**1. Introduction**

There are currently 70.8 million forcibly displaced people worldwide, with approximately 37,000 people displaced every day [1]. This includes refugees "who have fled war, violence, conflict or persecution, have crossed an international border and been granted protection/safety" and asylum seekers "who have sought international protection and whose claims for refugee status have not yet been determined" [2]. Many of the refugees and asylum seekers arrive in Western resettlement countries with complex psychological and physiological health needs. They face challenges accessing and utilizing healthcare due to numerous factors, such as unfamiliarity with the healthcare system, language and cultural barriers, cost and other social circumstances [3–6].

**Citation:** Patel, P.; Bernays, S.; Dolan, H.; Muscat, D.M.; Trevena, L. Communication Experiences in Primary Healthcare with Refugees and Asylum Seekers: A Literature Review and Narrative Synthesis. *Int. J. Environ. Res. Public Health* **2021**, *18*, 1469. https://doi.org/10.3390/ ijerph18041469

Academic Editors: Lillian Mwanri, Hailay Gesesew, Nelsensius Klau Fauk and William Mude Received: 8 December 2020 Accepted: 29 January 2021 Published: 4 February 2021

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Primary healthcare services are usually refugee and asylum seekers' first point of care in the resettlement countries [3,5,7,8]. Such services often face challenges in not only training healthcare providers (HCP) in effectively responding to the healthcare needs of the refugee and asylum seeker patients but also in identifying issues with patient's immigration status and access to healthcare [9]. Apart from these broader system-level challenges, another key area where challenges arise is the healthcare encounter between refugee and asylum seekers and HCP [9]. Communication plays a key role in the healthcare encounter between refugee and asylum seekers and healthcare providers and is an essential starting point for patient satisfaction and positive health outcomes [10].

Experiences within the healthcare encounter, in particular the interpersonal relationships, are fundamental to good healthcare provision [11,12]. Clinician–patient relationships and patient health outcomes rely on effective communication between the clinician and patient [10]. When considering people from culturally and linguistically diverse backgrounds, communication has been identified as the starting point for building up confidence between the healthcare provider and patient [13]. Evidence has shown that patient satisfaction is strongly associated with communication behaviors during the clinician–patient interaction [14–16].

This aim of this review is to summarize the literature on the communication experiences of refugee, asylum seekers and healthcare providers during primary healthcare consultations in Western countries (defined by UN regional grouping) in order to inform recommendations for practice [17].

#### **2. Methods**

This review summarizing current research on communication experiences is guided by a systematic literature searching methodology [18] with narrative data synthesis and analysis techniques [19].

#### *2.1. Search Strategy*

Seven electronic databases were systematically searched from inception to 31 March 2019: OVID Medline, EMBASE, CINAHL, Web of Science, Scopus, Global Health and Informit.

Search terms for primary healthcare, refugees and asylum seekers and communication were combined to develop the search strategy (Appendix A). No date limits were applied, but studies were limited to those with titles and abstracts in English. Further hand-searches were conducted based on included studies' reference lists and citations (in Google Scholar).

After the removal of duplicates using Endnote X8 software (Clarivate Analytics, Philadelphia, PA, USA), the remaining references were imported to the Rayyan online tool [20] for screening and data extraction. The titles and abstracts were screened by two researchers, excluding articles that did not clearly meet the pre-defined inclusion criteria. The full texts of the remaining articles were obtained and assessed by two independent researchers, according to prespecified study selection criteria (detailed below). Any disagreements were resolved via discussion. Where full texts were not in English, native speakers completed the screening process. Full texts of studies which met the pre-specified study selection criteria were translated into English using Google Translate and proofread by native speakers prior to data extraction.

Studies were excluded if the full-text could not be obtained either through institutional access or from requests sent to authors through Research Gate.

#### *2.2. Selection Criteria*

#### 2.2.1. Population

Studies were included if participants were refugees and asylum seekers living in Western countries (defined as countries that are members of UN classification of Western European and Other States Group (WEOG)) [17]. Studies were limited to Western countries because of the authors' interests in developing recommendations for practice applicable to primary healthcare systems in this context.

The literature that presented a mixed population broader than refugees and asylum seekers was excluded, as were studies which referred to "migrants" or "immigrants" but had no information on the migration pathway. Studies regarding "Undocumented migrants," defined as anyone residing in any given country without legal documentation, were also excluded as this population is known to have unique characteristics that would not necessarily be typical of refugees and asylum seekers [21].
