Health Professionals' Experiences of and Attitudes Towards Mental Healthcare For Migrants and Refugees in Europe A Qualitative Systematic Review

Review article
Transcultural Psychiatry
1–24
Health professionals’ experiences of and © The Author(s) 2022
attitudes towards mental healthcare for Article reuse guidelines:

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migrants and refugees in Europe: A DOI: 10.1177/13634615211067360
journals.sagepub.com/home/tps
qualitative systematic review
E. Peñuela-O’Brien1,2 , M. W. Wan1, D. Edge1,2, and K. Berry1,2
Abstract
Migrants living in Europe constitute over half of the world’s international migrants and are at higher risk of poor mental
health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of
care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify
professionals’ attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to
service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic
synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the
migrant status; 2) professionals’ emotional responses to working with migrants; and 3) delivering care in the context
of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes
towards this patient group were polarized. Professionals described mental health issues as being inseparable from material
and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organiza-
tions, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for pro-
fessionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in
meeting migrants’ needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect
frustrations in being part of a system with insufficient resources and without universal access to care that effectively stig-
matizes the migrant status.
Keywords
Europe, healthcare professional attitudes, mental health, mental health services, migrants, thematic synthesis
Introduction experiences of discrimination systemic within government

institutions related to healthcare, employment, and social
Of the 272 million migrants worldwide, over half reside in services can negatively impact on mental health (Bhugra
Europe (International Organisation for Migration, 2020). & Becker, 2005; European Monitoring Centre on Racism
The term ‘migrant’ refers to a person who has moved & Xenophobia, 2006; Wu et al., 2015). The migratory
from their country of birth to settle elsewhere temporarily journey and post-migration issues related to poverty, uncer-
or permanently, irrespective of the reason—including refu- tainty about the future, and a lack of social networks in the
gees and people seeking asylum (Zimmerman et al., 2011). new country also take a toll on mental health (Kirmayer
Multiple factors place migrants at elevated risk of mental et al., 2011). Evidence suggests that migrants face escalat-
health problems, which may include the complex process ing levels of xenophobia and racism in Europe related to
of migration itself. While the European Union supports political change (Jaskulowski & Pawlak, 2020), which
initiatives to improve migrant mental healthcare (Mental
Health Europe, 2019), there continue to be substantial dis-
parities in both the mental health and mental healthcare 1
Division of Psychology and Mental Health, School of Health Sciences,
experienced by migrants living in Europe. University of Manchester
2
Many migrants experience adversities associated with Greater Manchester Mental Health NHS Foundation Trust
leaving regions of conflict, persecution, and socioeconomic
Corresponding author:
deprivation (Miller & Rasmussen, 2017). Once settled, E. Peñuela-O’Brien, Division of Psychology and Mental Health, School of
communication barriers, social isolation, the loss and Health Sciences, University of Manchester, UK.
adjustment of cultural norms and religious practices, and Email: stef_penuela@hotmail.com
2 Transcultural Psychiatry 0(0)
contribute to their vulnerability and exploitation, and affect- Europe, and to describe their perceptions of barriers and
ing mental health outcomes (Szaflarski & Bauldry, 2019). facilitators to service provision. The review also appraised
Diversity among the migrant population presents a chal- the quality of the studies on this topic.
lenge to health organizations attempting to tailor services to
meet their mental health needs (Bempong et al., 2019).
Stigma and communication difficulties with healthcare pro- Method
fessionals and lack of knowledge about services (Blignault
et al., 2008) may prevent migrants from seeking mental
Search strategy
healthcare, while undocumented migrants may fear deport- Four electronic databases (PsycINFO, CINAHL,
ation (Hacker et al., 2015). Once engaged with services, MEDLINE, Web of Science), selected for their coverage
health professionals experience cultural and language bar- of literature pertaining to physical and mental health,
riers, limitations of legal entitlement (which also vary patient care, and clinical practice, were searched using the
between European countries), inadequate training to meet following terms in the title, abstract, or keywords:
need, and the complexity of dealing with trauma presenta- (migrant* OR immigrant* OR asylum seek* OR
tions (Barrington & Shakespeare-Finch, 2013). Limited refugee*) AND (satisfaction OR opinion* OR attitude*
and delayed access to interpreting services and a lack of OR view* OR experience* OR perception* OR evaluation
political support are further structural issues preventing OR value* OR perspective* OR challenge* OR facilitator*
access to mental healthcare (O’Donnell et al., 2016; OR barrier* OR assumption* OR belief* OR judgement*
Wohler & Dantas, 2017). OR understanding*) AND (mental health OR mental
Since mental health problems are often presented to and health service* OR mental health provider*). Reference
managed by a range of professionals within primary care lists of the included studies were also searched. To identify
(Wittchen et al., 2003; World Health Organisation, 2018), studies relevant to current care provision in Europe (Knapp
gaining the perspectives of a range of health professionals is et al., 2007), studies included those published between
important to understand how best to meet migrant mental January 2000 and October 2020. The review protocol was
health needs. Much of the work to date has focused on refu- registered with PROSPERO (http://crd.york.ac.uk/
gees. In a qualitative synthesis of professionals’ experiences prospero, registration number CRD42019155360).
of working with refugees specifically, mental health needs
were identified as best met through interdisciplinary and psy-
chosocial work, practical interventions, and advocacy Inclusion and exclusion criteria
(Karageorge et al., 2017), while a qualitative synthesis of Papers were included if they: 1) were written in English; 2)
refugee and professional perspectives highlighted the thera- employed qualitative methodology (individual and/or
peutic relationship, cultural sensitivity, and the need to group interviews) in whole or as a component; 3) focused
provide support to staff and adapt interventions to meet on the perspective of the health professional; 4) focused
migrants’ needs (Duden et al., 2020). The therapeutic relation- on first-generation migrants (including specifically refugees
ship, particularly regarding trust and flexible boundaries, has or people seeking asylum) presenting with mental health
been evidenced as especially important in the field of problems; 5) were conducted in Europe; and 6) were pub-
migrant mental healthcare (Duden & Martins-Borges, 2020; lished in peer-reviewed journals between January 2000
Kirmayer et al., 2011). However, professionals’ experiences and October 2020.
related to working with migrants are likely to shape their per- Given the research questions were focused on under-
ceptions of and attitudes towards this group (Fox & Tang, standing professionals’ experiences and attitudes, papers
2016), and this may affect the professional–patient relation- with a qualitative component were included as they offer
ship (Zestcott et al., 2016) and clinical outcomes of migrants. more in-depth and rich information. The review focused
In view of the continued increase of migrants in Europe, on European studies due to the established European
the diversity of this group, and their increased mental health policy of migrant mental healthcare, high inter-European
risk (Carta et al., 2005), a review of the qualitative research migration, and migrants often travelling through multiple
to date enables us to understand in depth the range of pro- European countries towards their end destination
fessionals’ experiences of providing mental healthcare to (Parliamentary Assembly, 2015), within which they may
migrants and in navigating challenges, their attitudes access mental healthcare. Studies related to migration
towards migrant patients, and how they can be best from within and outside of Europe were included. Health
equipped to provide high quality care to this group. Given professionals, irrespective of discipline, were included if
that migrant mental healthcare is not limited to specialist the focus addressed mental health problems (i.e., any inter-
mental health services or professionals, we explored these action between professionals and migrants in relation to
issues across a range of professional groups and service set- their mental health).
tings. The aim of this review was to identify professionals’ The term ‘migrant’ was defined as anyone living in a
attitudes towards migrants and their mental healthcare in country other than their place of birth, including
Peñuela-O’Brien et al. 3
undocumented migrants, people seeking asylum, and refu- NVivo software (QSR International Pty Ltd. Version 12,
gees. While differences between these groups are acknowl- 2018) for analysis. Only data related to professionals’
edged, for this review, the term ‘migrant’ refers to all the experiences of mental healthcare were coded.
above groups. Papers focused on the descendants of Comparisons were made within and across studies, and a
migrants were excluded as they have not experienced coding frame was developed from the derived codes.
migratory processes first-hand, which may differentially Coding discrepancies were resolved through research
impact on mental health (Schneider, 2016). Papers team discussion and the coding frame adjusted accordingly.
focused on children’s mental healthcare, patient perspec- All coding and theme development were completed induc-
tive, and physical healthcare provision were excluded, tively to capture the meaning and content of each sentence.
and have been reviewed elsewhere (Curtis et al., 2018; Codes similar in content were grouped into descriptive
Robertshaw et al., 2017; Satinsky et al., 2019). themes, capturing patterns in the data. Each theme was
recorded in tabular form, with coded data presented in
each row to facilitate the constant comparison analytic
Study selection process and show any divergence of findings in each
Figure 1 outlines the search process based on Preferred theme. The final stage of synthesis involved the develop-
Reporting Items for Systematic Reviews and Meta-Analyses ment of analytic themes by going beyond the primary
(PRISMA) guidelines (Moher et al., 2009). All papers identi- data and interpreting their meaning in relation to the
fied were imported into Mendeley (Version 1.19.4) and dupli- research questions. All stages were undertaken by the
cates were removed. Initial screening of titles, abstracts, and primary author, and the coherence of themes was estab-
full texts was carried out by the primary author. Agreement lished via discussion within the research team and a doc-
with a sub-sample screened by a second reviewer independent toral student independent of the team. A matrix of themes
of the research team was 98% (kappa = 0.97) for initial screen- was created to demonstrate transparency and rigor, adher-
ing and 100% (kappa = 1) for full-text screening. ing to the ‘enhancing transparency in reporting the synth-
Disagreements were discussed with the team to reach a esis of qualitative research’ (ENTREQ) guidelines (Tong
consensus. et al., 2012).
Quality assessment Reflexivity statement

Using the Critical Appraisal Skills Programme (CASP) The review adopted a critical realist perspective, which
checklist (Critical Appraisal Skills Programme, 2018) to accepts the existence of an independent social world that
assess quality involved attributing a numerical value (No can only be understood through the perspectives and
= 0, Can’t Tell = 0.5, Yes = 1) to checklist items experiences of both research participants and researchers
(maximum total score = 10). The total CASP score referred (Fletcher, 2016). The primary author was a trainee clinical
to methodological quality as ‘high’ (>8–10), ‘moderate’ (6– psychologist, who previously worked with migrants in a
8), or ‘low’ (≤5). Papers were rated by an independent range of UK mental healthcare settings. The research
reviewer to assess the reliability of quality assessment team consists of clinical and academic researchers with
ratings. Agreement between raters was high (96%, kappa expertise in mental health and/or culture and diversity.
= 0.92) and any disagreement was resolved with discussion. The primary author is of migrant heritage, and a range of
ethnic backgrounds are represented within the team.
While these factors are considered as strengths in providing
Data synthesis deeper understanding on the topic, the team’s shared
A thematic synthesis (Thomas & Harden, 2008), an adapta- knowledge and experiences may also have influenced
tion of thematic analysis (Braun & Clarke, 2006) to analyze data interpretation. For instance, increased importance
primary qualitative data across multiple studies, was may have been placed on challenges in care provision
selected due to its lack of restriction to a particular metho- which mirrored the researchers’ experiences, such as insuf-
dology, good transparency, and suitability to the aim by ficient time for consultations. Care was taken to minimize
staying ‘close’ to the results of the primary studies and the impact of prior assumptions through the use of reflec-
facilitating the creation of new concepts and hypotheses tion and team discussion.
(Barnett-Page & Thomas, 2009).
The three stages of thematic synthesis were: 1) free
line-by-line coding of the findings of included studies; 2) Results
the organization of these codes into related areas to create
descriptive themes; and 3) the development of analytical Characteristics of included studies
themes. All text data under the heading ‘results’ within Twenty-three papers were identified for inclusion, utilizing
papers were extracted electronically and imported to individual (n = 20) or group interview (n = 3) study
Figure 1. PRISMA flow diagram.
designs and conducted across seven European countries. papers used these terms interchangeably. Most papers
Six papers included professionals from several European focused on professionals’ work with migrant groups from
countries. Sample sizes were diverse, ranging from six low socioeconomic backgrounds. The most common
to 240. Overall, there were slightly more male participants methods of analysis were thematic analysis (n = 8),
(n = 55) than females (n = 49) across the 10 studies that pro- grounded theory (n = 3), and constant comparative method
vided sample sex information; however, Samarasinghe et al. (n = 3). Additional study characteristics are presented in
(2010) had a majority female sample (93%). Professionals Table 1.
included physicians (n = 278), nurses (n = 166),
psychologists (n = 92), service managers (n = 75), social
workers (n = 72), psychiatrists (n = 53), and psychothera- Methodological quality of included studies
pists (n = 24). Studies focused on patient groups of migrants Studies were categorized as ‘high’ (n = 17) or ‘moderately
(n = 4), refugees (n = 3), people seeking asylum (n = 1), or a high’ (n = 6) in methodological quality, so no studies
combination of these groups (n = 15); however, several were excluded on the grounds of low quality. While
Figure 2. Proposed thematic relationships and their effects on the mental healthcare of migrants.
consistently high (>87%) on items related to aims, Theme 1: The management of multifaceted and
methodology, and findings, only 10 (43%) papers contained complex challenges associated with the migrant
evidence adequately considering the researcher–participant
status
relationship. Of the six ‘moderately high’ quality
papers, five lacked detail on reflexivity, ethical considera- Professionals identified several major factors that hinder
tions, and contribution to existing knowledge. Given engagement with services and clinical progress. Firstly,
that there is no widely accepted or empirically tested the stigma and discrimination attached to the immigrant
approach for excluding qualitative studies from synthesis status and mental health is reflected in healthcare services
on the grounds of quality (Dixon-Woods et al., 2006), the (Franks et al., 2007). Occupational therapists in Sweden
CASP was used to remind readers of potential influences encountered difficulty gaining support from other services
which can present in studies but higher quality studies when working with migrants: “if I have someone called
weighed more strongly in the interpretation of the findings. ‘Svensson’ with me, it takes less time to find a contact
person than if I have someone called ‘Ahmed’ with me”
(Pooremamali et al., 2011, p. 114). Secondly, adverse
socioeconomic conditions including poverty, housing inse-
Thematic synthesis curity, and social isolation also formed barriers to mental
Three themes were created from the synthesis: 1) the man- healthcare (Teunissen et al., 2015). Professionals from
agement of multifaceted and complex challenges associated many countries agreed that addressing these adverse cir-
with the migrant status; 2) professionals’ emotional cumstances was a priority and described referring migrants
responses to working with migrants; and 3) delivering care to housing facilities, writing letters, and consulting with
in the context of cultural difference. Figure 2 depicts the rela- other professionals (Century et al., 2007). Thirdly, profes-
tionship between the themes. Factors related to the migrant sionals noted the importance of identifying psychological
status posed challenges to the delivery of care (theme 1) trauma in this patient group, yet counsellors (Century
and learning about the difficulties associated with the et al., 2007) and primary care nurses (Suurmond et al.,
migrant status could evoke strong emotional responses for 2010) expressed reluctance to work with such trauma; for
professionals (theme 2). Such responses may influence the counsellors because “life for the client was so uncertain
delivery of care, including the development of negative atti- and sometimes unsafe” (p. 29) and for nurses because of
tudes towards migrants. Theme 3 represents the interface a lack of confidence. Others were concerned with patholo-
between migrant and professional, and the ways in which gising what they considered to be normal responses to
cultural barriers could affect care provision. See Table 2 adverse life experiences (Apostolidou, 2016). Fourthly,
for details of the quality assessment and matrix of themes given the frequent need for multiple services, problems in
across studies. collaboration between services were identified to be
6
Table 1. Characteristics of included studies.
Authors, publication Participantsa Data collection

year, & country (professionals) Patients methodb Topic guide items Method of analysis Main themes identifiedc
1 Teunissen et al. (2016) N = 12 Migrants Structured 1) GP’s experiences with Constant comparative 1) Undocumented migrants
Greece Primary care interviews undocumented migrants; 2) method avoid contact with physicians;
physicians the barriers and facilitators 2) Barriers in disclosure and
8 Males undocumented migrants and engagement; 3) Recording by
4 Females GPs face regarding accessing; physicians; 4) Problems in
and 3) the delivery of treatment; 5) Strategies to
healthcare to undocumented provide mental health; and 6)
migrants with mental health Required changes to improve
problems care
2 Onyiguo et al. (2016) N=6 Migrants Semi-structured No details provided Interpretative 1) Providers’ perception of
UK Clergy, primary interviews phenomenological barriers to health-seeking
healthcare analysis behaviors; 2) Issues in
professionals collaboration; and 3) Contexts
Sex of sample for integration
not provided
3 Suurmond et al. (2010) N = 36 Asylum Semi-structured 1) Problems experienced with Framework analysis 1) Training and education in
Netherlands Nurse seekers group interviews providing medical care; 2) the cultural competence; 2)
practitioners specific role of the nurse Knowledge of the political and
Sex of sample practitioner in the system of humanitarian situation in the
not provided medical care; 3) perceived country of origin; 3)
expectations of asylum Knowledge of epidemiology
seekers; and 4) what was seen and the manifestation of
as an ideal situation in which diseases in asylum seekers’
to provide high-quality care countries of origin; 4)
Knowledge of the effects of
refugeehood on health; 5)
Awareness of the juridical
context in which asylum
seekers live; 6) Skills to develop
a trustful relationship with an
asylum seeker; 7) Ability to ask
delicate questions about
traumatic events and personal
problems; 8) Ability to explain
what can be expected from
healthcare; and 9) Improving
cultural competence
4 Feldmann et al. (2007) N = 24 Refugees Semi-structured No details provided Constant comparison 1) Physicians on refugee
Netherlands Primary care interviews analysis problems; 2) How physicians
Transcultural Psychiatry 0(0)
physicians deal with refugee problems; 3)

Human interest strategy; 4)
(continued)
Table 1. Continued

17 Males Technical strategy; 5) Elements

7 Females that occur in both human
Peñuela-O’Brien et al.
interest and technical

strategies; and 6) Consultation
with or referral to social work
or mental healthcare
5 Holmqvist and Andersen N=9 Refugees Semi-structured 1) General reactions to the Thematic categorization 1) The work is meaningful and
(2003) Psychotherapists interviews project; and 2) specific rewarding; 2) Guilt; 3) View of
Sweden 4 Males reactions to the individual life; 4) Uncertainty; 5)
5 Females clients Exhaustion; 6) Symptoms; and
7) Protection mechanisms
6 Griffiths et al. (2017) N = 14 Refugees Semi-structured No details provided Framework analysis 1) Facilitating Factors; and 2)
Italy Psychiatrists Migrants interviews Barriers
Sex of sample
not provided
7 Jensen et al. (2013) N = 12 Refugees Semi-structured 1) The experiences of general Qualitative content 1) Communication; 2) Quality
Denmark 9 primary care Migrants interviews practitioners with delivery of analysis of care; 3) Referral pathways;
physicians (2 care to immigrants in general and 4) Understandings of
males and 7 disease and expectations for
females), 3 treatment
psychiatric
inpatient
managers
(sex split not
provided)
8 Priebe et al. (2011) N = 240 Refugees Structured 1) General experiences; and Thematic content 1) Differences in further
Austria, Belgium, 156 physicians, Asylum interviews 2) problems and strengths in analysis treatment for migrants; 2)
Denmark, Finland, 44 nurses, 7 seekers providing healthcare to Problem areas; 3) Components
France, Germany, psychologists, 4 Migrants migrants of good practice; and 4)
Greece, Hungary, Italy, physiotherapists, Differences between types of
Lithuania, Netherlands, 3 social workers, services
Poland, Portugal, Spain, 26 healthcare
Sweden, UK managers
Sex of sample
not provided
9 Priebe et al. (2012) N = 125 Refugees Semi-structured Four general questions on the Thematic analysis 1) Outreach Programs; 2)
Austria, Belgium, Czech 20 psychiatrists, Asylum interviews quality of mental healthcare in Facilitating access to general
Republic, France, 26 psychologists, seekers the given area for that group health services; 3)
Germany, Hungary, 55 social workers, Migrants Collaboration and coordination
7
Ireland, Italy, 3 occupational of services; and 4) Information

(continued)
8
Table 1. Continued

Netherlands, Poland, therapists, 9

Portugal, Spain, Sweden, nurses 12
UK physicians
Sex of sample
not provided
10 Straßmayr et al. (2012) N = 23 Refugees Semi-structured 1) Pathways to services; 2) Thematic analysis 1) Barriers to mental
Austria, Belgium, Czech 12 healthcare, 11 Asylum interviews barriers encountered by healthcare; and 2) Overcoming
Republic, France, social workers seekers irregular migrants; 3) ways to barriers
Germany, Hungary, Italy, Sex of sample Migrants overcome them; 4) overall
Ireland, Netherlands, not provided quality of mental healthcare
Poland, Portugal, Spain, for irregular migrants in the
Sweden, UK given area; 5) the
coordination of care at the
administrative and the
individual patient level; 6) the
strengths and weaknesses of
care provided to irregular
migrants; and 7) suggestions
for improving the quality of
care for this group
11 Dauvrin et al. (2012) N = 192 Refugees Semi-structured 1) The specific problems Thematic content 1) Access; 2) Notifying the
Austria, Belgium, 144 primary care Asylum interviews encountered with all analysis authorities; and 3)
Denmark, Finland, services, 48 seekers migrants; 2) good practice Communication
France, Italy, Lithuania, mental health Migrants when delivering services’ care
Germany, Greece, services to migrants; and 3) the need
Hungary, Netherlands, Sex of sample to improve the services’ care
Poland, Portugal, Spain, not provided for such target groups
Sweden, UK
12 Misra et al. (2006) N = 13 Refugees In-depth No details provided Grounded theory 1) Problems of access; 2) Main
UK 2 psychiatrists, 2 Asylum Interviews mental health needs; 3) Main
psychologists, 2 seekers service issues; 4) Provider’s
managers, 4 suggestions for improvement;
commissioners, 3 and 5) Proposed service model
asylum seeker
services
(continued)
Table 1. Continued

Sex of sample
not provided
13 Hultsjö and Hjelm N = 35 Refugees Semi-structured No details provided Focus group analysis 1) Differences related to care
(2005) Sweden 12 clinic Asylum focus groups of asylum-seeking refugees; 2)

managers, 12 seekers Difficulties related to different
ambulance staff, Migrants cultural behaviors; 3)
11 psychiatric Difficulties related to contact
staff (4 males and with relatives; 4) Difficulties
7 females) related to gender roles; 5)
Complicating organizational
factors; 6) Language barriers; 7)
Difficulties related to earlier
experiences of migration; and
8) Situations perceived as
threatening
14 Franks et al. (2007) N=9 Refugees In-depth interviews No details provided Grounded theory 1) Barriers to seeking services;
UK Voluntary workers Asylum and 2) Barriers to accessing
Sex of sample seekers services
not provided Migrants
15 Teunissen et al. (2015) N = 16 Asylum Semi-structured 1) Barriers and facilitators in Constant comparative 1) Disclosure of mental health
Netherlands Physicians seekers interviews the GPs’ work in these method problems by migrants; 2)
9 Males Migrants consultations with specific Recognition of mental health
7 Females attention to recognition, problems by physicians; 3)
recording, and treatment of Discussion of mental health
mental health problems of the problems by physicians with
undocumented migrants; and documents; 4) Recording of
2) barriers and facilitators mental health problems by
regarding consultations with physicians; 5) Treatment of
documented migrants mental health problems by
physicians; and 6) Solutions to
overcome barriers in treatment
16 Pooremamali et al. N=8 Migrants Interviews Participant experiences from Grounded theory 1) Dilemmas in clinical practice;
(2011) Occupational and thoughts about working 2) Feelings and thoughts; and 3)
Sweden therapists with immigrant clients Building cultural bridges
Sex of sample
not provided
17 Samarasinghe et al. N = 34 Refugees Interviews No details provided Phenomenography 1) An ethnocentric approach
(continued)
9
10
Table 1. Continued

(2010) Primary care Asylum focusing on the physical health

Sweden nurses seekers of the individual; 2) Empathic
7% Male Migrants approach focusing on the
93% Female mental health of the individual
in a family context; and 3)
Holistic approach empowering
the family to function well in
everyday life
18 Sandhu et al. (2013) N = 48 Refugees Semi-structured Identifying the experiences of Thematic analysis 1) Complications with
Austria, Belgium, 17 psychiatrists, 9 Asylum interviews healthcare professionals on diagnosis; 2) Difficulty in
Denmark, Finland, psychiatric seekers delivering care to immigrants developing trust; and 3)
France, Germany, nurses, 5 Migrants within the participating Increased risk of
Greece, Italy, Hungary, psychologists, 1 countries marginalization .
Lithuania, Netherlands, therapist, 2 social
Poland, Portugal, Spain, workers, 14
Sweden, UK mangers
Sex of sample
not provided
19 Apostolidou (2016) N=8 Refugees Semi-structured 1) Th experience of working Discourse analysis 1) The use of clinical
UK 4 psychologists, 4 Asylum interviews with asylum seekers; 2) the supervision; and 2)
therapists seekers experience of supervision; 3) Organizational context
3 Males the experience of the
5 Females organizational context in
which the professionals
worked; and 4) the way the
experience of working with
this population informed the
way in which practitioners
perceive their professional
role and clinical work
20 Century et al. (2007) N = 13 Refugees Semi-structured 1) Personal and professional Thematic analysis 1) Counselling refugees; 2)
UK Counsellors, Asylum interviews details; 2) general attitudes to Limitation of resources; 3) Use
psychologists, seekers refugee counselling; 3) of interpreters; and 4)
therapists problematic issues; 4) issues Emotional impact
Sex of sample related to the primary care
not provided context; 5) personal
psychological impact on
counsellors; and 6) level and
(continued)
Table 1. Continued

usefulness of support and

training
21 Harris et al. (2020) N = 15 Refugees Semi-structured 1) GP first impression of the Thematic analysis 1) Language barriers limit our
Norway GPs interviews patient; 2) diagnoses and ability to give and receive help;
8 Males treatment options; 3) GP 2) When worldviews clash; 3)
7 Females feelings during and following Great expectations and not
the consultation; 4) GP living up to them; 4) I was not
perception of the relationship prepared for it; 5) Trust as a
to the patient; 5) extent bridge; and 6) These
education and training had consultations are deeply
prepared GP for consultation; meaningful
6) experiences providing care
for refugees with trauma; and
7) experiences using an
interpreter
22 Nonnis et al. (2020) N = 150 Irregular Semi-structured Negative and positive aspects Semiautomatic text 1) Exhaustion and engagement;
Italy 91 operators, 34 migrants interviews of work, covering domains of analysis 2) Disengagement and
psychologists, 25 1) psychophysical exhaustion; (computer-assisted involvement; 3) Efficacy and
healthcare staff 2) relational deterioration; 3) qualitative data analysis effectiveness; and 4)
46.6% Male professional inefficacy; and 4) software) Disillusionment and fulfilment
53.4% Female disillusion.
23 Chiarenza et al. (2019) N = 120 Refugees Focus groups and 1) Challenges for health Thematic analysis 1) Challenges related to specific
Austria, Belgium, 31 doctors, 18 Asylum semi-structured professionals and healthcare phases of the migration
Denmark, Greece, managers, 22 seekers interviews managers; 2) solutions and trajectory; 2) Barriers and
Hungary, Italy, nurses, 14 Migrants best practice; and 3) solutions related to accessing
Netherlands, Slovenia, psychologists, 12 development and healthcare services in general;
Spain, UK social workers, 9 dissemination of the resource 3) Barriers and solutions
mediators, 7 package related to accessing four
admin staff, 7 specific healthcare services; and
others 4) Development and
Sex of sample dissemination of a resource
not provided package
a
Only data from participants that meet the inclusion criteria for the review are presented.
b
Other methods of data collection may have been used in the included studies but only data gathered from interviews or focus groups are included in the review.
c
Only themes derived from professional interviews or focus groups have been included.
11
Table 2. Included studies, methodological quality scoring, and identified themes.
CASP
Score 1) The management of multifaceted 2) Professionals’ emotional 3) Delivering care in the
(Max = and complex challenges associated responses to working with context of cultural
Study 10) with the migrant status migrants difference
1 Teunissen et al. 9 ✓ × ✓
(2016)
2 Onyiguo et al. 9 × × ✓
(2016)
3 Suurmond et al. 8 ✓ ✓ ✓
(2010)
4 Feldmann et al. 8.5 ✓ ✓ ✓
(2007)
5 Holmqvist and 6.5 × ✓ ✓
Andersen (2003)
6 Griffiths et al. 7.5 ✓ × ✓
(2017)
7 Jensen et al. (2013) 10 ✓ ✓ ✓
8 Priebe et al. (2011) 10 ✓ × ✓
9 Priebe et al. (2012) 10 ✓ × ✓
10 Straßmayr et al. 9.5 ✓ × ✓
(2012)
11 Dauvrin et al. 9.5 ✓ × ✓
(2012)
12 Misra et al. (2006) 6 ✓ × ✓
13 Hultsjö and Hjelm 9 ✓ ✓ ✓
(2005)
14 Franks et al. (2007) 7 ✓ × ✓
15 Teunissen et al. 9.5 ✓ ✓ ✓
(2015)
16 Pooremamali et al. 9.5 ✓ ✓ ✓
(2011)
17 Samarasinghe et al. 10 ✓ ✓ ✓
(2010)
18 Sandhu et al. (2013) 9.5 ✓ × ✓
19 Apostolidou (2016) 7 ✓ ✓ ✓
20 Century et al. 10 ✓ ✓ ✓
(2007)
21 Harris et al. (2020) 9.5 ✓ ✓ ✓
22 Nonnis et al. (2020) 9 ✓ ✓ ✓
23 Chiarenza et al. 9 ✓ × ✓
(2019)
Key: ✓ = Theme present.
x = Theme not present.
particularly relevant in the context of migrant care provi- administrative procedures for treating undocumented
sion, preventing referral and information-sharing migrants (Dauvrin et al., 2012) and legal migrant difficul-
(Chiarenza et al., 2019) and hindering clinical outcomes. ties obtaining health insurance (Priebe et al., 2012).
The range of needs presented by migrants and the barriers Undocumented migrants were considered particularly vul-
to accessing mainstream services meant that professionals nerable: “illegal immigrants have no rights to anything …
considered effective liaison with specialist and voluntary they feel like they were shadows. The barriers are every-
services to be crucial in providing holistic care (Priebe where: inside, outside” (Straßmayr et al., 2012, p. 4). All
et al., 2012). professionals who raised legal and administrative issues
Professionals lacked clarity on the entitlement and eligi- reported willingness to treat migrants regardless of legal
bility of different groups of migrants to receive mental entitlements (Priebe et al., 2011) and that access to health-
healthcare (Chiarenza et al., 2019), further complicated by care should not entail reporting to authorities (Chiarenza
et al., 2019). Professionals circumnavigated the barriers in their mental health symptoms in support of their application
various ways, including altering administrative processing, for housing or legal status to remain (Hultsjö & Hjelm,
submitting prescriptions in their own name, and not char- 2005). Whilst some professionals empathized that this was
ging for services: “we are doctors and we do not care out of desperation (Teunissen et al., 2015), others reported
whether the patient is illegal or not” (Teunissen et al., what they perceived as exploitation of the system: “we
2016, p. 122). have had situations where it has been obvious afterwards
Professionals described working with migrants in ways that they were just faking” (Hultsjö & Hjelm, 2005,
that empathized with and recognized their struggles. Firstly, p. 280). However, Nonnis et al. (2020) found that some pro-
physical and mental health professionals focused on the fessionals held negative attitudes towards migrants related to
importance of developing trusting relationships using frustration in reaching mutual understandings, leading them
empathy “because people need a long time before they will to attempt to distance themselves from this group.
disclose things, especially painful things” (Suurmond et al., Feelings of hopelessness were reported with respect to
2010, p. 824). Counsellors stressed the need to “give the patients’ mental health (Jensen et al., 2013), primarily
witness” and “offer validation” (Century et al., 2007, p. 33) by physicians and psychotherapists, and using “weary and
to engage migrants and build rapport, while Nonnis et al. defeated” language (Century et al., 2007, p. 34). These feel-
(2020) highlighted sharing stories as a powerful way to ings were associated with reduced confidence in the ability
build relationships between professionals and migrants. to deliver mental healthcare to migrants (Suurmond et al.,
Secondly, due to the complexity of need relative to available 2010). Physicians in Norway reflected that working with
resources, some primary care staff reported focusing on more migrants could leave them feeling unprepared despite
‘addressable’ issues rather than mental health problems their training: “It was a big shock. I felt like I almost
(Teunissen et al., 2016). Meeting the needs of migrants also couldn’t use anything of what I had learned during my edu-
required more flexible administrative procedures and offering cation and that was very strange” (Harris et al., 2020, p. 6).
longer consultations (Priebe et al., 2011). Professionals described negative feelings about failed inter-
actions with migrants and used words relating to exhaustion
Theme 2: Professionals’ emotional responses to and excessive use of personal resources: “I’m mentally
exhausted, tired of working in this sector. I’m tired of
working with migrants dealing with difficult clients” (Nonnis et al., 2020, p. 13).
The specific struggles faced by migrants, particularly refu- Vicarious traumatization was raised by some psy-
gees and people seeking asylum, elicited polarized chotherapists and counsellors. Hearing migrants’ stories
responses, including among those occupying roles deliver- profoundly affected clinicians, which could make it difficult
ing therapy. Some spoke about their patients with admir- to control feelings during sessions and maintain boundaries
ation and warmth for the courage and resilience shown in (Century et al., 2007). The following quote from psy-
the face of adversity: “it’s the inner strength of the person chotherapists in Holmqvist and Andersen’s (2003) study
… you can feel that flame and you think I shall want to demonstrates how such narratives could permeate the ther-
keep it alight, I don’t want it to be crushed anymore” apeutic space: “I was without protection, I had no defences
(Century et al., 2007, p. 32). Awareness of the social injus- against such things, it went right into me” (p. 298).
tices faced by migrants produced an “activist way of being” The use of supervision to manage emotional responses
(Apostolidou, 2016, p. 14) for some professionals, resulting was reported; however, some psychotherapists reflected
in them adopting a role of advocacy on behalf of their that a lack of specialist supervision could result in inad-
patients, often beyond the context of mental healthcare pro- equate professional support: “I think the problem is that
vision: “I get them lawyers so they can see a GP” supervisors often have less experience than you do in
(Apostolidou, 2016, p. 14). Nonnis et al. (2020) found working with [migrants]. And that is really troubling …
that words such as “pleasure” and “passion” were used they are in a position of trying to guide you, but they
more frequently by professionals who were engaged in can’t really guide you” (Apostolidou, 2016, p. 12).
their work, many of whom were “willing to go above and
beyond for [migrants]” (Harris et al., 2020, p. 7).
However, other professionals used negative, untrusting Theme 3: Delivering care in the context of cultural
language, such as feeling “manipulated” and “suspicious,”
to describe their feelings about undocumented migrants difference
and refugees (Holmqvist & Andersen, 2003, p. 296). This theme captures the interface between the professional
Professionals in Swedish and UK-based studies particularly and patient, noting how challenges in delivering mental
questioned the legitimacy of undocumented migrant claims healthcare can arise from variations in belief systems,
upon public health resources, with some viewing migrants culture, and communication. Professionals reported adapt-
as having a sense of “entitlement to welfare” (Century ing their practice to engage migrants and meet their
et al., 2007, p. 33), querying whether they exaggerated mental health needs.
Professionals described migrants as having either a “lack Some professionals reported problems related to migrant
of” or “different” understanding of mental health problems patients choosing not to work with professionals of the
(Franks et al., 2007, p. 10), which has led some to reflect opposite sex (Dauvrin et al., 2012). While some services
that “westernized ideas of depression may not be appropri- were able to meet this requirement on request, others
ate” for migrants (Misra et al., 2006, p. 252). Both physical struggled to do so (Priebe et al., 2011). Gender roles were
and mental health professionals reported that migrants’ cul- also highlighted as a difficulty in providing care to
turally informed understandings of mental health problems migrants, particularly when the professional was female
present challenges in providing care, especially when they and the patient male (Pooremamali et al., 2011).
differ markedly from the biopsychosocial model that pre- Responding to cultural differences appropriately was
vails in most of Europe (Feldmann et al., 2007). Dutch phy- considered crucial to building trust and providing effective
sicians struggled to discuss depression and psychosis due to care; specialist training and improved cultural competence
migrants’ spiritual explanations of symptoms: “it is difficult were viewed to inform such responses (Straßmayr et al.,
to discuss [mental illness], they have the idea that they are 2012). This notwithstanding, professionals described
demonized … they often have magical thoughts” adopting an “open” (Pooremamali et al., 2011, p. 116)
(Teunissen et al., 2015, p. 86). Some professionals and “curious” (Century et al., 2007, p. 30) approach to
acknowledged that a lack of knowledge about a migrant’s enquire about cultural values and beliefs, which enabled
cultural background could lead to misunderstandings of them to “reach more accurate diagnoses and provide appro-
what was considered a socially acceptable response to the priate treatments, while meeting patient needs for cultural
patient or what indicated psychopathology (Sandhu et al., acceptance and understanding” (Priebe et al., 2011, p. 8).
2013). Chiarenza et al. (2019) reported that professionals consid-
Professionals noted the tendency of migrants to focus on ered intercultural mediation services as crucial in the
somatic symptoms without connecting them to mental overall development of a culturally competent healthcare
health problems (Teunissen et al., 2015). They hypothe- system.
sized or perceived that migrants may be more prepared to
speak about somatic symptoms due to cultural stigma
(Pooremamali et al., 2011), may prefer to communicate Discussion
non-specific health problems to avoid revealing This review of qualitative studies of professionals’ experi-
trauma-related experiences (Chiarenza et al., 2019), or ences of delivering mental healthcare to migrants across a
may lack psychological insight (Feldmann et al., 2007). range of healthcare settings yielded 23 mostly high
The challenges of explaining psychological and behav- quality papers. Despite the variation in healthcare profes-
ioral symptoms in the host country’s language also contrib- sions, settings, and countries, similar challenges of deliver-
uted to difficulty identifying psychological distress: ing migrant mental healthcare were reported—associated
“linguistic difficulties can sometimes give the impression with the migrant status, emotive reactions evoked by
that the patient is psychologically disturbed when all he is working with this group, and differences in culture.
trying to do is express things that belong to another Moreover, there was general consensus on how to over-
culture” (Straßmayr et al., 2012, p. 5). Most studies high- come the identified barriers to provide high quality care.
lighted the implications that language barriers can have Twenty (87%) of the included studies were published
on care provision; including restrictions on treatment post 2007, suggesting that this is an area of research that
options (Jensen et al., 2013) as most interventions are has grown in popularity. In particular, there has been
focused on talking therapies. Professionals adapted their growth over the last decade in studies of refugees and
practice to facilitate access and engagement with services, people seeking asylum linked to conflicts in the Middle
including the adoption of a client-led approach and adjust- East.
ing pacing (Priebe et al., 2012).
Interpreter issues were reported by most studies to add
challenges to care provision, including variability in Theme 1
access, poor quality of interpretation, and a lack of inter- Professionals perceived great challenges in delivering
preters with mental health-related training (Griffiths et al., mental healthcare to migrants, including the lack of
2017; Harris et al., 2020). There was a sense of profes- clarity regarding eligibility for mental healthcare and the
sionals disliking joint work with interpreters and preferring extra work involved in delivering such care. Professionals
to try and communicate independently with patients: “It reported migrant experiences of stigma and discrimination
was a heart-sink piece of work … even though I could within healthcare, poor socioeconomic conditions, social
see that talking was working … I didn’t enjoy doing it … isolation, and trauma, which mirrored the findings of
I was heavy-hearted about it at each session, and it was studies undertaken from the migrants’ perspective (Derlet
just about what hard work it was” (Century et al., 2007, & Deschietere, 2019; Dow, 2011) and which contribute to
p. 31). the marginalization of migrants (Andersen et al., 2009).
The complexity of trauma, and presentation of trauma governmental organizations (Dwyer & Brown, 2005).
symptoms as somatic complaints (Gupta, 2013) affected Support of migrant mental healthcare from other commu-
primary care health professionals’ confidence and perceived nity organizations with professional supervision (e.g.,
ability to manage such presentations (Green et al., 2011), Goodkind et al., 2014; Karageorge et al., 2017) may help
and often present in physical healthcare settings with staff increase service use by reducing stigma and increasing
without specialist mental health training. engagement in culturally meaningful ways (Wong et al.,
However, professionals reported various ways in which 2006). Such inter-agency working may also positively
they attempted to overcome these challenges, such as treat- impact on health professionals’ perceptions of addressing
ing migrants irrespective of legal status, as aligned to the mental health of migrant groups.
reviews of physical healthcare provision (Robertshaw Ultimately, however, professionals need longer consul-
et al., 2017). While the sustainability of professionals cir- tations to explore the complexity of needs among migrants
cumnavigating policies to provide care has been questioned (Scheppers et al., 2006), and to recognize the need to build
given the implications for the appropriate funding and professional–patient trust (Yohani, 2010) and mutual
human resourcing of services (Ingleby et al., 2019), understanding (Sveaass & Reichelt, 2001) when working
studies have shown that providing care to all migrants is with migrant communities, as well as the frequent need
beneficial for host countries, public health, and social cohe- for interpreters (Wiking et al., 2013). Given the short time
sion (Trummer et al., 2016). allocated to primary care consultations (Irving et al.,
In recognition of the vulnerable backgrounds of many 2017) and minimal mental health-related training
migrant groups and their general distrust in healthcare pro- (England et al., 2017), it is not surprising that physicians
viders (Warr, 2010), the review highlighted the importance struggled to address both psychological and physical
some professionals placed on building a positive and trust- health problems. Failure to address mental health concerns
ing professional–patient alliance when working with could, however, inadvertently reinforce migrants’ beliefs
migrants, in line with previous reviews (Duden et al., that mental health is a taboo subject (Schnyder et al.,
2020). A process of reciprocal learning and patience are 2017), which may reduce help-seeking. Without appropri-
needed to facilitate mutual understanding that provides ate allocation of resources to recognize such need, migrants
the foundation to a trusting relationship (Karageorge will continue to not have their mental health needs appro-
et al., 2017). Professionals’ attitudes relating to migrants’ priately met.
entitlement to receive care and the ability of migrants to
understand and engage in mental healthcare can influence
the professional–patient relationship in healthcare contexts Theme 2
(Ferguson & Candis, 2002) and influence the quality of the Working with migrants evoked a range of emotive reactions
therapeutic relationship and subsequent care provision. among professionals, with notably polarized responses
Another strategy reportedly used by professionals was to towards refugees and people seeking asylum. Among
focus on addressable issues or more immediate concerns mental health professionals, some adopted a stance of admir-
rather than complex mental health needs. Time pressures ation and others reported suspicion, replicating quantitative
motivate this, particularly in primary care, and are seen in findings of health workers’ attitudes towards migrants
physical healthcare (Suphanchaimat et al., 2015). (Dias et al., 2012) and the experiences of third sector organi-
However, this also highlights professionals’ awareness zation staff (Barrington & Shakespeare-Finch, 2013).
that practical support may be more helpful to and preferred Regular therapeutic sessions with these patients seemed to
by migrant groups, such as problem solving and promotion increasingly polarize professionals’ attitudes—leading to
of self-efficacy (Karageorge et al., 2017; Marusiak, 2013). more rapport, empathy, and positive attitudes, or more suspi-
A phased approach to mental healthcare may be appropriate cion and negative attitudes. Studies in the current review
for migrants; firstly, to address immediate resettlement which reported on the perceived exploitation of services
needs and provide emotional support, followed by a referral (e.g., to further applications for asylum) were conducted in
for more intensive intervention (Rousseau & Frounfelker, countries that offer very limited or no free public healthcare
2019). to undocumented migrants (e.g., Sweden). These findings
The review highlighted inter-agency collaboration as and others (Rousseau, 2018; Vanthuyne et al., 2013) may
crucial yet challenging for meeting the complex needs suggest that legality influences professional attitudes, or
encountered in migrant mental healthcare, as recent that their attitudes—irrespective of experience and training
studies of such initiatives have found (Anguiano et al., —reflect the wider political sentiment in that society
2019; Duden & Martins-Borges, 2020). Working with towards healthcare and migrants, including or exacerbated
other agencies may also be necessary for reducing the emo- by negative media coverage about migrants (Kosho, 2016;
tional burden felt by mental health professionals, who may Michaelsen et al., 2004).
assume responsibility beyond their role (Duden et al., While no professionals who participated in studies on
2020). Migrants may be more likely to trust non- this topic refused to offer treatment, negative, suspicious
attitudes would likely influence the provision of care, such review took on the role of advocacy on behalf of migrants
as different treatment recommendations (FitzGerald & to support them in overcoming the challenges of belonging
Hurst, 2017) and unspoken cues reflecting implicit biases to a marginalized group, which has been shown to build
picked up by service users that professionals are unaware trust between patients and professionals (Puvimanasinghe
of (Aggarwal et al., 2016). While there was little explicit et al., 2015) and help empower migrants (Goodkind,
mention of possible biases by professionals in the treatment 2006; Rawlett, 2014), offering them an exit from the med-
of migrants, clinician biases are potential key barriers to icalization of what are arguably socio-political problems
effective mental healthcare that may be mistaken as cultural (Drož đek, 2007).
barriers (though the two may be related). Unsurprisingly,
such behavioral changes and biases, whether implicit or
explicit, impact on migrants’ trust of healthcare profes- Theme 3
sionals and contribute to health disparities (Hall et al., Differences in cultural understandings of mental health and
2015). Addressing bias is inherently extremely challenging the challenges to providing culturally competent mental
to do, but implicit bias awareness training, educating pro- healthcare are well documented (Carbonell et al., 2020).
fessionals about the unique difficulties associated with Since much of mental healthcare practice emerged from
migration and seeking asylum, and reflective practice are ‘Western’ understandings of the human condition
necessary for the indiscriminatory practice of mental (Wildeman, 2013), such conceptualizations of mental
healthcare. health have proved problematic when applied elsewhere
The feelings of hopelessness reported by psychothera- without careful consideration (Fernando, 2014). The
pists and physicians in relation to their work has also review found that professionals voiced feeling incompetent
been reported elsewhere (Tynewydd et al., 2020). While or ill-equipped to address the mental health of this
only psychotherapists referred to such experiences as vicar- population, perceiving migrants to either have a lack of
ious trauma (Baird & Kracen, 2006), possibly reflecting mental health understanding or an understanding that dif-
their training, the psychological impact of working with fered from the Western biomedical perspective. The
migrants is seen across healthcare (Crumpei & Dafinoiu, former assumes that Western biomedicine itself is not cul-
2012). Professionals are often expected to provide care turally embedded but a universal truth (Gopalkrishnan,
whilst being restricted by a range of factors, such as lack 2018; Rondelez et al., 2016), leading professionals to
of resources or cultural training. Additionally, many of assign responsibility to migrant patients for their feelings
the difficulties professionals encounter when working of unpreparedness in dealing with non-biomedical
with migrants relate to contextual factors, such as a lack perspectives.
of housing, rather than being solely related to mental The perspective of accepting a ‘different’ understanding
health problems (Hynie, 2018), which can add to this per- of mental health could be a starting point for professionals’
ceived sense of hopelessness (Guhan & Liebling, 2011). respectful exploration of migrants’ cultural belief systems
To manage such feelings, clinical supervision is crucial to reach a shared understanding of problems (Karageorge
(Berger & Quiros, 2014), particularly specialized supervi- et al., 2017; Procter, 2016). A person-centered approach
sion from organizations experienced in working with that shifts from the perspective of “what’s wrong with
these groups (Duden et al., 2020), and peer supervision you?” to “what happened to you?” (Harris & Fallot,
(Barrington & Shakespeare-Finch, 2014). Ensuring all pro- 2001) may be particularly helpful for professionals
fessionals have a safe environment to discuss personal trying to make sense of presentations that may differ from
responses to their work is important in maintaining their the host country’s social norms. Adopting an open
wellbeing (Tomlinson, 2015). Online and telephone and curious approach to exploring differences further facil-
methods of communication could be used to facilitate net- itates culturally competent practice (Bansal, 2016; Epner &
works between professionals in different geographical loca- Baile, 2012). On the other hand, therapist avoidance of
tions or for those working in remote areas to share skills. such discussions may be due to time pressures (Filler
In relation to professionals’ positive feelings about et al., 2020), anxiety from a lack of knowledge and
working with migrants, some showed warmth and admir- over appearing insensitive (Guregård & Seikkula, 2014),
ation for the challenges overcome by some migrants, and or professionals considering such discussions irrelevant
some were motivated to adopt roles of social activism. if they expect migrants to assume the host country’s
Others have also called for professionals to adopt roles of cultural norms (Al-Roubaiy et al., 2017). However, such
social activism to challenge the societal contexts impacting absence of discussion around cultural understanding of
their patients and to promote social change in the wider the issues is noticeable by patients (Al-Roubaiy et al.,
community (Apostolidou, 2015; Marsella, 2011). This 2017).
requires an understanding of the social structures that The need for improved cultural competence training
shape mental health presentations and health inequalities identified in this review is an issue across healthcare set-
(Metzl & Hansen, 2014). Some professionals in our tings (Kaihlanen et al., 2019; Matthews, 2020).
Systems-level cultural competence training and training (Tribe & Thompson, 2008) and highlight the features of
in specific culturally adapted evidence-based interven- effective communication, for example non-verbal
tions (Rathod et al., 2018) have been associated with communication.
improved clinical outcomes. However, the training
received varies hugely between countries, organizations,
and type of health professional, and according to perso- Strengths and limitations
nal motivation. Our review suggests that professionals Due to limited interpreting capacity, the review only
view migrants as somatizing their psychological symp- included English language papers, introducing bias as
toms, supported by migrants’ perspectives (Lanzara non-English studies may encapsulate a wider range of
et al., 2019), although the inherent mind–body dualism experiences. The search strategy only included papers
of the ‘Western’ biomedical approach has been ques- published in peer-reviewed journals; whilst promoting
tioned (Al-Busaidi, 2010; Mumford, 1993). However, academic rigor, this introduced publication bias.
given that migrants are more likely to access physical Omitting keywords relating to specific professional
health services than specialist mental healthcare (Credé groups in the search strategy may have led to relevant
et al., 2018), there is a need to ensure physical health pro- studies being missed; however, the number of search
fessionals feel competent addressing trauma presenta- returns identified and included studies is comparable
tions. The review found that nurses who felt more able with other reviews on similar topics, suggesting the
to work with trauma relied on rapport-building and review was sufficiently comprehensive. The inclusion
allowing the patient to narrate their story. In a review of diverse professional backgrounds was considered
of refugee mental health interventions, bearing witness appropriate given the aims of the review, and consider-
to personal testimonies of adversity was highlighted as ation was given to the potential differences between pro-
an essential component of ‘healing’ (Murray et al., fessions when analyzing the data; however, some studies
2010), suggesting that trauma-related training in included a combination of professional backgrounds and
primary care need not be overly technical and could it was not always possible to match the professional to
build on existing skills around building therapeutic rela- the data.
tionships and containment to facilitate discussion of sen- The time span allowed for included studies potentially
sitive topics. limited the relevance of some papers as it is possible that
As well as cultural considerations specifically, migrants’ attitudes of health professionals have changed in line with
current socioeconomic situation in the host country is also societal attitudes, therefore earlier papers may be less repre-
important (Duden et al., 2020). Previous research has iden- sentative of current practice. All content themes identified
tified that psycho-education, coping strategies, and creative were represented in published papers within the last 16
therapies were considered helpful to migrants (Koch & years, suggesting that the attitudes both are relevant and
Weidinger-von der Recke, 2009). Moreover, equitable cul- align with the systemic biases that continue to persist in
tural partnerships between services and migrant communi- healthcare today (FitzGerald & Hurst, 2017).
ties and diversification of the workforce could help Although some studies included migrants without a pre-
towards promoting shared understandings of different cul- carious legal status, there was no explicit mention of advan-
tural explanations of distress. taged or settled migrants, such as expatriates or
Finally, while it is possible that some interpreters find international students. The generic term ‘migrant’ is proble-
translating for mental health-related matters more challen- matic as it makes it difficult to determine samples and could
ging (Costa, 2011), the language barriers and interpreter- be considered a value-laden description and may elicit a
related problems frequently reported in the current review stereotype in professionals. Given participants may have
are echoed in the wider healthcare literature (Ahmed been referring to migrants other than those of a higher
et al., 2017) and from migrants’ perspectives (Hadziabdic socioeconomic or professional status, findings may have
et al., 2009). Therefore, this reflects a wider issue that limited applicability to more advantaged groups.
exacerbates health disparities in the migrant population Although some studies referred to the extent of profes-
which can only be addressed by creating clearer, more sionals’ experience of working with migrants, many gave
straightforward, and thus less time-consuming procedures no details about their backgrounds or whether they had
around the financing and administration of interpreting ser- received cultural training. Limited information about
vices (Basu et al., 2017; Jaeger et al., 2019) and by improv- sample and contexts provided by primary studies is a pre-
ing the training provision of healthcare professionals on viously documented issue in qualitative synthesis
consulting through interpreters, as other research indicates (Paterson et al., 2001). Whilst completing the review
that healthcare staff are perceived to be unclear about from the perspective of the professional provided valuable
how to work with interpreters (Kai et al., 2011). Such train- insights, patients are, ultimately, the expert in their own
ing would build on the numerous available guidelines on experiences and their perspective needs to be considered
how to achieve the best outcomes from interpreted sessions in future research.
Whilst several studies included countries from across ORCID iD

Europe, most were conducted in Western and Northern E. Peñuela-O’Brien https://orcid.org/0000-0001-9433-2505
European countries, so findings may have limited applic-
ability to other parts of Europe. Relevant international
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of therapeutic approaches. Pastoral Care in Education, 28(4), Manchester. Dr. Wan is Co-Director of the Perinatal Mental
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research Principal Investigator on two community-led projects
Consultations between immigrant patients, their interpreters,
and their general practitioners: Are they real meetings or just on parenting and wellbeing in UK minority ethnic families. She
encounters? A qualitative study in primary health care. is also currently the UK Principal Investigator of a culturally
International Journal of Family Medicine, 2003(1-10), adapted parenting intervention trial for depressed fathers in
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Challenges to global mental health policy in light of the health in diverse contexts.
Dawn Edge, PhD, is Professor of Mental Health & Inclusivity related psychoses, and Co-Principal Investigator of several
in the Division of Psychology & Mental Health, The other studies. A health services researcher, her published
University of Manchester. Professor Edge is Director of the works focus on tackling disparities experienced by under-
Equality, Diversity & Inclusion Research Unit within served populations and disparities in service delivery.
Greater Manchester Mental Health NHS Trust. She is cur-
rently the Chief Investigator of a national Randomised Katherine Berry, ClinPsyD, PhD, is a Professor of Clinical
Controlled Study to evaluate Culturally adapted Family Psychology and Health Service Researcher at the
Intervention (CaFI) with families of Sub-Saharan African University of Manchester, specializing in the field of psy-
and Caribbean backgrounds affected by schizophrenia and chosis and therapeutic relationships.

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E. Peñuela-O’Brien1,2 , M. W. Wan1, D. Edge1,2, and K. Berry1,2

Introduction experiences of discrimination systemic within government

Quality assessment Reﬂexivity statement

Figure 1. PRISMA ﬂow diagram.

Authors, publication Participantsa Data collection

physicians deal with refugee problems; 3)

Authors, publication Participantsa Data collection

17 Males Technical strategy; 5) Elements

interest and technical

Ireland, Italy, 3 occupational of services; and 4) Information

Authors, publication Participantsa Data collection

Netherlands, Poland, therapists, 9

Authors, publication Participantsa Data collection

(2005) Sweden 12 clinic Asylum focus groups of asylum-seeking refugees; 2)

Authors, publication Participantsa Data collection

(2010) Primary care Asylum focusing on the physical health

Authors, publication Participantsa Data collection

usefulness of support and

Table 2. Included studies, methodological quality scoring, and identiﬁed themes.

Whilst several studies included countries from across ORCID iD

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