Allan Krasnik

The Danish National Health Service Register

Introduction: To describe the Danish National Health Service Register in relation to research. Content: The register contains data collected for administrative and scientific purposes from health contractors in primary health care. It includes information about citizens, providers, and health services but minimal clinical information. Validity and coverage: The register covers everyone living in Denmark and data is available from 1990. No validity studies have been reported. Because the data is connected to reimbursement the coverage is assumed to be good. Conclusion: The strengths of the register include completeness, size, and long follow-up period. It is useful for research purposes but reservations must be made regarding its validity.

Poorer self-perceived health among migrants and ethnic minorities versus the majority population in Europe: a systematic review

ObjectivesKnowledge about self-perceived health can help us understand the health status and needs among migrants and ethnic minorities in the European Union (EU) which is essential to improve equity and integration. The objective was to examine and compare self-perceived health among migrant and ethnic minority groups in the EU countries.MethodsPublications were ascertained by a systematic search of PUBMED and EMBASE. Eligibility of studies was based on the abstracts and the full texts. Additional articles were identified via the references. The final number of studies included was 17.ResultsPublications were identified in 5 out of the 27 EU countries. In regard to self-perceived health, most migrants and ethnic minority groups appeared to be disadvantaged as compared to the majority population even after controlling for age, gender, and socioeconomic factors. Only limited cross-country comparisons could be carried out, still they revealed a parallel pattern of self-perceived health among similar migrant/ethnic minority groups.ConclusionsPolicies to improve social and health status, contextual factors, and access to healthcare among migrants and ethnic minorities are essential to reduce ethnic inequalities in health.

Good practice in health care for migrants: views and experiences of care professionals in 16 European countries

BackgroundHealth services across Europe provide health care for migrant patients every day. However, little systematic research has explored the views and experiences of health care professionals in different European countries. The aim of this study was to assess the difficulties professionals experience in their service when providing such care and what they consider constitutes good practice to overcome these problems or limit their negative impact on the quality of care.MethodsStructured interviews with open questions and case vignettes were conducted with health care professionals working in areas with high proportion of migrant populations in 16 countries. In each country, professionals in nine primary care practices, three accident and emergency hospital departments, and three community mental health services (total sample = 240) were interviewed about their views and experiences in providing care for migrant patients, i.e. from first generation immigrant populations. Answers were analysed using thematic content analysis.ResultsEight types of problems and seven components of good practice were identified representing all statements in the interviews. The eight problems were: language barriers, difficulties in arranging care for migrants without health care coverage, social deprivation and traumatic experiences, lack of familiarity with the health care system, cultural differences, different understandings of illness and treatment, negative attitudes among staff and patients, and lack of access to medical history. The components of good practice to overcome these problems or limit their impact were: organisational flexibility with sufficient time and resources, good interpreting services, working with families and social services, cultural awareness of staff, educational programmes and information material for migrants, positive and stable relationships with staff, and clear guidelines on the care entitlements of different migrant groups. Problems and good care components were similar across the three types of services.ConclusionsHealth care professionals in different services experience similar difficulties when providing care to migrants. They also have relatively consistent views on what constitutes good practice. The degree to which these components already are part of routine practice varies. Implementing good practice requires sufficient resources and organisational flexibility, positive attitudes, training for staff and the provision of information.

Cooperating with a palliative home-care team : expectations and evaluations of GPs and district nurses

Background: Palliative home-care teams often cooperate with general practitioners (GPs) and district nurses. Our aim was to evaluate a palliative home-care team from the viewpoint of GPs and district nurses. Methods: GPs and district nurses received questionnaires at the start of home-care and one month later. Questions focussed on benefits to patients, training issues for professionals and cooperation between the home-care team and the GP/ district nurse. A combination of closed-and open-ended questions was used. Results: Response rate was 84% (467/553). Benefits to patients were experienced by 91%, mainly due to improvement in symptom management, ‘security’, and accessibility of specialists in palliative care. After one month, 57% of the participants reported to have learnt aspects of palliative care, primarily symptom control, and 89% of them found cooperation satisfactory. Dissatisfaction was caused mainly by lack of information from the home-care team to primary-care professionals. Conclusion: GPs and district nurses welcomed the palliative home-care team and most experienced benefits to patients. Strengthened communication initiated by the home-care team would enhance cooperation.

Providing medical care for undocumented migrants in Denmark: what are the challenges for health professionals?

BackgroundThe rights of undocumented migrants are frequently overlooked. Denmark has ratified several international conventions recognizing the right to health care for all human beings, but has very scanty legislation and no existing policies for providing health care to undocumented migrants. This study focuses on how health professionals navigate and how they experience providing treatment for undocumented migrants in the Danish health care system.MethodsThe study was carried out as part of an EU-project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). This presentation is based on 12 semi-structured interviews with general practitioners (9) and emergency room physicians (3) in Denmark.ResultsThe emergency room physicians express that treatment of undocumented migrants is no different from the treatment of any other person. However, care may become more complicated due to lack of previous medical records and contact persons. Contrary to this, general practitioners explain that undocumented migrants will encounter formal barriers when trying to obtain treatment. Additional problems in the treatment of undocumented migrants include language issues, financial aspects for general practitioners, concerns about how to handle the situation including possibilities of further referrals, and an uncertainty as to whether to involve the police.ConclusionsThe health professionals in our study describe that undocumented migrants experience an unequal access to primary care facilities and that great uncertainties exist amongst health professionals as how to respond in such situations. The lack of official policies concerning the right to health care for undocumented migrants continue to pass on the responsibility to health professionals and, thereby, leaves it up to the individual to decide whether treatment can be obtained or not.

Excess use of coercive measures in psychiatry among migrants compared with native Danes

Norredam M, Garcia‐Lopez A, Keiding N, Krasnik A. Excess use of coercive measures in psychiatry among migrants compared with native Danes.

Inequalities in mortality among refugees and immigrants compared to native Danes – a historical prospective cohort study

BackgroundComparisons of mortality patterns between different migrant groups, and between migrants and natives, are relevant to understanding, and ultimately reducing, inequalities in health. To date, European studies on migrants’ mortality patterns are scarce and are based solely on country of birth, rather than migrant status. However, mortality patterns may be affected by implications in relation to migrant status, such as health hazards related to life circumstances before and during migration, and factors related to ethnic origin. Consequently, we investigated differences in both all-cause and cause-specific mortality from cancer and cardiovascular disease among refugees and immigrants, compared with the mortality among native Danes.MethodsA register-based, historical prospective cohort design. All refugees (n = 29,139) and family-reunited immigrants (n = 27,134) who, between 1 January1993 and 31 December1999, were granted right of residence in Denmark were included and matched 1:4 on age and sex with native Danes. To identify deaths, civil registration numbers were cross-linked to the Register of Causes of Death (01.01.1994–31.12.2007) and the Danish Civil Registration System (01.01.1994–31.12.2008). Mortality rate ratios were estimated separately for men and women by migrant status and region of birth, adjusting for age and income and using a Cox regression model, after a median follow-up of 10–13 years after arrival.ResultsCompared with native Danes, all-cause mortality was significantly lower among female (RR = 0.78; 95%CI: 0.71;0.85) and male (RR = 0.64; 95%CI: 0.59-0.69;) refugees. The rates were also significantly lower for immigrants: women (RR = 0.44; 95%CI: 0.38;0.51) and men (RR = 0.43; 95%CI: 0.37;0.51). Both migrant groups also had lower cause-specific mortality from cancer and cardiovascular diseases. For both all-cause and cause-specific mortality, immigrants generally had lower mortality than refugees, and differences were observed according to ethnic origin.ConclusionsMortality patterns were overall advantageous for refugees and immigrants compared with native Danes. Research should concentrate on disentangling the reasons behind migrants’ health advantages, in order to enlighten future preventive public-health efforts, for the benefit of the entire population.

The Concept of Equity in Health Services Research

A population approach and the general right to health and medical care have been important issues in the development of health policy over many centuries. However, equity is still a crucial issue in the planning and evaluation of health care. Many definitions and criteria related to equity have been formulated on the basis of conflicting theories and models. Three dimensions of fair and just resource allocation are essential when needs-based models are used: equity in access, utilization, and quality of care relative to needs. Health services research should concentrate on such outcome measures regarding equity and the effect of organizational and processual characteristics of health care systems. Prominent examples of such research efforts are presented, but, unfortunately, there are few reliable and systematic data from this kind of study. Health care researchers have a special responsibility towards the population at large to undertake qualified research on equity and to communicate the results to the general public.

Is there equity in use of healthcare services among immigrants, their descendents, and ethnic Danes?

Background: Legislation in Denmark explicitly states the right to equal access to healthcare. Nevertheless, inequities may exist; accordingly evidence is needed. Our objective was to investigate whether differences in healthcare utilisation in immigrants, their descendents, and ethnic Danes could be explained by health status, socioeconomic factors, and integration. Methods: We conducted a nationwide survey in 2007 with 4952 individuals aged 18–66 comprising ethnic Danes; immigrants from the former Yugoslavia, Iran, Iraq, Lebanon, Pakistan, Somalia, Turkey; and Turkish and Pakistani descendents. Data were linked to registries on healthcare utilisation. Using Poisson regression models, contacts to hospital, emergency room (ER), general practitioner (GP), specialist in private practice, and dentist were estimated. Analyses were adjusted for health symptoms, sociodemographic factors, and proxies of integration. Results: In adjusted analyses, immigrants and their descendents had increased use of ER (multiplicative effect 1.19–5.02 dependent on immigrant and descendent group) and less frequent contact to dentist (multiplicative effect 0.04–0.80 dependent on the group). For hospitalisation, GP, and specialist doctor, physical health symptoms had positive but different explanatory effects within groups; however, most immigrant and descendent groups had increased use of services compared with that of ethnic Danes. Socioeconomic factors and integration had no systematic effect on the use in the different groups. Conclusions: The Danish healthcare system seems responsive to health across different population groups. We found no systematic pattern of inequity in use of free-of-charge healthcare services, but for dentists, who require co-payment, we found inequity among immigrants and descendents compared with ethnic Danes.

Participation in mammography screening among migrants and non-migrants in Denmark

Background. Inequality in use of mammography screening across population groups is a concern since migrants are more likely to become non-users compared to the general population. The aim of this study was to a) identify determinants of participation among migrant groups and Danish-born women with emphasis on the effect of household size, socioeconomic position and use of healthcare services, and b) test whether effects of determinants were consistent across migrant and non-migrant groups. Material and methods. We used data from the first eight invitation rounds of the mammography screening programme in Copenhagen, Denmark (1991–2008) in combination with register-based data. Results. The crude odds ratio (OR) for not participating in mammography screening was 1.38 (95% CI, 1.30–1.46) for women born in other-Western and 1.80 (95% CI, 1.71–1.90) for women born in non-Western countries compared to Danish-born women. The adjusted OR was 1.14 (95% CI, 1.06–1.21) for other-Western and 1.19 (95% CI, 1.11–1.27) for women born in non-Western countries. Lack of contact with a general practitioner or dental services, and not being employed had a significant negative effect on use of mammography screening. Higher-educated women were significantly less likely to use mammo-graphy screening in all groups whilst hospitalisation had a significant effect among Danish-born women. Living alone was consistently associated with non-use of mammography screening. The probability of becoming a non-user was significantly less among women living within households of two to four persons compared to women living alone. Except in the case of age and hospitalisation, trends were similar across country of birth, but the relative importance of specific determinants in explaining use of mammography screening differed. Conclusion. Household size, socioeconomic position and use of healthcare services were determinants of participation in mammography screening. This study emphasises the need for conducting refined analyses distinguishing among subgroups within diverse populations when explaining differences in screening behaviour.