Achieving Equity in Mental Health Services for Refugees: A Focused Ethnography of Public Health Providers' Perspectives on Mental Health Screening Processes

Background and Purpose:  In the past ten years, 34,455 refugees from Burma, Bhutan, Somalia, Ethiopia, and Iraq have arrived to the Twin Cities (MN Department of Health, 2015). Between 30 to 50% of refugees from these countries have experienced torture (Jaranson et al., 2004; Shannon, Vinson, Wieling, Cook, 2014; Tol, et al., 2010, Willard, Rabin, and Lawless, 2013). Research indicates that up to 30% of refugees suffer with posttraumatic stress disorder and major depression (Steel, et al., 2009). This research evaluates a recent change in the state public health screening protocol to include mental health screening of all arriving refugees beginning in 2016.  Findings represent an evaluation of providers’ perspectives on the process of mental health assessment and referral at three pilot implementation sites identified by the Minnesota Department of Health.

Methods: Using community-based participatory research design (Minkler & Wallerstein, 2008), a steering committee comprised of refugee leaders, mental health providers, and research partners guided the research process. We chose a focused ethnographic approach that is widely used in implementation research, particularly in primary care settings (Bunce et al., 2014; Russel et al., 2012).  We conducted individual interviews with 11 professionals who implement the screening protocol.  Each provider was interviewed twice to capture changes in processes over time with questions relating to provider training and experience of the screening and referral process.  

Interviews were recorded and transcribed prior to data analysis.  Qualitative analysis utilized Spradley’s Developmental Research Sequence (1979) which explores taxonomies among and within domains, categories, themes and subthemes related to participants’ experiences (emic perspective) (Parfitt, 1996). Analysis began with transcription of the first interview. The research team initially coded interviews for domains. Once all domains were identified and agreed upon, coding proceeded to articulate the categories within domains and themes related to these categories. To enhance trustworthiness of the data, credibility, transferability, dependability and confirmability were tracked.  We established data trustworthiness through regular consultation with healthcare providers and cultural leaders. Summaries of categories and findings were prepared for member checking with pilot sites interviewed.  Findings were presented to the steering committee and pilot sites with recommendations for improvements incorporated in the implementation of statewide screening.  

Results:  We found nine domains in common across all interviews: (a) professional roles in the health care team; (b) training and experience with refugee mental health; (c) experience of implementing protocol; (d) view of team functioning related to screening (e) comfort and confidence with refugee mental health; (f) psychoeducation and referral processes (g) refugee patient understanding; (h) protocol changes observed over time; and (i) recommendations for final implementation. 

Conclusions and Implications:  Results demonstrate that systemic barriers to refugees’ mental health care are specific to individual providers and clinic structures (county public health, primary care, and clinics with integrated behavioral health).  We discuss implications for the development of ongoing and individualized provider and clinic level training as well as final recommendations for implementation of statewide screening.