Health needs of refugees: port of arrival versus permanent camp settings

306 EMHJ – Vol. 25 No. 5 – 2019Research article Health needs of refugees: port of arrival versus permanent camp settings Monica Matsumoto,1 Gabrielle Wimer 2 and Aisha Sethi 3 1Pritzker School of Medicine, Biological Sciences Division, University of Chicago, Chicago, United States of America.2University of Chicago, Chicago, United States of America. 3Department of Dermatology, Yale University, New Haven, United States of America. (Correspondence to: Monica Matsumo- to: mmmatsumoto3@gmail.com). Abstract Background: The world’s refugee population has surpassed 21 million, the large majority of which resides in developing countries. Refugees have relatively high rates of healthcare utilization for management of both long-term needs, such as diabetes, and acute conditions, such as scabies. Aims: Using interviews of stakeholders in disparate healthcare settings, we aimed to elucidate both common themes and areas of difference that should be recognized and addressed as the refugee crisis continues. Methods: This qualitative interview study compared and contrasted two settings for healthcare provision for refugees: the permanent setting of Za’atari, a camp in Jordan, versus the transitory arrival location of Lampedusa, Italy. Results: We presented data from 12 semi-structured interviews with experts in refugee health care that have experience in these two locations. We focused on issues of disease burden and health screening, organizational structures and ser- vices, cultural competency, and international response. Conclusions: We compiled recommendations to improve health care for refugees include recognizing differing health needs of refugees in Za’atari and Lampedusa, training providers in culturally-competent care, screening for and treating psychiatric disorders, and prioritizing agency coordination, documentation, and advocacy. Keywords: refugee health, education, non-governmental organizations, international health policy, cultural competency Citation: Matsumoto M; Wimer G; Sethi A. Health needs of refugees: port of arrival versus permanent camp settings. East Mediterr Health J. 2019;25(5):306-314 https://doi.org/10.26719/emhj.18.041 Received: 22/11/16; accepted: 22/10/17 Copyright © World Health Organization (WHO) 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction The number of refugees worldwide reached over 21 mil- lion at the end of 2015 (1). Much of the recent displace- ment stems from political turmoil throughout the Mid- dle East and North Africa. Many of these conflicts have evolved into humanitarian crises as fleeing civilians attempt to find safety. In 2015, over 1 million arrived in Europe by sea via Spain, Italy, or Greece, with over 3700 reported dead or missing (2). In January 2016, over 5200 refugees arrived in Italy—a 50 percent increase over January 2015 (2,3). Twenty- one percent of refugees who arrived in 2015 landed in Lampedusa, Italy, a small island off the coast of Libya, on their way to mainland Europe (4). As a transitory location, Lampedusa serves short-term health needs of refugees, funded primarily by the Italian government. In contrast, Za’atari camp in Jordan houses 80 000 Syrian refugees, many of whom have lived there for years due to the protracted conflict (5). Most of the estimated 4.3 million Syrian refugees live in neighbouring countries (Egypt, Iraq, Jordan, Lebanon, Turkey), and as the largest refugee camp for Syrians, Za’atari has an established healthcare system and data collection mechanisms. We believed that a comparison between Za’atari and Lampedusa would elucidate important lessons learned by stakeholders providing care to refugees and would allow us to create more generalizable and actionable policy recommendations regarding the refugee crisis. Refugees are at risk for a variety of health problems be- cause of travel through unsafe, unsanitary, and poorly resourced settings, exposing them to physical and psy- chological dangers. Even after reaching a border, refu- gees face continued challenges as they integrate into new communities, adapt to altered lifestyles, access health- care, and deal with the effects of trauma. These influxes can strain resources of local communities, which are of- ten assisted by nongovernmental organizations (NGOs), governments, and agencies like the World Health Organ- ization (WHO) to provide basic health services (6). As the number of refugees grows and outpaces available international funding, it becomes increasingly important to identify major gaps in healthcare, eliminate wasteful duplication, and prioritize areas of greatest need. We identify common trends across agencies and initiatives providing healthcare to refugees, including structural pitfalls and emerging problems. We devote much-needed attention to bringing together diverse experiences of healthcare providers in order to identify common themes and ideas for developing new programmes with the greatest amount of beneficence, justice, and efficacy. 307 Research article EMHJ – Vol. 25 No. 5 – 2019 Methods Lampedusa, Italy and Za’atari camp in Jordan were cho- sen as representative settings of a transitory arrival centre and a permanent camp setting, respectively. Lampedusa was chosen because of Italy’s history of receiving refu- gees and Za’atari because it is the largest camp for Syrian refugees (7,8). We then conducted a literature review of scholarly articles on Pubmed, as well as news sources and grey literature (technical reports by NGOs and UN agen- cies) of healthcare provision in these two settings from the past five years. The results informed the creation of a questionnaire (Supplement 1) for semi-structured in- terviews, conducted between January and March 2016, with individuals working with refugees in either Jordan or Italy. This interview format was chosen to minimize the time demands placed on interviewees, while still al- lowing for the emergence of new themes. The interview- ees were selected based on author AS’s contacts having worked in refugee response in Lampedsua and Za’atari, as well as individuals that were identified during the lit- erature review. The interviewees were ultimately chosen to represent a cross-section of the different organiza- tions involved in refugee health response: NGOs, nation- al governments, and international organizations. The questionnaire and project received IRB approval from the University of Chicago’s Biological Sciences Division Institutional Review Board. Individuals were contacted via email addresses obtained either through publicly-available sources or private contacts. An initial email – and if necessary, one follow-up email – was sent requesting a Skype interview about his/her experience working with refugees in either Jordan or Italy, with a specific focus on health- related issues. The interviewee received the questions beforehand, and verbal consent was obtained prior to beginning the interview. Of the 17 people contacted, 15 responded, and 12 were interviewed. The semi-structured interviews were conducted by authors MM and GW. GW developed the list of initial codes based on the questionnaire. MM and GW coded all the interviews and identified nine emergent codes to be added. Following the finalization of the coding criteria, MM re-coded all of the interviews, the tabulation of which can be found in Table 1. The results of the coding were discussed by all authors to develop the set of policy recommendations. Results The following five themes were identified through the interviews and are referenced with the coding in Table 1: Recognition of the burden of disease Burden of disease, including health problems and medical supplies, was a recurrent theme referenced 40 times. The most recurrent healthcare need of refugees in Za’atari was chronic disease management, including emergent needs and long-term complications (Table 2). Refugees with preexisting conditions such as diabetes may arrive to Jordan with serious exacerbations because of lack of access to medications during their travel and in the Syrian Arab Republic. In addition, Za’atari’s setting in the open desert with hot summers, dust storms, and cold winters, coupled with a dearth of options for exercise and healthy food, can worsen many chronic conditions. In contrast, the biggest health issues for refugees arriving in Lampedusa are infectious diseases (Table 2). Even if refugees are otherwise healthy, the unsanitary and low-resource conditions in which they travel increase their susceptibility to communicable diseases. Scabies and bacterial infections are prevalent, as well as skin burns due to exposure to the overseas traveling conditions, including salty water, urine accumulated in the crowded boats, sun exposure, and proximity to the boat motor (9–11). Reproductive health is a priority, whether in Lampedusa or in Za’atari. One in five households in Za’atari is led by a woman, and the average weekly birth rate in the camp is 80 per 80 000 total persons of concern (12). Moreover, refugees often spend three or more years in camp, necessitating comprehensive paediatric and maternal healthcare services. Currently, 100% of births are attended by skilled medical personnel, and no maternal deaths were reported in 2015. Pregnant refugees arriving in Lampedusa require immediate gynecologic care, although the population’s transience makes long- term antenatal and postpartum care difficult to provide. In addition, sexual or gender-based violence has been documented and identified as an important area of concern by the UNHCR, requiring specialized services in both Za’atari and Lampedusa (13). Health screening and documentation needs Screening and treatment for psychiatric disorders is a critical health need in Za’atari and Lampedusa (Table 3). In Za’atari, the International Medical Corps (IMC), a UN- HCR-funded NGO, has been tasked with mental health service coordination with the goal of integrating mental health into primary care (14). Currently, refugees enter- ing Jordan are screened for general health conditions at a government-run registration centre in collaboration with NGOs and are then sent to a UNHCR camp for potential follow-up. Some health clinics in Za’atari per- form their own screenings, but the presence of an on-site trained mental health provider is not guaranteed. Mental health screening on arrival in Lampedusa is burdensome owing to the sheer number of refugees, making it im- possible to screen everyone for psychological disorders (7,9). Most refugees do not stay in the migrant centres for long, so many mental disorders may not be diagnosed. Overall, mental health screening was referred to as being conducted in three instances and was lacking in seven instances. Mechanisms for improving coordination of care While more interviewees referred to coordination of care being effective than lacking, at 19 and eight, respective- ly, five referred to centralizing coordination in order to 308 EMHJ – Vol. 25 No. 5 – 2019Research article improve health service delivery. Providing healthcare to refugees in Jordan is logistically more feasible inside the camp than in urban settings because of the centralized framework and geographic proximity (14). Communica- tion between the registration centre and the camp ap- pears to be done on an informal basis (15). The UNHCR, which receives funds from international donors and na- tional governments, is the coordinating arm of Za’atari camp (Table 4). It manages the multifaceted health sector and mediates with the Jordanian government. An exten- sive list of UNHCR implementing partners is available on its webpage, but no comprehensive compilation of servic- es, facilities, or medications exists for healthcare provid- ers to use in either Za’atari or Lampedusa (9,16). However, the UNHCR recently launched the Inter-Agency Coordi- nation Briefing Kit to facilitate information sharing and improve coordination (17). Furthermore, minutes from UNHCR’s bimonthly management and sectorial coordi- nation meetings, including health services in Za’atari, are posted online (18). While areas of need remain, Za’atari camp has been recognized for its coverage of primary and secondary health needs of refugees, as well as out- break response mechanisms, especially in light of the fluctuating number of refugees, NGO participation, and funding (14,19). Starting with the influx of refugees in 2010, the Italian government implemented a health information system, including public health surveillance mechanisms to report to the Italian ministry of health (MoH) (20,21). The MoH has also adapted a WHO toolkit to conduct a series of assessments on the health system impact of the influx of migrants and crisis management (Table 3) (22,23). Upon arrival to Lampedusa, NGOs such as the Red Cross and Doctors Without Borders triage patients with assistance from the MoH, but within the migrant centres that house refugees, the provision of services is the responsibility of the Ministry of the Interior (Table 4) (9,24). Cultural competency training for healthcare providers There were 19 references to cultural competency and 11 references to language concordance in the interviews. Refugee healthcare providers often lack linguistic or cultural concordance with their patients, so training and interpreter services are critical to maintaining high-qual- ity care. Many organizations in Za’atari rely on volunteer healthcare providers who may be unfamiliar with the culture and language, underscoring the need for prior training (Table 3). Similarly, refugees arrive at Lampedu- sa from dozens of countries with unique languages and practices, increasing the complexity of healthcare provi- sion. In Lampedusa, cultural mediators can help provide culturally competent translation. Medical providers in Za’atari said some of their best interpreters had been res- idents of the camp because they understood the “culture” of the camp, including additional resources available to patients (11,12,25). Long-term needs and international response Addressing mental health needs, social determinants of health, such as job opportunities, and follow-up care, were referred to 11, 12, and 14 times respectively. Thus, providing healthcare to refugees is not a one-time en- deavour but an ongoing commitment by the interna- tional community. Components of this international response include not only funding, but also awareness and advocacy initiatives, trained medical providers, and ultimately, a political solution to the conflict. Discussion and recommendations A summary of the following recommendations organ- ized by theme can be found in Table 5. In both Jordan and Italy, leaders have called for a more coordinated and centralized approach to delivering healthcare to refugees (7,9,10,16). The coordination of healthcare services should be centralized with one entity in all settings and integrat- ed into an overarching model of care. In Italy, the govern- ment should lead coordination efforts because it is the main funder of healthcare. In Lampedusa, centralizing control of health services with the Servizio Sanitario Na- zionale would improve coordination among the various organizations and allow for more collaboration and in- put from WHO (11). In Za’atari, services are coordinated by the UNHCR, which is taking concrete steps towards management and dissemination of information among its implementing partners. For example, it has helped de- velop implementation tools and standard operating pro- cedures, such as a cholera preparedness plan, which has been adopted by the Jordanian MoH as a national guide- line (14,26). This model of multisector meetings and focus groups is also applicable in the context of Lampedusa. For mental health, screening and treatment should be combined with primary healthcare services rather than the current vertical model. Psychoeducational materi- als must be made available to refugees in order to raise awareness about mental health conditions and complica- tions, provide basic management techniques, and bolster community support (16,25). Many refugees, especially parents with affected children, are unaware of or con- fused about symptoms (16). Importantly, a robust infra- structure must be in place for psychotherapeutic treat- ment to accommodate follow-up for both paediatric and adult patients (27). Better communication can be achieved through providing a list of available follow-up services and resources for psychosocial therapy and would help improve coordination among organizations and assist healthcare providers in making better referrals. Government engagement is critical in order for the response to be coordinated and integrated within a national system. Regular meetings between the MoH, NGOs, and UNHCR/WHO will promote communication among stakeholders, as well as public dissemination of the results. Even though NGOs often provide basic healthcare, government involvement is necessary for disease surveillance and referrals, especially in Jordan 309 Research article EMHJ – Vol. 25 No. 5 – 2019 where refugees often reside for years. Since a Jordanian government policy change in 2014, only limited financial assistance is available to refugees in non-camp settings seeking care in MoH facilities (28). More focus should also be directed towards providing care to city-dwelling populations. Provider training in refugee health While many organizations still rely on volunteers, train- ing local healthcare providers will increase cost effective- ness and sustainability. The limited number of health professionals, especially psychiatrists and psychologists, is a major barrier in providing care. Community-based healthcare workers can increase awareness about disease prevention and management, connect refugees to health resources, and improve system efficiency, especially with limited numbers of physicians available (28,29). Pro- grammes to train refugees in this capacity will improve health and contribute to livelihood engagement, especial- ly in the camp settings where long-term care is impor- tant. In addition, more resources for identifying and training high-quality interpreters is important so that language is not the primary barrier for refugees to access care. In Za’atari, Jordanian physicians have higher linguistic, religious, and cultural concordance with Syrian refugees than do many of the physicians who come from other countries. Furthermore, hiring locally can contribute to the local economy. We recommend that refugees be trained as interpreters, especially in camp settings, where such opportunities can lead to local empowerment as well as sustainable delivery. Training programmes for healthcare providers in refu- gee healthcare and cultural competency are an underuti- lized but valuable tool (11). Culturally competent care can improve recognition of medical problems, build trust and relationships, provide context for seemingly unusual be- haviours, and improve communication between patient and provider. For example, the American University in Beirut, Lebanon, recently established a Conflict Medicine Programme, and Unite for Sight partnered with Harvard Medical School, United States, to offer a certificate pro- gramme for refugee health and trauma (30,31). Other tools including case-based learning, shadowing opportunities, and Internet resources should be used by students and professionals. These programmes should be part of a larger initiative in cultural competency training. Investment in robust documentation Poor documentation is a major barrier to providing care to refugees. Systems for tracking top health issues have been put in place in Za’atari and Lampedusa. Disease surveillance programmes in Jordan have proven to be in- valuable for obtaining health-related data and allocating resources (14). Readily available technology, including SMS, should be utilized to provide health-related updates and reporting (14). The current minimal health record documentation presents major complications with continuity of care, especially since providers are constantly changing. Furthermore, refugees may arrive without any information on prior medical conditions, so the documentation process should start as soon as possible. Especially when handling personal health information, a formal process for communicating and maintaining privacy must be in place. In Za’atari each registered refugee should have an electronic file with the results of the initial health screening, which can be updated and shared with healthcare providers in the camps. Currently, providers write medical information on a WHO paper form given to each refugee, but these can be misplaced easily, and records may be incomplete or inadequate. On the other hand, paper documentation for refugees arriving in Lampedusa is ideal because despite drawbacks, it would allow patients to carry their medical information with them to their final destination. Organizations must adopt standard operating procedures that require documentation and transparency. Available health services and facilities should be compiled to help physicians make referrals, identify gaps in services, and improve utilization of available resources in the camp. It would also improve integration of temporary volunteers and continuity of care with long-term providers. Similarly, a comprehensive list of medications and medical supplies should be maintained so that the available resources are known and depleted resources identified. Funding and advocacy Funding for health services is overstretched, and re- sources are limited, so monetary and technical assistance from the international community is critical. UNHCR in Za’atari and the Italian government in Lampedusa must continue to improve coordination to utilize healthcare funding efficiently and to integrate services. While not directly related to healthcare provision, advocacy is critical for spreading awareness about the support needed for refugees. For example, healthcare providers who return from service missions have a unique opportunity to become advocates for refugees, whether through conferences, interviews, opinion articles, or mentoring other students and colleagues. In addition, local NGO initiatives for refugees that address social determinants of health, such as offering language courses, can also have positive effects on the host communities. Conclusion The health of refugees is of utmost importance not only for their personal well-being and safety but also for the health of host communities. Through our interviews with individuals who have worked in either Za’atari, Jor- dan or Lampedusa, Italy, we identified themes and cre- ated recommendations to further improve healthcare response efforts targeted for refugees. Chronic disease management for camp-based refugees, and infectious disease management for in-transit refugees remain pri- 310 EMHJ – Vol. 25 No. 5 – 2019Research article Table 1. Development and counts of interview codes* Theme Code Cluster Preliminary Codes Emergent Codes Category Count Category Count 1 Health problems Infectious disease 7 Burns 3 Chronic conditions 9 Hypothermia 1 Mental health 17 Maternal health 3 Medical supplies - - Insufficient supplies 4 - - Sufficient supplies 8 2 Health screening Mental health screening conducted 3 General health screening conducted 8 Mental health screening lacking 7 General health screening lacking 2 Documentation Medical records present 6 Surveillance 4 Medical records lacking 5 - - 3 Coordination of care Effective coordination 19 Centralizing control 5 Ineffective coordination 8 - - Financing National health system/MoH 10 WHO/UN 18 NGOs 15 - - Resource priorities - - Access to resources 26 - - Discrimination 7 4 Healthcare providers Volunteers 13 Training 23 Paid employee/staff 20 - - Humanistic competency Cultural competency 19 - - Language concordance 11 - - 5 Long-term health needs Mental health 11 Social determinants of health 12 Chronic conditions 5 Follow-up care 14 International response Funding 6 Awareness/advocacy 9 2 Political solution 6 *Preliminary codes were created a priori based on the interview questions; emergent codes were created after coding of the interviews; and then code clusters were formed to form five overarching themes. MoH = Ministry of Health; NGO = Nongovernmental Organization; UN = United Nations; WHO = World Health Organization orities. Mental health screening and services need con- sistent standards of care and dedicated provider training, especially in cultural competency. Healthcare-providing organizations can improve their efficacy by both invest- ing in documentation strategies and centralizing their care models. Finally, as many gap remains in local, na- tional, and international funding, public engagement and advocacy for refugees’ rights remain critical aspects of an integrated response to providing healthcare for ref- ugees, whether in Jordan, Italy, or around the world. Acknowledgements We would like to express our gratitude to the following individuals for taking time out of their busy schedules to share their experiences and views: Mohammad Abo-Hilal, co-founder, Syria Bright Future; Sara Barragan-Montes, technical officer on public health and migration, WHO/Europe; Gianfraco Costanzo, head international relations, The National Institute for Health Migration and Poverty in Rome, Italy; Asaad Kadhum, public health officer, UNHCR Office in Jordan; Marissa Leslie, medical director, behaviour health and wellness services, Adventist Health Care; Gregory Lewis, clinical psychologist, Alliance Clinical Associates; Alberto Mallardo, analyst and cultural mediator, Mediterranean Hope; Aldo Morrone, director, Mediterranean Institute of Hematology (former director, National Institute of Health, Migration, and Poverty in Rome, Italy); Valeska Padovese, dermato-venereology consultant, Maltese Ministry of Health; Zaher Sahloul, president, Syrian American Medical Society; and Iyad Shytiat, assistant public health officer, UNHCR Za’atari Camp. Funding: None. Competing interests: None declared. 311 Research article EMHJ – Vol. 25 No. 5 – 2019 Table 2. Comparison of health needs and services in Za’atari vs. Lampedusa* Theme Za’atari Lampedusa Health Needs - Chronic disease management (hypertension, diabetes, asthma) (6,14,16,19,26) - Healthy lifestyle and food options - Tertiary care - Infectious diseases (scabies, bacterial infections) (9,20,26) - Hypothermia (11) - Skin burns (9,11) - Mental health (depression, anxiety, and posttraumatic stress disorder) (11,16,19,20,25,26,29) Available Health Services - Free primary and secondary health care - Disease surveillance and outbreak response (7,14,20,26) - Maternity health care - Variable, although a disease surveillance system is in place Gaps in Health Services - Screening and treatment for mental health (9,14,16,19,29) - Sexual or gender-based violence prevention, reporting system, and treatment - Tertiary care coverage *Specific health needs and services were identified based on the literature review and interviews. Table 3. Interview quotes related to refugee healthcare organized by theme* Theme Quote Za’atari Lampedusa Health Problems: Mental Health & Screening Mental health services in Jordan are vertical, but they need to be part of primary health care, so a more integrated approach is needed to reduce the stigma and improve cost-effectiveness. This will be a goal for 2016 (14). - Infectious diseases (scabies, bacterial infections) (9,20,26) - Hypothermia (11) - Skin burns (9,11) Coordination of Care “There are processes that could be streamlined if UNHCR took a more proactive role on this issue.” (19) “In many countries, this work is developed in close collaboration with international organizations, especially where UN country teams are present; and in the specific case of the MOH, the work is done in close collaboration with the WHO Country Office and Regional Office for Europe.” (11) Healthcare Providers: Training “I also think there could be benefit for people going on missions to have some type of orientation or training...I think just understanding what it means to work with someone from a different culture, inter- cultural sensitivity. Trauma, understanding inter-cultural sensitivity, learning how to work with people. How we often see things through our own eyes...we need to be aware of our own biases and blind spots before we go learn about your culture.” (16) International Response: Advocacy/ Awareness “I just want to ensure that our voice reaches all decision-makers to support and continue supporting refugees in all aspects, including health services. We are doing our best to serve refugees, but one hand cannot clap—we need all the help and support we can get. Any donation or any mission can make the refugee’s life better—it can improve their health, access to health.” (26) “I think that we have to organize international and national fundraising for refugee health services because if we improve their health conditions we improve the health conditions of the Italians or Europeans too.” (7) *Representative examples of quotes were selected from interviews. Table 4. Interagency coordination mechanisms for health services* Coordination Mechanisms Za’atari Lampedusa Implementing Organization UNHCR, MoH Italian government Documentation and Screening Jordanian government, UNHCR and implementing partners NGOs, migrant centers (MoI) Surveillance UNHCR implementing partners WHO, Italian government Standard Operating Procedures WHO, UNHCR, Jordanian government National Institute of Health, Migration, and Poverty; WHO/ Europe Meeting of Stakeholders UNHCR and partners WHO and European government leaders *Differing structures of healthcare delivery options for refugees exist in Za’atari vs. in Lampedusa. MoH = Ministry of Health; MoI = Ministry of Interior; NGO = Non-governmental Organization; UNHCR = United Nations High Commissioner for Refugees; WHO = World Health Organization 312 EMHJ – Vol. 25 No. 5 – 2019Research article Supplement 1. Semi-structured inter- view questions. Interview questions were created based on a literature re- view and were sent to interviewees prior to the interview. Background of interviewee 1. How have you been involved over the past few years with healthcare for refugees? Health issues and services 2. In your opinion, what are the top three health issues among refugees/migrants? 3. What materials and products are the most important for health maintenance for refugees and migrants? a. Who is paying for/providing these? b. Are there enough of these materials? 4. What health issues are refugees screened for upon ar- rival? a. Follow up: Are all or most refugees screened for mental health? Can you explain the process 5. What follow-up is there to the screening results, and how are records kept (e.g., electronically)? a. How do patients with chronic conditions receive and pay for their medication? b. How are immunizations tracked? 6. Who are the main health care providers (nationality, training, volunteer vs. paid)? a. What type of health care workers and services are most needed at this time and for the near future? 7. How are healthcare provision efforts coordinated be- tween different organizations (government, non-pro it, etc.) a. How do you think coordination can be improved? 8. What have been the greatest successes in health care provision that you have witnessed so far? a. Are there particular models that have worked well? 9. As international funding decreases, where do you think resources for refugee health services should be prioritized? Training 10. What sort of humanistic competency training do “health care providers” receive, such as linguistic, cul- tural, or religious competency? a. Who provides these trainings? b. What aspects are most lacking? 11. In what specific ways can training for staff members and healthcare providers be improved to meet the needs of refugees? 12. How have security issues (within the camps) affected the health of the refugees? a. How are security issues addressed (e.g., programs, edu- cation initiatives, trainings)? Resettlement 13. How long do most refugees actually stay in the mi- grant centers/camps? a. Where do most refugees go after they leave the camps? 14. As refugees resettle in other communities across the world, what do you expect their most pressing health- care needs to be? 15. What can the international community do to help most? Table 5. Summary of recommendations to improve healthcare for refugees* Coordination Mechanisms Za’atari Coordinated Response Efforts Improve communication and collaboration between various stakeholders and centralize response effort within one organization or agency, and integrate mental healthcare into existing primary care infrastructure Improved Training for Providers Teach healthcare professionals to provide culturally-competent care, and provide opportunities for refugees to serve as interpreters Robust Documentation Mechanisms Improve documentation, both for individual patients to improve medical record keeping, and of existing resources to improve communication Funding and Advocacy Raise awareness about the magnitude of the current refugee crisis and the gap in funding and resources currently available * Recommendations are based on recurrent themes from the 12 interviews that were conducted 313 Research article EMHJ – Vol. 25 No. 5 – 2019 References 1. United Nations High Commissioner for Refugees. Figures at a Glance. Geneva: UNHCR; 2015. (http://www.unhcr.org/figures-at- a-glance.html, accessed 7 May, 2017). 2. United Nations High Commissioner for Refugees. Refugees/Migrants Emergency Response Mediterranean Regional Overview. Geneva: UNHCR; 2016. (http://data2.unhcr.org/en/situations/mediterranean). 3. International Organization for Migration. Europe/Mediterranean: mixed flows in the Mediterranean and beyond; flows compilation overview 2015. Geneva: IOM; 2016. (https://www.iom.int/sitreps/europemediterranean-mixed-flows-mediterrane- an-and-beyond-flows-compilation-overview-2015). 4. WHO Regional Office for Europe. Sicily, Italy: Assessing health-system capacity to manage sudden large influxes of migrants. Joint Report on a Mission of the Regional Health Authority of Sicily. Copenhagen: EURO; 2015. (http://www.euro.who.int/en/ publications/abstracts/sicily,-italy-assessing-health-system-capacity-to-manage-sudden-large-influxes-of-migrants2). 5. United Nations High Commissioner for Refugees. Camp ZR. Geneva: UNHCR; 2017. (http://data.unhcr.org/syrianrefugees/settle- ment.php?id=176&region=77&country=107). ةمئادلا تمايخلماو لوصولا ءانيم ينب ةنراقم :ينئجلال ةيحصلا تاجايتحلاا يثيس ةشئاع ،رمياو لييرباج ،وتوموستام اكينوم ةصلالخا ةياعرلا نم اًيبسن ةعفترم تلادعم لىإ نوئجلالا جاتيحو .ةيمانلا نادلبلا في مهبلغأ شيعيو ،ًانويلم 21 لماعلا لوح ينئجلالا ددع زواتج :ةيفللخا .بَرَلجا لثم ،ةدالحا تلاالحاو ،يركسلا ءاد لثم ،ليوطلا ىدلما تاجايتحلا يجلاعلا يربدتلا لجأ نم ةيحصلا فلاتخلاا تلاامجو ةعئاشلا تاعوضولما يرسفت لىإ انفده ،ةيحصلا ةياعرلا قفارم فلتمخ في ةحلصلما باحصأ عم تلاباقلما للاخ نم :فادهلأا .ينئجلالا ةمزأ رارمتسا لظ في اهتلجاعمو اهديدتح بيج يتلا ناكم لباقم ،ندرلأا في يترعزلا ميخلم مئادلا قفرلما :ينئجلال ةمدقلما ةيحصلا ةياعرلل ينقفرم ينب هذه ةيعونلا ةلباقلما ةسارد نراقت :ثحبلا قرط .ايلاطيإ في ازوديبملا لياقتنلاا لوصولا تلاكشم لىع زكرنو .ينناكلما هذه في ةبرخ ميهدل نيذلا ينئجلال ةيحصلا ةياعرلا في ءابرلخا عم ةلكيهم هبش ةلباقم 12 نم تانايب مدقن :جئاتنلا .ةيلودلا ةباجتسلااو ،ةيفاقثلا ةءافكلاو ،ةيميظنتلا تامدلخاو لكايلهاو ،يحصلا صحفلاو ،ضرلما ءبع ميمخ في ينئجلال ةفلتخلما ةيحصلا تاجايتحلاا ديدتح كلذ في ماب ،ينئجلال ةمدقلما ةيحصلا ةياعرلا ينستح فدبه تايصوت انعجم :تاجاتنتسلاا ،اهتلجاعمو ةيسفنلا تابارطضلاا صحفو ،ةيفاقثلا تارابتعلااب ةيفاولا ةياعرلا ميدقت لىع ةيحصلا ةياعرلا يمدقم بيردتو ،ازوديبملاو يترعزلا .ةصرانلماو معدلاو قيثوتلاو تلااكولا ينب قيسنتلا تايولوأ بيترتو Besoins de santé des réfugiés au port d’arrivée par rapport aux camps permanents Résumé Contexte : La population mondiale de réfugiés a dépassé les 21 millions, dont la grande majorité se trouve dans des pays en développement. Les réfugiés ont des taux relativement élevés de recours aux soins de santé pour la prise en charge des besoins à long terme, tels le diabète, et des maladies aiguës, telles que la gale. Objectifs : Par le biais d’entrevues avec des intervenants dans des milieux de soins de santé différents, notre objectif était de déterminer les thématiques communes ainsi que les domaines montrant des différences qui devraient être identifiés et pris en compte au fur et à mesure que la crise des réfugiés se poursuit. Méthodes : La présente étude qualitative par entretiens compare et met en contraste deux contextes de prestation de soins de santé aux réfugiés : le camp permanent de Za’atari, en Jordanie, et le point d’arrivée transitoire de Lampedusa en Italie. Résultats : Nous présentons les données de 12 entrevues semi-structurées avec des experts en soins de santé aux réfugiés ayant de l’expérience avec ces deux types d’emplacements. Nous nous sommes concentrés sur les questions de la charge de morbidité et du dépistage des maladies, des structures et des services organisationnels, des compétences culturelles et des interventions internationales. Conclusions : Nous avons compilé des recommandations pour améliorer les soins de santé aux réfugiés, y compris la reconnaissance des différents besoins de santé des réfugiés à Za’atari et Lampedusa, la formation de prestataires de soins culturellement compétents, le dépistage et la prise en charge des troubles psychiatriques et l’établissement de priorités en matière de coordination, de documentation et de plaidoyer. 314 EMHJ – Vol. 25 No. 5 – 2019Research article 6. World Health Organization. From the migration front line: interview with Lampedusa doctor. Geneva: World Health Organiza- tion; 2015. (http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/news/news/2015/04/from-the- migration-front-line-interview-with-lampedusa-doctor). 7. 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Asaad Kadhum (UNHCR), interview by Monica Matsumoto, February 25, 2016, transcript. 15. Anonymous. Refugee health in Za’atari. 2016; Online interview, Feb. 2016. 16. Gregory Lewis, interview by Monica Matsumoto, February 25, 2016, transcript. 17. United Nations High Commissioner for Refugees. Jordan Refugee Response: Inter-agency coordination briefing kit. Geneva: UNHCR; 2017. (http://data.unhcr.org/syrianrefugees/download.php?id=11118). 18. United Nations Development Programme. Updated overview: 2015 Syria Response Plan and 2015-2016 Regional Refugee and Resilience Plan. New York: UNDP; 2015. (http://www.undp.org/content/dam/rbas/doc/SyriaResponse/Kuwait III/Overview of 2015 Response Plans for Syria Crisis.pdf). 19. Zaher Sahloul, interview by Monica Matsumoto, January 21, 2016, transcript. 20. Gianfranco Costanzo, interview by Gabrielle Wimer, March 9, 2016, transcript. 21. Napoli C, Riccardo F, Declich S, Dente MG, Pompa MG, Rizzo C, et al.; The National Working Group. 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