Regular Article Factors Leading to Health Care Exclusion Among African Refugees in Australia: The Case of Blood Donation Michael Jay Polonsky, Ahmed Shahriar Ferdous, Andre M.N. Renzaho, Neil Waters, and Zoe McQuilten Abstract Developed countries that accept refugees are obligated, under the UN Convention for Refugees, to integrate refugees into host communities, with inclusion in the health system being pivotal. Integration programs can be difficult though, because many ref- ugees’ home countries have different health systems, lower health literacy, and different expectations of health services. Country health system differences require cultural adaptation of host country services when designing targeted, inclusive health care programs. Using a sample of 317 Australian-based African refugees, the authors examine how refugees’ acculturation, perceptions of discrimination, past behavior, objective knowledge, and medical mistrust affect their health inclusion, depending on their blood donation intentions. The results indicate that perceived discrimination and objective blood donation knowledge directly affect donation intentions. Perceived discrimination mediates the relationships between acculturation and intentions and between medical mistrust and donation intentions, and objective knowledge mediates the relationship between past behavior and donation intentions. The authors offer recommendations to policy makers designing social inclusion programs and health service providers designing and delivering targeted initiatives, to better facilitate refugee participation in host country health systems. Keywords refugees, health care inclusion, perceived discrimination, acculturation, medical mistrust, blood donation Globally, there were approximately 19.5 million refugees in 2014, with 16% hosted by developed countries, and reports predict this number to continually increase (UNHCR 2014). For example, Australia’s acceptance of13,000-14,000 refugees per year is already on the rise (ABC 2015). Recent conflicts in the Middle East and North Africa have led to an explosion of refugees seeking access to Europe, with governments strug- gling to cope (Catchpole and Coulombier 2015). According to the UNHCR (2016), 26% of all refugees are from Africa. Most refugees represent vulnerable communities (Baker, Gen- try, and Rittenburg 2005) and therefore need substantial assistance to integrate into their new host country’s economic and social systems. This high level of vulnerability is why host countries, via United Nations conventions, continue to design integration programs to address gaps in education, social integration, employ- ment, and health care (Johnston, Vasey, and Markovic 2009). Yet, while the primary objectives of such programs are to address refugees’ needs to better integrate into host societies, not all ref- ugees necessarily embrace the options provided, even when there is a demonstrable need (Peisker and Tilbury 2003). For example, Morris et al. (2009) find that some U.S.-based refugees are wary of using doctors from outside their home community, even though services are designed for their specific refugee group’s needs. The provision of targeted services is not always sufficient; there must also be an inclusive process that addresses real or perceived bar- riers that impede migrant participation. Inclusive service programs must also ensure the effective allo- cation of resources, as such initiatives often have significant bud- getary costs (Howlett 2012). For example, the 2015–2016 Australian Federal budget included several funding initiatives tar- geting migrant and refugee social inclusion, including AUD$149.5 Michael Jay Polonsky is Alfred Deakin Professor, Department of Marketing, Deakin University (email: Michael.Polonsky@Deakin.edu.au). Ahmed Shahriar Ferdous is Senior Lecturer in Marketing, Department of Marketing, Deakin University (email: Ahmed.Ferdous@deakin.edu.au). Andre M.N. Renzaho is Professor of Humanitarian and Development Studies, School of Social Sciences and Psychology, Western Sydney University (email: Andre. Renzaho@westernsydney.edu.au). Neil Waters is Senior Projects Manager, School of Public Health and Preventive Medicine, Monash University (email: neil.waters@monash.edu). Zoe McQuilten is Senior Research Fellow, School of Public Health and Preventive Medicine, Monash University (email: zoe. mcquilten@monash.edu). Journal of Public Policy & Marketing 2018, Vol. 37(2) 306-326 ª American Marketing Association 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0743915618813115 journals.sagepub.com/home/ppo