Project Summary
The COVID-19 pandemic has highlighted critical gaps in healthcare service delivery, coordination, and planning for vulnerable populations like refugees. Although refugees undergo increased health risks due to poor living conditions, trauma, and interrupted healthcare access, their needs are often sidelined during public health events that overwhelm local response capacities.
This research examines the healthcare experiences of government-assisted refugees during COVID-19, focusing specifically on the United States’ response as a case study. Through surveys, interviews, health data analyses, and policy reviews, the study will assess healthcare service access, timeliness, affordability, adequacy, acceptability, and coordination during COVID-19. Refugees who were resettled in the US in the last 5 years will be randomly sampled to gather quantitative data on demographics, health status, healthcare utilization, and qualitative insights on navigating healthcare during COVID-19. Experiences with telehealth access, medication availability, language interpretation, and coordination across refugee agencies and public health authorities will be analyzed.
Study findings will identify key gaps in the United States’ healthcare policies, planning, and interventions for refugees during public health crises. By centering on refugee lived experiences, it will recommend targeted measures to improve healthcare delivery, continuity, and crisis preparedness through evidence-based planning, coordination, accessibility, quality assurance, and cultural responsiveness mechanisms. Overall, the study aims to contribute robust evidence on enhancing refugee health equity, especially among displaced populations who depend on government assistance for healthcare access during emergencies when local capacities become constrained. Findings will be relevant for refugee-hosting countries globally as they brace health systems for managing emerging disease outbreaks and future pandemic events.
Rationale and Background Information
Background
Refugees are at high health vulnerability due to numerous factors along their displacement journeys right from the onset of conflicts or disasters that forcibly displace them from their homes. In refugee camps and temporary shelters, overcrowding, and inadequate access to nutrition, shelter, sanitation, and healthcare begin to impact refugee health status (UNHCR, 2022). Interrupted healthcare for chronic conditions, limited access to essential medicines, maternal care, or immunization further compound existing risks. By the time refugees are repatriated or settled in host countries, elevated rates of infectious diseases, malnutrition, maternal-child morbidity, and mental health issues are common (CDC, 2022).
However, healthcare service planning for refugees rarely considers these complex health profiles and needs. As vulnerabilities get further heightened during public health crises like disease outbreaks or pandemics, gaps in healthcare access and coordination become more apparent. COVID-19 especially highlighted numerous existing barriers refugees face in affording testing and care for the illness. Lack of interpretation services, inability to take time off work to seek healthcare, and fragmented care coordination across refugee agencies and public health systems affected continuity and outcomes (Armitage & Nellums, 2020). Discrimination and xenophobia also negatively impacted healthcare experiences, with refugees even avoiding seeking timely care.
As refugees constitute a significant population group within migrant communities, planning inclusive public health responses is essential. However, current systems seem ill-prepared to offer comprehensive, accessible, good quality, and well-coordinated care for refugees in normal circumstances, let alone public health events that overwhelm local capacities. This indicates major policy and planning gaps in how refugee healthcare considerations are integrated into national public health crisis response roadmaps like pandemic preparedness pathways.
Problem Statement
There are considerable gaps within United States public health policy frameworks and service capacities to protect and support government-assisted refugees adequately during disease outbreak events. The COVID-19 pandemic response highlighted existing barriers to healthcare access, affordability, utilization, coordination, and cultural responsiveness that underserve the refugee population’s health needs. Immediate evidence is required specifically examining refugee experiences navigating healthcare services across screening, testing, case management, and vaccination for COVID-19 in the United States context. Study findings can significantly strengthen the incorporation of targeted refugee healthcare planning within broader public health emergency protocols at national, state, and county administration levels. Long-term policy and capacity improvements will also better secure government-assisted refugees’ health outcomes throughout all stages of healthcare delivery across prevention, diagnosis, and treatment during future disease outbreak events.
Objectives
General Objective
To undertake a comprehensive mixed-methods research study that critically examines the gaps and limitations in the United States’ healthcare and policy ecosystems which have systematically neglected equitable inclusion and prioritization of refugee populations’ specific healthcare needs and cultural considerations during critical public health events like the COVID-19 pandemic. The study aims, through in-depth quantitative surveys and qualitative interviews centered on government-assisted refugees’ navigation experiences of the nation’s healthcare systems alongside analyses of health outcome data and policy reviews, to construct a set of targeted, evidence-based recommendations focused on reforming and redesigning existing healthcare emergency response protocols and social safety nets at federal, state and local levels.
The overarching focus on principles of health equity, cultural competence, non-discrimination, and social justice is further envisaged to inform the development of a comprehensive framework to uphold displaced refugee communities’ right to accessible, affordable, and good quality healthcare during current and future public health crises or disease outbreak events. The general objective sets the stage for the study to create long overdue conversations on the intersections of migration policies, public health emergency response capacities, and universal healthcare rights in high-income host countries like the United States through exposing systemic gaps that forfeit equitable healthcare access for legally protected forced migrants during the pandemic management. Findings aim to provide policymakers and practitioners with a refugee-centered pandemic preparedness model that proactively embeds protections for accessible continuous care for asylum-seekers, resettled refugees, and other displaced populations within national and state-level healthcare emergency protocols for present and future disease outbreaks.
Specific Objectives
- To analyze COVID-19 health outcome indicators represented through verified infection rates, hospitalizations, recovery trends, and mortality data among refugee populations across 5 major refugee-hosting states compared to non-refugee populations. Quantitative data analysis seeks to systematically surface variances in pandemic impacts attributable to existing healthcare access barriers, lack of affordable testing/treatment facilities in resettlement clusters, and absence of tailored response considerations for refugees’ socioeconomic needs.
- To extensively capture government-assisted refugees’ lived experiences of navigating the multi-layered healthcare systems across 300 surveys and 50 in-depth qualitative interviews during the domestic COVID-19 response. Assess differences in affordability, wait times, and care coordination complexities about accessing testing, hospital admissions, isolation facilities, treatment, and vaccines for COVID-19 based on ethnicity, gender, age, mobility status, and income levels.
- To qualitatively examine recurring barriers faced by refugees through 150 hours of testimony gathering on attempting to secure equitable and culturally/linguistically appropriate healthcare throughout the pandemic response across camps, asylum application processes, resettlement, and integration. Particularly highlight the consequences of interrupted services for chronic conditions.
- To systematically review existing health policies and statutes on rights and protections for asylum-seekers and refugees during public health crises across 3 federal policies, 5 state-level policy frameworks, and 10 county administrative health directives. Assess the degree and quality of considerations extended to refugees’ unique healthcare needs, cultural barriers, communication gaps, and continuity of care challenges through robust policy gap and accountability analysis.
- To inform recommendations for legal statutes, healthcare system reforms, and planning protocols focused on securing refugees’ equitable access to affordable diagnostic, treatment, and preventive services throughout all phases of current and future public health disasters by upholding human rights, cultural safety, and social justice obligations to displaced populations.
Methods
Study Design:
An explanatory sequential mixed methods study allows qualitative data to explain significant quantitative survey findings on refugee healthcare experiences during COVID-19.
The first phase involves quantitative surveys conducted remotely using phone/online methods with 300 government-assisted refugees across 5 major refugee resettlement states – Texas, New York, California, Ohio, and Pennsylvania. Surveys will gather closed-ended inputs on demographics (age, gender, etc), socioeconomics, health history, COVID-19 health impacts, healthcare access modes, utilization rates, service affordability, adequacy and quality ratings across testing, case management, and vaccination stages; including basic descriptive statistical analysis.
The second phase entails one-on-one qualitative semi-structured interviews done remotely with a sub-sample of 30-50 refugees to explain significant survey results; investigating themes like healthcare navigation complexity, cultural/language responsiveness, service coordination between agencies, barriers faced, and recommendations. Thematic analysis will be done to supplement survey findings and capture subjective experiences.
Additional data collection involves COVID-19 health indicators comparison between resettled refugees and citizens, and policy review of pandemic response plans across federal, state, and county jurisdictions to assess refugee consideration integration.
Data Collection
Primary quantitative data comprises a statistically representative survey sample of government-assisted refugees on demographics, health status, healthcare access modes, affordability ratings, and utilization rates for COVID-19 across testing, treatment, and vaccination stages.
Primary qualitative data includes in-depth individual interviews with refugees on healthcare navigation complexity, coordination between refugee agencies/public health systems, barriers faced, recommendations, and experiences with cultural/language responsiveness.
Secondary data compiles verified COVID-19 health indicators like transmission, hospitalization, recovery rates, and mortality for refugee and non-refugee populations from state public health departments.
Policy review data contains published pandemic response plans and public health crisis protocols across federal/state/county jurisdictions with discourse analysis on refugee healthcare rights and access considerations.
Data Analysis
Descriptive statistics will be calculated for demographics and healthcare ratings from surveys using SPSS. Intergroup variance across location, age, gender, etc will be analyzed using tests like ANOVA. Qualitative data will undergo thematic analysis with iterative coding to identify emerging themes about barriers, coordination gaps, and recommendations. Health indicators between groups will be compared using percentage change, and ratio analysis. The policy review will involve discourse analysis to identify mentions of refugee considerations based on principles like Sphere standards and UNHCR guidelines on refugee health equity rights. Triangulation will confirm findings across data sources.
Ethical Considerations
Voluntary Participation & Informed Consent
Participants will be provided with a detailed informed consent form outlining the exact nature of the study, potential risks and benefits, measures to protect privacy, and the voluntary nature of participation. Consent forms will be verbally translated when needed to facilitate comprehension. Signatures indicating participants have understood the information and agree to participate freely will be taken before inclusion. Options to leave the study anytime or skip questions will be emphasized to assert voluntary participation right through data collection.
Risk Mitigation
Trained counselors and local service referrals will offer psychosocial support if needed. Distress protocol will involve immediately stopping interviews and providing emotional assistance. Plain, transparent language will manage expectations and prevent misconceptions that could heighten emotional reactions or distrust. Reporting will contain aggregate-level data only.
Estimated Budget and Funding
Personnel & Staffing
A dedicated research staff across roles of principal investigator, project manager, field coordinator, research assistants, interviewers, policy analysts, biostatisticians, and community mobilizers will be recruited on a full-time basis across the 3-year project timeline. Competitive salaries as per industry standards need to be allocated to hire specialized expertise and build a skilled interdisciplinary team to steer this intensive mixed methods research. Personnel costs will also account for existing administrative, financial, procurement, and human resource support within the university/non-profit organizational systems to manage staffing, payroll, training, and evaluations.
Participant Incentives
Reasonable incentives in the form of cash honorariums, travel reimbursements, meal/phone credits, and other provisions will be vital to enabling refugee participation, especially those from low-income backgrounds, in extensive interviews and long surveys that can require multiple visits. Incentivizing participants is also an ethical way to value their time and contributions when seeking sensitive personal data.
Data Collection
A significant project expense will involve the logistics of widespread data collection across 5 states from 300 refugees and 50 agency partners. Costs include but are not limited to digital survey platforms and qualitative software, device procurement, call minutes, internet plans, interpretation services, transcription support, travel, and supplies for in-person site visits once COVID-19 protocols permit.
Analysis & Dissemination
Specialized statistical software like SPSS, NVIVO, geospatial mapping tools, and policy discourse analysis suites will need procurement for the extensive quantitative, qualitative, and policy data compilation and evaluation. Archival database subscriptions, fact-checking processes, and citation tools constitute other analysis expenses. Budgeting dissemination through community meetings, and tailoring findings for multiple formats like academic papers, policy briefs, multimedia presentations, and printing costs will enable wider reach and impact.
Institutional Overheads
The organization hosting the research project will incur overheads related to communications, technology equipment, legal and ethical compliances, training, evaluation, and material archiving over 36 months. About 15-20% of indirect costs will be factored for university/non-profit management, facilities, and supervision to conduct responsible and high-quality research.
Contingency Funds
At least 10-15% contingency funds of the total budget estimate will be allocated for unanticipated expenses arising during such an ambitious large-scale project spanning 3 years on a sensitive topic involving vulnerable refugees. Additional funds build buffers for evolving interview contexts, expand participant incentives if required, and prolong timelines due to external factors like COVID-19 variants and related uncertainty.
The comprehensive budgeting process will align adequate funding to personnel, fieldwork, analysis, and organizational needs to undertake rigorous mixed methods research that maintains both scientific credibility and ethical protections.
Expected Duration, Sustainability, Timeline
This refugee healthcare experiences research constitutes an intensive 3-year mixed methods investigation needing an adequate timeframe to incorporate explanatory sequential study design spanning surveys, in-depth interviews, and policy analyses towards a nuanced understanding of where existing systems fail crisis-affected displaced populations.
Year 1: Study Start-up, Tool Design & Surveying (Months 1-12)
Months 1-4: Recruit research staff, establish organizational infrastructure, complete IRB ethical permissions, voucher procurement
Months 5-8: Design quantitative survey tools on health parameters, translate into 5 languages, pre-test for validity/reliability
Months 9-12: Recruit participants across 5 states, distribute vouchers/devices, collect a minimum of 300 survey responses
Key Milestones:
- The core research team onboarded
- Survey design finalized after pre-testing amendments
- Statistically relevant survey sample target achieved
Year 2: Interviews, Policy Review & Data Integration (Months 13-24)
Months 13-17: Develop a qualitative semi-structured interview guide focused on barriers and recommendations based on preliminary survey analysis
Months 18-22: Recruit subsample for interviews, conduct through translators, transcribe and translate discussions
Months 20-24: Perform systematic policy and secondary health data analysis on refugee protections
Months 22-24: Triangulate quantitative findings with interview themes and policy review deductions
Key Milestones:
- Interview guide designed based on emerging survey results
- Rich qualitative datasets gathered from refugee participants
- Compilation of verification data from policy briefs and health records
- Connections drawn across data pieces to enhance credibility
Year 3: Analyze, Disseminate, and Evaluate Impact (Months 25-36)
Months 25-28: Analyze triangulated inferences to identify consistent and discordant results
Months 29-30: Draft a comprehensive research report consolidating evident gaps and recommendations
Months 31-33: Tailor findings towards publications, presentations, briefs, workshops
Months 34-36: Actively disseminate outcomes through conferences, online mediums, community meetings, and regulatory authorities
Key Milestones:
- Data analysis and interpretation completed
- Conclusions articulated through an evaluation report
- Diverse mediums were created to communicate findings to academia, communities, and policy institutions
The detailed timeline across 3 years will enable the methodical completion of study components meeting scientific rigor standards and generate evidence to catalyze policy reforms that uphold refugee healthcare rights in times of public health crises.
References
Blanchet, K., Ramesh, A., Frison, S., Warren, E., Hossain, M., Smith, J., … & Roberts, B. (2017). Evidence on public health interventions in humanitarian crises. The Lancet, 390(10109), 2287-2296.
Spiegel, P. B., Checchi, F., Colombo, S., & Paik, E. (2018). Healthcare needs of people affected by conflict: future trends and changing frameworks. The Lancet, 391(10125), 741-751.
Tran, N. T., Schulte-Hillen, C., Fisher, J., & Pearson, R. M. (2018). Ensuring continuity of care for refugees with non-communicable diseases: systematic review. Bulletin of the World Health Organization, 96(1), 42-52.
World Health Organization. (2019). Health of refugees and migrants: Report by the Secretariat (No. A72/25). World Health Organization.
write