Unfamiliarity with mainstream health systems, lack of ability to communicate in the language of the host community, cultural differences, poverty, and marginal-ization combined with pre-migration and settlement stressors all contribute to social and health disadvantage identified in many refugee groups. These factors are also the main barriers to accessing health services (Jones & Gill, 1998; Palmer & Short, 2000).
The provision of health care to resettling refugees in a third country depends to a large extent on the policy environment towards migrants. Over time and in various contexts, governments have adopted policies broadly based on philosophies of assimilation, integration, or multi-culturalism (Palmer & Short, 2000). Assimilation, which reflects current trends in Europe, is based on an expectation that migrants and refugees will blend in with the dominant culture with no significant change expected from the host community. There is little recognition of or tolerance for diversity under policies of assimilation. Integration recognizes and respects differences in culture and provision is made for language and cultural differences. Integration policies provide assistance to refugees to function within the dominant culture. Multi-culturalism or cultural pluralism is based on total participation of all cultural and ethnic groups in the political process in recognition of their contribution to the development of a dynamic, evolving culture of diversity.
In reality, there is a broad variation in the implementation of these policies into service provision. In broad terms, the policy environment dictates the allocation of resources that enable health services to respond in one way or another. However, services also need to some degree to reflect the needs of their client group. Within health service provision for refugees, service delivery models have ranged from specialized ethno-specific services to mainstream services with no clear agreement of the advantages of either. The debate is ongoing in part because of the differences in outcome indicators, which may be based on efficiency in health service provision or on specific outcomes for the patient. The most desirable would achieve both.
Ethno-specific models provide targeted services to ethnic groups, ensuring that the providers of the service are either from the same ethnic backgrounds or are culturally sensitive to the needs of the specific groups. Other refugee-targeted services include dedicated clinics that recognize the special health needs of this group such as particular parasitic conditions that are not endemic within the host population and, more commonly, specialized trauma counseling services for survivors of torture and trauma (Palmer & Short, 2000). It has been argued, however, that while these services may meet a need, they are not an efficient use of health care resources and they further marginalize refugees from the host community, especially in a policy environment of multi-culturalism (Kelaher & Manderson, 2000). On the other hand, providing refugee care within a mainstream service risks the failure to identify and respond to special needs due to the cultural chasm between service providers and refugees. There has been some attempt to address this failure through a growing body of resources, the aim of which is to increase the cultural awareness and sensitivity of staff to the range of issues that may affect the health, presentation and symptoms, attitudes, response to and compliance with treatment within the health care system (Allotey et al., 1998; Geissler, 1998; Jones & Gill, 1998; Kirkwood, 1993; Levenson & Coker, 1999; Lipson, Dibble, & Minarik, 1996). Under this model, some training is also provided to refugee groups on the available services and negotiation of the health system.
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