Complex situations and biology, disempowerment and system-factors: Health professionals' perspectives on challenges to refugees' access to and engagement in pain care.

Chronic pain is common among refugees, who report challenges in accessing and engaging in care. As part of a wider program of research focussed primarily on refugee perspectives on this issue, we were interested in the insights and perspectives of healthcare professionals, who are key agents in improving refugees' health outcomes. We used an interpretivist ontology and a relativist social constructionist approach to analyse data from semi-structured interviews with 22 health and medical professionals who work with refugees across refugee resettlement settings in ten different countries. Interview transcriptions were analysed in NVivo using reflexive thematic analysis. We identified three broad themes that captured health professionals' perspectives: 1) 'Adversity and pain experiences are intertwined', suggested that health professionals saw pain in refugees as a manifestation of trauma, loss, and cultural dislocation. 2) 'Disempowerment shapes refugee engagement with care' suggested that health professionals saw that a loss of autonomy, invalidation and disruption of social networks disrupts refugees' engagement with pain care. 3) 'Barriers within and beyond the healthcare system' suggested that health professionals saw communication and cultural safety as significant barriers to access and engagement, and an unmet need for specific skills, training and support, with a focus on effective communication, cultural safety, the promotion of trauma-informed approaches to care and strategies to ensure health professional wellbeing. PERSPECTIVE: This article fills an important gap in understanding how resettlement countries can best provide care for refugees with chronic pain, by focusing on the perspectives of health professionals engaged in providing that care. Their perspectives contribute important considerations for the design and implementation of services to meet refugees' complex needs.