Results are presented according to the study’s objectives: (1) specific health problems among refugees; (2) factors influencing access to and utilization of healthcare - particularly for NCDs - including barriers and facilitators; and (3) behaviours and measures adopted by refugees and professionals involved in refugee reception and integration to overcome constraints in healthcare access and utilization.
5.1. Perceptions of refugee health problems
Although counterintuitive, the most common health problems among refugees resemble those found in the general population; however, certain groups exhibit a higher prevalence of specific conditions (24). While some participants described refugees’ health needs as broadly comparable to those of the Portuguese population, others perceived them as more vulnerable, with greater needs. As one participant observed, Refugees arrive… not only to Portugal, but to our clinic, with a range of needs. I think that they may not necessarily need extensive help” (E1). Another added, “In terms of physical health, not as much—some arrive with serious conditions, but for most it’s nothing major” (E2). Similar views were expressed by others, such as E3, who noted, “Refugees’ health needs are the same as those of ordinary people. What makes it urgent here is the time we must work with them. Many have never seen a doctor, or only once or twice, without follow-up.” In contrast, some participants considered refugees to have a greater health burden: “It’s clear that refugees have greater needs than the general population” (E8), and “Most of these people, when they arrive here… eventually have some health problem” (E10).
Participants frequently distinguished between physical and mental health concerns, highlighting that refugees are not a homogeneous group and may differ in the relative burden of these issues. For example, E2 stressed that “it’s important to separate mental from physical health—the needs are different. Mental health is an absolute necessity for most of them”. At the same time, E4 remarked, “There’s always something psychological, even for those who say they are unaffected. Breaking away from their lives leaves a mark.” This perception was echoed by E5: “In terms of mental health, I can say all of them arrive with some issue.”
Mental health emerged as the most prominent concern, particularly depression, anxiety, and post-traumatic stress disorder (PTSD). Participants described a wide range of psychiatric symptoms, from pre-existing diagnoses to conditions emerging after arrival. As one reported, “Not rarely, we receive cases with serious mental health diagnoses made before departure” (E3). Others described “anxieties, depressions, even panic attacks from extreme anxiety” (E4) and “frequent anxiety, sleep disturbance, depression” (E6). Depression was identified as the most common, but PTSD was regarded as “unique to this population” (E8), particularly among those with war-related trauma (E9).
The literature corroborates that refugees face a higher risk of psychiatric disorders—including PTSD, depression, anxiety, complicated grief, psychosis, and suicide. These conditions stem from pre-migration experiences such as exposure to violence, forced displacement, and resource scarcity, as well as post-migration stressors like overcrowded camps, prolonged asylum procedures, and legal insecurity (25–30). Participants’ narratives reinforced the link between migration processes and mental health. As E3 explained, “Mental health issues often stem from migration itself—whether from traumatic events before departure or the migration process itself, which can include slavery or continuous abuse.” Similarly, E5 stated, “Almost all arrive with some mental health issue, even if only due to the change in environment and what they experienced before arriving.” In contrast, others noted the elevated risks faced by individuals from conflict-affected countries (E12) and the distinct problems that arise from the migration journey (E13).
Not all refugees, however, present with enduring symptoms. Some may exhibit transient stress reactions that resolve with adaptation to the host environment (31, 32). As one participant noted, “Some symptoms are part of a normal adaptation process, even if they cause distress” (E1). Another observed that “in the first days there may be many symptoms—anxiety, sleeplessness, crying—but after a week or two, about 40% no longer need care” (E7).
Nevertheless, in some cases, health concerns may remain hidden, as refugees prioritise survival, housing, and income over medical care: “Only later do they reveal health problems—the priority is survival, food, money, not health” (E11).
The migration process can heighten refugees’ vulnerability to NCDs and other “physical” health issues. For individuals already diagnosed, health status may deteriorate due to loss of medical care, treatment interruptions, inadequate shelter or nutrition, and the psychological stress linked to displacement (33). Differences in health status, influenced by local epidemiology and migration trajectories, were evident in participants’ accounts. These narratives illustrate how specific refugee subgroups—based on country of origin, demographic profile, and migration experience—displayed distinct patterns of illness.
Some participants reported that, overall, physical health problems were not always severe, although certain conditions were recurrent. As one explained, “In physical health, not so much—some arrive with serious problems, but most are minor. The main physical health issues in refugees are… hepatitis, diabetes, epilepsy” (E2). Others described variations linked to migration context: “From 2020 to early 2021, we worked a lot with boat arrivals—mostly young people, generally without major health issues. But in earlier resettlement programs, or during the Afghan emergency, we saw older individuals, and then diabetes became more common, linked not only to age but also to a more urban origin with prior healthcare access” (E3).
The importance of NCDs was repeatedly emphasized. One participant noted, “NCDs are an important issue. People may arrive with them, but often they’ve disregarded them all their lives” (E5). Another highlighted the combined influence of epidemiology and migration stressors: “Most refugees come from countries with different health access, different epidemiology, and complex migration processes that make them vulnerable to transmissible and non-communicable diseases, as well as deficiencies - both physical and psychological - often interlinked” (E6).
According to some participants, diabetes is persistent in some groups. At the same time, high blood pressure was more common among men over 40 years of age or in humanitarian boat arrivals, many of whom had never accessed healthcare.
These findings align with the existing literature, which indicates that although limited data on NCDs prevalence, multimorbidity patterns, and risk factors among refugees is available, country of origin and local epidemiology are key considerations in health assessments of newly arrived populations. NCDs are a significant burden among refugees, most of whom come from low- and middle-income countries where such conditions already strain healthcare systems (34). Specific patterns differ by origin: higher diabetes mortality among refugees from North Africa, the Caribbean, and South Asia; higher hypertension and cerebrovascular disease among West Africans; and higher coronary heart disease among those from Afghanistan, Iraq, and North Africa (35–37). Delays in diagnosis and treatment contribute to higher stroke mortality, while iron-deficiency anaemia is more prevalent among migrant women and children (35). Infection-related cancers (e.g., liver, cervical, stomach) occur more frequently in refugee populations, whereas Western lifestyle–related cancers (e.g., colorectal, breast, prostate) are less common (38, 39).
Participants also linked epidemiological trends to the country of origin. As one noted, “Among Middle Eastern and Syrian populations, we saw a blood disorder—quite common there. Another pattern: poor oral health, especially in the Middle East, more so than in Africa” (E3). Others stressed the need for early screening: “Needs begin at arrival. Screening is crucial to identify problems, since origins vary—some countries have virtually no health system, others have access only for those with money, often just in major cities” (E11).
The World Health Organization (WHO) (2019) identifies migration-related exposures—psychosocial stress, reproductive health problems, higher neonatal mortality, substance use, nutritional disorders, alcohol use, and exposure to violence - as factors increasing NCD vulnerability (40). Refugees also face barriers to accessing primary healthcare, considered essential for NCD prevention and management (40).
Patterns of alcohol and tobacco use among refugees were described by participants as influenced by both cultural background and post-migration circumstances. According to one participant, “…they drink to get drunk… smoking is completely normalised” (E3). For individuals from countries where alcohol consumption was absent, migration to Portugal sometimes triggers drinking, with a parallel rise in smoking (E5). Substance use patterns were also perceived to differ across nationalities: “Tobacco and alcohol are more common, for example, in Iraq. In Afghanistan, hardly anyone smokes—surprisingly. Syrians drink; in Africa, cannabis and hashish use are also common” (E11). Several participants linked tobacco and alcohol with coping strategies: “Tobacco and alcohol are coping strategies for discomfort in their present reality—tobacco especially, but also alcohol” (E12).
Dietary habits were reported to reflect both the traditions of the country of origin and post-migration constraints. One participant noted that diets often consisted mainly of rice, vegetables, and eggs, with low fruit intake (E2). At the same time, another highlighted “a lot of fried food and very high sugar intake” despite a greater presence of vegetables compared to Portugal (E3). Urban, younger refugees were perceived to consume “chips, fried food, [and] soft drinks” (E11), and food insecurity was also a concern, with some individuals reducing food expenditure to send part of their small allowance to family abroad (E12).
Physical activity patterns varied widely. Some refugees engaged in regular exercise, joining gyms or playing football on weekends, although depression was noted as a barrier that kept some indoors for extended periods (E2). Others reported that “only those previously active tend to maintain exercise” after resettlement (E4), while some observed that physical activity was generally not a priority (E5) or even absent (E9).
Participants underscored the reciprocal relationship between mental and physical health, noting that mental illness can increase the risk of NCDs through unhealthy lifestyle behaviours. In contrast, physical illness can increase the risk of mental health problems (41). As one participant stated, “Mental illness predisposes to, and masks, physical disease—and vice versa” (E6). Another observed that “physical problems can trigger mental health issues, often stress-related, which in turn contribute to addictive behaviours” (E8).
Refugees’ self-perception of health is often influenced by the limited recognition of mental health problems in many countries of origin, which can delay access to care. These conditions are frequently expressed through somatic symptoms - such as headaches, dizziness, palpitations, or fatigue - to avoid the stigma associated with mental illness (31). As one participant (E3) explained, “In seven years, I’ve never met an asylum seeker without some mental health issue—awareness varies widely.” Others emphasised that these problems are “often unaddressed—due to unawareness or shame” (E6), and that “mental illness carries stigma—only some groups like Afghans, Kurds, Assyrians show more awareness” (E11). The importance of culturally sensitive communication was also highlighted: “It helps to have someone acceptably explain the need for care in an acceptable manner” (E13). From the perspective of healthcare professionals, refugees’ health is shaped by pre-migration conditions, the migration journey, and the post-migration environment. Nevertheless, participants noted a general lack of awareness among practitioners. As one stated, “Mostly no—neither professionals nor the system” (E3), while another observed, “It’s not something professionals consider” (E8). Others expressed similar views: “In my centre, they don’t fully understand” (E9); “Doctors aren’t aware of pre/post-migration experiences—it’s a discovery” (E11). The need for targeted training was emphasized: “We need training for each new population—training is rare” (E12), highlighting gaps in professional preparedness to address the specific health needs of refugees.
Pre-migration and post-migration emerged as a critical aspect in the interviews. Participants highlighted that health issues are shaped not only by conditions in host countries but also by those in countries of origin and during the migration process. This aligns with Spallek et al. (2011), who argue that migrants' health is the cumulative result of exposures across all phases of their migration (42).
However, several professionals reported limited awareness of these temporal dimensions among healthcare providers, reflecting a gap in training and preparedness:
“Most professionals are unaware… neither professionals nor the system itself address it” (E3); “It's not something professionals generally consider” (E8); “They don’t fully understand these aspects” (E9); “I don’t think doctors are aware of the pre- and post-migration experience” (E11);”There’s a lack of training on cultural specificity, which is essential for adequate care” (E12).
Mental and physical health interdependence also played a prominent role. Participants identified poor mental health as a barrier to overall well-being (43–49). This is supported by existing literature showing a strong connection between mental health disorders and the development or worsening of NCDs (43, 45, 47).
These findings underscore the importance of: (1) integrating mental health into primary care; (2) ensuring culturally sensitive mental health interventions; and (3) recognizing traumatic experiences—such as family separation, poverty, and reception processes—as potential mediators of mental health conditions (50, 51).
5.2. Perceptions of access and utilization of healthcare
Participants’ accounts reveal a complex set of interconnected challenges faced by refugees in accessing healthcare services in Portugal. One of the main issues raised is the mismatch between refugees’ expectations and the actual functioning of the NHS. Many refugees arrive with idealized notions of Europe and anticipate prompt, comprehensive, and high-quality healthcare. When these expectations are unmet, they often experience confusion and frustration. As one participant stated: “The challenge of expectations is terrible, terrible (…) We don’t have a perfect healthcare system, and people arrive here with high expectations” (E5); Another noted: “Most of them had great expectations regarding our services, but when they encountered linguistic and cultural barriers, many ended up frustrated with the care they received” (E9).
The complexity of navigating the NHS was also emphasized as a major barrier, particularly for those unfamiliar with the bureaucratic and procedural demands of the Portuguese healthcare system. This challenge was vividly described by one professional: “If the system is already strange for us—and it is—we're constantly discovering more: ‘You had to come at 6 a.m.? Sorry.’ Now imagine someone coming from a place where they had no access to public healthcare—it’s all very confusing” (E3).
Participants highlighted that limited appointment availability, long waiting times, and the fragmentation of care pathways often place additional burdens on both refugees and the professionals assisting them. This is especially challenging in group situations, where access must be coordinated for several individuals: “There are tests that are covered in one clinic, but not others. You end up taking a group of ten people to multiple clinics to do different tests... And the interpreter has to explain all this to them” (E11). Furthermore, the lack of continuity after the initial 18-month integration program was seen as a critical issue, raising concerns about sustainability and long-term access. As one participant asked rhetorically: “When the integration period ends, what guarantees are there? None. Absolutely none” (E4). Healthcare professionals were also described as not always being adequately prepared or culturally sensitive to address the specific needs of refugees, particularly in the area of mental health. Language barriers, time constraints, and unfamiliarity with cultural expressions of illness can obstruct effective communication and care. One professional observed: “We need to understand that when dealing with these people, we’ll probably need more time - and that’s something we’re already lacking in general” (E6). Another added: “Some doctors said: ‘I’m not prepared, and I don’t want to see them. Don’t schedule appointments with me’” (E4).
The low health literacy among some refugees, differences in the perception of illness and treatment, and confusion regarding the structure of the healthcare system (such as the role of primary care vs. specialist care) were also noted as key challenges. Mental health symptoms may be expressed somatically, which can complicate diagnosis and treatment. As one participant remarked: “They show symptoms very different from what we’re used to, and sometimes we just don’t understand them. Mental illness is not easy to address—especially for those outside the mental health field” (E6).
These findings align with existing literature, which highlights that displaced people face distinct structural, linguistic, and cultural barriers in host countries' healthcare systems (52, 53). Additionally, the UNHCR (2018) emphasizes the importance of a reciprocal integration process, whereby both the host society and migrants share responsibilities and rights (54).
Barriers to accessing and utilizing healthcare services emerge as a significant subtheme in participants’ narratives. These include socioeconomic obstacles as well as non-financial barriers such as language, cultural differences, structural issues, lack of information, and healthcare professionals’ attitudes. Legal and bureaucratic barriers also notably impact access. Dias et al. (2018) acknowledge that migrants encounter challenges related to sociocultural differences between patients and healthcare providers, including language barriers and a lack of cultural competence (55). This may result in the stereotyping or infantilization of migrant patients, as culture is sometimes reduced to nationality, ethnicity, or language, becoming a source of discrimination. From the interviews, the main barriers identified among refugees, ranked by frequency, are: 1) Cultural/Cultural Competence (41 units of meaning, 12 interviews), 2) Administrative/Bureaucratic (36 units, 11 interviews), 3) Linguistic (33 units, 13 interviews), and 4) Socioeconomic (10 units, six interviews).
Participants consistently reported a lack of cultural competence in healthcare services: “The biggest specific barrier for this population is cultural sensitivity… individually, you find some health professionals more sensitized, but generally, there is no cultural competence” (E3). Another participant stated, “I think there is no cultural competence, period” (E4), and “It is not a concept that we talk about… zero, I don’t think it exists” (E10). The lack of cultural competence leads to inappropriate responses, as illustrated by a case where a young female refugee was shocked by a healthcare professional’s reaction to a harmful traditional practice, female genital mutilation: “She [the colleague] screamed… misbehaved… and even took photos with her phone to show others. The girl never wanted to return” (E9).
Cultural mediators were highlighted as vital for bridging communication and cultural gaps: “If it weren’t for the cultural mediator, we might have interpreted things differently… they facilitate the work a lot” (E1). Another example shows the mediator helping a young Muslim woman feel comfortable during a gynecological examination: “If I weren’t there with her, she would never have undressed” (E3).
Administrative and bureaucratic barriers also hinder access, such as difficulties in obtaining health system numbers, slow registration processes, and restrictions on accompaniment during consultations: “Access is not always easy because not all refugees have the NHS number” (E2); “They often prohibit accompaniment during consultations or emergencies” (E3).
Language barriers remain a significant challenge. Participants report doctors refusing to attend to patients due to communication difficulties: “I encountered doctors who refuse to attend because we need a phone translator… some doctors don’t speak English or refuse to speak it” (E2). The shortage of qualified translators results in problematic translation chains, diminishing the quality of communication: “There was a chain of one, two, three, four people translating… the doctor didn’t understand the English from the translator” (E13).
Economic barriers were also mentioned, with the high cost of exams and medication limiting healthcare utilization: “Some people even gave up and didn’t do the endoscopy because of economic difficulties” (E4); “Some exams out of pocket were 200 euros, which was unaffordable” (E13).
In summary, these interconnected barriers—cultural, bureaucratic, linguistic, and economic—severely constrain refugees’ equitable access to healthcare. Improving cultural competence, administrative processes, interpreter availability, and financial support are essential steps toward better healthcare integration for refugees.
Professionals’ accounts revealed several facilitators that enhance refugees’ access to and utilization of healthcare services, although these facilitators are less frequently addressed in the literature compared to barriers. Analysis of the interviews identified 34 meaningful references related to facilitators, primarily categorized as administrative/bureaucratic (22 references across 10 interviews), linguistic (7 references across seven interviews), cultural/cultural competence (4 references across three interviews), and socioeconomic (1 reference in 1 interview).
Administrative/bureaucratic facilitators were the most frequently mentioned, particularly the role of third-sector organizations and healthcare professionals who accompany refugees and help them navigate the system. As one participant noted: "What leads me to think that if we didn’t exist – the support technicians – people would not just have difficulties but be outright blocked, meaning they would have no access to the health system... But when we accompanied them, things would unblock" (E4).
Another emphasized the importance of these organizations: "The refugees I have worked with are connected to an organization, which makes things much easier because they have someone on the ground helping, guiding, and advocating for them, which is a major facilitator" (E7).
Healthcare professionals themselves are also key facilitators: "There is always a healthcare professional. To get certain things done, there is always a healthcare professional who either solves or guides us with the problem... that’s how we manage, otherwise we won’t get much done" (E2).
Linguistic facilitators, especially sociocultural mediation and translation, were highlighted as crucial for overcoming communication barriers between refugees and healthcare providers. One participant illustrated: "These same people accompany us in emergencies, explain the patient’s story to the medical team. Sometimes they even provide translation, and that alone makes a huge difference" (E7); "Thinking of patients with less access to translators… sometimes we find more sensitive doctors who use their phones to translate" (E12). The presence of cultural mediators greatly facilitates communication and understanding: "It makes life easier because we have translators and cultural mediators to work with... without the cultural mediator, we might have interpreted the same word differently" (E1).
Although less frequently mentioned, socioeconomic facilitators also exist, such as organizations that provide financial support to refugees for medical appointments and medication: "Some organizations have professionals who accompany these people to appointments... and some entities help even to finance medication" (E6).
These facilitators emphasize the importance of a structured, migrant-friendly organizational culture and policies that are institutionalized and consistent, rather than relying solely on individual professionals’ goodwill, to ensure equitable access to healthcare for refugees.
Among strategies employed by refugees and professionals to overcome the disadvantages they face in accessing and utilizing healthcare, the one most frequently mentioned to be adopted by refugees to overcome barriers was administrative/bureaucratic, linguistic, and cultural.
Professionals in reception and integration reported using various strategies to overcome administrative/bureaucratic barriers faced by refugees when accessing healthcare. They often consider themselves or their institutions as key facilitators. Informal networks and partnerships with other organizations were considered to enhance refugees’ access, as reflected in the participants’ statements: "(...) especially those organizations that have good psychological support and can manage initial adjustment, anxiety, and mild depression, then refer more severe cases to us" (E8); "When we see empathetic professionals, we often ask for favors to expedite tests or consultations, knowing the patient needs support during the first eighteen months to focus on language and work" (E12);
"They provided a brief training to sensitize us about the issues they would likely face." (E13). Some professionals described strategies refugees use to bypass administrative barriers: "Sometimes refugees, unsure if an appointment will be scheduled, opt to go to the emergency room instead" (E2); "The community itself helps; those who have been here longer assist others by sharing knowledge about how the system works" (E6).
"Some refugees learn the system and attend on days when they know a familiar doctor is available" (E11).
Promoting refugees’ autonomy throughout the reception program is also seen as a strategy to overcome healthcare access barriers: "For chronic diseases, we teach the patient every step they need to follow to reach autonomy, including blood tests, hospital specialists, and medication" (E12).
Healthcare professionals themselves are another vital strategy to overcome barriers. Health centers or hospitals are preferred because they provide better care and follow-up:
"Refugees understand the system and prefer appointments on days with familiar doctors" (E11); "Many refugees return to the same place after the eighteen-month program because they don’t know other options" (E13).
Positive attitudes from healthcare providers also facilitate access:
"I’ve seen some medical staff who actively help to speed up care for refugees" (E3);
"We know doctors who arrange special consultations outside normal hours to accommodate refugees" (E4, E13).
Linguistic barriers were addressed through various strategies, including family or friends acting as translators, translation software, and interpreters from reception organizations:
"Sometimes refugees bring another refugee to help at medical appointments, not only as interpreters but also as companions" (E4); "They often call our interpreters or use Google Translate when making appointments" (E11).
Healthcare professionals are also seen as facilitators in overcoming linguistic and cultural barriers: "The strategy is to find availability to respond as quickly as possible" (E1); "We open transcultural consultations at our hospital to better address refugees’ needs" (E7);
"When the system doesn’t work, we register refugees as residents to enable access through the computer system" (E13). Some professionals mentioned the telephone translation service provided by the High Commission for Migration (ACM) as helpful, however, of limited use: "There is a free translation phone line from ACM, but many doctors are unaware of it" (E11); "Sometimes the service is complicated to access, especially outside working hours" (E13).
Regarding cultural barriers, some organizations offer cultural competence training to facilitate access to healthcare. For instance, "When we receive a specific population, we provide training on their cultural particularities to better support them" (E12). Additionally, "They provided training to sensitize us to the problems refugees might face" (E13). Despite these strategies, some participants perceive that refugees generally lack options to access healthcare autonomously: "I don’t see refugees having their strategies" (E1); "While at the center, it’s mostly us who have strategies to get things done, not the refugees themselves" (E2); "I don’t know many strategies used by refugees because they tend to be very dependent" (E5). A lack of knowledge about the legislation regulating access to the NHS may partly explain refugees’ limited strategies for accessing healthcare.