Innovation Toward Improving the Refugee Mental Health Service Delivery System

Background and Purpose: The lack of mental health resources has been identified as a reason for not screening the mental health of newly arriving refugees.  This study has two objectives as Minnesota prepares to begin screening the mental health of refugee arrivals:  1) Identify the barriers that impede access to and delivery of culturally appropriate mental health services for Minnesota’s refugee communities? And 2) Identify likely interventions at individual and health care system levels for improving access and the delivery of culturally appropriate mental health services for refugee populations?

Methods: This is a community-based participatory research design that engaged all stakeholders in the development of an interview protocol to investigate effectiveness and barriers to care in the mental health service delivery system processes from initial public health screening through referral processes to successful enegagement with mental health providers ( Creswell, 2007; Minkler, 2008; Patton, 1997). We composed a steering committee of public health screening clinic staff, health network administrators, mental health providers, and refugee cultural leaders from each of five ethnic groups (Somali, Oromo, Bhutanese, Karen, and Iraqi) to discuss the development of an interview protocol. Questions were developed in a participatory way to include the perspectives of all community stakeholders.  Confidential interviews were piloted and revised in collaboration with stakeholders. Interviews were conducted with key public health screening clinics, a sample of trauma trained providers from each insurance network, and cultural leaders and recent arrivals from each of the refugee groups.  A subset of the key stakeholders met on a quarterly basis to review the progress of the evaluation process. 

Critical incident technique methods were used to better understand critical incidents that inform access to and quality of care.  Participants identified 200 critical incidents related to access to care.  Critical incidents were independently sorted by content experts (i.e., members of the population) into categories of their own choosing.  Because all sorters sort the same answers, associations between the answers were modeled statistically using Principle Components Analysis to extract common categories across all answers and sorters.  From this categories were defined and associations between categories were calculated along with an estimate of the magnitude of sorter agreement for the categories.

Results:  Processes of collaboration toward the evaluation of the mental health service delivery system for newly arriving refugees will be discussed. The stakes and stakeholders in this process will be identified and processes for overcoming conflict will be discussed. Outcomes of interviews identified common barriers to care including the lack of mental health services (including access to appointments and  pharmacies), lack of interpreters and culturally competent services in mental health clinics, cultural differences in understanding mental health, transportation barriers, problems obtaining and maintaining medical insurance, and difficulty navigating complex systems of care.

Implications: The strength of participatory methodologies and critical incident technique for conducting system evaluations will be discussed.  Recommendations for culturally appropriate provider training will be outlined. System interventions will be outlined from referral to successful provider engagement and evaluation of service outcomes.