Summary: A rapid scoping review of antibiotic access and use barriers among refugee and migrant populations

Publication Authors: Suzanne Garkay Naro, Michèle Palkovits, Arne Ruckert, Andrea Morales Caceres, Ranjana Nagi, Cordelia Chik, Steven J. Hoffman & Susan Rogers Van Katwyk

Introduction: What did we do and why did we do it 

• Antibiotic resistance (ABR) – a global health and development threat – impacts refugees and migrants in unique ways due to increased exposure to infections and inequitable access to healthcare.
• We conducted a global rapid scoping review to collect evidence on barriers to access and appropriate use of antibiotics among migrants and refugees.

Findings: What we found out

• Migrants and refugees experience barriers along the continuum of care from both the patient and health-system side, impacting access to and appropriate use of antibiotics.
• Key barriers along the patient side undermine migrants and refugees from accessing quality-assured and appropriate antibiotics.
• Complex healthcare systems, previous unsatisfactory experiences with health services, language barriers, and the ability to acquire antibiotics informally, can contribute to making formal healthcare services less approachable for migrants and refugees.
• Migrant and refugee populations’ ability to seek care is shaped by self-medication norms, stigma of certain infections, discrimination, and fear of deportation for irregular migrants.
• Availability and accommodation of health services for migrants and refugee populations were predominantly impeded by a lack of personal time and limited transportation means.
• For migrants and refugees, affordability was shown to deter formal healthcare access and ability to purchase antibiotics, if prescribed.
• Limited knowledge on ABR – which is not exclusive to migrant and refugee populations – can influence lack of adherence to antibiotic treatments or use of antibiotics without prescriptions.
• Health system barriers can also limit access and appropriate use of quality-assured antibiotics.
• Density of facilities and presence of ample healthcare providers, and waiting times and service availability, can influence migrants and refugees’ healthcare seeking behaviours.
• Low affordability and inability to access health insurance coverage are principal factors limiting migrants and refugees from accessing healthcare and prescriptions in their host countries.
• Diagnostic uncertainty, lack of translated services, and substandard medications can limit refugees’ and migrants’ access to quality antibiotics and may lead to their unnecessary and incorrect use.

Recommendations

Global Policy Recommendations:

• Implement a global surveillance system which systematically includes migrants and refugees to fill knowledge gaps and support the development of targeted interventions to address health barriers in these populations.
• Include refugees and migrants into WHO’s Global Action Plan on AMR to promote an equity-focused framework for coordinated action.
• Strengthen global governance mechanisms to promote appropriate antibiotic use and availability in low-resource settings by implementing redistributive financing models, building on and scaling up WHO’s Expanding Sustainable Access to Antibiotics (SECURE) initiative.

National Policy Recommendations:

• Integrate cultural competency training into pre-service education and continuing professional development for healthcare workers to strengthen their skills to understand diverse health beliefs, communication norms, and healthcare seeking behaviours among migrants and refugees.
• Expand language support, culturally tailored health education, and health literacy programs to promote access to appropriate antibiotic use.
• Adopt equity-focused financing mechanisms to make essential, quality-assured antibiotics accessible to all individuals regardless of legal status.

Conclusion

• Our scoping review found that refugees and migrants encounter significant barriers in obtaining and using antibiotics effectively throughout their healthcare journey.
• Exclusion from formal health services often leads displaced populations to rely on informal antibiotic access pathways, increasing the risk of inappropriate antibiotic use and ABR emergence. Previous experiences, cultural norms, and personal preferences may create a negative perception towards formal healthcare, while legal and financial obstacles further undermine adequate access to antibiotics.
• Because refugees and migrants are more vulnerable to antibiotic resistance while facing unique socio-economic challenges, it is imperative to enhance global efforts to facilitate safe and sustainable access to antibiotics for migrants and refugees. This means aligning AMR action plans with strategies to mitigate migrants’ and refugees’ barriers to healthcare access, and better coordination of policies across borders.