Evidence of what works
Language and communication
Finding an effective way to communicate between healthcare professionals and AS is absolutely vital but stakeholders, and the published literature, gave mixed views on whether interpretation is best provided by telephone or face-to-face.
Telephone interpretation is more flexible so is more appropriate for services where AS have difficulty sticking to appointment times. A telephone service can also be viewed as more confidential and so may feel more acceptable for the AS. (A. Gachango, personal communication, 16/08/2019)
Face-to-face interpretation may be considered more appropriate for mental health therapy, especially where an AS is being asked to talk about the trauma they have experienced. (K.Young, personal communication, 13/09/2019).
The comparative analysis in this assessment revealed the value that other areas have found in using the same interpreters regularly and engaging them in the process. For instance, in the Bristol Traumatic Stress Service, clients speaking several different languages may be present in a ‘Moving On After Trauma’ (MOAT) group so three or four interpreters are sometimes required at the same time. However, because the service has used the same interpreters for quite a while, these individuals have a good understanding of the sessions and are very experienced so have almost become co-facilitators. (M. Griggs, personal communication, 23/07/2019)
Other ways of improving the interpretation include booking the same interpreter in advance for all future appointments and asking the interpreter to arrive early so they can briefly meet with the AS before the appointment.60 Additionally, training healthcare professionals in working through interpreters can be useful; for instance, Lancashire Care NHS Trust have made the RCPsych e-learning module on working through interpreters61 freely available to all staff (A. Summers, personal communication, 02/09/2019).
Improving Cultural Awareness
‘Cultural competence’ is a term used to describe having an awareness of, and responding appropriately to, a person’s cultural background. Betancourt et al defined cultural competence in healthcare as ‘the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs’.62
A recent systematic review confirmed that gaining cultural awareness and understanding is an important facilitator of AS care. This included understanding differences in values, body language, health practices and health presentations. Cultural understanding allowed health professionals to adjust their healthcare practice accordingly. Personal qualities in health professionals that were deemed to enhance cross-cultural interactions were sensitivity, empathy and cultural humility.19
At its most basic, cultural awareness requires knowledge of the political system, religious beliefs and infectious diseases in the AS country of origin. It is clearly not reasonable to expect health professionals to know about all possible countries of origin so it is important to provide them with resources to access this information.5 Locally, factsheets about different countries of origin of UASC in Portsmouth have been supplied to key workers (D. Dunne, personal communication, 09/07/2019) so that they can understand more about the background of the young people they are working with. There are also various websites available providing this type of information63 64.
However, healthcare professionals need much more support than this to become culturally competent. There needs to be awareness and understanding of the context in which AS are seeking health; for instance, the fact that clinical environments can mimic interrogation rooms and, therefore, re-traumatize the individual. Also, therapists need to understand how alien it can be to ask an AS to describe their historical experiences, their traumas, their journeys and their losses; AS may have no experience of describing or expressing their emotional and psychological experiences through one-to-one formal conversation, instead being more used to the concept of healing through methods such as meditation, herbal medicine and dance. (A. Stoddard-Ajayi, personal communication, 03/04/2019). There are some sources of help for both clinicians and patients to better communicate about symptoms and needs65.
Dorset has adapted it’s GP training curriculum to include refugee health38. In Southampton, GP trainees cover these issues within a diversity module whilst in Portsmouth cultural awareness is on the curriculum, but this does not currently include migrant health.
Providing a flexible approach to care, acknowledging the difficulty many AS have in consistent engagement, is one way of making culturally competent services. This has been shown to work in Manchester using Methods of Levels theory with a patient group affected by psychosis who, similar to AS, are not stable enough to commit to regular, routine treatment. Providing a flexible service, that allowed them to drop in and out, gave positive outcomes as well as being cost-effective through reducing missed appointments.66
Much of the published evidence suggests the importance of involving refugees in policy, planning, design and delivery of their own care in order to provide culturally competent services 25. There are examples this type of ‘cultural advisory group’ working elsewhere in the UK67 68 69. In the men’s focus group in Portsmouth, providing advice to the NHS was felt like a positive experience that they could engage with; one participant commented:-
“good idea that every 3 months you have a group like this....and bring someone from the NHS...”
Initial health assessments
There are examples from elsewhere in the UK of providing comprehensive initial health assessments for AS when they first arrive in the Home Office dispersal accommodation.
In Bristol, ‘The Haven’ is a specialist primary healthcare service for AS and refugees70. The service sees between 300-400 people per year. A member of the Haven team visits each new AS in their accommodation and offers them a health assessment at the clinic. This is a comprehensive assessment carried out in a 90-minute appointment slot. The AS may then see one of the doctors at the clinic for a 60-minute appointment and/or an in-house psychologist. Although registered with a GP elsewhere, the AS will have follow-on appointments at The Haven. A telephone interpretation service is used if necessary and clients are sent text message reminders to help avoid late or missed appointments. (A. Gachango, personal communication, 16/08/2019)
NICE Guidance states that services should consider the routine use of a validated, brief screening instrument for PTSD as part of any comprehensive physical and mental health screen71. As previously mentioned, St Marys surgery in Southampton, has developed a refugee health check which does include an informal assessment of mental health. This has not been rolled out to other Southampton practices and there is nothing similar currently available in Portsmouth.
Reducing social isolation
“For many seeking asylum, it is all too easy to remain isolated in their room which may feel safe, however, it is well recognised that social isolation makes people vulnerable to depression and to deteriorating health…..Those who do well form new connections.”72
When AS in the focus groups were asked what would help to reduce their stress several mentioned the benefit of social interaction, for instance:-
“people need somewhere to get together and have a chat....groups of people talking, laughing makes you forget the stress”
Peer support is an effective way of reducing social isolation and is included in NICE recommendations for the treatment of PTSD71.
Evidence from a local peer support project ‘Gateway Portsmouth – co-producing community integration’73 found even under the least favourable assumptions the project provided a very good social return on investment. The following recommendations came out of the project:-
- Early interventions to support integration for new migrants, perhaps as a welcome pack offering both training and participation opportunities, is life changing for participants and communities.
- Support for new women migrants is particularly valuable in community building, as they often face cultural, practical and emotional barriers.
Guidance from Wales suggests peer support for refugees and AS as a way of reducing social isolation and engaging with service providers. It also offers a chance to get involved in social activities, education and training which can improve physical and mental wellbeing as well as aiding integration.74
In Southampton, the women in the focus group particularly mentioned the benefit of being involved in their local church and that this could offer a suitable route for mental health support:-
“it would be divine....if the health service was more joined up with the church. There is more acceptance in the church. The church is where we run to, that’s where we feel comfortable”.
Mental Health Services
Trauma-focused therapy should start as soon as possible because then AS will find it easier to move on with other aspects of their life and to interact socially. The fact that AS can be transient is not a reason to delay therapy; evidence from refugee camps shows that trauma therapy can have positive outcomes even whilst a person is still in a traumatic and transient situation. (K. Young, personal communication, 13/09/2019)
Helping AS to address basic needs can result in better engagement with mental health services. At the Woodfield Trauma Service in London, the first stage of treatment for complex PTSD is stabilisation which includes both psychological and practical support. The practical aspects are done by a support worker who sign-posts to other services, writes letters and acts as a mediator. This means that the therapy time is not taken up with dealing with these practical issues. (K. Young, personal communication, 13/09/2019)
AS who are experiencing mental health difficulties could benefit from psycho-education which aims to help people understand what is happening to them and how to manage these difficulties. Grounding exercises and breathing techniques, along with a whole range of anxiety management techniques, such as progressive muscle relaxation, can be easily taught and help AS to feel more present and in control of their own functioning.72
Currently, Narrative Exposure Therapy (NET) is accepted as the treatment with the most evidence for effectiveness in treating PTSD in refugees and AS who have experienced multiple traumatic events75 76 77.
NET is a short-term therapy for multiple trauma. It involves mapping out life experiences to work out which are the traumatic events that need processing. The idea being to contextualise each traumatic event and thus allow painful emotions to be linked to these past episodes rather than the her and now.
In the Bristol Traumatic Stress Service, AS are assessed within IAPT by specialist assessors. If they are considered appropriate for trauma work within IAPT then they follow a 3-phase trauma model. Most of the AS assessed at the Bristol Service would not meet the criteria for secondary MH service. Phase 1 is stabilisation which is done through ‘Moving on after trauma’ (MOAT) groups where the purpose is to normalise reactions to trauma. There are separate male and female groups plus a young persons’ group (16-21 year olds). Some groups have crèche facilities and the service pays bus fares and provides some food. The aim is to have 8-10 people in a group (although it can be up to 13) and there may be 3 or 4 interpreters. The groups meet for 2 hour sessions once a week for 7-8 weeks. Phase 2 is therapy such as NET and phase 3 is re-integration. (M. Griggs, personal communication, 23/07/2019)
In Norwich forced migrants with mental health needs were mainly seen in primary care or in the local IAPT service. Most of those forced migrants referred to the secondary mental health services were either unable to engage (due to communication difficulties, transportation problems etc) or were discharged shortly after the initial assessments. The reason for discharge was mainly because their mental health problems were often seen as “situational” (i.e. due to desperation to stay in the UK if they were AS, or due to the adjustment reaction to resettlement and cultural bereavement process for refugees). A clinic was set up to bridge this gap in the service. The clinic is run by a consultant psychiatrist and is held in the community at premises familiar to the forced migrants. The clinics are not intended to replace care through the mental health services but aim to assess, advice and signpost patients for further treatment. (Y. Hameed, personal communication, 05/08/2019)
Trauma-informed cities
There is a growing movement of trauma-informed communities, particularly around adverse childhood experiences. A trauma-informed community is an area where knowledge of how trauma can affect people – and how best to respond to this impact – is commonplace so that all key local services can integrate this knowledge into the way they interact with people every day.
NHS Education for Scotland has a project to develop trauma-informed organisations so has developed a range of resources including training materials and competency frameworks78.
Plymouth has a Trauma-Informed Network which is derived from a ground-up coalition of professionals from across services, with professional experience of how trauma can affect people. The Network currently includes 70 individuals, representing approximately 30 agencies ranging from Police, schools, Barnardo’s, NSPCC, Devon CCG as well as Plymouth City Council.
“Plymouth as a trauma aware city recognises the evidence base that is emerging day by day, across both national and international communities, which identifies that the impact of trauma and the consequences of exposure to harmful experiences of adversity, as a profound health, wellbeing and social care issue of our time. This understanding creates an exciting and definitive opportunity to fundamentally shift the agenda, by bringing people, communities, city services and systems together to address the causes of adversity at the earliest opportunity, thereby becoming more boldly prevention focused.”79