Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research

Objectives To thematically synthesise primary qualitative studies that explore challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries. Design Systematic review and qualitative thematic synthesis. Methods Searches of MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science. Search terms were combined for qualitative research, primary healthcare professionals, refugees and asylum seekers, and were supplemented by searches of reference lists and citations. Study selection was conducted by two researchers using prespecified selection criteria. Data extraction and quality assessment using the Critical Appraisal Skills Programme tool was conducted by the first author. A thematic synthesis was undertaken to develop descriptive themes and analytical constructs. Results Twenty-six articles reporting on 21 studies and involving 357 participants were included. Eleven descriptive themes were interpreted, embedded within three analytical constructs: healthcare encounter (trusting relationship, communication, cultural understanding, health and social conditions, time); healthcare system (training and guidance, professional support, connecting with other services, organisation, resources and capacity); asylum and resettlement. Challenges and facilitators were described within these themes. Conclusions A range of challenges and facilitators have been identified for health professionals providing primary healthcare for refugees and asylum seekers that are experienced in the dimensions of the healthcare encounter, the healthcare system and wider asylum and resettlement situation. Comprehensive understanding of these challenges and facilitators is important to shape policy, improve the quality of services and provide more equitable health services for this vulnerable group.


Strengths and limitations of this study
• This is the first review to systematically identify and synthesise qualitative research exploring challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers.
• Thematic synthesis of studies from a range of countries and primary healthcare settings allows identification of common, generalisable themes with potential to influence policy and practice.
• The review was limited to English language studies, which may have led to over-representation of studies conducted in English-speaking highincome countries.
• The review was limited to core, clinical health professionals: doctors nurses and midwives.

Background and introduction
Throughout human history, countless people have been forced to flee from their homes and countries due to violence or threats of violence. Other nations may provide refuge for those seeking a safe haven, and In 1950, the Office of the United Nations High Commissioner for Refugees (UNHCR) was established to provide international leadership and coordination for the protection of refugees and promotion of their wellbeing. [1] The UNHCR convention defines refugees as persons who have a "well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." [2] Those in the application process to be granted refugee status are referred to as 'asylum seekers'. By the end of 2015 there were an estimated 65.3 million forcibly displaced people worldwide, including  4 40.8 million internally displaced people, 21.3 million refugees and 3.2 million asylum seekers. [3] Refugees and asylum seekers are a vulnerable group with significant and complex health needs. [4] A survey by the UK Border Agency in 2010 showed refugees to be in poorer health than the general population. [5] As most refugees and asylum seekers originate from low-mid income countries, there are, accordingly, higher prevalence's of pre-existing infectious diseases such as Hepatitis B, TB and HIV compared to host populations. [6] The risk of contracting infectious diseases may be further exacerbated by poor hygiene conditions during flight from conflict, coupled with insufficient vaccine coverage. [7] Studies have also highlighted the sexual and reproductive health needs of this group, [8] with high levels of sexual gender based violence (SGBV) being reported along with limited access to contraception. [8,9] A further concern for refugee and asylum seeker populations is their mental health. Violence experienced in countries of origin, including war, sexual abuse and torture are reported, that may lead to psychological and physical trauma.
[10] These pre-migration traumas are compounded by post-migration stressors such as loss of social networks, shifting societal roles and crosscultural stress while integrating into countries of settlement. [11] Fazel et al [12] estimated that 9% of adult refugees may suffer with post-traumatic stress disorder (PTSD), which is approximately ten times estimates in an age-matched American population. [12] Considering the complex health and social needs presented by refugees and asylum seekers, significant challenges are faced by healthcare providers [13][14][15] that may contribute to recognised healthcare inequalities, where refugees and asylum seekers experience lower quality of care compared to other service users. [16] Primary healthcare teams are at the front-line of such healthcare provision in high-income countries. [17] These teams may include members from a variety of professional backgrounds, clinical and non-clinical, but typically include a core of general practitioners, community based nurses and midwives. [18,19] Experiences of health professionals caring for refugees and  [20] synthesised challenges providing healthcare services to migrants from a provider perspective. The review included a minority of studies that had refugees and asylum seekers as service users, focussed purely on challenges of healthcare provision, and adopted a limited, purposive search strategy. To our knowledge, this present review is the first to synthesise experiences of health provision for migrants defined specifically as refugees and asylum seekers; synthesise both challenges and facilitators for health professionals; and adopt a systematic approach to identification of qualitative research.
Therefore, this review aims to systematically identify and thematically synthesise challenges and facilitators experienced by health professionals that provide primary healthcare for refugees and asylum seekers in high-income countries.

Methods
This systematic review sought qualitative research studies as they are the appropriate design for understanding perceptions and experiences of healthcare provision. [21,22] Systematic identification and synthesis of these studies may consolidate the current evidence-base, increase the breadth and depth of understanding and provide more generalisable conclusions than individual primary studies. [23,24] This review was guided by established methodology for systematic review and After removal of duplicates, titles and abstracts were screened by one researcher, excluding articles that clearly did not meet the inclusion criteria.
Full-texts of remaining articles were obtained and assessed by two independent researchers, according to pre-specified study selection criteria (detailed below).
Disagreements were resolved via discussion. Mixed-methods studies were included if the qualitative element's methods and results could be isolated for synthesis. As definitions of health professionals in primary healthcare teams are diverse, [19] this review was limited to articles that interviewed core clinical healthcare professionals including: general practitioners, nurses, pharmacists and midwives working in primary healthcare settings. Articles were excluded if: they were not based on peer reviewed primary qualitative studies (i.e. reviews, case studies, reports, opinion pieces); were conducted in a secondary care setting; or if the service users were described as illegal immigrants, undocumented migrants, migrants or immigrants. Articles interviewing mental health professionals were excluded as this clinical area has specific characteristics. Where studies contained a mixture of eligible and ineligible participants, they were only included if data for eligible participants could be isolated for synthesis. Studies were also excluded if the full text articles could not be obtained through institutional access or requests sent to authors through Research Gate. The full inclusion and exclusion criteria applied in this review are documented in online supplement 2.

Box 1: Definitions of challenge and facilitator
Challenge: A factor that inhibits, obstructs or creates difficulties for health professionals when providing primary healthcare.
Facilitator: A factor that promotes, enables or assists health professionals when providing primary healthcare

Data extraction
Study characteristics were extracted by one author using a data extraction proforma. Characteristics included aims, setting, participants, methodology, results and recommendations/applications. Findings (results) and discussion sections from included studies were imported into NVivo 11 software (NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 11, 2016) for analysis.

Assessment of quality
Included studies were assessed by one author using the Critical Appraisal Skills Programme (CASP) tool for appraisal of qualitative research.
[30] Studies were not excluded from the synthesis or given weighting based on this assessment as there is currently no accepted method for this in syntheses of qualitative research.
[31] All studies were included irrespective of their reporting quality given that they contributed to the conceptual richness of the synthesis. Where studies used mixed-methods, only the qualitative element was appraised.

Data synthesis
A thematic synthesis was conducted broadly following the methodology outlined by Thomas and Harden.
[25] An article, considered data-rich (containing numerous challenges and facilitators), was selected as an index-article and uploaded into NVivo 11 software. The findings (results) and discussion sections were coded inductively within an a priori framework of challenges and facilitators. Primary quotations, author's commentary and author's interpretations were coded. Sections were only coded if they contained challenges or facilitators (Box 1), and referred to the health professionals defined for this review. Following the index-article, subsequent articles were coded using the same method in approximate order of descending datarichness. Concepts in each article were coded into existing concepts, with new codes being added as deemed appropriate to develop a codebook. The final codebook was analysed to inform descriptive themes closely resembling the prevailing concepts across primary studies. These themes were discussed and agreed within the research team. An analytical model was then developed to create higher-order constructs within which descriptive themes were located. Additional records identified through other sources Reference list searches n= 8; Citation searches n=8) (n = 16)

Refugees Semi-structured interviews
Template analysis To document the existence and nature of challenges for GPs who do this work in SA.
To explore the ways in which these challenges could be reduced.
To discuss the policy implications of this in relation to optimising the initial health care for refugees.

Refugees with depression
In-depth interviews Thematic analysis We explore a set of cultural boundaries across which depression is contested: between recent migrants to Australia from East Timor and Vietnam, and their white 'Anglo' family doctors.
Kurth, E. [ To explore midwives' perceptions and experiences of providing care to women in the asylum process and to gain insight into how midwives can be equipped and supported to provide more effective care to this group in the future.
Full details of the CASP assessment are provided in online supplement 4.

Thematic synthesis findings
Challenges and facilitators for health professionals providing primary healthcare to refugees and asylum seekers were interpreted within 11 descriptive themes, embedded in 3 analytical constructs: healthcare encounter (trusting relationship, communication, cultural understanding, health and social conditions, time), healthcare system (training and guidance, professional support, connecting with other services, organisation, resourcing and capacity), and asylum and resettlement. Figure 2 illustrates the relationships between analytical constructs and descriptive themes. Healthcare encounters occur within the environment of healthcare systems, both of which operate within wider asylum and resettlement policies and processes. Table 2 provides a taxonomy of challenges and facilitators and Table 3 contains illustrative quotations from primary studies for each descriptive theme.      Table 3 Illustrative quotations  Theme  Quotation and reference a Challenge: 'I am quite overwhelmed at times as to how complex these ladies' lives are . '[33] 'I guess it is out of our comfort zone, because our medical experience doesn't include the exotic illnesses that they front up with...' [42] 'Midwives spoke of the emotional impact of working with women with trauma histories: "How does it affect me, you just feel sad you know, but you just do the best that you can and that's all you can do' [  Healthcare system Organisation Facilitator 'The flexibility of the general practice setting enabled providers to act on their commitment to provide refugee health care, allowing them to be responsive and innovative in their approach to caring for refugees and also providing flexibility in the hours they work.' [38] Participants felt that significant gains had been made to the refugee health care system, with the establishment of a specialised service. One provider working in the field for some time described thinking, '. Challenge 'These requirements differed: on the one hand to be the care giver, to be the patient's advocate in fact, and on the other to act as advocate of the Federal Office for Refugees, and thirdly to be responsible for the organisation, to save costs for the health insurance. But that is simply not possible.' [15] 'I don't know if there is some sort of system that they go through, or some sort of protocol that they, medically, have to go through before they are granted visas...' [42] a Participant's quotations are in italics, study authors text is normal typeface.

Trusting relationship
Building trusting relationships with refugees or asylum seekers featured in 15 of the articles. [14, 35- Utilising interpreters was considered a major facilitator in communication [13,32,33,35,38,40,45,46,52] and was maximised when interpreters were welltrained and familiar with medical terminology. [13,40]  It was also reported that some refugees or asylum seekers had very high, and sometimes unrealistic, expectations of health services or health professionals, [13,32,35,47,48] which needed to be counteracted by participants. [13,48]  achieving cultural understanding, [42] and dealing with complex health conditions. [14,33,42,45,46] This additional time demand meant that appointments needed to be extended in duration [32,42] or occur more frequently. [14,44] Health professionals were concerned that time limitations could lead to 'rushed consultations' [54] and the potential to miss some conditions. [54] Some also commented that the extra time spent caring for refugees and asylum seekers drew them away from other patient groups.

The healthcare system
Health systems have been defined as "the combination of resources, organization, financing and management that culminate in the delivery of health services to the population". [56] They are the environment in which healthcare encounters take place. Healthcare professionals described health system related challenges and facilitators within 5 areas: training and guidance, professional support, connecting with other services, organisation, and resourcing and capacity.
Training and guidance were not able to be utilised because of lack of finance. [50] Shortages in workforces were reported in some articles, [41,42,44] putting additional workload and stress onto health professionals. [41,44] Reported consequences of this were closures of services to new patients [42,44] and health professionals leaving their posts, further exacerbating the problem. [44] Interpreter shortages were also mentioned as a difficulty [41,44,51]  for their patients whilst requirements were placed on them to conduct assessments used to inform the asylum process. [15,41] Another concern raised was a perception that service users were abusing the health and welfare systems, [14,32,35,54]  inequalities. [57,58] Trusting relationships are essential for effective healthcare delivery [59][60][61] Murray et al [62] identified continuity of relationship, time, interpersonal skills and 'getting to know patients' as enhancers of trust between health professionals and patients. The current review likewise recognised these elements, and it can be argued that even greater attention to trust-building is needed for refugees and asylum seekers, a vulnerable and ethnically diverse group who may be apprehensive about engagement with healthcare systems. [63,64] Communication between health professionals and patients is also regarded as essential. [65] Language discordance may compromise the quality of healthcare, lessening detection of ill health and referral to further healthcare. [66,67] Health professionals in the current review consistently thought language barriers hindered their work with refugees and asylum seekers. concerns were raised about the quality and availability of interpreters.
Generally, it is recommended that professional interpreters are used, as they have been trained in professional standards, medical terminology and ethical issues. [70] Ad-hoc interpreters such as family or community members may be used pragmatically, although this may diminish the quality of interpretation and threaten patient confidentiality. [69,70] Remote interpretation, such as telephone or video services have been developed to provide more efficient and timely services. [71,72] The merits of such services have been debated [71,72] and conflicting opinions were likewise given in this review. A systematic review [72] reported no significant difference in patient and provider satisfaction between remote and face-to-face interpreters, although subsequent primary studies have suggested a significant preference for in-person interpreters. [71] Consistent with other research, [6][7][8][10][11][12] health professionals encountered challenges dealing with complex physical, psychological and social problems of refugees and asylum seekers and did not always feel prepared to meet their needs. They also reported challenges in cross-cultural care such as different understandings of health, healthcare and healthcare systems, which introduced complications.
Participants in this review saw opportunities for improving care by working together with other health services and civil society. Identifying these organisations and possible areas of collaboration such as information sharing, referral pathways and joint service delivery may benefit health providers, health professionals and service users. isolating refugees and asylum seekers from general practice, which was a concern raised by some participants in this review.
Health professionals and health services operate within, and are influenced by, the wider healthcare policy environment. Decisions made at a political and health system levels invariably impact on front-line clinical practice in areas such as resourcing priorities, health professional roles and healthcare access. [75] Health professionals in this review recognised associated challenges, particularly when healthcare pathways were unclear and changeable. This emphasises the need for policy-makers to provide consistant, clear and up-to-date guidance on asylum and resettlement health policy for health professionals.

Public health implications
A central concern in public health is reduction of inequalities in health and healthcare. [76,77] The WHO has established a commission on the social determinants of health that recommends actions addressing inequalities in health. [77] Healthcare inequalities exist when certain groups systematically receive lower quality care than the general population, resulting in poorer health outcomes. [75,78] These inequalities have been widely observed in healthcare provision to ethnic minority groups across a broad range of health services [75] and has been highlighted as an issue for refugees and asylum seekers in the UK. [

Conclusions
Many people continue to be displaced due to conflict and persecution, seeking sanctuary in high-income countries. Health professionals experience a range of challenges and facilitators providing primary healthcare for this vulnerable group within the healthcare encounter, the environment of the healthcare system and in the broader context of asylum and resettlement policy and process. These challenges and facilitators provide valuable insight to inform practice and policy, supporting quality healthcare and minimising healthcare inequalities for refugees and asylum seekers.   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59          > There is a service and professional responsibility to ensure that health visiting and public health nursing practice is developed from the best evidence available and that collective knowledge and expertise are shared, rather than left for each practitioner to discover through trial and error. > Both professional education providers and service providers need to pay attention to the specific health and social needs of asylum seeking women, who will unfortunately continue to arrive in the UK and other parts of the world. > In education and training this rough framework thus can be used as a means to reflect upon priorities in health care to asylum seekers as well as being aware of possible pitfalls, dilemmas and difficulties. > Potential aspects of training: the need for good communication skills (including the skill to work with a professional interpreter) to deal with cultural differences and to deal with possible high expectations of asylum seekers. >Training may help care providers reflect upon their own boundaries of their medical profession: for example, should they be the ones to assess mental health problems of asylum seekers or is it better to refer to another institution with more relevant competencies? >Sufficient time is needed for a consultation when all four elements are included. > These results add more specific competences to the cultural competences that have been described in other studies. > It is not merely education or training that helps nurse practitioners feel culturally competent. Equally significant is the concrete experience of working with asylum seekers. This suggests that 'learning in action' by way of adequate supervision, mutual peer supervision, and systematic feedback on the work floor may also be a key teaching instrument. Thus, experiential and didactic learning may be integrated in order to develop relevant cultural competences. > Cultural competences should not be seen as a list of skills that are acquired and ticked off one at a time, resulting in a person who is culturally competent. Acquiring cultural competence is an ongoing process, driven by the practitioners' self-reflection. >For women in the asylum process, having access to dedicated community-based services would begin to address the problems of access, late booking, and development of midwife/client relationships which in turn would help to decrease fear and anxiety for both the women themselves and the midwives who care for them. >Cultural competency training: When considering how best to educate midwives to provide culturally competent care, the most important focus should be on using a framework of cultural humility. > There is an urgent need for increased clinical support for midwives who care for traumatized women. >Access to continuing education is also essential, along with debriefing and clinical supervision in order to maintain providers' own health and well-being. > Trained interpreter service should be embedded within hospitals. >dedicated community-based services that provide the possibility of continuity of care, make access to care easier for women, and provide the possibility of good midwife/client relationships and trust building. > Revision of the government policy of forced dispersal for women in the asylum process who are pregnant or in the early postpartum period is urgently needed. what health care providers need to be mindful of in providing care to families of refugee background, and knowledge of services for referral, is likely to go some way in building workforce capacity to assess and respond to the social circumstances of refugees. >Interactive training opportunities incorporating knowledge of the refugee and asylum seeker experience and ways of working with these families is a strategy to enhance health professionals understanding and skills. >Any attempts to improve the responsiveness of health services to the needs of families of refugee background need to consider innovative ways to work within system constraints. > Improving identification of language needs at point of entry into healthcare, developing innovative ways to engage interpreters as integral members of multidisciplinary healthcare teams and building health professionals' capacity to respond to language needs, especially when clients' have experienced trauma that is likely to impact on their capacity to engage with healthcare, are critical to reducing social inequalities in maternal and child health outcomes for refugee and other migrant populations. >Potential 'solutions' in the context of maternity care include community and language-specific group pregnancy care sessions combining antenatal checkups with information and support provided by a multidisciplinary team of health professionals including an accredited interpreter.
* These participants are not within the study definition of primary health care professionals and therefore their data have not been included in the thematic synthesis. "A thematic analysis was used to capture emerging patterns of data. These were reviewed and grouped into two overarching themes and four interconnected sub-themes. Rigour was maintained through a systematic process of enquiry, sampling and analysis." No indication of involvement of multiple researchers in the analysis. Sufficient data were presented to support the findings. Contradictory data not discussed.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data. Only some of the themes from the analysis are reported in this paper. A framework method was used that involved a constant comparative approach in which the codes were continually reassessed and interpreted. The themes that were identified were compared across the data and discussed with external researchers.
Quotations were chosen to illustrate the particular issues described. Sufficient data were presented to support the findings. Contradictory data were not presented.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data. "Key themes were identified using inductive thematic analysis and NVivo software was used to assist with data management. Analysis was iterative and data collection ceased when no new issues emerged, suggesting data saturation. RF and MK read each transcript and independently coded data, identifying a preliminary list of themes. RF produced a refined list of major themes and subthemes; MK endorsed these themes. Because similar themes were identified during the focus groups and interviews, the data were considered comparable and therefore analysed together." Sufficient data were presented to support the findings. Some Contradictory data were presented in the findings. Authors were aware of the potential bias in data analysis and stated that they critically reflected on how their own views and differing perspectives were influencing interpretation. One of the authors worked outside the field and was able to bring more objectivity.
The findings were explicit and clearly discussed in relation to the research question. Adequate discussion of the findings in relation to the wider literature.
The researchers discuss the use of more than one analyst enhancing the credibility of the study. In addition, anonymised transcripts were provided to participants to give an opportunity for any further feedback. schematic presentation in short quotes was made of each refugee interview" GPs: "The GP interviews were analysed and coded in the same way. A short profile was written for each doctor, linking interview results to doctor and practice variables. In an initial analysis, rough codes were assigned for the doctors' perceptions of the refugee groups, the problems the refugees presented to them, the way they dealt with these problems, and the constraints they met." A secondary analysis was performed on both refugee and GP data with further content analysis, which formed the body of the article. Sufficient data are presented to support the findings. Contradictory data were taken into account.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data.
credibility of the findings. obtain a sense of the whole. The text was then divided into meaning units, which were then condensed and assigned categories and themes in a process moving towards a higher level of abstraction. The creation of categories and themes took place as an iterative process with ongoing reflection and revision of categories and themes. The whole context of the interviews was considered concurrently throughout this process. The initial analysis was carried out by the first author, but presented to and discussed with co-authors and other researchers with a background in public health, medicine and anthropology as part of the analytic process." Sufficient data are presented to support the findings. Contradictory data are presented and discussed.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data. was used. "The first author with experience of working within PHC carried out the analysis, while the two co-authors with specialized knowledge of the methodology served as additional evaluators in the categorization procedure.…The analysis was carried out in six steps: (1) the transcribed interviews were read several times to obtain a sense of the whole; (2) the interviews were processed, and descriptive statements relating to the aim of the study were identified, delimited, analysed and structured into an overview of concepts and keywords; (3) a comparative reduction of the data was commenced by giving a summarized description of each interview from this overview; (4) the summarized descriptions were differentiated by comparisons in relation to similarities and differences of the summarized descriptions, and were grouped together in three qualitatively distinct groups; (5) the underlying structure of the grouped descriptions was identified and described by going back and forth between the grouped descriptions and the original interviews; (6)  A thematic analysis approach was taken and the analysis process is described for analysing qualitative data from Afghan parents and health professionals. Afghans: "Analysis began after the first three interviews with women which were coded, informing the coding manual. A coding manual was developed using some a priori codes from the interview schedule; an iterative process was used to add additional codes to the manual (undertaken by ER, JY, FF,SW). This coding manual was used to code all women and men's interviews. JY and ER cross-checked the coding of all interview transcripts, providing an opportunity to discuss differences in the interpretation of the data. Codes were then grouped into logical categories which then provided the overarching themes." Health professionals: "All transcripts were read (by ER, JY) and imported and stored in

2
Synthesis methodology Identify the synthesis methodology or theoretical framework which underpins the synthesis, and describe the rationale for choice of methodology (e.g. metaethnography, thematic synthesis, critical interpretive synthesis, grounded theory synthesis, realist synthesis, meta-aggregation, meta-study, framework synthesis). 6 3 Approach to searching Indicate whether the search was pre-planned (comprehensive search strategies to seek all available studies) or iterative (to seek all available concepts until they theoretical saturation is achieved).    Asylum and resettlement. Challenges and facilitators were described within these themes.

Conclusions: A range of challenges and facilitators have been identified for
health professionals providing primary healthcare for refugees and asylum seekers that are experienced in the dimensions of the healthcare encounter, the healthcare system and wider asylum and resettlement situation.
Comprehensive understanding of these challenges and facilitators is important to shape policy, improve the quality of services and provide more equitable health services for this vulnerable group.

Strengths and limitations of this study
• This is the first review to systematically identify and synthesise qualitative research exploring challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers.
• Thematic synthesis of studies from a range of countries and primary healthcare settings allows identification of common, generalisable themes with potential to influence policy and practice.
• The review was limited to English language studies, which may have led to over-representation of studies conducted in English-speaking highincome countries.
• The review was limited to core, clinical health professionals: doctors nurses and midwives.

Background and introduction
Throughout human history, countless people have been forced to flee from their homes and countries due to violence or threats of violence. Other nations may provide refuge for those seeking a safe haven, and in 1950, the Office of the United Nations High Commissioner for Refugees (UNHCR) was established to provide international leadership and coordination for the protection of refugees and promotion of their wellbeing. [1] The UNHCR convention defines refugees as persons who have a "well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." [2] Those in the application process to be granted refugee status are referred to as 'asylum seekers'. By the end of 2015 there were an estimated 65.3 million forcibly displaced people worldwide, including Refugees and asylum seekers are a vulnerable group with significant and complex health needs. [4] A survey by the UK Border Agency in 2010 showed refugees to be in poorer health than the general population. [5] As most refugees and asylum seekers originate from low-mid income countries, there are, accordingly, higher prevalences of pre-existing infectious diseases such as Hepatitis B, TB and HIV compared to host populations. [6] The risk of contracting infectious diseases may be increased by poor hygiene conditions during flight from conflict, coupled with insufficient vaccine coverage. [7] Studies have also highlighted the sexual and reproductive health needs of this group, [8] with high levels of sexual gender based violence (SGBV) being reported along with limited access to contraception. [8,9] Refugees and asylum seekers also suffer from non-communicable diseases such as hypertension, musculoskeletal disease, chronic respiratory disease and diabetes, which may be undermanaged and exacerbated when they are forced to flee their countries. [10] A further concern for refugee and asylum seeker populations is their mental health. Violence experienced in countries of origin, including war, sexual abuse and torture are reported, that may lead to psychological and physical trauma. [11] These pre-migration traumas are compounded by post-migration stressors such as loss of social networks, shifting societal roles and crosscultural stress while integrating into countries of settlement. [12] Fazel et al [13] estimated that 9% of adult refugees may suffer with post-traumatic stress disorder (PTSD), which is approximately ten times estimates in an age-matched American population. [13] Primary healthcare teams are on the front-line of healthcare provision for refugees and asylum seekers that arrive in high-income countries. [14] These teams may include a variety of professional backgrounds, clinical and nonclinical, but typically include a core of general practitioners, community based nurses and midwives. [15,16] These health professionals face significant challenges when caring for refugees and asylum seekers. [17][18][19] They must  [17][18][19][20] These challenges impact on their ability to provide the same quality of care as the general population, leading to healthcare inequalities. [20,21] Experiences of health professionals caring for refugees and asylum seekers in high-income countries have been investigated through a range of qualitative research studies conducted across several countries and primary healthcare settings. A recent systematic review by Suphanchaimat et al [22] synthesised challenges providing healthcare services to migrants from a provider perspective. The review included a minority of studies that had refugees and asylum seekers as service users, focussed purely on challenges of healthcare provision, and adopted a limited, purposive search strategy. To our knowledge, this present review is the first to synthesise experiences of health provision for migrants defined specifically as refugees and asylum seekers; synthesise both challenges and facilitators for health professionals; and adopt a systematic approach to identification of qualitative research. Therefore, this review aims to systematically identify and thematically synthesise challenges and facilitators experienced by health professionals that provide primary healthcare for refugees and asylum seekers in high-income countries. After removal of duplicates, titles and abstracts were screened by one researcher (LR), excluding articles that clearly did not meet the inclusion criteria. Full-texts of remaining articles were obtained and assessed by two independent researchers, according to pre-specified study selection criteria (detailed below). Disagreements were resolved via discussion. for analysis. Where articles used mixed-methods, only the qualitative element was appraised.

Data synthesis
A thematic synthesis was conducted broadly following the methodology outlined
Full details of the CASP assessment are provided in online supplement 4.

Thematic synthesis findings
Challenges and facilitators for health professionals providing primary healthcare to refugees and asylum seekers were interpreted within 11 descriptive themes, embedded in 3 analytical constructs: healthcare encounter (trusting relationship, communication, cultural understanding, health and social conditions, time), healthcare system (training and guidance, professional support, connecting with other services, organisation, resourcing and capacity), and asylum and resettlement. Figure 2 illustrates the relationships between analytical constructs and descriptive themes. Healthcare encounters occur within the environment of healthcare systems, both of which operate within wider asylum and resettlement policies and processes.

Healthcare system
Organisation Facilitator 'The flexibility of the general practice setting enabled providers to act on their commitment to provide refugee health care, allowing them to be responsive and innovative in their approach to caring for refugees and also providing flexibility in the hours they work.' [43] Participants felt that significant gains had been made to the refugee health care system, with the establishment of a specialised service. One provider working in the field for some time described thinking, '. . . fantastic, finally' [43]  Utilising interpreters was considered a major facilitator in communication [17,37,38,40,43,45,50,51,57] and was maximised when interpreters were welltrained and familiar with medical terminology. [17,45] [17,38,42,43,47,55] which could lead to delayed, extended or rearranged appointments. [17,38,47] This led, in some cases, to family or other community members being asked to translate instead of professional interpreters. [42,55] Participants were also concerned that interpreters did not always accurately communicate [37,40,43,45,55,56] and may impose their own views. [40,43] The use of telephone interpreters received mixed opinions. Advocates welcomed the increased availability of interpreters at any time of the day,[37] but others felt they were more impersonal [50,58] and pointed to technological failures that hindered communication. [50,58] Further communication challenges included unavailability of written health information in service users' languages [53,57] and in some cases patients were unable to read or write. [43] To improve communication with those with limited language skills, some participants used objects or other visual aids. [51] Cultural understanding Cultural understanding was a theme described across 21 articles. [17, 18,  Differences in health culture presented difficulties for health professionals' understanding of patient's symptoms [45] and required additional time and effort explaining health conditions, healthcare concepts or health systems. [42,47,51] It was also reported that some refugees or asylum seekers had very high, and sometimes unrealistic, expectations of health services or health professionals, [17,37,40,52,53] which needed to be counteracted by participants. [17,53] Disparities in cultural values such as gender roles, decision-making, social taboos and time-orientation were also mentioned as challenges, [41,47,48,53] with some health professionals expressing uncertainty about approaching some clinical tasks such as physical examinations. [47] Gaining knowledge and understanding about cultures of refugees and asylum seekers was viewed as an important facilitator in cross-cultural care. [38,40,42,47,52,54,55,57] This included understanding differences in values, [42] body language, [52] health practices [42] and health presentations [52]. Cultural understanding allowed health professionals to adjust their healthcare practice accordingly. [40,45,48,49,51,55,56] Personal qualities in health professionals that were deemed to enhance cross cultural interactions were sensitivity, [49,52,54] empathy [40,41,54] and cultural humility. [54,55] Health and social conditions Health professionals spoke of challenges in dealing with physical, psychological and social problems that were typically presented by refugees and asylum seekers. [ 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   27 professionals did not always feel prepared or equipped to deal with these conditions [43,47] and there were concerns from general practitioners that some conditions could remain undiagnosed. [43,44,47] Psychological conditions were considered challenging to deal with, [17,37,40,43,46,52,53,[55][56][57] and were frequently seen among refugees and asylum seekers.
Time A significant challenge faced by health professionals was the time required to provide healthcare for refugees and asylum seekers. [18, 37, 38, 40, 43, 47, 49-51, 55, 56, 59] More time was necessary due to the aforementioned challenges around building relationships, [18,38,40] communication, [38,50,55,59] achieving cultural understanding, [47] and dealing with complex health conditions. [18,38,47,50,51] This additional time demand meant that appointments needed to be extended in duration [37,47] or occur more frequently. [18,49] Health professionals were concerned that time limitations could lead to 'rushed consultations' [59] and the potential to miss some conditions. [59] Some also commented that the extra time spent caring for refugees and asylum seekers drew them away from other patient groups. [40,43] The healthcare system Health systems have been defined as "the combination of resources, organization, financing and management that culminate in the delivery of health services to the population". [61] They are the environment in which healthcare encounters take place. Healthcare professionals described health system related challenges and facilitators within 5 areas: training and guidance, professional support, connecting with other services, organisation, and resourcing and capacity.

Professional support
As reported in the earlier section 'health and social conditions', professional support was needed by health professionals working with refugees and asylum seekers. However professional support was identified as deficient in healthcare systems.
[37, 43, 46, 55] Participants in one study described 'isolation' [43] that they felt within the healthcare system and another study described support networks as 'non-existent'.
[37] Concerns were raised that health professionals exposed to distressing stories were not provided with sufficient psychological support. [46,55]

Resourcing and capacity
Longer, more frequent appointments and utilisation of interpreters led to additional costs being incurred, [18,19,37,43,47,49,51] which some felt was not taken into account in health system financing models. [43,47,49] Some participants did not think that they could deliver adequate care as a result of funding shortages,[37, 55] with one study citing an example where interpreters were not able to be utilised because of lack of finance. [55] Shortages in workforces were reported in some articles, [46,47,49] putting additional workload and stress onto health professionals. [46,49] Reported consequences of this were closures of services to new patients [47,49] and health professionals leaving their posts, further exacerbating the problem. [49] Interpreter shortages were also mentioned as a difficulty [46,49,56] along with inflexibility of their service operations.[37, 42,55] Asylum and resettlement  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Further challenges were associated with the immigration status of, and legislative policy towards, refugees and asylum seekers. [18,19,37,39,40,46,47,59] In some instances, health professionals were hindered in meeting health needs due to policy restrictions. [40] Difficulties understanding the frequently-changing policies towards, and entitlements for, refugees and asylum seekers were reported [39,40] and uncertainty was expressed about healthcare pathways for this group upon arrival in the host country. [47] Some health professionals described conflicts in their professional duty to act as an advocate for their patients whilst requirements were placed on them to conduct assessments used to inform the asylum process. [19,46] Another concern raised was a perception that service users were abusing the health and welfare systems, [18,37,40,59] such as feigning symptoms of post-traumatic stress disorder to further their asylum claims [37] or illegal benefit claims. [18] Page 31 of 80 For peer review only -http://bmjopen.bmj.com/site/about/guidelines.xhtml 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  The growing research field of 'cultural competence' identifies components that can be incorporated into practice to enhance quality of care towards ethnic minority groups and reduce healthcare inequalities. [62,63] Betancourt et al [62] defined cultural competence in healthcare as "the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients' social, cultural, and linguistic needs". [62] This literature mirrors themes interpreted in the current review, including trusting relationships, communication and cultural understanding, as key components that may be optimised to improve healthcare and reduce inequalities. [62,63] Trusting relationships are essential for effective healthcare delivery. [64][65][66] Murray et al [67] identified continuity of relationship, time, interpersonal skills and 'getting to know patients' as enhancers of trust between health professionals and patients. The current review likewise recognised these elements, and it can be argued that even greater attention to trust-building is needed for refugees and asylum seekers, a vulnerable and ethnically diverse group who may be apprehensive about engagement with healthcare systems. [68,69] Communication between health professionals and patients is also regarded as essential. [70] Language discordance may compromise the quality of healthcare, lessening detection of ill health and referral to further healthcare. [71,72] Health professionals in the current review consistently thought language barriers hindered their work with refugees and asylum seekers. The main strategy used to overcome language barriers was communication through  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   33 interpreters, as is recommended in the wider literature. [73][74][75] However, concerns were raised about the quality and availability of interpreters.

BMJ Open
Generally, it is recommended that professional interpreters are used, as they have been trained in professional standards, medical terminology and ethical issues. [75] Ad-hoc interpreters such as family or community members may be used pragmatically, although this may diminish the quality of interpretation and threaten patient confidentiality. [74,75] Remote interpretation, such as telephone or video services have been developed to provide more efficient and timely services. [76,77] The merits of such services have been debated [76,77] and conflicting opinions were likewise given in this review. A systematic review [77] reported no significant difference in patient and provider satisfaction between remote and face-to-face interpreters, although subsequent primary studies have suggested a significant preference for in-person interpreters. [76] Consistent with other research, [6][7][8][11][12][13] health professionals encountered challenges dealing with complex physical, psychological and social problems of refugees and asylum seekers and did not always feel prepared to meet their needs. They also reported challenges in cross-cultural care such as different understandings of health, healthcare and healthcare systems, which introduced complications.
Participants in this review saw opportunities for improving care by working together with other health services and civil society. Identifying these organisations and possible areas of collaboration such as information sharing, referral pathways and joint service delivery may benefit health providers, health professionals and service users.
The organisation and delivery of primary healthcare services to refugees and asylum seekers is a growing research area, with service models being developed that integrate specialised components with existing structures. [78,79] A model innovated in Australia established 'Beacon practices', which have expanded capacity for refugee care and may flexibly resource local services. [79] Such integrated services provide specialised resources without  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   34 isolating refugees and asylum seekers from general practice, which was a concern raised by some participants in this review.
Health professionals and health services operate within, and are influenced by, the wider healthcare policy environment. Decisions made at a political and health system levels invariably impact on front-line clinical practice in areas such as resourcing priorities, health professional roles and healthcare access. [80] Health professionals in this review recognised associated challenges, particularly when healthcare pathways were unclear and changeable. This emphasises the need for policy-makers to provide consistent, clear and up-to-date guidance on asylum and resettlement health policy for health professionals.

Public health implications
A central concern in public health is reduction of inequalities in health and healthcare. [81,82] The WHO has established a commission on the social determinants of health that recommends actions addressing inequalities in health. [82] Healthcare inequalities exist when certain groups systematically receive lower quality care than the general population, resulting in poorer health outcomes. [80,83] These inequalities have been widely observed in healthcare provision to ethnic minority groups across a broad range of health services [80] and has been highlighted as an issue for refugees and asylum seekers in the UK. [21] However, through knowledge translation, where evidence is moved into practice, challenges and facilitators identified in this review may be mapped onto components of healthcare interventions that may minimise such healthcare inequalities. [84] Reduction in healthcare inequalities will likely require targeting healthcare resources towards disadvantaged groups. [79] For example, health professionals in this review highlighted the need for additional resources such as interpreter services, training and professional support to improve quality of care for refugees and asylum seekers.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  preferences.

Policy
Healthcare policy makers and commissioners should recognise the complex needs of refugees and asylum seekers, providing enhanced resources for quality and equitable service provision. Adequate human resourcing would allow health professionals to spend the necessary time to follow best practice.
Integration of specialised components with existing general practice may facilitate care. Asylum and resettlement policy makers should seek to promote continuity of relationship with healthcare providers, limiting relocations.
The outputs from this review may be used to inform service models for refugees and asylum seekers. Healthcare evaluations may be conducted to evaluate these models and identify areas that are able to improve quality of care

Strengths and limitations
An extensive and systematic search that was carried out across four databases complemented by reference and citation searches and it is therefore unlikely that published studies would have been overlooked. The inclusion of only English language studies may have led to under-representation of health professionals working in non-English speaking countries leading to a greater applicability to healthcare policy and practice in English speaking high-income countries. It is also possible that the database searches may not have identified studies where refugees and asylum seekers were referred to as 'migrants' or 'immigrants'; however, the additional hand-searches conducted would likely have identified any further key studies relevant for this review.
In study selection, titles and abstracts were screened by one reviewer, giving potential for selection bias or for relevant studies to be missed. By involving a second reviewer at the full-text selection stage, the study team sought to minimise bias, and supplementary searches of reference lists and citations reduced the potential for missing key studies. A second reviewer in data extraction could have reduced possibility of transcription errors, and in the quality appraisal stage could have minimised potential for biased assessment.
Ideally, the analysis process would also have involved multiple reviewers in coding and formation of descriptive and analytical themes, bringing a wider perspective to interpretation.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  perceived limitation of thematic syntheses is that they introduce a greater degree of abstraction from original experiences, sacrificing thickness of data and details found within the primary studies. [88] In this case, given that refugees are not a homogeneous group, it is perhaps acceptable to emphasise only the more generalised themes that transcend the contexts of individual studies.

Focus of study:
Include Exclude Experiences providing primary healthcare for refugees and asylum seekers Experiences treating a specific condition common in refugees and asylum seekers, but no focus on healthcare interactions. Experiences of a particular service or organisation for refugees and asylum seekers HCP's perspectives on refugees and asylum seekers' experiences  The aim of this research was to gain an in depth analysis of the experiences of midwives and their understanding of the specific needs of asylum-seeking women. The findings would be used to inform education, practice and policy to enable more effective delivery of womancentred care for this group locally.

Time 2. Communication
>Midwives deserve support in practice and enhanced education, and policy around asylum-seeking women would facilitate more effective, evidence-based care. >It is essential that midwives (and other members of the multi-disciplinary team) have access to and training in the use of interpreting services. >The additional time required to provide care to women seeking asylum should be factored into midwives' workloads. >Education programmes to prepare/enhance knowledge and skills in caring for asylum seekers >Web based resource with information about asylum seekers. > There is a service and professional responsibility to ensure that health visiting and public health nursing practice is developed from the best evidence available and that collective knowledge and expertise are shared, rather than left for each practitioner to discover through trial and error. > Both professional education providers and service providers need to pay attention to the specific health and social needs of asylum seeking women, who will unfortunately continue to arrive in the UK and other parts of the world. >For women in the asylum process, having access to dedicated community-based services would begin to address the problems of access, late booking, and development of midwife/client relationships which in turn would help to decrease fear and anxiety for both the women themselves and the midwives who care for them. >Cultural competency training: When considering how best to educate midwives to provide culturally competent care, the most important focus should be on using a framework of cultural humility. > There is an urgent need for increased clinical support for midwives who care for traumatized women. >Access to continuing education is also essential, along with debriefing and clinical supervision in order to maintain providers' own health and well-being. > Trained interpreter service should be embedded within hospitals. >dedicated community-based services that provide the possibility of continuity of care, make access to care easier for women, and provide the possibility of good midwife/client relationships and trust building. > Revision of the government policy of forced dispersal for women in the asylum process who are pregnant or in the early postpartum period is urgently needed. "Key themes were identified using inductive thematic analysis and NVivo software was used to assist with data management. Analysis was iterative and data collection ceased when no new issues emerged, suggesting data saturation. RF and MK read each transcript and independently coded data, identifying a preliminary list of themes. RF produced a refined list of major themes and subthemes; MK endorsed these themes. Because similar themes were identified during the focus groups and interviews, the data were considered comparable and therefore analysed together." Sufficient data were presented to support the findings. Some Contradictory data were presented in the findings. Authors were aware of the potential bias in data analysis and stated that they critically reflected on how their own views and differing perspectives were influencing interpretation. One of the authors worked outside the field and was able to bring more objectivity. schematic presentation in short quotes was made of each refugee interview" GPs: "The GP interviews were analysed and coded in the same way. A short profile was written for each doctor, linking interview results to doctor and practice variables. In an initial analysis, rough codes were assigned for the doctors' perceptions of the refugee groups, the problems the refugees presented to them, the way they dealt with these problems, and the constraints they met." A secondary analysis was performed on both refugee and GP data with further content analysis, which formed the body of the article. Sufficient data are presented to support the findings. Contradictory data were taken into account.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data.
credibility of the findings. discussed with the wider group, and concepts were further refined. Additional thematic categories were added as the analysis developed." Authors emphasise that transparency in analysis and reporting was achieved by providing extensive verbatim quotes and independent assessments of transcripts and themes. Sufficient data were presented to support the findings. Contradictory data were not presented in the findings No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data.
wider literature is discussed in relation to the findings of the study.
Authors acknowledge that the sample was small and that the physicians were working with specific cultural groups. They also mention that 3 authors were involved in the thematic analysis and themes were discussed with the wider group. Researcher explains that all the nurses and midwives employed at the centre during its 14-month operation were invited to participate in focus group discussions (Convenience sampling). 14 positive responses were received, which included a medical records clerk. Unclear how the two nurse managers were chosen for semi-structured interviews. Unclear why some people did not participate in the study, but the authors hypothesise that it could have been due to the distance from residence to study location, nurses no longer working in the same workplace or unable/unwilling to participate.
Data was collected through 2 focus groups (13 nurses and 1 medical records clerk) and 2 semi-structured interviews (Nurse managers). No information is given about the settings of data collection or the researcher(s) that conducted interviews. No justification given for methods or setting of data collection. For focus groups, an interview schedule developed by the researchers was used to guide discussion. 5 areas of discussion were described that were triggered by interview questions. Semistructured interviews lasted 60-9-0 min and followed another format developed by the researchers, but lacking detail on the areas of discussion. Data were audiorecorded and transcribed Data saturation not discussed. "Thematic analysis of focus group and in-depth interview transcripts was undertaken by a multidisciplinary research team, who re-read them several times to become immersed in the data. The team, drawing upon informants' stories of their experiences, then generated broad themes common throughout the text. Themes and emerging subthemes identified by the research team were then coded from the transcripts using a qualitative data management program (QSR Nvivo, QSR International)." Sufficient data were presented to support the findings, however the authors did not include many quotations. Some contradictory data are presented in the findings No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data. obtain a sense of the whole. The text was then divided into meaning units, which were then condensed and assigned categories and themes in a process moving towards a higher level of abstraction. The creation of categories and themes took place as an iterative process with ongoing reflection and revision of categories and themes. The whole context of the interviews was considered concurrently throughout this process. The initial analysis was carried out by the first author, but presented to and discussed with co-authors and other researchers with a background in public health, medicine and anthropology as part of the analytic process." Sufficient data are presented to support the findings. Contradictory data are presented and discussed.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data.
original research question. Findings are discussed within the context of evidence in the wider literature. Credibility of findings not explicitly discussed, but the author mentions that the initial stages of the analysis were conducted by the lead author and as themes emerged, they were discussed with the wider group including members from different discipline backgrounds.
policy for health care management of refugees. Briefly suggests ways to improve practice. Suggest the development of conversational models for general practitioners with points to be aware of in consultations with refugees.
There is some discussion of the transferability of the results. The authors acknowledge that the participants had high levels of knowledge about refugees and asylum seekers, which is not true of many general practitioners. In addition, the vignette used for the interview gave a theoretical, isolated situation, which they acknowledge may limit generalisability. Considered the findings of the study in relation to practice and policy. Suggested that to provide more generalisable results a quantitative study should be conducted, but does not give any information about the aims of such a study. The authors discuss the transferability of the study and state that the small numbers limit its generalisability. Committee.
An inductive thematic approach was taken. The themes from the preliminary coding were used to create a coding frame which was applied to the data across all transcripts. The transcripts were marked and annotated, and emerging themes were then discussed among authors. Unclear who and how many people coded the transcripts. Sufficient data are presented to support the findings. Researchers refer to contradictory data within their dataset.
No examination of researcher's role, potential bias and influence during the analysis and in presentation of the data. In-depth interviews were conducted with participants with most taking place at the clinic and some in the workplace of representatives. All interviews were conducted by the first author.
Authors justify their use of in-depth interviews: "Our rationale for this approach is that experience is constituted in participants' accounts as they talk about their surroundings and reactions to them in ways which others can accept and understand. In-depth interviews are a suitable way of gathering and accessing such talk". Setting justified on The researcher's role and potential bias in the formulation of questions or data collection was not discussed.
Not clear how the study was explained to participants. Respondents gave permission in accordance with agreed ethics protocols, but no further details. No discussion of how confidentiality was maintained or how issues raised in the study were handled by researchers.
No reference to ethics committee reported.
A thematic analysis process is described, but it isn't clear whether this applied to all participant groups. "we used a research framework that was built on a critical realist theoretical base, which assumes that realities are socially, culturally and historically situated, but are, nevertheless, experienced as material, objective and stable by participants ...After a period of familiarisation with the transcribed narratives, key themes were identified with reference to topics discussed in the interviews. Indicative narratives identified through this exercise are used to illustrate themes in this paper." No indication of involvement of multiple researchers in the analysis. Sufficient data are presented The findings of the study were explicit, and discussed in relation to the research question. Limited discussion of the findings in the context of the wider literature.
No discussion of the credibility of the findings.
Authors discuss the contribution the study makes to existing knowledge and understanding. The findings are discussed in relation to practice and policy. It is acknowledged that the study focussed on one clinic in one city. Suggestion of conducting further similar studies in other locations to increase generalisability. State the research question the synthesis addresses.

2
Synthesis methodology Identify the synthesis methodology or theoretical framework which underpins the synthesis, and describe the rationale for choice of methodology (e.g. metaethnography, thematic synthesis, critical interpretive synthesis, grounded theory synthesis, realist synthesis, meta-aggregation, meta-study, framework synthesis). 6 3 Approach to searching Indicate whether the search was pre-planned (comprehensive search strategies to seek all available studies) or iterative (to seek all available concepts until they theoretical saturation is achieved). 6 4 Inclusion criteria Specify the inclusion/exclusion criteria (e.g. in terms of population, language, year limits, type of publication, study type). Identify the number of studies screened and provide reasons for study exclusion (e,g, for comprehensive searching, provide numbers of studies screened and reasons for exclusion indicated in a figure/flowchart; for iterative searching describe reasons for study exclusion and inclusion based on modifications to the research question and/or contribution to theory development).

9-10
10 Rationale for appraisal Describe the rationale and approach used to appraise the included studies or selected findings (e.g. assessment of conduct (validity and robustness), assessment of reporting (transparency), assessment of content and utility of the findings). 8 11 Appraisal items State the tools, frameworks and criteria used to appraise the studies or selected findings (e.g. Existing tools: CASP, QARI, COREQ, Mays and Pope [25]; reviewer developed tools; describe the domains assessed: research team, study design, data analysis and interpretations, reporting).

12
Appraisal process Indicate whether the appraisal was conducted independently by more than one reviewer and if consensus was required.

13
Appraisal results Present results of the quality assessment and indicate which articles, if any, were weighted/excluded based on the assessment and give the rationale.

17-18 14
Data extraction Indicate which sections of the primary studies were analysed and how were the data extracted from the primary studies? (e.g. all text under the headings "results /conclusions" were extracted electronically and entered into a computer software). 8 15

Software
State the computer software used, if any.

Number of reviewers
Identify who was involved in coding and analysis. 8

17
Coding Describe the process for coding of data (e.g. line by line coding to search for concepts).

1Study comparison
Describe how were comparisons made within and across studies (e.g. subsequent studies were coded into pre-existing concepts, and new concepts were created when deemed necessary). 8 19

Derivation of themes
Explain whether the process of deriving the themes or constructs was inductive or deductive. 8

Quotations
Provide quotations from the primary studies to illustrate themes/constructs, and identify whether the quotations were participant quotations of the author's interpretation.