The results are presented thematically, addressing the aims of the study: (1) knowledge and confidence: “Providers don’t want to deal with it or they can’t deal with it”; and (2) training experience and needs: “It’s an entirely different topic not covered in the universities”. Within each theme, a number of factors were identified at individual, organisational and societal levels of the socio-ecological model. These factors interact across levels to influence HCP’s preparedness for providing SRH care to refugee and migrant women. For example, at individual level the data indicated that work experience in SRH care, cross-cultural knowledge, on job training and confidence to initiate and discuss SRH influenced HCP’s ability to provide SRH care to refugee and migrant women. At the organisational level, university education/curricula and training availability in refugee and migrant women’s SRH care impacted HCP’s knowledge and confidence in SRH care provision. Influential societal level factors included SRH taboo, health system priorities of providing resources instead of training in SRH care, and emphasis on aboriginal cultural training. These suggest that HCP preparedness to provide SRH care to refugee and migrant women is influenced by multiple factors across the socio-ecological model, and multiple and multilevel interventions are necessary. Figure 1
shows a summary of factors at each level. In the presentation of the two major themes below, the ways in which the identified factors across the socio-ecological model were constructed to influence HCP’s preparedness to provide SRH care to refugee and migrant women are discussed.
3.1. Knowledge and Confidence: “Providers Don’t Want to Deal with It or They Can’t Deal with It”
Although no significant differences were observed between professional groups in relation to perceived knowledge and confidence, more than a quarter (26%) of HCPs rated their knowledge of refugee and migrant women’s SRH as very low or low, and 16.4% of HCPs rated their confidence to provide SRH care as low or very low (Table 2
). A number of areas where HCPs across all occupational groups described their knowledge and confidence to provide SRH care to refugee and migrant women as inadequate were also identified from the semi-structured interviews. For example, many HCPs explained that engaging in SRH conversations was difficult:
Broaching the subject is the challenge I face because lots of women tell you “oh, I don’t want to talk about it.” So it’s a challenge to be able to break that barrier to let them know that it’s important to talk about what’s going on because you need to help them in regards to not having any problem now or in the future.
(Alice, GP, 35)
This perceived difficulty demonstrates the challenges and cultural barriers on which HCPs need more training to effectively raise discussions about SRH, as Hannah (GP, 31) indicated:
Hell, the majority of them (HCPs) can’t do (talk about) sexual and reproductive health to these women…You can’t sit there and giggle and say, “oh I’m sorry I’ve got to ask you a personal question.” The challenge is getting them (the women) to bring it up as they are not going to say “I have got a discharge.”
This may hinder the HCP’s ability to understand the women’s needs and provide appropriate SRH care. According to some of the HCPs, the difficulty in discussing sexual health was related to their lack of awareness about the women’s attitude towards sexual health: “I don’t know their attitude towards sexual pleasure or towards sexual practice to talk about it” (Emma, sex therapist, 6). Consequently, some HCPs may just refer refugee and migrant women to specialist services to avoid the difficulty: “Often GPs will just refer (women) to sexual health (clinics) because they don’t want to deal with it (difficulty of raising SRH discussions) or they can’t deal with it” (Amy, nurse, 17). This implies that HCPs may miss opportunities to gain experience in SRH care provision to refugee and migrant women.
Not all HCPs described themselves as inadequately prepared to discuss SRH with refugee and migrant women. Few nurses indicated that they were confident talking to refugee and migrant women about SRH, with their confidence stemming from previous training in SRH care provision: “I’ve done a number of courses as part of my work and I’m very comfortable talking about sexuality” (Alex, nurse, 42). Others reported that their confidence stemmed from their extensive work experience in SRH:
“I have worked in sexual health for a long time. So to me it’s no different to addressing the health of their eyes or their lungs or their feet or anything else. There is no cultural group that I can’t discuss these (sexual health) issues with.”
(Amy, nurse, 17)
This indicates that extended work experience in SRH care improves the HCP’s confidence to initiate and discuss SRH topics with women from refugee and migrant backgrounds. A number of HCPs shared strategies they had found effective in helping to overcome the difficulty of initiating SRH discussions with refugee and migrant women. They emphasised the need to prepare the women, by starting the discussion by highlighting the benefits of engaging in an open conversation with HCPs:
“Generally no one likes talking about that area of their health. So the way I do it is prepare them first, that I would like to ask them these questions, and give them a benefit to answering those questions for themselves. So for example, I ask this for your health. I want to make sure you’re all right. There is a positive in it for them.”
(Amy, nurse, 17)
This result highlights the importance of how HCPs initiate SRH discussions with refugee and migrant women seeking SRH care. It is imperative that HCPs use different approaches to discuss SRH as societal taboos associated with this topic may hinder the women from seeking information and service leading to misconceptions and knowledge gaps.
3.2. Training Experiences and Needs: Moving across Levels of Influence
HCPs in this study recognised refugee and migrant women’s SRH as a “more complex” and “entirely different topic”. They also reported that SRH care provision to refugee and migrant women requires a “different skill set to give these messages to these ladies”. Despite these acknowledgements, the majority of nurses (59.4%), 50% of GPs and 38.6% of health promotion officers had not undertaken any training or professional development that specifically addressed refugee and migrant women’s SRH (Table 2
). The absence of HCP training in refugee and migrant women’s SRH was also identified by many participants across all professional groups in the interviews. HCPs provided many reasons why they had not received training in refugee and migrant women’s SRH. Some participants described refugee and migrant women’s SRH as “not covered in the universities” and that HCPs are “not taught as much as (they) could be during training”. For example, Grace (nurse, 13) explained that “there is more emphasis on providing resources than educating HCPs about refugee and migrant health issues” in the health system. Another nurse stated that “something that’s easily accessible and affordable education about these cultural issues is not available for migrant and refugee groups” (Harper, 19). Where cross-cultural training exists in the healthcare system, some HCPs reported that it focused on Indigenous Aboriginal health with little attention to refugee and migrant health:
“There is now a huge push for us to learn about the Aboriginal culture and it’s become mandatory that we do some of the training on that. But there’s nothing really to—along similar lines to educate us about these other cultures and about some of the traumas and such that people go through.”
(Grace, nurse, 13)
Whilst some of the HCPs did not mind having more training on the SRH of refugee and migrant women, others reported a lack of time to undertake additional training:
“So time constraint is a big issue for health professionals. Because they’re always short of time, I think that they don’t spend the time or don’t put the time aside to do extra training in terms of sexual and reproductive health care, and when training does come up, often they can’t go because they’re so short of time, or because they just don’t want to do it because it’s too hard.”
(Amy, nurse, 17)
Consequently, many HCPs noticed that they were underprepared to provide SRH care to refugee and migrant women: “We’re taught some and we’re taught not enough in so many areas (of refugee and migrant women’s SRH). There are a lot of areas that I feel inadequate in” (Hannah, GP, 31). Finally, several HCPs suggested areas where additional training is needed. For instance, Chloe (nurse, 13) explained that with “cultural awareness training … I like to know what messages I’m conveying subconsciously. I would like to improve that and be able to convey my messages a bit more clearly”. Importantly knowing the women’s cultural background is reported to be important in delivering SRH messages. Grace (GP, 13) added, “We need more education on the cultures, cultural norms and the cultural expectations of these migrant and refugee women and some understanding of how they would like care to be provided when it’s care around sexuality and sexual health”. Learning about the role of culture and ethnicity in refugee and migrant women’s SRH was viewed by many as facilitating self-reflection and analysis and leading to better patient care:
“Sometimes you can be having a consultation—it’s all going well, and then something just changes. I think I would really like to know why in some of those cases. Some of them you can sit back and think, oh, I shouldn’t have said that or I should have said this differently, or I should have backed off and asked that in a different way. I think having increased knowledge helps to do that sort of analysis afterwards.”
(Chloe, nurse, 13)
HCPs described increased SRH knowledge as an imperative to improved service delivery versus being elective with regards to professional development. Tayla (GP, 22) noted, “All GPs (need) to be adequately trained in sexual and reproductive health, rather than regarding it as an optional extra for those with special interest”. Few participants also recommended training to medical support staff such as receptionists to help them understand the contexts of refugee and migrant women and assist the women in booking and re-booking appointments:
“I guess that’s the same for even potentially medical receptionists as well, because if a woman misses her appointments a couple of times, or comes extremely late for an appointment, sometimes that can be quite frustrating for receptionists who have to re-book their appointments, yet they don’t actually understand the reasons why that might be occurring.”
(Kokob, health promotion officer, 8)
Given that 88.9% of nurses, 75% of GPs and 76% of health promotion officers reported need for and demonstrated willingness to engage with further training in this area, the modes of delivering for such training are important. The majority of the HCPs preferred online self-directed learning (66.67%), workshop methodologies (65.22%) and professionally accredited courses (43.48%). These results imply that HCP SRH education programs in the health system need to consider their audience, scope, timing, content, accessibility and recognition relating to modes of training delivery.