How do I see a doctor?
I don’t know the man approaching me, but he’s seen my self-injury-scarred arms and wonders if I’ve successfully navigated a psychiatric system that’s turned him away.
It’s May 2024, and I’m standing outside a Home Office building giving information to migrants with appointments inside. The UK government just announced it’s increasing migrant detentions, intensifying the “hostile environment” which sees doctors and landlords police borders (Praxis, 2024). I don’t have answers for this man.
Refugees and asylum seekers have worse mental health than the general population, especially depression and post-traumatic stress disorder (PTSD) (Blackmore R. et al, 2020). Asylum seekers – applicants for legal refugee status – are at particular risk (Jannesari S. et al, 2020a; Delilovic S. et al, 2023).
Swedish law entitles newly-arrived forced migrants with various legal statuses to a health assessment (HA): theoretically, it’s easier to get help there. However, access is patchy (Jonzon R. et al, 2018), and psychological needs commonly deprioritised (Lobo Pacheco, L. et al, 2016). The social-legal environment is increasingly hostile, holding migrants in painful legal limbo and granting only conditional access to necessities like housing (Canning, V., 2019 & 2021; van Eggermont Arwidson C. et al, 2022; Giansanti E. et al, 2022).
Against this backdrop, Hagström et al (2024) discuss implementing the Refugee Health Screener 13 (RHS-13), screening for PTSD, depression, and anxiety during HAs.
Forced migrants face fragmented access to care, with psychological needs often sidelined amid hostile legal and social systems.
Methods
The RHS-13 is a 13-item, self-administered, written questionnaire in 20 languages, with cut-off scores indicating severity in PTSD, depression, and anxiety (Bjärtå, A. et al, 2018). It is not intended to diagnose, but screen for follow-up (Hollifield M. et al, 2016). Stockholm rolled out RHS-13 use across HAs (health assessments) in 2020-21, supported by an educational programme for health centres part-facilitated by the lead author.
Hagström et al. investigated a) level of RHS-13 use; and b) barriers and facilitators to its use. Ten of 16 nurses administering HAs across Stockholm’s eight primary healthcare centres carrying out HAs participated for six months.
Nurses recorded whether each assessment used the tool, and if not, why not. Two authors interviewed nurses on barriers and facilitators to RHS-13 use, with transcripts analysed deductively via qualitative content analysis. The coding framework was based on the Consolidated Framework for Implementation Research (CFIR) 2.0 (Damschroder L.J. et al, 2022). Qualitative results are reported according to the Consolidated Criteria for Reporting Qualitative Research (CORE-Q) (Tong, A. et al, 2007).
Results
RHS-13 usage varied from 92% of assessments at the top centre to none at the bottom two. The authors split participating centres into “high-use” (above 50%, three centres) and “low-use” (below 50%, 5 centres) groups: these reported overlapping reasons for non-adoption. The main barriers across both groups were lack of time and language barriers, with the former the most common barrier in low-use centres, and language the most common barrier in high-use centres.
Qualitative results are reported according to four of CFIR 2.0’s five domains.
Innovation: the RHS-13
- Qualitative data illuminated language barriers further: either the RHS-13 was not available in the patient’s language, or patients spoke but did not read the relevant language, making a written tool useless. Administering it orally via an interpreter proved impracticably time-consuming.
- Some at low-use centres did not trust the RHS-13 evidence base, and were skeptical that one tool could pick up cross-cultural expressions of distress; some patients scored low but had significant difficulties on further probing.
- However, both groups reported the tool helped start and/or structure otherwise challenging conversations about mental health.
Inner setting: time and information
- No extra time was allocated to HAs to incorporate the RHS-13, although in a few centres (including two of the three high-use ones) nurses had more freedom to manage their own schedules and could adjust appointments accordingly.
- Some nurses also requested ongoing training on when to use the tool and its scores’ implications.
Outer setting: referral pathways
- Some nurses said they made more referrals after using the RHS-13, i.e. it helped detect and act on support needs. However, psychiatric services commonly bounced referrals back.
- At one (low-use) centre, implementing the RHS-13 led to standardisation of referral pathways, but this was uncommon.
Individuals
- Not all patients wanted to complete the RHS-13, talk about mental health, or be referred onwards with high scores. Nurses attributed this to stigma, different cultural approaches to mental health, and fear of mental health services. They also reported that some thought the RHS-13 was required by immigration authorities, and could feel like a tick-box exercise.
- Nurses varied in how motivated they were to use the RHS-13. Faith in the tool was less of an issue when nurses considered it a complement to clinical interviews rather than a replacement; most described planning to continue using it in this way.
The use of the RHS-13 screening tool varied widely across centres, with time and language barriers consistently limiting implementation.
Conclusions
The domains described above overlap, but help structure implementation analysis. Nurses implementing the RHS-13 found it helped standardise and/or initiate mental health conversations during Sweden’s statutory HAs for forced migrants, rather than functioning effectively as a universal screener. Implementation rates depended on tool-specific, contextual, and individual (i.e. relating to nurses and patients) factors. Addressing issues around time, resourcing, language barriers, and nurses’ confidence in the tool would increase implementation. However, the authors suggest the huge variation in RHS-13 implementation across centres means solutions should be locally-tailored, based on assessment before further roll-out.
Rather than serving as a universal screener, the RHS-13 mainly helped facilitate mental health conversations, with its use shaped by the local context and individual factors.
Strengths and limitations
Quantitative and qualitative data provide valuable context for each other here. It might have been helpful to collect baseline and post-RHS-13-rollout data on psychiatric referrals offered, made, and accepted, since some nurses perceived themselves to refer more post-rollout.
It is a strength that the study recruited nurses from all eight healthcare centres conducting HAs in the study region. Just under two-thirds of assessors participated, so quantitative data are not comprehensive, but participants’ varying experience and different local set-ups led to rich qualitative data representing multiple perspectives.
Reporting according to the CORE-Q tool supports the results’ trustworthiness, although qualitative experts caution against using this as a definitive quality benchmark (Braun, V. & Clarke, V., 2024). The lead author was involved in the implementation process, organising initial educational meetings about the RHS-13. Such involvement is not necessarily a limitation in qualitative work, but it would be helpful to reflect on how this shaped the analysis and/or interview dynamics.
Using the recently-updated, clearly-structured CFIR 2.0 framework is a strength, although it is unclear why its “implementation process” domain was not used. CFIR prompts detailed contextual exploration, and its “innovation” domain highlights mismatches between the tool and its original purpose: the RHS-13 is intended as a universal screener, and it did not prove useful as one here.
However, context is explored more fully for nurses than for patients. Given the hostile social-legal environment described above, it could have been helpful to ask more contextual questions around some elements listed as “individual”: for example, what was it about psychiatric services that provoked fear where patients refused onward referrals?
It is a broader limitation that patients’ perspectives, where they feature, are filtered through nurses’ perceptions. US-based evidence suggests there are risks as well as benefits to mental health screening in forced migrants, particularly if it feels tick-box (Sheth, N. et al, 2023). Not everyone who experiences an assessment as such will tell the assessor, particularly since some come to their HA believing it could affect their asylum claim (Lobo Pacheco, L., et al, 2016). Nurses conducting HAs may therefore underestimate potential harms.
The study benefited from diverse nurse participation, but lacked direct patient input and overlooked how fear, stigma, or legal uncertainty shaped patients’ responses.
Implications for practice
This paper has implications for implementing innovations in healthcare, and raises questions about future research directions.
Implementation in healthcare
Two implications jump out here: first, if you want people to adopt something extra, they need extra time, or at least autonomy to rearrange other workload demands. Second, the innovation you’re implementing must be accessible. It could perhaps have been anticipated that a written questionnaire would be complex to administer. Forced migrants’ education access is frequently disrupted; common languages among those in Sweden such as Arabic have distinct written and spoken varieties, affecting literacy rates (Myhill, J., 2014). The authors suggest analysing local healthcare systems before wider roll-out; we should also explore patients’ needs, considering whether the innovation can meet them.
Healthcare for forced migrants: asking the right questions?
The authors support wider RHS-13 roll-out, with some caveats; I am less sure their results warrant this yet. Specifically, further evidence is needed on how forced migrants experience the RHS-13 and whether it increases access to meaningful support: implementing an innovation is only useful if it improves experiences and outcomes on the receiving end.
Jannesari et al (2020b) critique an over-reliance on Western diagnostic constructs in research on asylum seeker mental health. They highlight forced migrant populations’ diversity, and examples of more culture-specific tools developed collaboratively with the communities concerned. This raises further questions about the suitability of the RHS-13 for wider use which warrant exploration – although there is always a tension between the practicality of using a single tool and the need for tailored support.
More broadly, as someone involved in migrant solidarity organising, researching interventions with a focus on individual mental health sometimes feels like distraction from a bigger question: how do we dismantle systems that actively harm (forced) migrants to Western countries? I can’t help wondering what it means for one arm of a state to try to identify and resolve psychological trauma sequelae, while another – immigration authorities – inflicts more suffering.
But people do need access to help urgently. The man I met outside the Home Office building wanted to see a doctor; I’m not sure if a Swedish-style HA including an RHS-13 would have helped him do so, but the UK system clearly hadn’t. So perhaps big-picture critique of harmful systems and working towards their abolition should co-exist with supporting access to what is currently available, as harm-minimisation, across research and practice.
Successful implementation of the RHS-13 requires giving nurses more time and flexibility, addressing literacy and language mismatches, and centring migrant patients’ needs and experiences in tool design.
King’s MSc in Mental Health Studies
This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.
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Links
Primary Paper
Hagström, A., Hasson, H., Hollander, A.-C. et al (2024). “Sometimes it can be like an icebreaker”: A mixed method evaluation of the implementation of the Refugee Health Screener-13 (RHS-13). Journal of Migration and Health 2024, 10, Article 100243.
Other References
Braun, V. & Clarke, V. (2024) How do you solve a problem like COREQ? A critique of Tong et al.’s (2007) Consolidated Criteria for Reporting Qualitative Research, Methods in Psychology 2024 11, Article 100155.
Bjärtå, A., Leiler, A., Ekdahl, J. et al (2018). Assessing severity of psychological distress among refugees with the Refugee Health Screener, 13-Item Version. Journal of Nervous & Mental Disease 2018 206(11), 834–839.
Blackmore, R., Boyle, J. A., Fazel, M. et al (2020). The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLOS Medicine 202017(9), Article e1003337.
Canning, V. (2019). Degradation by design: women and asylum in northern Europe [Abstract]. Race & Class 2019 61(1), 46-63.
Canning, V. (2021) Managing Expectations: Impacts of Hostile Migration Policies on Practitioners in Britain, Denmark and Sweden. Social Sciences 2021 10(2), Article 65.
Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O. et al (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science 2022 17(1), Article 75.
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Myhill, J. (2014). The effect of diglossia on literacy in Arabic and other languages [Abstract]. In: Saiegh-Haddad, E., Joshi, R. (eds) Handbook of Arabic Literacy. Literacy Studies, vol 9. Springer, Dordrecht.
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Sheth, N., O’Connor, S., Patel, S. et al. (2023) To screen or not to screen: Exploring and addressing effective screening processes for trauma among forced migrants. Journal of Migration and Health 2023 7, Article 100148
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van Eggermont Arwidson, C., Holmgren, J., Gottberg, K. et al (2022) Living a frozen life: a qualitative study on asylum seekers’ experiences and care practices at accommodation centers in Sweden. Conflict and Health 2022 16(1), Article 47.
