Introduction

Sexual and reproductive health (SRH) is a fundamental component of women's well-being and quality of life.1 Sexual and reproductive health is defined as "a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity."1^(p.2646) Women are entitled to a distinct set of universally recognized SRH rights, including the right to have their bodily integrity and autonomy respected, decide whether and when to have children, and have access to the information resources, services, and supports necessary to achieve good SRH.1 Alongside these rights, there are a set of essential services integral to comprehensive SRH care, including evidence-based SRH education; counseling and care related to sexual function and satisfaction; prevention, detection, and management of gender-based violence; provision of modern contraceptives; safe abortion services; and the prevention and treatment of STIs.1

Access to SRH has direct benefits for women's physiological functioning and mental health.2 High-quality SRH reduces the incidence of gender-based violence, unplanned pregnancy, reproductive cancers, unsafe abortion, and HIV/AIDS, ultimately contributing to gender equality, social justice, and economic development.1 While improvements have been made to the accessibility and availability of SRH services, disadvantaged and marginalized populations with unique health care needs, including refugee and refugee-claimant women, are experiencing challenges when accessing SRH care and are in need of special attention.1,3

Refugee and refugee-claimant women

The world is currently in the midst of the largest global migration crisis ever recorded. The United Nations High Commissioner for Refugees (UNHCR) has estimated that 70.8 million people are currently displaced across the globe, including 25.9 million refugees and 3.5 million refugee-claimants.4 A refugee is defined as someone who has been forced to flee their country of origin due to conflict, persecution, or violence, and who cannot return to their home country.5 On the other hand, a refugee-claimant (also referred to as asylum seeker or undocumented migrant) is someone who has fled their home country in search of protection, but may not fulfil the strict criteria outlined in Convention Relating to the Status of Refugees. They have applied for refugee status and are awaiting a decision.6 Annually, approximately 1% of the world's refugee population is resettled internationally.4 In 2018 alone, nearly 100,000 refugees were resettled by the UNHCR across 28 high- and upper-middle-income nations.4 In 2018, 2.1 million people claimed asylum or refugee status, with 254,300 asylum claims in the United States, 161,900 in Germany, 114,500 in France, and 55,400 in Canada.4

Approximately half of all refugees and refugee-claimants (hereafter collectively referred to as refugees) are women.4 In situations of armed conflict and forced displacement, the breakdown of social infrastructures, disintegration of families and communities, and high rates of poverty create a context in which women are particularly vulnerable to gender-based violence, including sexual assault and exploitation, human trafficking, intimate partner violence, and child marriage.7,8 Women traveling alone or with children, and transgender women are particularly vulnerable to abuse and exploitation at the hands of partners, people smugglers, and humanitarian and security workers.7

High rates of gender-based violence, coupled with limited access to SRH in refugee camps and temporary settlements, leave refugee women vulnerable to negative SRH outcomes. This includes the transmission of STIs, unwanted pregnancies, and self-induced and unsafe abortion.9 Refugee women may be in particular need of accessible and affordable SRH services upon arrival in their resettlement/host countries. Despite a demonstrated need for SRH care, refugee women who have resettled in high-income countries demonstrate a reduced uptake of SRH services and supports,10,11 which has resulted in negative SRH outcomes.12-15

Barriers to sexual and reproductive health care for refugee and refugee-claimant women

Previous studies have shown that pre-arrival disruptions, such as periods of interrupted schooling, reduced access to SRH services, and a lack of educational materials, may impact refugee women's SRH literacy.16 A paucity of evidence-based resources forces women to seek information from peers and informal media, allowing for the spread of misinformation and sexual myths.16,17 Sociocultural and religious factors further influence and restrict SRH knowledge and practices among refugee women.13,16 Within many cultures, talking about SRH and accessing related services is seen as taboo, with many religious and cultural groups promoting abstinence before marriage.16,18-20

Post-resettlement, women's SRH is often neglected, with the demands of resettlement taking precedence. Priority is given to fulfilling basic needs, such as finding affordable housing and employment.10,16,19 Direct access to services is limited by women's ability to obtain childcare and find transportation to appointments, in addition to navigating the health system of the host country.10,21 Language and communication barriers can complicate service use and limit the uptake of treatment and educational resources.16,19 The cost of contraceptives has often been reported as a deterrent to use.22

The reduced accessibility of SRH services and supports has resulted in negative SRH outcomes among resettled refugee women in high-income countries, including unwanted pregnancy and abortion,12,13,15 lower than recommended rates of cervical cancer screenings,11 avoidance of HPV vaccinations,13 high rates of STIs,12 negative attitudes and reduced uptake of contraception, and non-consensual or painful sex.13,18,20 A review of the existing literature is warranted to more completely understand access to and use of SRH services among resettled refugees and refugee-claimant women in high-income countries.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, Open Science Frameworks, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or in-progress scoping reviews or systematic reviews on the topic were identified. There have been several scoping and systematic reviews on the perinatal health outcomes and experiences among refugee, immigrant, and asylum-seeking women23-25; however, these reviews have focused exclusively on prenatal, intrapartum, and postnatal care and did not include access to sexual health or non-perinatal reproductive services. Other reviews have been conducted on the experiences of refugee women accessing SRH services, but were focused on low- or middle-income countries22 or only included one high-income country (eg, Australia).26

The purpose of this review is to understand access to and use of SRH services among resettled refugees and refugee-claimant women in high-income countries.

Review question

What evidence is currently available to describe access to and use of SRH services for refugee women in high-income countries?

Inclusion criteria

Participants

This review will consider studies that focus on refugee or refugee-claimant women (also referred to as asylum-seeking or undocumented women) who have been resettled in or have fled to high-income countries. Immigrant and migrant women will not be included. No restrictions will be placed on country of origin, women's age, length of time in their host country, religion, sexual orientation, whether they have had children, or their marital status. Studies that have elicited health care providers perceptions on access to SRH services for refugee women will also be included. This includes nurses, family physicians, obstetrician gynecologists, midwives, doulas, social workers, refugee resettlement workers, and other relevant key informants.

Concept

The main concept under study is sexual and reproductive health care services for women. Sexual and reproductive health services have been previously defined to include the provision of accurate information and counseling on sexual and reproductive health, including comprehensive, evidence-based sexuality education; information, counseling, and care related to sexual function and satisfaction; prevention, detection, and management of sexual- and gender-based violence and coercion; a choice of safe and effective contraceptive methods; safe and effective abortion services and care; prevention, management, and treatment of infertility; prevention, detection, and treatment of sexually transmitted infections, including HIV, and of reproductive tract infections; and prevention, detection, and treatment of reproductive cancers.1 While this definition also includes access to safe and effective antenatal, childbirth, and postnatal care, access to this has already been studied and reported elsewhere23 and thus will be excluded from this review.

Access to health care has been defined as "the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care."27^(p.4) Access to health care has five key features: the ability of the user to i) identify their health care needs, ii) seek out health care services, iii) reach necessary health care resources, iv) obtain or use health care services, and v) be offered services appropriate to the needs of care.27

Context

This review will consider studies that describe the SRH of refugee and refugee-claimant women that have been resettled or are seeking asylum in high-income countries. See Appendix III for a complete list of all currently listed (2020) high-income countries, as outlined by the World Bank.28 Studies conducted and data collected in any of the listed countries will be included in this review. Given the potential for similarities across high-income countries, it is possible that results from one high-income country may generalize or be representative of others. Access to services in refugee camps or other temporary settlements will not be included in this review.

Types of sources

This scoping review will consider all study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies.

Qualitative studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will also be considered. Other sources that meet the inclusion criteria, such as systematic reviews, dissertations, gray literature, opinion papers, and research papers that include sub-analyses, will be considered for inclusion. Studies published in all languages will be included; outside translators will be used where necessary. No date restrictions will be made as the purpose of the review is to report on all relevant literature.

Methods

The proposed scoping review will be conducted in accordance with JBI methodology.29

Search strategy

A three-step search strategy will be implemented in this review.29 The search strategy, developed in cooperation with a librarian scientist, will aim to locate both published and unpublished studies. An initial limited search of CINAHL (Appendix I) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of articles selected for full-text review will be screened for additional studies.

The databases to be searched include CINAHL (EBSCO), MEDLINE (Ovid), Embase (Elsevier), Studies on Women and Gender Abstracts (Taylor and Francis), Academic Search Premier (EBSCO), Sociological Abstracts (ProQuest), Social Services Abstracts (ProQuest), PAIS Index (ProQuest), Public Affairs Index (EBSCO), and PsycINFO (American Psychological Association). Sources of unpublished studies and gray literature to be searched include: the United Nations, the United Nations High Commissioner on Refugees, the International Organization for Migration, Centers for Disease Control, United Nations Population Fund, the World Health Organization, Google Scholar, ProQuest Dissertations and Theses, Migration Policy Institute, Refugee Council, Canadian Council for Refugees, Gray Literature Report (via New York Academy of Medicine website), and Grey Source: a Selection of Web-based Resources in Grey Literature.

Study selection

Following the search, all identified records will be collated and uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant papers will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). If any systematic reviews are identified in the search, relevant studies will be extracted individually and analyzed separately from the review, and used to identify individual research papers for inclusion in the review. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) flow diagram.30

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. A draft data extraction tool has been piloted and is provided in Appendix II. The data extracted will include specific details about the population, concept, context, methods, and key findings relevant to the review question. The draft data extraction tool may be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in tabular form in a manner that aligns with the objective of the scoping review. The table will include the following: author(s), year of publication, the country the study was conducted in, methodology, participant characteristics, SRH services used/under study, and access to services (eg, barriers and facilitators). A narrative summary will accompany the tabulated results and will describe how the results relate to the review's objective and question. Findings will be discussed in relation to future research needs, policy, and practice for high-income countries.

Acknowledgments

Shelley McKibbon, a health science librarian at Dalhousie University, for her assistance in developing the search strategy for this review. This review will contribute toward an MA in Health Promotion for ESC.

Funding

ESC has received student support funding from the following sources: The Faculty of Graduate Studies at Dalhousie University and the Social Sciences and Humanities Research Council of Canada.

Appendix I: Search strategy

CINAHL (EBSCO)

Searched February 7, 2020.

Appendix II: Data extraction instrument

Appendix III: High-income countries

References