Discussion
In our study, three out of four newly arrived refugees who were retrospectively assessed as high risk for mental disorders – based on health assessments conducted three months after arrival in Norway – were later recorded as having mental health symptoms, compared to just 10 % of the low-risk group. The risk of a mental disorder could not be assessed for a quarter of the participants due to insufficient medical record documentation.
Incomplete or missing health assessments, and consequently the ability to retrospectively assess the risk of a mental disorder in the future, appeared to be more common at Hommelvik Medical Centre than the Centre for Migration Health. At Hommelvik, the health assessments were carried out by general practitioners (GPs) and specialty registrars, whereas the Centre for Migration Health has a multidisciplinary team consisting of doctors, (public health) nurses, a physiotherapist, a psychologist, a social worker and language consultants. This may provide a better foundation for a structured health assessment. Several local authorities, including Malvik, have established multidisciplinary migration health teams in recent years. However, little is known about whether such teams or GPs are better equipped to follow up on symptoms identified during assessments. It is reasonable to assume that the proportion of incomplete health assessments has decreased as local authorities have gained more experience in conducting them.
Our study does not provide a basis for evaluating the validity of the Norwegian Directorate of Health's recommended assessment, partly because the Centre for Migration Health used its own assessment template rather than the Directorate's form. Furthermore, little is known about whether it is the introduction of the guidelines or the organisation of the services that has the greatest impact on how refugees with mental health problems are identified and followed up. Unsystematic implementation of health assessments can also lead to unsystematic follow-up (16). A European systematic review from 2019 found underuse of mental health services among refugees, despite a higher prevalence of mental disorders (17). This could be due to various barriers (18).
Our study has several limitations, including its retrospective design and differences in assessment methods, study period and follow-up times between the two study centres. The study also has a limited sample size. A calculation of statistical power was conducted prior to the study to estimate how many participants would be needed to demonstrate a difference in the prevalence of mental health symptoms of 10 % or more between the risk groups. The calculation estimated a need for 246 participants. This quickly proved to be unrealistic. Contributing factors included a change in the medical record system at the Centre for Migration Health, which led to a shorter inclusion period and follow-up time. As a result, we were unable to conduct the planned regression analyses. Our findings should therefore be interpreted with caution, as potential confounding factors were not factored in. A larger study would enable the stratification of participants by country of origin, a more detailed analysis of diagnoses during the follow-up period, follow-up in the specialist health service and examination of the correlation between findings from the health assessment and the degree of subsequent integration.
We did not have access to medical records from other GP practices, primary care services or the specialist health service in this study. Potential underreporting of mental disorders must therefore be taken into consideration. Furthermore, the distinction between normal reactions and mental health symptoms during assessment is based on subjective judgements to a certain extent, which can lead to misclassification. It must also be considered that individuals with mental health symptoms during the follow-up period may not necessarily have had contact with the health service.
The Norwegian Healthcare Investigation Board (Ukom) published a report in 2021 on the health and care service provision for newly arrived refugees (19). The investigation was prompted by the so-called Tromsø tragedy, in which a refugee drowned herself and her three children. The report concluded that the Norwegian Directorate of Health's guidelines are one of several instruments that have been 'insufficiently applied'. We therefore believe that a thorough review is needed to determine whether the Directorate's guidelines are being followed by municipal migrant health services and GPs, the organisation of these services, and the implications. This will provide a basis for determining the most appropriate organisational model.
In this study, we sought to examine whether health assessments for trauma and mental health symptoms conducted three months after resettlement can help identify refugees who subsequently experience mental health symptoms. Despite several limitations, the results suggest that such assessments can identify individuals who will subsequently require follow-up due to mental health symptoms. The study highlights the need for further research to improve knowledge about health assessments and healthcare services for refugees.