Background

In 2019, 109,000 people were granted refugee status within the European Union (EU) [1]. Refugees experience poorer health outcomes including mental health and maternity health [1,2,3,4,5]. Specifically, these outcomes include low birth weight, preterm delivery, perinatal mortality, congenital malformations, higher prevalence of mental distress, PTSD, and depression [1,2,3,4]. Other health concerns among refugees include difficulties accessing general practice care, and higher dependency on accident and emergency care for non-emergency treatments. These poor health outcomes can be exacerbated by or can be a result of low health literacy of refugee populations as well as negative encounters when accessing healthcare services including racism and differential medical treatment [6]. To address poor health outcomes, health literacy, and health usage in refugee populations, it is essential to develop health educational interventions for refugees’ healthcare integration.

To do so, learning objectives must be identified based on refugees’ health knowledge gaps. Therefore, the overall aim of this study is to identify these knowledge gaps. The objective of this study is to conduct a modified delphi study to define and prioritise competencies and learning objectives to inform the development of web-based educational materials for refugees by gathering information from a wider set of stakeholders. Ultimately, this project aims to identify and describe specific knowledge and skills that would be helpful for refugees in their efforts to navigate a new and complex healthcare system and achieve health integration. This research builds upon previous research from the Refugees’ Health Integration (ReHIn) project in which a list of prioritised topics for refugees’ health integration was identified by key organisations engaged in the field [7].

Theoretical/Conceptual Framework

According to the 1951 refugee convention, a refugee refers to one who is no longer able to rely on the protection of one’s home country due to a legitimate fear of persecution as a result of one’s race, religion, nationality, membership to a social group, or political opinions [8, 9]. The United Nations Refugee Agency (UNHCR) includes individuals fleeing their country due to war, violence, conflict, or persecution [8].

Although not a homogenous population, as a whole, refugees’ health literacy and self-efficacy in accessing healthcare are more limited [10, 11]. Refugees report poorer health and well-being and report refraining from seeking healthcare [1, 2, 10, 12]. Their healthcare experiences can often be compromised due to a variety of factors, including language difficulties, and a lack of knowledge about the structure and delivery of healthcare, and dealing with prejudice [Patillo,[13, 14]. Wångdahl, et al. posits that refugees with limited health literacy may receive less information pertaining to their healthcare rights and accessing healthcare [10]. These factors highlight the importance of identifying and addressing refugees’ health education needs to encourage health literacy, enhance health-seeking behaviours, and, in turn, refugee health. [10, 11].

This research aims to understand how to participate in meeting these needs by identifying specific knowledge gaps and prioritising learning objectives for educational interventions for refugees to address.

Methods

A modified Delphi method [15,16,17,18] was employed to identify and prioritise learning objectives needed for refugees in regards to navigating healthcare systems and culture in their host country. The Delphi technique is used to gather expert opinion and achieve expert consensus in a reliable way [12, 19]. After being solicited for their views individually in the first round, participants are provided with an opportunity to reflect and reconsider their views in light of the information presented in another round [19]. This modified Delphi method includes three rounds of survey [15,16,17,18] and includes a thematic analysis [20, 21] between the first and second round.

Participants

Participants were recruited for these surveys through purposive sampling. For this study, individuals researching or working with or for refugees were reached out to given their familiarity with the refugee population and their healthcare needs. Notably, people who were refugees and have integrated have been included in this study. Efforts were made to include individuals who were current refugees, but we received no participation from this population. Our outreach might have been impacted by the COVID-19 pandemic (this study took place between 2019 and 2022). Information about study participants were collected in the first round (N = 41). Out of these participants, 85% had been researching or working with or for refugees for more than one year. 37% of participants worked in research or in an academic setting, 37% worked in a non-governmental organisation, and 22% worked in healthcare.

Data Collection

Round 1: Identification of Needs

In the first round (N = 41), preliminary content was gathered [16, 18]. Experts were asked open-ended questions on competencies and knowledge and skills or topics refugees should have to facilitate healthcare integration. Experts were asked to list COVID-19-related topics separately.

Round 2: Prioritisation of Needs

Learning objectives sorted by theme were created after round 1 were used in the second round (N = 51). COVID-19-related learning objectives were listed separately. For this survey, all identified experts were invited again and asked to rate the importance of each objective on a 1–5 Likert Scale where 1 was labelled as “not important” and 5 was labelled as “very important.”

Round 3: Categorisation of Needs

In the third round (N = 36), all identified experts were invited again and the same 65 learning objectives were presented to them in order of overall importance determined by the results from the previous round. These results were not sorted by theme. Experts were asked to sort each learning objective into one of three options based on the recommendation of teaching: (1) Highly recommended or must teach, (2) Partially recommended or optional or may teach, (3) Not recommended or don’t teach (Fig. 1).

Fig. 1
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Delphi study procedure

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Analysis

The metrics measured from the results of round 2 and 3 were mean, strength score, and endorsement level, and rank, following the approach of Mitzman, et al. [18]. A thematic analysis [20, 21] was performed by two authors on the results of the first survey. These results were combined with data gathered from literature to inform discussions amongst authors to develop 13 themes of learning objectives. A list of 65 candidate learning objectives under these themes was generated.The nominations for each learning objectives were calculated by counting how many times the objective was suggested during the first round of the study [18].

There were minor conflicts on identified learning objectives, which were resolved including an additional two authors in a consensus meeting. Learning objectives were organised in topics by two authors and agreed in a consensus meeting with all authors.

Results

Themes were identified from a thematic analysis of participants’ responses to the first survey. These themes are listed in Table 1. Learning objectives for each theme were created by one author and revised and finalised by an additional three authors using the survey responses and additional learning objectives were added considering a more holistic perspective of refugee health integration. These learning objectives were created to focus on integration into healthcare cultures and healthcare systems.

Table 1 Themes for learning objectives
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The results of rounds 2 and 3 of the survey for the general learning objectives and the COVID-19-specific learning objectives are depicted in Appendix 1. For the third round, only the learning objectives that received 75% endorsement from the second round (i.e. those that were labelled as ‘important’ or ‘very important’ by 75% of participants) were used. The following eight learning objectives in Table 2—six general learning objectives and two COVID-19 related learning objectives—did not meet this cut-off point and are, therefore, not recommended.

Table 2 Not recommended learning objectives
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To determine which learning objectives were partially recommended and highly recommended, a cut-off of 75% endorsement for the most favourable rating out of three for the third round was used. Learning objectives with < 75% endorsement were labelled optional or partially recommended and learning objectives with ≥ 75% endorsement were labelled must-teach or highly recommended. Table 3 displays partially recommended learning objectives and Table 4 displays highly recommended learning objectives.

Table 3 Partially recommended learning objectives
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Table 4 Highly recommended learning objectives
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Discussion

16 learning objectives were highly recommended. Of the two COVID-19-related learning objectives, an emphasis seemed to be placed on understanding transmission prevention and hospital translation services. Educational interventions for refugees that address these learning objectives would help address one of the major themes of patient experience identified by Yeheskel, et al. [21]: Communication, Language Barriers, and Health Literacy.

Within the 14 general learning objectives, an overarching theme of utilising the healthcare system and its various services effectively and efficiently was recognised. These results align with some studies that find that refugees require improved skills to optimise care-seeking behaviours and health service utilisation [1]. Lebano et al. specifically mention the overuse of emergency care, and the underuse of primary care services [22].

While this study focused on educational needs concerning health integration and healthcare services broadly, other studies were more focused on specific health conditions such as sexual and reproductive health [23, 24], diabetes [25], oral health [26,27,28], and cancer [29, 30].

Overall, learning objectives within the theme self-care and preventative health were ranked as most important while learning objectives within the theme of digital skills were ranked least important. However, when considering sub-themes, learning objectives within access to healthcare services were ranked most favourably. Within the COVID-19-related themes, learning objectives within the theme of preventative measures were ranked as most important. Meanwhile, learning objectives within the theme of limitations to healthcare services during COVID-19 were ranked as least important.

There may be a discrepancy between what is important for refugees to know and what is feasible given the scope of web-based educational materials being created [31]. For instance, acquiring a social security number, health card, or national health identification is a crucial part of accessing healthcare. However, the process differs from country to country, so this learning objective cannot be supported within an RLO targeted towards refugees across Europe. To address this situation, perhaps links to this information can be shared within the RLO.

Another difficult topic that faces a similar issue involves how to assess emergencies and understand which care providers or healthcare services to access given the situation. There are many possible ways a health emergency can arise and many healthcare services that can be accessed. In this case, perhaps the most important and widely applicable situations should be prioritised.

Study Limitations

Incomplete answers from survey respondents led to limitations in the study. Survey participants’ answers are, at times, not complete sentences which complicates the process of deriving meaning from these answers. Additionally, answers for COVID-19-specific and general knowledge topics were mixed. There are instances in which participants wrote about COVID-19 in the general knowledge topics section and vice versa. This can also lead to lack of clarity in how the answers could be interpreted.

Lastly, efforts to try to reach current refugees for participation in this study were unsuccessful which is another limitation of this study. Reaching this population would have improved our understanding of the very people we are trying to help. Although individuals who were previously refugees did participate in this study, different generations of refugees might have different needs that this study might not have captured.

Conclusions

16 learning objectives were identified in this study as being highly recommended. Of the two COVID-19-related learning objectives, an emphasis seemed to be placed on understanding transmission prevention and hospital translation services. Within the 14 general learning objectives, an overarching theme of utilising the healthcare system and its various services effectively and efficiently was recognised.

Further studies could explore if there are discrepancies in the perceived health educational needs of refugees and professionals who care for, educate, or propose or implement policies regarding refugees. Moreover, further studies could explore specific differences in health educational needs and optimal pedagogical methods for different groups of refugees.

This study is part of the Refugee Health Integration (ReHIn) project. ReHIn is an ERASMUS + Strategic Partnership for Adults involving the multicentre collaborative efforts of Karolinska Institutet (KI), Aristotle University of Thessaloniki (AUTH), University of Nottingham (UoN), and Universitat Politècnica de València (UPV) [7]. The results from this study are used to inform the production of Reusable Learning Objects (RLOs) as well as Massive Open Online Courses (MOOCs) to promote refugees’ health integration into the EU health culture.