At the Frontlines of Access: Challenges Faced By Refugee Support Organizations In Healthcare Delivery

Background: Refugees in the United States experience disproportionately limited access to healthcare compared to other populations, driven by structural inequities, linguistic barriers, cultural mismatches, and restrictive policies. While prior research has documented patient-level challenges, far less is known about the barriers faced by refugee support organizations that serve as critical intermediaries in facilitating care. Understanding these institutional challenges is essential for developing responsive interventions and policies that strengthen service delivery, improve coordination, and ultimately reduce disparities in healthcare access and outcomes among refugee populations. Hence, this study aims to examine the multi-level barriers experienced by refugee support organizations and develop viable policy and practice recommendations.

Methods: This qualitative study employed a grounded theory approach to explore the challenges experienced by refugee support professionals in providing health-related services. Participants (N=13) were recruited through purposive and snowball sampling from organizations in the U.S. states of Florida and Missouri, and were interviewed via Zoom or phone. Eligible participants were professionals over 18 and those working in refugee-support organizations in Missouri and Florida. Interviews were audio-recorded, transcribed verbatim, and analyzed using open and axial coding in NVivo 14. Researchers developed themes through constant comparison and collaborative analysis, leading to a framework that identifies upstream and downstream barriers to health-related services for refugees.

Results: The thematic analysis revealed multiple barriers that refugee support professionals face when providing health-related services. The identified barriers fall into two major categories: upstream and downstream. Upstream barriers included large-scale challenges at national and state levels: a) change in national policy landscape and political rhetoric, b) funding cuts, c) unfavorable state policies, d) bureaucracy and red tape. Downstream barriers included challenges related to healthcare systems and institutions, as well as the personal circumstances of refugees. These included a) communication barriers, b) delays in accessing care, c) inadequate transportation, d) long wait hours, e) recurrent medical challenges, f) workloads, and g) financial barriers. The upstream and downstream barriers intersect in limiting refugees' healthcare access. Policy shifts at the national level aimed at cutting back on refugee resettlement and funding affected refugee support organizations’ efforts to provide health-related services and refugees’ ability to afford care. No Medicaid expansion at the state level, limited access to care, and negative political rhetoric fueled fear, leading to healthcare avoidance. Institutional challenges, such as lengthy bureaucracy and red tape, coupled with higher workloads, hindered service provisions. Refugees’ circumstances, such as language and communication barriers, lack of adequate transportation, and limited finances, further constrain access to healthcare.

Conclusion: The study revealed that refugees' support organizations’ health-related services were constrained by interrelated upstream and downstream barriers that required coordinated policy and practice actions. Policy advocacy targeting the transition and continuation of care for refugees, expanding employment opportunities and financial self-sufficiency, ensuring affordable, culturally tailored community health, and curbing anti-refugee rhetoric is recommended. Programs expanding driver’s license support, transportation access, legal support, translation services, and expedited care processing could complement support organizations’ services and improve access to care.