ASF Standards · Laboratory · Standard 9
Standard 9 — Refugee & Migrant Health
Criteria in this standard
9.1 — Specimen Collection Adapted to Migration and Displacement Experience
9.2 — Trained Interpreters, Not Family Members, for Test Explanation
9.3 — No Documentation Status Barrier to Urgent Testing
9.4 — Results Explained in Plain Language, Understanding Verified
9.5 — Records Transferable When a Patient Relocates
9.6 — Staff Trained on Migration-Competent Practice
9.2 — Trained Interpreters, Not Family Members, for Test Explanation
9.3 — No Documentation Status Barrier to Urgent Testing
9.4 — Results Explained in Plain Language, Understanding Verified
9.5 — Records Transferable When a Patient Relocates
9.6 — Staff Trained on Migration-Competent Practice
9.1
Specimen Collection Adapted to Migration and Displacement Experience
Non-Negotiable
Specimen collection is genuinely adapted to a patient’s migration and displacement experience — including trauma-informed phlebotomy practice and awareness that prior experiences of detention or coercive medical procedures may affect how collection is approached — not delivered identically regardless of that history.
In plain terms: Collection staff genuinely understand that for some patients, a blood draw can trigger real trauma from past experiences — and they adjust how they approach it, not just proceed as usual.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Full | Full | Full |
Why this matters
For a patient with a history of detention or coercive medical procedures, a routine blood draw can trigger genuine, significant distress that generic phlebotomy training doesn’t prepare staff to recognize or respond to appropriately. Treating every patient identically, rather than being attentive to signals that someone may need a different, more carefully explained approach, can turn a routine procedure into a re-traumatizing experience that also undermines future willingness to seek care.
What good looks like
- Collection staff receive training specific to trauma-informed phlebotomy.
- Consent for collection is genuinely explained and confirmed, not assumed.
- Staff can recognize and appropriately respond to visible distress during collection.
Common failure modes
- Training covers only general cultural awareness, not collection-specific trauma response.
- Consent is assumed from the patient’s presence at the scheduled appointment.
- Staff proceed with collection despite visible patient distress, unsure how to respond.
Worked example
In practice
A community clinic laboratory serving a significant refugee population.
BeforeA phlebotomist proceeded with a routine blood draw on a patient who became visibly distressed and withdrew his arm partway through, and the phlebotomist, uncertain how to respond, simply tried to continue more quickly rather than pausing.
ActionThe laboratory introduced specific trauma-informed collection training covering recognition of distress signals, the importance of pausing and explaining each step before proceeding, and the patient’s right to stop the procedure at any point.
AfterThe Monitor reviewed the training curriculum and confirmed it specifically addressed collection-related trauma response, distinct from general cultural awareness content, and confirmed completion records for current collection staff. Criterion verified.
If you are starting from zero — do this first
- Check whether current staff training addresses collection-specific trauma response, not just general cultural awareness.
- Build or source specific trauma-informed phlebotomy training.
- Establish a clear, known process for pausing collection if distress is observed.
The most common mistake: Treating general cultural-sensitivity training as sufficient, when it typically doesn’t address the specific, practical response needed when a patient shows distress during an actual blood draw.
Self-assessment questions
1. Are collection staff trained in trauma-informed practice specific to blood draw and specimen collection, not just a general cultural-awareness session? — Genuine adaptation to the collection act itself, which can be a specific trigger point.
Evidence: Training curriculum and completion records
Evidence: Training curriculum and completion records
2. Is consent for collection genuinely explained and confirmed, not assumed from the patient’s presence at the appointment? — Presence at a scheduled visit is not the same as informed, freely given consent for the specific procedure.
Evidence: Direct observation
Evidence: Direct observation
3. Can staff recognize and appropriately respond to visible distress during collection linked to past medical trauma? — A documented, practiced response, not an assumption that staff will improvise appropriately.
Evidence: Staff interview, training record
Evidence: Staff interview, training record
Common reasons for a PARTIAL answer
- Training exists but is general cultural awareness, not collection-specific.
- Consent is implicitly assumed rather than actively confirmed each time.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current training content for collection-specific trauma coverage. |
| Week 2 | Source or build specific trauma-informed collection training. |
| Week 3 | Train all current collection staff and establish a pause process. |
| Ongoing | Include this training in onboarding for all new collection staff. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Training content review | Reviews training curriculum for collection-specific trauma-informed content, distinct from general awareness training. |
Evidence base
World Health Organization. Health of refugees and migrants: regional situation analysis, practices, experiences, lessons learned and ways forward. Geneva: WHO; 2018.
World Health Organization Regional Office for Europe. Global Competency Standards for Refugee and Migrant Health. Copenhagen: WHO/Europe; 2024.
9.2
Trained Interpreters, Not Family Members, for Test Explanation
Non-Negotiable
Trained interpreters or cultural mediators are engaged for language-discordant explanation of tests, collection procedures, and results — never minor children, and only family members when genuinely no other option exists and the situation is not high-risk or sensitive.
In plain terms: When a patient doesn’t share a language with staff, a real trained interpreter explains things — never a child, and a family member only as a genuine last resort for low-risk situations.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Full | Full | Full |
Why this matters
Using a minor child to interpret sensitive medical information places an inappropriate burden on that child and can produce inaccurate or incomplete interpretation at exactly the moment accuracy matters most. Family member interpretation, even from willing adults, introduces real risks for sensitive results — a patient may not disclose or fully understand a reproductive health or infectious disease finding honestly through a relative, and the family member’s own emotional involvement can distort what gets communicated.
What good looks like
- A trained interpreter is actually used, verifiable through a usage log.
- No instance exists of a minor child interpreting a sensitive result.
- Sensitive results specifically use a qualified interpreter, not a willing family member.
Common failure modes
- An interpreter contract exists but is rarely actually used in practice.
- A child accompanying a parent is used informally to interpret.
- A willing, available family member is used even for sensitive results.
Worked example
In practice
A laboratory explaining a sensitive infectious disease result to a language-discordant patient.
BeforeThe patient had arrived with her teenage son, who spoke the local language fluently from school. Staff, under time pressure and without easy access to the contracted interpreter service, asked the son to interpret the sensitive result directly.
ActionThe laboratory invested in a faster-access phone interpreter line specifically to remove the time-pressure justification for informal interpretation, and explicitly trained staff that minors are never used to interpret, regardless of apparent fluency or convenience.
AfterThe Monitor reviewed the interpreter usage log and found consistent use of the professional phone interpreter service for sensitive results, with no documented instance of minor interpretation since the change. Criterion verified.
If you are starting from zero — do this first
- Check your interpreter usage log — is it actually being used, or bypassed under time pressure?
- If access is slow, consider a faster-access phone or video interpreter line.
- Explicitly brief all staff that minors are never used to interpret, regardless of convenience.
The most common mistake: Using an available child or family member specifically when the contracted interpreter service feels too slow or inconvenient to access in the moment, rather than treating interpreter access as non-negotiable.
Self-assessment questions
1. Is a trained interpreter actually engaged for language-discordant patients, verifiable through a usage log, not just available in policy? — Verified against actual recent use, not only the existence of an interpreter contract.
Evidence: Interpreter usage log
Evidence: Interpreter usage log
2. Is there any documented instance of a minor child being used to interpret a sensitive result? — A single such instance is a direct, serious failure of this criterion.
Evidence: Incident review, staff interview
Evidence: Incident review, staff interview
3. For sensitive results — infectious disease, reproductive health — is a qualified interpreter used rather than a family member, even when a family member is readily available and willing? — Availability and willingness of a family member does not substitute for a qualified, impartial interpreter on sensitive results.
Evidence: Sensitive result interpreter usage record
Evidence: Sensitive result interpreter usage record
Common reasons for a PARTIAL answer
- An interpreter service exists but is slow to access, encouraging informal workarounds.
- Family members are used for sensitive results when “readily available.”
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current interpreter access speed and usage patterns. |
| Week 2 | Improve access speed if delays are driving informal workarounds. |
| Week 3 | Brief all staff explicitly on the no-minors, sensitive-results-require-professional-interpreter rules. |
| Ongoing | Review interpreter usage logs periodically for consistency. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Interpreter usage log review | Reviews the usage log for actual, consistent interpreter engagement, particularly for sensitive results. |
Evidence base
World Health Organization Regional Office for Europe. Global Competency Standards for Refugee and Migrant Health. Copenhagen: WHO/Europe; 2024.
9.3
No Documentation Status Barrier to Urgent Testing
Non-Negotiable
Lack of national identification, insurance documentation, or immigration status documentation never delays or blocks urgent or clinically necessary testing, and front-line staff are explicitly trained that this is the rule, not left to infer it.
In plain terms: Not having the “right” papers never stops someone from getting an urgent test — and staff know this rule clearly, not just as something they’re left to guess at.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Full | Full | Full |
Why this matters
An undocumented or underdocumented patient facing urgent clinical need cannot afford administrative delay, yet front-line staff who are never explicitly told this policy may default to the cautious, delay-causing choice of insisting on standard documentation first, simply because nobody told them clearly that urgent testing takes priority. The gap between a written policy existing somewhere and front-line staff genuinely, confidently knowing and applying it in the moment is exactly where this criterion is most often only partially met.
What good looks like
- Front-line staff state the rule clearly, without hesitation, when asked.
- A documented instance exists of testing proceeding without standard documentation.
- An alternative identity verification method is actually used, not simply skipped.
Common failure modes
- Staff hesitate or seem unsure when asked about the policy directly.
- No real example exists of the policy being applied in an actual situation.
- Removing documentation requirements also inadvertently removes any identity verification at all.
Worked example
In practice
A clinic laboratory receiving an urgent test request for an undocumented patient.
BeforeA written policy existed stating documentation status should never delay urgent testing, but front-line reception staff had never been specifically briefed on it and, when an undocumented patient arrived needing urgent testing, hesitated and asked a supervisor before proceeding, causing a meaningful delay.
ActionThe laboratory explicitly briefed all front-line staff on the policy, built a simple alternative identity verification method using a name, date of birth, and photograph taken at the point of care, and ran a tabletop scenario to confirm staff understood the process.
AfterThe Monitor asked front-line staff directly about the policy and received clear, confident, correct answers, and reviewed a recent documented instance of urgent testing proceeding without standard documentation. Criterion verified.
If you are starting from zero — do this first
- Ask front-line staff directly, right now, what happens if an undocumented patient needs urgent testing.
- If the answer is hesitant or unclear, brief staff explicitly on the policy.
- Build a simple alternative identity verification method.
The most common mistake: A correct, well-intentioned policy exists in writing but was never explicitly communicated to the front-line staff who actually encounter the situation, leaving them to default to caution and delay when the policy actually requires the opposite.
Self-assessment questions
1. Can front-line staff state clearly, without hesitation, that undocumented status does not block urgent testing? — Hesitation or uncertainty in the answer suggests the policy isn’t genuinely embedded in practice.
Evidence: Staff interview
Evidence: Staff interview
2. Is there a documented instance of testing proceeding for a patient without standard documentation? — Evidence the policy functions in practice, not only on paper.
Evidence: Case record
Evidence: Case record
3. Is patient identity still verified through an alternative, documented method even without standard documentation? — Removing the documentation barrier does not mean removing identity verification; an alternative method must still exist.
Evidence: Alternative identification procedure
Evidence: Alternative identification procedure
Common reasons for a PARTIAL answer
- The policy exists in writing but front-line staff were never explicitly briefed.
- No alternative identity verification method exists once standard documentation is waived.
Implementation plan
| When | What |
|---|---|
| Week 1 | Ask front-line staff directly about the current policy understanding. |
| Week 2 | Brief staff explicitly if any hesitation or gap is found. |
| Week 3 | Build an alternative identity verification method. |
| Ongoing | Include this explicitly in onboarding for all front-line staff. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| ASK | Front-line staff interview | Asks front-line staff directly, without prompting, what happens when an undocumented patient needs urgent testing. |
Evidence base
World Health Organization. Health of refugees and migrants: regional situation analysis, practices, experiences, lessons learned and ways forward. Geneva: WHO; 2018.
9.4
Results Explained in Plain Language, Understanding Verified
Core
Where the laboratory communicates results directly to a patient, this is done in plain language, with understanding actively verified through methods like teach-back, not assumed from silence or a nod.
In plain terms: When a patient gets their results explained directly, it’s in genuinely plain language — and staff actually check the patient understood, rather than assuming from a nod.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Where applicable | Where applicable | Where applicable |
Why this matters
A patient’s silence or nod during a results explanation is frequently a signal of politeness, deference, or simple confusion rather than genuine comprehension, particularly across language and cultural differences where a patient may feel it’s inappropriate to admit not understanding. Teach-back — asking the patient to explain the result back in their own words — is a specific, evidence-based technique precisely because it tests comprehension directly rather than relying on an ambiguous social cue.
What good looks like
- Teach-back is actively used, for both the result and its clinical meaning.
- Results are explained without unexplained medical jargon.
- Written material, where provided, is in the patient’s own language or plain translated form.
Common failure modes
- “Do you have any questions?” is used instead of genuine teach-back.
- Explanations include unexplained technical terms assumed to be understood.
- Written material exists only in the facility’s operating language.
Worked example
In practice
A laboratory explaining a diabetes screening result directly to a patient.
BeforeA technologist explained an elevated glucose result using the term “hyperglycemia” and reference range numbers, then asked “does that make sense?” The patient nodded, and the technologist moved on, with no actual confirmation of genuine understanding.
ActionThe laboratory retrained staff on teach-back specifically, requiring the patient to explain the result and its meaning back in their own words before the conversation concluded, and built simplified, plain-language explanation scripts for common result categories.
AfterThe Monitor observed a results explanation and confirmed genuine teach-back was used, with the patient accurately restating the result’s meaning in her own words. Criterion verified.
If you are starting from zero — do this first
- Observe a current results explanation — is it teach-back, or “any questions?”
- Build plain-language explanation scripts for common result categories.
- Train staff specifically on genuine teach-back technique.
The most common mistake: Treating “does that make sense?” or a patient’s nod as equivalent to teach-back, when genuine comprehension verification requires the patient to actively explain the information back, not simply confirm understanding passively.
Self-assessment questions
1. Is understanding actively checked using teach-back, for both the result and its clinical meaning? — Asking the patient to explain back in their own words, not just “do you understand?”
Evidence: Direct observation
Evidence: Direct observation
2. Are results explained without unexplained medical jargon or reference-range numbers presented with no context? — A number and a reference range alone, with no explanation, is not meaningful communication for most patients.
Evidence: Direct observation of explanation content
Evidence: Direct observation of explanation content
3. Is written material, where provided, available in the patient’s own language or in plain, translated form? — Written material only in the facility’s operating language is not genuinely accessible.
Evidence: Written material review
Evidence: Written material review
Common reasons for a PARTIAL answer
- “Any questions?” is used in place of genuine teach-back.
- Written material exists only in the operating language.
Implementation plan
| When | What |
|---|---|
| Week 1 | Observe current results-explanation practice. |
| Week 2 | Train staff on genuine teach-back technique. |
| Week 3 | Build plain-language scripts and translated written materials for common languages served. |
| Ongoing | Spot-check results explanations periodically. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| OBSERVE | Results explanation observation | Observes an actual results explanation for genuine teach-back and plain-language use. |
Evidence base
World Health Organization Regional Office for Europe. Global Competency Standards for Refugee and Migrant Health. Copenhagen: WHO/Europe; 2024.
9.5
Records Transferable When a Patient Relocates
Core
A patient who relocates, including across borders, can obtain a copy or transfer of their laboratory history in a usable format, without unreasonable cost or delay acting as a practical barrier.
In plain terms: If a patient moves away, including to another country, they can actually get their lab history in a form a new doctor can use — without it costing too much or taking too long to be realistic.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Full | Full | Full |
Why this matters
Displaced and migrant patients relocate far more frequently than settled populations, which makes continuity of their own medical history disproportionately important to their ongoing care — yet they are also the patients most likely to face practical barriers like cost or bureaucratic delay when records systems weren’t designed with this need in mind. A record technically available but practically unaffordable or impractically slow to obtain fails this requirement just as surely as a policy that outright denies the request.
What good looks like
- A straightforward, documented process exists for requesting one’s own history.
- Any fee charged is genuinely proportionate, not a practical barrier.
- The record is provided in a format usable by a receiving facility elsewhere.
Common failure modes
- A process exists on paper but is burdensome enough to function as a barrier.
- A fee is set without consideration of affordability for low-income patients.
- Records are provided only in a proprietary format unusable elsewhere.
Worked example
In practice
A patient relocating internationally and requesting her laboratory history.
BeforeThe laboratory’s standard record request process required a written application, a processing fee set at a level reasonable for most local patients but genuinely difficult for someone with very limited means, and a two-week processing time — workable for routine requests but a real barrier for someone relocating urgently.
ActionThe laboratory introduced a fee waiver option for patients demonstrating financial hardship, an expedited request path for relocation-driven requests, and began providing records in a standard, portable format alongside any internal system export.
AfterThe Monitor reviewed a recent relocation-driven record request and found it processed within three days at no cost, in a portable format. Criterion verified.
If you are starting from zero — do this first
- Review your current record request process for cost and realistic processing time.
- Build a fee waiver option for patients facing financial hardship.
- Check whether records are exported in a format usable elsewhere, not just internally.
The most common mistake: Setting a standard fee and processing timeline that’s reasonable for the general patient population without considering that displaced or low-income patients relocating urgently may find even a modest fee or short delay a genuine, practical barrier.
Self-assessment questions
1. Is there a documented, straightforward process for a patient to request their own laboratory history? — A process that exists but is so burdensome in practice that it functions as a barrier fails this criterion’s intent.
Evidence: Record request process documentation
Evidence: Record request process documentation
2. Is any fee charged for this proportionate and not a practical barrier to a patient with limited means? — A fee that most displaced or low-income patients genuinely cannot afford defeats the purpose of the right to transfer.
Evidence: Fee schedule, waiver policy
Evidence: Fee schedule, waiver policy
3. Is the record provided in a format usable by a receiving facility elsewhere, not only in a proprietary format the laboratory’s own system produces? — A record unusable outside the originating laboratory’s own system does not genuinely support continuity.
Evidence: Sample exported record format
Evidence: Sample exported record format
Common reasons for a PARTIAL answer
- No fee waiver exists for patients facing genuine financial hardship.
- Records export only in a proprietary, internally-usable format.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current record request process for cost and timing barriers. |
| Week 2 | Build a fee waiver and expedited path for relocation-driven requests. |
| Week 3 | Confirm records export in a portable, externally usable format. |
| Ongoing | Review request processing time and fee impact periodically. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Record request process review | Reviews the record request process for genuine accessibility, including cost and format. |
Evidence base
World Health Organization. Health of refugees and migrants: regional situation analysis, practices, experiences, lessons learned and ways forward. Geneva: WHO; 2018.
9.6
Staff Trained on Migration-Competent Practice
Core
Staff with direct patient contact receive specific training on migration- and displacement-competent practice — not general cultural-sensitivity training alone — covering trauma-informed collection, working with interpreters, and recognizing documentation-status barriers.
In plain terms: Patient-facing staff get real, specific training on working with migrant and displaced patients — not just a generic “be culturally sensitive” session.
| Facility category | Standalone lab | Hospital lab | Clinic lab |
|---|---|---|---|
| Applicability | Full | Full | Full |
Why this matters
This criterion functions as the training backbone supporting every other criterion in this standard — trauma-informed collection, proper interpreter use, and documentation-status awareness all depend on staff actually having received specific training in these areas, not general cultural-sensitivity content that often doesn’t translate into concrete behavioral change. Training delivered once at onboarding and never refreshed also fails to keep practice current as staff turn over and as the laboratory’s own understanding of good practice develops.
What good looks like
- Training specifically addresses migration and displacement contexts, not generic content.
- All staff with direct patient contact complete it, not a subset.
- Training is refreshed on a schedule, not delivered once and forgotten.
Common failure modes
- Only general cultural-sensitivity or customer-service training is provided.
- Some patient-facing staff, especially newer or part-time hires, are missed.
- Training was delivered once, years ago, with no refresher since.
Worked example
In practice
A laboratory auditing its training coverage across all patient-facing roles.
BeforeFull-time collection staff had received migration-competent training during a one-time session two years earlier, but part-time and newer staff hired since then had never received it, and no refresher had been scheduled for anyone.
ActionThe laboratory built migration-competent training into mandatory onboarding for every patient-facing role, including part-time staff, with a biennial refresher requirement for all current staff going forward.
AfterThe Monitor reviewed training completion records across all patient-facing roles, including part-time staff, and found full, current coverage with no gaps. Criterion verified.
If you are starting from zero — do this first
- List every role with direct patient contact, including part-time and newer staff.
- Check training completion against this full list, not just full-time staff.
- Build a refresher schedule, not a one-time-only requirement.
The most common mistake: Training full-time, longer-tenured staff thoroughly while part-time or more recently hired patient-facing staff are quietly missed from the same requirement.
Self-assessment questions
1. Does training specifically address migration and displacement contexts, distinct from generic customer-service or cultural-sensitivity content? — General cultural-awareness training alone does not cover the specific issues this standard addresses.
Evidence: Training curriculum
Evidence: Training curriculum
2. Is this training completed by all staff with direct patient contact, not only a subset? — Any staff member who collects specimens or communicates results needs this training.
Evidence: Training completion records for all patient-facing roles
Evidence: Training completion records for all patient-facing roles
3. Is the training refreshed on a schedule, not delivered once at hiring and never revisited? — A single onboarding session years ago does not keep practice current.
Evidence: Refresher training schedule and records
Evidence: Refresher training schedule and records
Common reasons for a PARTIAL answer
- Part-time or newer staff are missed from the training requirement.
- No refresher schedule exists beyond the original onboarding session.
Implementation plan
| When | What |
|---|---|
| Week 1 | List all patient-facing roles and current training completion status. |
| Week 2 | Close any gaps found, including part-time staff. |
| Week 3 | Build a refresher schedule and add the training to standard onboarding. |
| Ongoing | Track completion for every new hire and scheduled refresher. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Training completion audit | Reviews training completion records across all patient-facing roles, including part-time staff, for current coverage. |
Evidence base
World Health Organization Regional Office for Europe. Global Competency Standards for Refugee and Migrant Health. Copenhagen: WHO/Europe; 2024.