accessing mental health services among urban refugees living in Kenya: the case of Somali refugees living in Eastleigh, Nairobi. J Immigr Refugee Stud. 2019;17(2):204–21.

    Article  Google Scholar 

  29. Azizi N, Delgoshaei B, Aryankhesal A. Barriers and facilitators of providing primary health care to Afghan refugees: a qualitative study from the perspective of health care providers. Med J Islam Repub Iran. 2021;35:1.

    PubMed  PubMed Central  Google Scholar 

  30. Torun P, Karaaslan MM, Sandikli B, Acar C, Shurtleff E, Dhrolia S, Herek B. Health and health care access for Syrian refugees living in a degrees stanbul. Int J Public Health. 2018;63(5):601–8.

    Article  PubMed  Google Scholar 

  31. Silveira C, Carneiro Junior N, Ribeiro MC, Barata Rde C. Living conditions and access to health services by Bolivian immigrants in the city of São Paulo, Brazil. Cad Saude Publica. 2013;29(10):2017–27.

    Article  PubMed  Google Scholar 

  32. Losco LN, Gemma SFB. Primary health care for Bolivian immigrants in Brazil. Interface Commun Health Educ. 2021;25.

  33. Talhouk R, Akik C, Araujo-Soares V, Ahmad B, Mesmar S, Olivier P, Balaam M, Montague K, Garbett A, Ghattas H. Integrating health technologies in health services for Syrian refugees in Lebanon: qualitative study. J Med Internet Res. 2020;22(7):e14283.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Gee S, Vargas J, Foster AM. The more children you have, the more praise you get from the community: exploring the role of sociocultural context and perceptions of care on maternal and newborn health among Somali refugees in UNHCR supported camps in Kenya. Confl Health. 2019;13:11.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Nikfarid L, Rassouli M, Shirinabadi Farahani A, Beykmirza R, Khoubbin Khoshnazar TA. Perspectives of Afghan refugee mothers on the experience of caring for a child with cancer: a qualitative analysis. East Mediterr Health J. 2020;26(6):680–6.

    Article  PubMed  Google Scholar 

  36. Rajaratnam S, Azman A. Refugee and asylum seeker women’s experiences with healthcare and social environment in Malaysia. Int J Environ Res Public Health. 2022;19(11).

  37. Maconick L, Ansbro E, Ellithy S, Jobanputra K, Tarawneh M, Roberts B. To die is better for me, social suffering among Syrian refugees at a noncommunicable disease clinic in Jordan: a qualitative study. Confl Health. 2020;14(1).

  38. Jannat S, Sifat RI, Khisa M. Sexual and reproductive health conditions of women: insights from Rohingya refugee women in Bangladesh. Sex Res Soc Policy. 2023 Sep;20(3):855-68.

  39. Harris P, Kirkland R, Masanja S, Le Feuvre P, Montgomery S, Ansbro É, Woodman M, Harris M. Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership. BMJ Global Health. 2022;7.

  40. Saleh S, Farah A, Dimassi H, El Arnaout N, Constantin J, Osman M, El Morr C, Alameddine M. Using mobile health to enhance outcomes of noncommunicable diseases care in rural settings and refugee camps: randomized controlled trial. JMIR mHealth uHealth. 2018;6(7):e8146.

    Article  Google Scholar 

  41. Iqbal P, Walpola M, Harris-Roxas R, Li B, Mears J, Hall S, Harrison J. R: Improving primary health care quality for refugees and asylum seekers: a systematic review of interventional approaches. In: Health Expectations: 2022;2022:2065–2094.

  42. Silbermann M, Daher M, Kebudi R, Nimri O, Al-Jadiry M, Baider L. Middle eastern conflicts: implications for refugee health in the European Union and middle eastern host countries. J Global Oncol. 2016;2(6):422–30.

    Article  Google Scholar 

  43. Amini E, Etemadi M, Shahabi S, Barth CA, Honarmandi F, Karami Rad M, Lankarani KB. Barriers and enabling factors for utilizing physical rehabilitation services by Afghan immigrants and refugees with disabilities in Iran: a qualitative study. BMC Public Health. 2024;24(1):1–15.

    Article  Google Scholar 

  44. Al Baz M, Law MR, Saadeh R. Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan – a cross-sectional study. Travel Med Infect Dis. 2018;22:25–9.

    Article  PubMed  Google Scholar 

  45. Ansbro É, Homan T, Qasem J, Bil K, Rasoul Tarawneh M, Roberts B, Perel P, Jobanputra K. MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework. BMC Health Serv Res. 2021;21(1):381.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Ansbro É, Garry S, Karir V, Reddy A, Jobanputra K, Fardous T, Sadique Z. Delivering a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: a descriptive costing study. Health Policy Plann. 2020;35(8):931–40.

    Article  Google Scholar 

  47. Truppa C, Leresche E, Fuller AF, Marnicio AS, Abisaab J, El Hayek N, Zmeter C, Toma WS, Harb H, Hamadeh RS, et al. Utilization of primary health care services among Syrian refugee and Lebanese women targeted by the ICRC program in Lebanon: a cross-sectional study. Confl Health. 2019;13(1):7.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Ratnayake R, Rawashdeh F, AbuAlRub R, Al-Ali N, Fawad M, Bani Hani M, Goyal R, Greenough PG, Al-Amire K, AlMaaitah R, et al. Access to care and prevalence of hypertension and diabetes among Syrian refugees in Northern Jordan. JAMA Netw Open. 2020;3(10):e2021678–2021678.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Lima Junior LPd L, KCOd, Bertolozzi MR, França FOS. Vulnerabilities of arab refugees in primary health care: a scoping review. Rev Saúde Pública. 2022;56.

  50. Shahabi S, Etemadi M, Hedayati M, Bagheri Lankarani K, Jakovljevic M. Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach. Health Res Policy Syst. 2023;21(1):94.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Sibai AM, Najem Kteily M, Barazi R, Chartouni M, Ghanem M, Afifi RA. Lessons learned in the provision NCD primary care to Syrian refugee and host communities in Lebanon: the need to ‘act locally and think globally’. J Public Health. 2020;42(3):e361–8.

    Article  Google Scholar 

  52. Ab Rahman N, Sivasampu S, Mohamad Noh K, Khoo EM. Health profiles of foreigners attending primary care clinics in Malaysia. BMC Health Serv Res. 2016;16(1).

  53. Yıldırım CA, Komsuoğlu A, Özekmekçi İ. The transformation of the primary health care system for Syrian refugees in Turkey. Asian Pac Migration J. 2019;28(1):75–96.

    Article  Google Scholar 

  54. Matlin SA, Depoux A, Schütte S, Flahault A, Saso L. Migrants’ and refugees’ health: towards an agenda of solutions. Public Health Rev. 2018;39:1–55.

    Article  Google Scholar 

  55. Jannesari S, Lotito C, Turrini G, Oram S, Barbui C. How does context influence the delivery of mental health interventions for asylum seekers and refugees in low- and middle-income countries? A qualitative systematic review. Int J Mental Health Syst. 2021;15(1):80.

    Article  Google Scholar 

  56. Kane JC, Ventevogel P, Spiegel P, Bass JK, van Ommeren M, Tol WA. Mental, neurological, and substance use problems among refugees in primary health care: analysis of the health information system in 90 refugee camps. BMC Med. 2014;12(1):228.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Darebo TD, Spigt M, Teklewold B, Badacho AS, Mayer N, Teklewold M. The sexual and reproductive healthcare challenges when dealing with female migrants and refugees in low and middle-income countries (a qualitative evidence synthesis). BMC Public Health. 2024;24(1):520.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Azizi N, Delgoshaei B, Aryankhesal A. Lived experience of Afghan refugees in Iran concerning primary health care delivery. Disaster Med Pub Health Prep. 2019;13(5–6):868–73.

    Article  Google Scholar 

  59. Amara AH, Aljunid SM. Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need. Globalization Health. 2014;10:1–15.

    Article  Google Scholar 

  60. Lindvall K, Kinsman J, Abraha A, Dalmar A, Abdullahi MF, Godefay H, Lerenten Thomas L, Mohamoud MO, Mohamud BK, Musumba J. Health status and health care needs of drought-related migrants in the Horn of Africa—a qualitative investigation. Int J Environ Res Public Health. 2020;17(16):5917.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Mohr O, Benner MT, Sansoenboon A, Kaloy W, McGready R, Carrara VI. Integrated primary health care services in two protracted refugee camp settings at the Thai-Myanmar border 2000–2018: trends on mortality and incidence of infectious diseases. Prim Health Care Res Dev. 2022;23.

  62. Saleh S, Alameddine M, Farah A, El Arnaout N, Dimassi H, Muntaner C, El Morr C. eHealth as a facilitator of equitable access to primary healthcare: the case of caring for non-communicable diseases in rural and refugee settings in Lebanon. Int J Public Health. 2018;63:577–88.

    Article  PubMed  Google Scholar 

  63. Doocy S, Lyles E, Akhu-Zaheya L, Burton A, Burnham G. Health service access and utilization among Syrian refugees in Jordan. Int J Equity Health. 2016;15(1):108.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Mishori R, Aleinikoff S, Davis D. Primary care for refugees: challenges and opportunities. Am Fam Physician. 2017;96(2):112–20.

    PubMed  Google Scholar 

  65. Barnabas G. Nutrition and child care amongst Ethiopian refugees in Eastern Sudan. Perspectives in primary case. J Trop Pediatr. 1982;28(4):218–20.

    Article  CAS  PubMed  Google Scholar 

  66. Powell TM, Qushua N. A qualitative study of a mental health awareness intervention for Jordanian and resettled Syrian refugees in host communities. Int J Soc Psychiatry. 2023 Feb;69(1):161-72.

  67. Losco LN, Gemma SFB. Health subjects, territory agents: the community health agent in immigrant primary care. Interface Commun Health Educ. 2019;23.

  68. Maybin S. A comparison of health provision and status in Ban-Napho refugee camp and Nakhon-Phanom Province, Northeastern Thailand. Disasters. 1992;16(1):43–52.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

This paper and the research behind it would not have been possible without the exceptional support of all the contributors who agreed to donate their time and ideas and take part in this study.

Funding

This research was supported by the Shiraz University of Medical Sciences, Shiraz, Iran (No: 27912).

Author information

Authors and Affiliations

  1. Health Policy Research Center, Institute of Health, School of Medicine, Shiraz University of Medical Sciences, Building No 2, Eighth Floor, Zand Avenue, Shiraz, 71348-45794, Iran

    Seyed Mohammad Iman Moezzi, Kamran Bagheri Lankarani, Hamidullah Katebzada & Saeed Shahabi

  2. NIHR Applied Research Collaboration (ARC) West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK

    Manal Etemadi

  3. Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

    Manal Etemadi

  4. Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran

    Masoud Behzadifar

Authors
  1. Seyed Mohammad Iman Moezzi
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Manal Etemadi
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Kamran Bagheri Lankarani
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Masoud Behzadifar
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Hamidullah Katebzada
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Saeed Shahabi
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

S.M.I.M, M.E, K.B.L, H.K, and S.SH contributed to the conception and design of the study. S.SH conducted the search, and S.M.I.M was co-moderator. S.M.I.M and H.K conducted screening and selecting the final studies, which K.B.L, S.SH, and M.B discussed regularly. S.M.I.M, M.E, K.B.L, H.K, and S.SH wrote the initial draft, and M.B contributed to manuscript revisions. All authors read and confirmed the final manuscript.

Corresponding author

Correspondence to Saeed Shahabi.

Ethics declarations

Ethics approval and consent to participate

The Research Ethics Committee of the Shiraz University of Medical Sciences provided the ethical approval for this study (IR.SUMS.REC.1402.141) previously. All methods were performed in accordance with the relevant guidelines and regulations such as Declarations of Helsinki. Informed consent for participating in this study was obtained from all the participants before the interview sessions.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moezzi, S.M.I., Etemadi, M., Lankarani, K.B. et al. Barriers and facilitators to primary healthcare utilization among immigrants and refugees of low and middle-income countries: a scoping review. Global Health 20, 75 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12992-024-01079-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12992-024-01079-z

Keywords

Globalization and Health

ISSN: 1744-8603