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ASF Standards · Telemedicine · Standard 8

Standard 8 — Health & Migration

10 criteria · 7 non-negotiable · 3 core · Version 3.0

Criteria in this standard

8.1 — People-Centred Care Adapted to Migration and Displacement Experience
8.2 — Digital Literacy and Device Access Barriers Are Actively Addressed
8.3 — Language and Communication Aids — Interpreters and Cultural Mediators
8.4 — Genuine Agency Is Respected, Not Treated as a Passive Technology Recipient
8.5 — Continuity Across Mobility Is Actively Supported Through Portable Records
8.6 — Evidence-Informed Care for Refugee and Migrant Populations
8.7 — Staff Reflective Practice, Bias Awareness, and Self-Care in Migration Contexts
8.8 — Digital Privacy Concerns Specific to Displaced Populations Are Genuinely Addressed
8.9 — Legal Status Diversity Recognition
8.10 — Care Is Documented and Provided Regardless of Immigration or Legal Status
8.1

People-Centred Care Adapted to Migration and Displacement Experience

Non-Negotiable

Care is genuinely adapted to a patient's migration and displacement experience — including trauma-informed practice and awareness of legal-status barriers to access — not delivered identically regardless of that history, whether the visit occurs in a stable setting or through the far more variable circumstances telemedicine allows a displaced patient to connect from.

In plain terms: Care is genuinely adapted for refugee and migrant patients — recognising trauma, legal-status fears, and the barriers they face — not just delivered the same way as for everyone else.

Facility category Crisis Transition Small Standard
Applicability Full Full Full Full

Why this matters

A refugee who has crossed a border on foot, lost family, and now fears deportation does not arrive at the telemedicine service as an ordinary patient. They may not disclose symptoms that could mark them as a burden. They may not return for follow-up because they moved or because the last clinic reported them. They may react to a physical examination with terror rooted in what was done to them before. Trauma-informed care means staff understand this, explain before touching, ask permission, avoid triggering procedures where possible, and never threaten legal consequences. It means the telemedicine service has decided that a person's migration status does not change their right to care — and staff know it.

What good looks like

  • Care is genuinely, visibly adapted to migration and displacement history.
  • Trauma-informed practice is actually applied, not just referenced.
  • Providers demonstrate specific awareness of legal-status access barriers.

Common failure modes

  • Care is delivered identically regardless of migration history.
  • Trauma-informed practice exists only as a stated principle, not applied practice.
  • Providers show no specific awareness of legal-status barriers.

Worked example

In practice
A 17-clinician telemedicine service in a city with a large refugee population.
BeforeRefugee patients were treated identically to others. Staff had no training on trauma or migration. The Coordinator observed a nurse insisting a woman remove her headscarf for a routine examination, and a receptionist asking for immigration documents at registration. Refugee patients reported avoiding the telemedicine service because 'they ask questions.'
ActionA half-day trauma-informed care module was delivered to all patient-facing staff, developed with a refugee support NGO. A written policy stated that immigration status is not asked and does not affect care. Registration was simplified to name, date of birth, and contact. Examination consent scripts were adapted. A refugee liaison worker was engaged part-time through the NGO.
AfterThe Monitor reviewed the policy, training records (94% of staff), and interviewed the liaison worker and two refugee patients who described feeling safe. Observed a consultation where the clinician explained each step before touching. Verified.

If you are starting from zero — do this first

  1. Ask refugee-serving organisations in your area what their clients say about your telemedicine service.
  2. Write one sentence: 'We do not ask immigration status and it does not affect care.' Post it.
  3. Arrange trauma-informed care training with an NGO that knows the population.
  4. Remove immigration document requests from registration.
The most common mistake: Believing that treating everyone 'the same' is equity — for a traumatised patient, the same treatment is a different experience.

Self-assessment questions

1. Is care genuinely adapted to a patient's migration and displacement experience, not delivered identically regardless of history? — Genuine adaptation, not a generic cultural-awareness statement.
Evidence: Training record on migration-adapted care
2. Is trauma-informed practice genuinely applied, not just referenced as a principle? — Actual practice adaptation, not an assumption of general sensitivity.
Evidence: N/A — tested directly
3. Are providers aware of legal-status barriers to access that may affect this specific patient? — Specific awareness, not a general sense that barriers can exist.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • Adaptation happens for patients who disclose their history but isn't proactively considered otherwise. — Not every patient will volunteer this history unprompted, even when it is clinically relevant.
  • Providers are aware of the principle but haven't received specific training on applying it remotely. — General awareness doesn't reliably translate into genuine practice adaptation without specific training.
  • Adaptation is strong for the first consultation but isn't sustained across ongoing remote follow-up.

Implementation plan

When What
Week 1 Review current practice for genuine adaptation to migration and displacement history.
Week 2 Train providers specifically on trauma-informed, migration-adapted practice.
Week 3 Build awareness of legal-status access barriers into standard practice.
Ongoing Revisit adaptation as the ongoing patient relationship develops.

How the Monitor verifies this

Method What Detail
ASK Migration-adapted care interview Asks providers how they adapt practice specifically for a patient's migration and displacement history.
OBSERVE Trauma-informed practice observation Observes an actual consultation for genuine trauma-informed practice, not generic sensitivity.
DOCUMENT Training content review Reviews training materials for specific coverage of migration-adapted, trauma-informed care.

Supervisor tips

  • Ask a provider to describe a specific example of adapting care for a patient's migration history. — A real, specific example reveals genuine practice, not familiarity with the principle.
  • Ask about continuity of care support specifically for patients without stable documentation. — This is where genuine adaptation is most tested.

Evidence base

[36] WHO Competency Standard 1 (Refugee and Migrant Health: Global Competency Standards for Health Workers, 2021) requires health workers to adapt practice to migration and displacement experiences, address trauma-informed care and psychosocial needs, and support continuity of care regardless of legal status.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.2

Digital Literacy and Device Access Barriers Are Actively Addressed

Non-Negotiable

Barriers to telemedicine access specific to displaced and migrant populations — limited device access, unreliable connectivity, lower digital literacy — are genuinely, actively addressed, not assumed absent simply because a patient has managed to connect for this particular visit.

In plain terms: The service actively removes the barriers refugees and migrants face in using telemedicine — no smartphone, no data, no quiet place, no digital experience — with loaner devices, data support, partner sites, and hands-on help.

Facility category Crisis Transition Small Standard
Applicability Full Full Adapted Full

Why this matters

Telemedicine assumes a smartphone, a data plan, a private space, and the skill to use an app. A refugee in a shelter, a migrant worker in shared housing, an elderly person who has never used video — each lacks one or more. 'Telemedicine is accessible' is true only for people who already have the means. Addressing barriers means: loaner devices; data credits or Wi-Fi access; partner sites (community centres, NGOs) with private rooms and equipment; a tech assistant who sets up the first call; phone-only options; and materials in the patient's language. The service that does not do this has excluded the people who most need it.

What good looks like

  • Device and connectivity barriers are genuinely, actively assessed.
  • Digital literacy support is genuinely offered where needed.
  • A real alternative access method exists for unreliable technology access.

Common failure modes

  • Barriers are assumed absent because a patient managed to connect for this visit.
  • No digital literacy support is offered; independent navigation is assumed.
  • No alternative exists for patients with unreliable technology access.

Worked example

In practice
A telemedicine service contracted to serve a refugee population.
BeforeConsultations required a smartphone app. Uptake among refugees was 15%. Interviews found: no smartphone (30%), no data (40%), no private space (50%), could not use the app (35%). The service had assumed the platform was accessible.
ActionPartnerships with three community organisations provided private rooms with tablets and Wi-Fi. A loaner device programme with data credits was set up. A bilingual tech assistant does a set-up call with every new patient. A phone-only pathway was created. Materials were translated into six languages with pictorial guides. Uptake rose to 68%.
AfterThe Monitor reviewed the partner site agreements, the loaner device register (45 devices), the tech assistant's set-up log, the phone pathway, and uptake data. Verified.

If you are starting from zero — do this first

  1. Ask ten refugee patients what stopped them using the service.
  2. Partner with a community organisation for private rooms and devices.
  3. Assign someone to set up the first call with every new patient.
  4. Offer a phone-only option.
The most common mistake: Declaring the service accessible because the app is free.

Self-assessment questions

1. Are device and connectivity barriers specific to this population genuinely, actively assessed, not assumed absent? — Real, active assessment, not an assumption a successful connection today means reliable access generally.
Evidence: Access barrier assessment process
2. Is digital literacy support genuinely offered where needed, not assumed unnecessary? — Real, offered support, not an assumption every patient can navigate the platform independently.
Evidence: Digital literacy support materials
3. Is there a genuine alternative access method for a patient whose connectivity or device access is unreliable? — A real, practical alternative, not care limited to those with reliable technology access.
Evidence: Alternative access method documentation

Common reasons for a PARTIAL answer

  • Assessment happens at intake but isn't revisited as a patient's actual circumstances may change. — A patient's access reliability can genuinely change, particularly for a population with real mobility.
  • Digital literacy support exists in the dominant local language but not in the patient's own language. — Genuine support needs to be usable in the language the patient actually understands.
  • An alternative access method exists but isn't proactively offered, relying on the patient to request it.

Implementation plan

When What
Week 1 Review current practice for genuine assessment of device and connectivity barriers.
Week 2 Build digital literacy support materials in relevant languages.
Week 3 Establish and proactively offer a genuine alternative access method.
Ongoing Revisit access barrier assessment as patient circumstances change.

How the Monitor verifies this

Method What Detail
DOCUMENT Barrier assessment review Reviews the process for genuinely assessing device and connectivity barriers for this population.
DOCUMENT Digital literacy support review Reviews materials or processes genuinely supporting patients with lower digital literacy.
DOCUMENT Alternative access review Reviews the genuine alternative access method available for patients with unreliable technology access.

Supervisor tips

  • Ask how the service would identify a patient struggling with the platform who hasn't said so directly. — A specific, thoughtful answer reveals genuine, proactive attention, not reliance on the patient to report difficulty.
  • Ask what alternative exists for a patient whose smartphone or data access is genuinely unreliable. — A specific, real answer reveals a genuine alternative, not an assumption everyone has adequate access.

Evidence base

[37] Systematic review of telemedicine for refugee populations identifies limited access to technology, unreliable internet connectivity, and insufficient digital literacy as key barriers hindering effective telemedicine use, requiring active strategies including affordable connectivity, digital literacy support, and multilingual platforms.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.3

Language and Communication Aids — Interpreters and Cultural Mediators

Non-Negotiable

Trained interpreters or cultural mediators are engaged for language-discordant remote consultations — never minor children, and only family members when genuinely no other option exists and the situation is not high-risk.

In plain terms: Trained interpreters or cultural mediators are used for language-discordant consultations — never children, and family members only when there is truly no alternative.

Facility category Crisis Transition Small Standard
Applicability Full Full Adapted Full

Why this matters

This is the refugee-specific counterpart of 8.3, and the stakes are higher. Refugee patients may be discussing torture, sexual violence, or mental illness — topics a family member cannot interpret and should not hear. A cultural mediator adds what an interpreter cannot: understanding of why a patient from a particular background may refuse a male examiner, may not disclose a symptom, or may interpret a question as a threat. Children must never interpret for parents: it exposes them to adult content, it distorts the information, and it places the child in an impossible position. Where the telemedicine service serves a refugee population, interpreter and mediator access is a core service, not an extra.

What good looks like

  • Trained interpreters or cultural mediators are the default for language-discordant consultations.
  • Providers confirm, without hesitation, that minors are never used to interpret.
  • Family-member interpretation, when it happens, is reserved for genuinely low-risk situations only.

Common failure modes

  • Ad hoc bilingual staff or family members are the default, with trained interpreters rarely engaged.
  • A minor has been used to interpret, even occasionally.
  • Family members interpret for high-risk situations like informed consent or bad news.

Worked example

In practice
A 16-clinician telemedicine service serving a refugee settlement of 30,000 people.
BeforeInterpretation was by family members or other patients from the same language group. A ten-year-old was observed interpreting her mother's gynaecological consultation. A man was asked to interpret for a woman describing sexual violence. There was no interpreter budget and no mediator role.
ActionWith NGO support, four cultural mediators from the main refugee language groups were recruited and trained. A phone interpretation service covered other languages. A written rule prohibited children interpreting and required same-gender interpreters for sensitive consultations. Interpreter and mediator use was documented. Staff were briefed on why family interpretation is unsafe.
AfterThe Monitor reviewed 20 refugee patient records: interpreter or mediator documented in all language-discordant consultations. Observed a mediator-supported consultation. Interviewed a mediator who described the same-gender rule in practice. Verified.

If you are starting from zero — do this first

  1. Ask how the last ten refugee consultations were interpreted. Count how many used a child or a family member.
  2. Write the rule today: no children; family only as a last resort and never for sensitive topics.
  3. Recruit mediators from the main language groups — NGOs can help.
  4. Contract a phone service for other languages.
The most common mistake: Using the patient's child to interpret because they speak the language best — the child is harmed and the information is distorted.

Self-assessment questions

1. Are trained interpreters or cultural mediators engaged for language-discordant remote consultations? — Not ad hoc bilingual staff or family members as the default.
Evidence: Interpreter engagement record
2. Is a minor ever used to facilitate interpretation for a family member? — This should never happen — a specific, absolute rule, not a judgement call.
Evidence: N/A — tested directly
3. When a family member interprets due to genuine unavailability of a trained interpreter, is this reserved for low-risk situations only? — Not used for informed consent, complex diagnoses, or bad news — situations requiring professional language support.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • Trained interpreters are engaged for scheduled consultations but not for urgent or same-day remote visits. — Risk doesn't scale down proportionally with how urgent or unscheduled an interaction feels.
  • The no-minors rule is understood by providers but not consistently reinforced with support staff scheduling sessions. — A critical safeguard needs to be embedded across the whole team, not held only by the treating provider.
  • Remote interpreter access exists but connection quality issues sometimes lead to reverting to a family member mid-session.

Implementation plan

When What
Week 1 Review recent language-discordant consultations for interpreter engagement patterns.
Week 2 Establish reliable remote interpreter access, tested for connection quality alongside the platform itself.
Week 3 Brief all staff on the firm exclusion of children as interpreters, without exception.
Ongoing Audit interpreter use records for consistency.

How the Monitor verifies this

Method What Detail
DOCUMENT Interpreter engagement review Reviews records for evidence of trained interpreter or cultural mediator engagement.
ASK Minor-interpreter policy check Asks providers directly whether minors are ever used to interpret, and confirms understanding that this is never acceptable.
OBSERVE High-risk situation check Checks whether family-member interpretation, where it occurs, is confined to genuinely low-risk situations.

Supervisor tips

  • Ask staff directly whether a child has ever interpreted for a parent during a remote session. — A direct question often surfaces what a general policy question won't.
  • Ask what happens if the remote interpreter's own connection fails mid-session. — This reveals whether a genuine backup exists, not reversion to an unqualified family member.

Evidence base

[38] WHO Competency Standard 3 explicitly states health workers have a responsibility not to engage minors to facilitate interpretation, given the associated significant risk, and identifies inaccuracy, information distortion, and compromised confidentiality as documented risks of family-member interpretation generally.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.4

Genuine Agency Is Respected, Not Treated as a Passive Technology Recipient

Core

Refugee and migrant patients are genuinely treated as having real agency and competence in using telemedicine technology — not designed for or spoken to as passive recipients presumed incapable, an assumption real research specifically warns against as its own documented harm.

In plain terms: Refugee and migrant patients are treated as capable people who can learn and use telemedicine — supported, not assumed helpless or handed off to a family member.

Facility category Crisis Transition Small Standard
Applicability N/A Full Adapted Full

Why this matters

There is a paternalism that looks like kindness: assuming the refugee patient cannot use technology, cannot make decisions, needs a relative to speak for them. It strips the patient of agency and often of privacy. Respecting agency means: teaching the patient to use the platform themselves; speaking to them directly, through an interpreter, not to their relative; asking their preferences; involving them in decisions; and recognising that someone who crossed a continent can learn a video app. Support is offered; capability is assumed.

What good looks like

  • Technology competence is genuinely assessed per individual, not assumed from population background.
  • Communication genuinely respects patient agency, not a presumptive tone.
  • Staff are specifically trained on this documented risk of over-generalizing incapability.

Common failure modes

  • All patients from this population are assumed uniformly incapable with technology.
  • Communication is presumptive or simplified based on the patient's background alone.
  • No specific training addresses this documented stereotype risk.

Worked example

In practice
A telemedicine service serving migrant families.
BeforeProviders routinely spoke to the English-speaking child or spouse rather than the patient. Technology set-up was done with the family member. Decisions were discussed with the relative. Patients were passive observers of their own care.
ActionA patient agency protocol was written: the patient is the primary participant; an interpreter is used rather than a family member; tech set-up is done with the patient (with a family member present only at the patient's request); consent and decisions are discussed with the patient directly; the patient's own preferences about family involvement are asked and recorded. Providers completed training on agency and paternalism in migrant care.
AfterThe Monitor reviewed the protocol, training records, and observed a session conducted directly with the patient through an interpreter. Interviewed a patient who described using the platform herself. Verified.

If you are starting from zero — do this first

  1. Watch three sessions with migrant patients. Who does the provider address?
  2. Require interpreters instead of family members.
  3. Do tech set-up with the patient, not the relative.
  4. Ask the patient how they want family involved.
The most common mistake: Speaking to the English-speaking relative because it is easier — the patient has been made invisible in their own consultation.

Self-assessment questions

1. Are patients genuinely assessed as individuals for technology competence, not assumed uniformly incapable based on background? — Real, individual assessment, not a blanket assumption applied to the whole population.
Evidence: N/A — tested directly
2. Does communication about technology use respect the patient's real agency, not speak to them as a passive recipient? — Genuine, respectful communication, not language or tone presuming incapability.
Evidence: N/A — tested directly
3. Are staff specifically trained to recognise this documented risk of over-generalizing incapability to this population? — Real, specific training on this documented concern, not an assumption good intentions alone prevent it.
Evidence: Staff training on agency and stereotype avoidance

Common reasons for a PARTIAL answer

  • Individual assessment happens for adult patients but assumptions persist more readily for older patients within this population. — Age within this population doesn't determine genuine technology competence any more than population background does.
  • Staff avoid overtly presumptive language but subtly simplify explanations more than the individual patient's demonstrated understanding warrants. — Genuine respect for agency means calibrating explanation to the actual person, not a background-based default.
  • Awareness of this concern exists informally but hasn't been specifically, formally trained.

Implementation plan

When What
Week 1 Review current practice for genuine, individual assessment versus population-based assumption.
Week 2 Train staff specifically on this documented stereotype risk and how to avoid it.
Week 3 Build communication practices that calibrate to individual demonstrated competence.
Ongoing Audit communication tone for continued respect of patient agency.

How the Monitor verifies this

Method What Detail
OBSERVE Individual assessment observation Observes whether technology competence is genuinely assessed per patient, not assumed from population background.
OBSERVE Communication tone observation Observes provider communication for genuine respect of patient agency, not a presumptive, simplified tone.
DOCUMENT Staff training review Reviews training records for specific coverage of this documented stereotype risk.

Supervisor tips

  • Observe how a provider explains platform use to a patient from this population, if possible. — Direct observation reveals genuine, individually calibrated respect, not a presumptive default tone.
  • Ask staff whether they've received specific training on avoiding this documented stereotype. — A specific, confident answer reveals genuine awareness, not an assumption good intentions are sufficient.

Evidence base

[39] Research on refugee telehealth implementation specifically cautions that health technologies should be designed to create space for refugees to practice and demonstrate genuine agency, rather than treating them as passive beneficiaries of the technology, a framing that itself perpetuates harmful assumptions about their capabilities.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.5

Continuity Across Mobility Is Actively Supported Through Portable Records

Non-Negotiable

When a genuinely mobile or displaced patient's location changes, the service actively supports continuity through a portable, patient-accessible record — not treating each new location, or each new provider the patient might reach, as an entirely fresh start with no continuity from what came before.

In plain terms: When a displaced patient moves, the service gives them a portable record — a summary they hold, in a form that works anywhere — and keeps the connection going where possible.

Facility category Crisis Transition Small Standard
Applicability Full Full Adapted Full

Why this matters

Telemedicine's advantage for displaced people is that it can follow them — a patient who moves from a shelter to a city to another country can, in principle, keep the same provider. In practice, licensure (2.4) may prevent that. The fallback is a portable record: a summary the patient holds (paper and digital), in their language and the destination's, covering diagnoses, medications, results, vaccinations, and the service's contact. Where licensure allows, care continues; where it does not, the record travels and a handover is attempted.

What good looks like

  • A genuinely portable, patient-accessible record format is actively provided.
  • The record is genuinely kept current, particularly near a known relocation.
  • Patients genuinely know how to access and use their own record independently.

Common failure modes

  • Records remain locked within this service's own system, not genuinely portable.
  • The record becomes outdated, not reflecting the patient's actual, recent status.
  • Patients remain dependent on requesting their own information from this service each time.

Worked example

In practice
A telemedicine service serving people in transit through a migration corridor.
BeforePatients moved on without records. A patient on TB treatment moved from one country to another; the service could not continue care and the patient had no documentation; treatment was interrupted for six weeks.
ActionA portable record is now issued to every mobile patient at each session: a PDF on their phone and a printed copy where possible, in their language and English, with diagnoses, medications and duration, results, vaccinations, and the service's contact. When a patient reports a move, the licensure check (2.4) determines whether care can continue remotely; if not, the service attempts a warm handover to a provider or NGO at the destination. High-priority conditions (TB, pregnancy, serious mental illness) get a follow-up call at two weeks.
AfterThe Monitor reviewed 20 portable records issued, 6 relocation cases with continued remote care, and 4 with documented handover attempts. Verified.

If you are starting from zero — do this first

  1. Give every mobile patient a portable summary at every session.
  2. Make it a PDF on their phone and a print if possible.
  3. When they move, check licensure; continue or hand over.
  4. Follow up high-priority conditions at two weeks.
The most common mistake: Keeping excellent records the patient cannot take with them.

Self-assessment questions

1. Does the service provide a genuinely portable record, not one locked within a single system? — A real, portable format the patient can carry forward, not accessible only here.
Evidence: Portable record format documentation
2. Is the record genuinely updated close to a known relocation, not left outdated? — Real, current information reflecting the patient's actual status, not a stale record.
Evidence: N/A — tested directly
3. Does the patient know how to access and use this record themselves? — Real, patient-controlled access, not continued dependency on this service.
Evidence: Patient record access instruction

Common reasons for a PARTIAL answer

  • A portable record format exists but isn't proactively offered unless the patient specifically requests it. — A patient who doesn't know to ask shouldn't be less likely to receive genuine continuity support.
  • The record is current at creation but isn't genuinely updated as the ongoing relationship continues. — Continuity value depends on the record reflecting the patient's actual, current status, not only their status at one point in time.
  • Patients are given the record but not specific instruction on how to actually use or share it with a future provider.

Implementation plan

When What
Week 1 Review current record practice for genuine portability versus system lock-in.
Week 2 Establish a standard, portable, patient-accessible record format, proactively offered.
Week 3 Build a process for keeping the record genuinely current, particularly near known relocations.
Ongoing Confirm patients understand how to access and use their own record independently.

How the Monitor verifies this

Method What Detail
DOCUMENT Portable record review Reviews whether patients genuinely receive a portable, accessible record format.
DOCUMENT Record currency review Reviews whether the record is genuinely kept current, particularly near a known relocation.
ASK Patient access interview Asks a patient whether they know how to access and use their own portable record.

Supervisor tips

  • Ask a patient whether they have their own accessible copy of their health record, and whether they know how to use it. — A real, specific answer reveals genuine portability, not a record locked within the service's own system.
  • Ask how the record is updated when a patient reports an upcoming relocation. — A specific, confident answer reveals genuine, proactive practice, not passive record-keeping.

Evidence base

[40] Refugees experience genuine difficulty accessing their medical records and maintaining continuity of care due to mobility-related challenges, with the absence of standardized, interoperable procedures between health systems resulting in fragmented records, incomplete medical history, and documented medical errors.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.6

Evidence-Informed Care for Refugee and Migrant Populations

Core

Staff use evidence-informed guidelines specific to refugee and migrant health where they exist, recognise where the health needs of this population differ from the general population, and identify where evidence gaps remain — not applying general telemedicine guidelines uncritically to a population with documented, different health needs.

In plain terms: Staff use clinical guidelines specific to refugee and migrant health where they exist, know where evidence is thin, and adapt sensibly.

Facility category Crisis Transition Small Standard
Applicability N/A Full Adapted Full

Why this matters

Refugee health has specific evidence: screening for TB, hepatitis B, and parasites by region of origin; vaccination catch-up schedules; recognition of conditions rare in the host country; management of trauma-related mental illness. Applying host-country guidelines without adaptation means missing conditions the host population does not have and over-testing for ones the refugee population does not. Where evidence exists — WHO, UNHCR, national refugee health guidelines — staff should use it. Where it does not, they should know that, and adapt with judgment rather than guess.

What good looks like

  • Staff are aware of and use population-specific evidence-informed guidelines where they exist.
  • Staff can describe specific, genuine differences in this population's health needs.
  • Practice is genuinely adapted where population-specific evidence indicates it should be.

Common failure modes

  • General telemedicine guidelines are applied uncritically with no population-specific awareness.
  • Staff cannot describe any specific way this population's needs differ.
  • Awareness exists but doesn't translate into any actual practice adaptation.

Worked example

In practice
A 14-clinician telemedicine service that had started receiving refugees from a region with high hepatitis B and TB prevalence.
BeforeRefugee patients were assessed using standard domestic protocols. Hepatitis B screening was not routine. Two cases of active TB were diagnosed late after multiple presentations. Clinicians were unaware of the WHO and national refugee health screening recommendations.
ActionThe Coordinator obtained the national refugee health guideline and the WHO recommendations for the relevant region. A refugee health screening protocol was written: TB screening, hepatitis B and C, HIV with consent, parasitic infection screening, vaccination status, mental health screen. Clinicians received a one-hour briefing. The guideline was reviewed annually with an infectious diseases specialist.
AfterThe Monitor reviewed the protocol with its sources, training records, and 20 refugee patient records showing protocol-based screening. Two hepatitis B cases identified and treated. Verified.

If you are starting from zero — do this first

  1. Find your national refugee health guideline, or the WHO/UNHCR one for your region.
  2. Compare it to what you currently do for refugee patients.
  3. Write a screening protocol based on the guideline.
  4. Brief clinicians and review annually.
The most common mistake: Applying the domestic screening protocol to refugee patients from regions with a completely different disease burden.

Self-assessment questions

1. Are staff aware of evidence-informed guidelines specific to refugee and migrant health where they exist? — Specific, current awareness, not general clinical knowledge assumed to be sufficient.
Evidence: Guideline awareness record
2. Do staff recognise where this population's health needs genuinely differ from the general population? — Genuine, specific recognition, not an assumption that general guidelines always apply equally.
Evidence: N/A — tested directly
3. Is practice adapted where population-specific evidence indicates a different approach is warranted? — Actual practice adaptation, not awareness without application.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • Awareness exists for well-known differences but not for more specific or recent evidence. — Evidence in this area continues to develop, and awareness needs to stay genuinely current.
  • Guidelines are known but not consistently applied under time pressure. — Consistent application under real conditions is what gives awareness genuine protective value.
  • Evidence gaps are acknowledged but staff default to general population assumptions rather than flagging genuine uncertainty.

Implementation plan

When What
Week 1 Review current awareness of population-specific evidence-informed guidelines.
Week 2 Establish access to current, relevant guidelines for staff.
Week 3 Train staff on specific, genuine population differences relevant to practice.
Ongoing Refresh awareness as evidence in this area develops.

How the Monitor verifies this

Method What Detail
DOCUMENT Guideline awareness review Reviews whether staff have access to and awareness of population-specific evidence-informed guidelines.
ASK Population-difference interview Asks staff to describe a specific way this population's health needs differ from the general population.
OBSERVE Practice adaptation check Checks whether practice genuinely reflects population-specific evidence where it exists.

Supervisor tips

  • Ask staff for a specific example of a practice adaptation based on population-specific evidence. — A real example reveals genuine application, not just familiarity with the concept.
  • Ask how staff would handle a genuine evidence gap for this population. — A thoughtful, honest answer reveals genuine engagement rather than a default assumption.

Evidence base

[41] WHO Competency Standard 7 requires health workers to use evidence-informed guidelines specific to refugee and migrant health where they exist, recognise where the health needs of this population differ from the general population, and identify where evidence gaps remain.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.7

Staff Reflective Practice, Bias Awareness, and Self-Care in Migration Contexts

Non-Negotiable

Staff maintain active awareness of their own culture, beliefs, and potential biases through structured reflective practice, and the service actively fosters a supportive environment with genuine access to psychological support — not assumed self-awareness or an assumption that staff will manage vicarious trauma exposure on their own.

In plain terms: Staff actively reflect on their own biases and culture, the telemedicine service supports this through structured practice, and staff working with traumatised patients are looked after.

Facility category Crisis Transition Small Standard
Applicability N/A Full Adapted Full

Why this matters

Every clinician has assumptions about people from other cultures, and most are unaware of them. The nurse who assumes a refugee is exaggerating pain, the doctor who is impatient with a patient who will not make eye contact, the receptionist who is curt with someone who does not understand the form — each is acting on bias, and each affects care. Reflective practice — structured time to examine one's reactions — reduces this. The second element is staff wellbeing: hearing accounts of torture and loss every day takes a toll, and staff who are burned out become staff who withdraw. Supervision, peer support, and access to counselling are not luxuries in a telemedicine service serving refugees.

What good looks like

  • A structured reflective practice process genuinely exists and is used, not just assumed.
  • Genuine, accessible psychological support exists and staff actually use it.
  • Staff can describe specific, real examples of both bias adaptation and vicarious trauma awareness.

Common failure modes

  • No structured reflective practice process exists beyond an assumption of individual self-awareness.
  • Psychological support exists only nominally, with no evidence staff actually access it.
  • Staff cannot describe any specific example of adapting practice or recognising vicarious trauma.

Worked example

In practice
A 15-clinician telemedicine service where a third of patients are refugees.
BeforeNo reflective practice existed. Staff complained about refugee patients in the break room; some described them as 'demanding.' A nurse who had heard multiple accounts of sexual violence had started avoiding female refugee patients. There was no supervision or support for staff exposed to trauma narratives.
ActionMonthly facilitated reflective practice sessions were introduced for clinical teams, led by a psychologist from a partner NGO, using real (anonymised) cases. An implicit bias workshop was run once for all staff. A peer support scheme was set up. Confidential counselling access was arranged through the NGO. Attendance was tracked.
AfterThe Monitor reviewed session records (10 sessions, average 70% attendance), workshop records, and the counselling access agreement. Interviewed three staff who described the sessions as valuable and gave examples of changed practice. Verified.

If you are starting from zero — do this first

  1. Listen in the break room. What do staff say about refugee patients when they think no one is listening?
  2. Arrange one implicit bias workshop with an NGO or university.
  3. Start monthly reflective practice sessions with a facilitator.
  4. Arrange confidential counselling access for staff.
The most common mistake: Training staff in cultural competence once and assuming bias is fixed — it is a practice, not a certificate.

Self-assessment questions

1. Does the service have a structured process for staff reflective practice regarding bias and cultural awareness? — A defined process, not an assumption that staff will naturally self-reflect adequately.
Evidence: Reflective practice process description
2. Does the service provide genuine, accessible psychological support and a real space to discuss difficult cases? — Actual, used support and a real, regular opportunity, not a theoretical benefit or informal hope.
Evidence: Psychological support access record
3. Can staff describe a specific instance of adapting their practice after recognising a bias, and do they recognise signs of vicarious trauma in themselves? — Genuine, concrete examples, not general statements of good intentions or awareness.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • Reflective practice happens informally but is not structured into any genuine, regular process. — Individual good practice does not reliably generalise without a defined, shared process.
  • Support exists but is genuinely difficult to access given remote staff working independently across locations. — A benefit's existence does not guarantee genuine, comfortable access to it, particularly for a dispersed remote team.
  • Support exists for acute incidents but not for the cumulative emotional weight of this work over time.

Implementation plan

When What
Week 1 Review current training content and support access for genuine coverage of bias and staff wellbeing.
Week 2 Establish a structured reflective practice process feasible for a remote or dispersed team.
Week 3 Identify genuine, accessible psychological support options appropriate to remote practice.
Ongoing Revisit reflective practice and wellbeing periodically, using real case examples where appropriate.

How the Monitor verifies this

Method What Detail
DOCUMENT Reflective practice process review Reviews the service's structured process, if any, for staff reflective practice on bias and cultural awareness.
DOCUMENT Support access review Reviews what psychological support and debrief structure genuinely exist and whether they are actually used.
ASK Staff example interview Asks a staff member for a specific instance of recognising and adapting for their own bias, and how they process the emotional weight of this work.

Supervisor tips

  • Ask for a specific personal example, not a general statement of awareness. — A concrete instance distinguishes genuine reflective practice from familiarity with the concept.
  • Ask directly whether support has been used, not just whether it exists. — Genuine uptake, not nominal availability, is the real test.

Evidence base

[42] WHO Competency Standards 8 and 9 (Refugee and Migrant Health: Global Competency Standards for Health Workers, 2021) require health workers to maintain structured awareness of their own biases and institutional discrimination's impact, and to engage in self-care within a supportive team environment addressing the wellbeing impacts of migration-context care.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.8

Digital Privacy Concerns Specific to Displaced Populations Are Genuinely Addressed

Non-Negotiable

The service genuinely recognises and addresses the specific, heightened digital privacy concerns displaced populations face — including the real possibility that health-related digital data could be requested or analyzed by immigration or asylum authorities — not treating this population's privacy needs as identical to a general patient's under standard confidentiality practice.

In plain terms: The service knows that displaced people have specific fears about digital privacy — surveillance, data reaching authorities or persecutors — and addresses them concretely, not with a generic privacy notice.

Facility category Crisis Transition Small Standard
Applicability Full Full Adapted Full

Why this matters

A refugee who fled a state that surveilled her may reasonably fear that a video consultation is being watched. A migrant without legal status may fear that health data will reach immigration authorities. An LGBTQ+ asylum seeker may fear disclosure to their community. These fears are rational and they suppress care-seeking. Addressing them means: an explicit statement of what data is collected, who can see it, and — crucially — who cannot (immigration authorities, employers, home-country governments); the legal protections that apply; the option of minimal data collection; and a conversation, in the patient's language, that takes the fear seriously.

What good looks like

  • The service genuinely recognises and addresses this population's distinct digital privacy concerns.
  • Specific, honest communication clarifies what is and isn't shared with any authority.
  • Staff are specifically trained on this documented, distinct concern.

Common failure modes

  • This population's privacy needs are treated identically to general patients, with no specific recognition.
  • Communication offers only vague, general privacy assurance, not specific clarity.
  • Staff rely on general privacy training, with no specific coverage of this distinct concern.

Worked example

In practice
A telemedicine service serving asylum seekers.
BeforeThe privacy notice was a standard legal document. Patients were reluctant to disclose mental health symptoms, HIV status, or sexual orientation on video. Interviews revealed fears that recordings would reach authorities or that the platform was monitored.
ActionA plain-language privacy explanation was written in the patients' languages: what is collected, where it is stored, who can access it, who cannot (with legal basis), that sessions are not recorded (6.3), and that the patient can request minimal data. It is discussed at intake, with time for questions. A pseudonymous registration option was introduced for those who need it. Providers were trained on the specific fears and how to address them. The service's data-sharing agreements were reviewed to ensure no pathway to immigration authorities.
AfterThe Monitor reviewed the privacy explanation in six languages, intake records with the discussion documented, the pseudonymous option, and the data-sharing review. Interviewed a patient who described feeling safe to disclose. Verified.

If you are starting from zero — do this first

  1. Ask five displaced patients what they fear about their data.
  2. Write a plain-language explanation that names who cannot see their data.
  3. Discuss it at intake in their language.
  4. Offer minimal-data or pseudonymous registration.
The most common mistake: Sending a standard privacy notice to a person who fled state surveillance.

Self-assessment questions

1. Does the service genuinely recognise this population's specific digital privacy concerns? — Real, specific recognition, not general confidentiality practice assumed sufficient.
Evidence: N/A — tested directly
2. Is there honest communication about what genuinely is and isn't shared with any authority? — Real, honest, specific communication, not a vague general assurance.
Evidence: Patient privacy communication materials
3. Are staff specifically trained on this concern, not assuming general privacy training suffices? — Real, specific training, not general health privacy training assumed sufficient.
Evidence: Staff training on migration-specific privacy concerns

Common reasons for a PARTIAL answer

  • Recognition exists informally among some staff but isn't consistently, formally addressed across the whole team. — Every staff member interacting with this population deserves the same genuine, formal understanding.
  • Communication is honest but not proactively offered, relying on the patient to raise the concern themselves. — A patient may not know to ask, and proactive communication reaches concerns that would otherwise go unaddressed.
  • Training references data privacy generally but doesn't specifically name this population's documented, distinct concern.

Implementation plan

When What
Week 1 Review current practice for genuine recognition of this population's distinct digital privacy concerns.
Week 2 Build specific, honest, proactive patient communication addressing this concern directly.
Week 3 Train all staff specifically on this documented, distinct concern, not general privacy training alone.
Ongoing Revisit communication and training as the relevant regulatory landscape evolves.

How the Monitor verifies this

Method What Detail
ASK Recognition interview Asks staff whether they specifically recognise and address this population's distinct digital privacy concerns.
DOCUMENT Patient communication review Reviews materials for genuine, specific, honest communication about data sharing with authorities.
DOCUMENT Staff training review Reviews training records for specific coverage of this documented, distinct privacy concern.

Supervisor tips

  • Ask staff directly whether they've discussed this specific concern with patients from this population. — A specific, real answer reveals genuine recognition, not an assumption general privacy practice covers it.
  • Ask to see the actual, specific language used to communicate this to a patient. — A real, specific example reveals genuine, honest communication, not a vague general assurance.

Evidence base

[43] Some governments have begun analyzing migrants' phone data as part of asylum adjudication processes, establishing genuine, documented grounds for displaced patients' distinct privacy concerns regarding digital health data, separate from general patient confidentiality practice.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.9

Legal Status Diversity Recognition

Core

The service can name which legal status categories it actually serves — asylum seeker, recognised refugee, stateless person, and others — and demonstrates it doesn't apply a single, uniform assumption about access rights across all of them.

In plain terms: The telemedicine service can name which legal status groups it serves — asylum seekers, recognised refugees, stateless people, internally displaced, undocumented — and knows what each group is entitled to.

Facility category Crisis Transition Small Standard
Applicability N/A Full Adapted Full

Why this matters

An asylum seeker in many countries is entitled to emergency care only. A recognised refugee has the same entitlements as citizens. A stateless person may have no entitlement at all under the letter of the law. An undocumented migrant may be entitled to nothing — or to everything, depending on the jurisdiction and the type of care. A telemedicine service that does not know these distinctions either turns away people who are entitled to care or treats people it cannot be reimbursed for without knowing it. Knowing the categories, the entitlements, and — critically — the telemedicine service's own policy on treating people regardless of entitlement is the foundation for consistent, fair, and legally defensible practice.

What good looks like

  • Staff can name the specific legal status categories this service actually serves.
  • Policy genuinely differentiates access considerations across status categories.
  • A specific, defined process exists for verifying unclear status.

Common failure modes

  • Staff have only a general sense that "migrants" are served, without specific categories.
  • A single, uniform assumption about access rights is applied regardless of status.
  • No process exists for verifying status when it's genuinely unclear.

Worked example

In practice
A 15-clinician telemedicine service in a country with five legal categories for displaced people and different entitlements for each.
BeforeRegistration staff did not know the categories. Patients were sometimes turned away because 'refugees are not covered' when in fact they were. Others were treated and the telemedicine service could not claim reimbursement because the correct category was not recorded. The telemedicine service had no written position on treating people outside any entitlement.
ActionThe Coordinator obtained the legal entitlements for each category from the Ministry and UNHCR. A one-page reference was created for registration staff. A telemedicine service policy stated: emergency care for everyone regardless of status; other care per entitlement; and a defined charity fund for those with no entitlement. Registration records the category (with the patient's consent) for reimbursement purposes only — it does not affect clinical care.
AfterThe Monitor reviewed the entitlement reference, the policy, and 20 registration records with category correctly recorded. Interviewed two registration staff who correctly described entitlements for three categories. Verified.

If you are starting from zero — do this first

  1. List the legal status categories that exist in your country for displaced people.
  2. Find out what each is entitled to — ask the Ministry or UNHCR.
  3. Write a one-page reference for registration staff.
  4. Decide and write down what you will do for people with no entitlement.
The most common mistake: Treating all displaced people as one category — 'refugees' — when the law treats them differently and the telemedicine service's obligations differ.

Self-assessment questions

1. Can staff name the specific legal status categories this service actually serves? — Specific, named categories, not a general sense that "migrants" are served.
Evidence: N/A — tested directly
2. Does the service avoid applying a single, uniform assumption about access rights across all statuses? — Genuine differentiation, not treating all categories identically.
Evidence: Status-specific access policy documentation
3. Is there a specific process for verifying which category applies when it's genuinely unclear? — A real, defined process, not guesswork or assumption when status is ambiguous.
Evidence: Status verification process

Common reasons for a PARTIAL answer

  • Staff can name the most common category served but not less frequent ones the service still encounters. — Even infrequent categories deserve genuine, specific awareness, not the risk of misapplied assumptions.
  • Differentiation exists in one provider's own understanding but isn't shared with the wider team. — Every staff member interacting with patients benefits from the same genuine understanding.
  • A verification process exists but staff are inconsistently confident applying it.

Implementation plan

When What
Week 1 Review current staff awareness of the specific legal status categories actually served.
Week 2 Build specific, differentiated access guidance for each relevant status category.
Week 3 Establish a clear verification process for genuinely unclear status.
Ongoing Refresh staff awareness periodically, particularly for less frequently encountered categories.

How the Monitor verifies this

Method What Detail
ASK Status category awareness interview Asks staff to name the specific legal status categories this service actually serves.
DOCUMENT Status-specific policy review Reviews documentation for genuine differentiation across status categories, not a uniform assumption.
DOCUMENT Verification process review Reviews the process for verifying status when it's genuinely unclear.

Supervisor tips

  • Ask staff to name every specific legal status category the service has served recently. — Specificity reveals genuine, current awareness rather than a general assumption.
  • Ask what happens when a patient's specific status is genuinely unclear. — A confident, specific answer reveals a genuine process, not improvisation.

Evidence base

[44] WHO's Competency Standards explicitly distinguish these legal status categories throughout, noting that access to health care and legal entitlements vary meaningfully by status and by country, and that health workers need specific awareness of this rather than a single generalised assumption.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

8.10

Care Is Documented and Provided Regardless of Immigration or Legal Status

Non-Negotiable

Care is provided and fully documented for every patient regardless of immigration or legal status, with no differential standard of care, documentation practice, or record-keeping applied based on status — not a lesser or informal standard applied to patients without documented status.

In plain terms: Every patient receives the same care and the same documentation regardless of immigration status — no lower standard, no incomplete record, no 'informal' sessions.

Facility category Crisis Transition Small Standard
Applicability Full Full Full Full

Why this matters

The principle is the same across every facility type. In telemedicine, the temptation is to serve undocumented patients 'off the platform' to protect them — which leaves them with no record, no continuity, and no protection. The policy must be explicit: identical care and documentation; status not asked; data protections that actually prevent disclosure to authorities (8.8); funding handled separately.

What good looks like

  • Care and documentation are genuinely consistent regardless of status.
  • Staff are specifically trained on this principle, not assumed to understand it.
  • Confidentiality protection is applied equally without exception.

Common failure modes

  • Care or documentation practice differs based on a patient's known or assumed status.
  • No specific training addresses this principle.
  • Status-related information is handled less carefully than other confidential information.

Worked example

In practice
A telemedicine service serving a mixed-status migrant population.
BeforeSome providers saw undocumented patients on personal video apps without creating records, believing this protected them. Those patients had no continuity, no prescriptions on file, no follow-up.
ActionA written policy: same care, same platform, same record for everyone; immigration status not asked; data-sharing agreements reviewed to confirm no pathway to immigration authorities; funding handled by the administrator after care. Providers were briefed on why informal care harms patients. All patients were moved onto the platform with records created.
AfterThe Monitor reviewed the policy, the data-sharing review, and 20 records of migrant patients with full documentation. Verified.

If you are starting from zero — do this first

  1. Ask providers whether any patients are seen off the platform. Why?
  2. Write the one-sentence policy.
  3. Confirm your data agreements do not allow disclosure to immigration authorities.
  4. Bring every patient onto the platform with a record.
The most common mistake: Protecting undocumented patients by not documenting them.

Self-assessment questions

1. Is the same standard of care applied and documented the same way regardless of a patient's immigration or legal status? — Genuinely equal treatment, not a lesser or informal standard for undocumented patients.
Evidence: N/A — tested directly
2. Are staff specifically trained that immigration status is never a reason to withhold or alter care or documentation? — Specific, documented training, not assumed understanding.
Evidence: Staff training record
3. Is patient information protected with the same confidentiality standard regardless of status, with no informal sharing of status-related information? — The same confidentiality protection extended to every patient, without exception.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

  • The principle is understood by treating providers but not consistently by administrative or scheduling staff. — A patient's first interaction is often with administrative staff, where the same principle needs to hold.
  • Care is consistent but documentation habits vary informally based on individual staff assumptions. — Consistency needs to extend to documentation practice specifically, not only the clinical care itself.
  • The principle is followed but has never been specifically, formally trained.

Implementation plan

When What
Week 1 Review current practice for any differential treatment based on status.
Week 2 Establish specific staff training on this principle, covering all staff, not only clinical roles.
Week 3 Confirm documentation practice is genuinely consistent regardless of status.
Ongoing Reinforce training periodically, particularly for new staff.

How the Monitor verifies this

Method What Detail
OBSERVE Care standard observation Observes whether care and documentation practice is genuinely consistent regardless of patient status.
DOCUMENT Staff training review Reviews training records confirming staff understand immigration status is never a basis for differential care.
ASK Confidentiality practice interview Asks staff how patient status information, where known, is protected.

Supervisor tips

  • Ask administrative or scheduling staff, not only providers, about this principle. — This reveals whether the principle genuinely extends beyond clinical staff.
  • Ask how patient status information, where it becomes known, is protected. — A specific, confident answer reveals genuine practice, not just a stated value.

Evidence base

[45] Equal standard of care and documentation regardless of immigration or legal status, without differential record-keeping practice, is established practice in international guidance on healthcare access for migrant and refugee populations.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

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