# “Sometimes it can be like an icebreaker”: A mixed method evaluation of the implementation of the Refugee Health Screener-13 (RHS-13)

## TL;DR

This study evaluates how well the Refugee Health Screener-13 is used in health assessments for forced migrants in Sweden, finding that language barriers and trust issues affect its implementation.

## Contribution

The study identifies specific barriers and facilitators to RHS-13 implementation in primary health care settings for forced migrants.

## Key findings

- RHS-13 usage varied significantly between health care centres, with some achieving high implementation rates.
- Language barriers, time constraints, and lack of trust in RHS-13 were key barriers to its use.
- The RHS-13 was perceived as a valuable complement to health assessments when available in multiple languages.

## Abstract

Forced migrants are at risk of developing mental illness, yet challenges remain with underutilization of mental healthcare among this population. This study examined the implementation of the Refugee Health Screener-13 (RHS-13) in the health assessment for forced migrants in eight primary health care centres in Stockholm Region, Sweden.

A mixed-methods convergent parallel design was used, combining nurses self-reported quantitative data on the levels and reasons for RHS-13 use in the health assessment with qualitative interview data on the barriers and facilitators for RHS-13 use. The Consolidated Framework for Implementation Research (CFIR) was used as a coding framework for the qualitative analysis.

Levels of RHS-13 use varied between primary health care centres, resulting in two groups: three centres with high-level (65–92%) and five centres with low-level (0–36%) implementation. Factors related to the tool itself, as well as the inner and outer context, influenced the use of RHS-13. Language barriers, insufficient time, and lack of trust in the validity and utility of RHS-13 were the main barriers, while its availability in many languages and that it was perceived as an important complement to the health assessment were the main facilitators.

RHS-13 contributes to the standardization of assessing mental health in the health assessment. Identifying context-based implementation strategies and addressing language and time issues as well as nurses trust in the tool's utility are recommended to enhance the use of RHS-13.