Natasja Koitzsch Jensen

Health care for immigrants in Europe: Is there still consensus among country experts about principles of good practice? A Delphi study

BackgroundEuropean Member States are facing a challenge to provide accessible and effective health care services for immigrants. It remains unclear how best to achieve this and what characterises good practice in increasingly multicultural societies across Europe. This study assessed the views and values of professionals working in different health care contexts and in different European countries as to what constitutes good practice in health care for immigrants.MethodsA total of 134 experts in 16 EU Member States participated in a three-round Delphi process. The experts represented four different fields: academia, Non-Governmental Organisations, policy-making and health care practice. For each country, the process aimed to produce a national consensus list of the most important factors characterising good practice in health care for migrants.ResultsThe scoring procedures resulted in 10 to 16 factors being identified as the most important for each participating country. All 186 factors were aggregated into 9 themes: (1) easy and equal access to health care, (2) empowerment of migrants, (3) culturally sensitive health care services, (4) quality of care, (5) patient/health care provider communication, (6) respect towards migrants, (7) networking in and outside health services, (8) targeted outreach activities, and (9) availability of data about specificities in migrant health care and prevention. Although local political debate, level of immigration and the nature of local health care systems influenced the selection and rating of factors within each country, there was a broad European consensus on most factors. Yet, discordance remained both within countries, e.g. on the need for prioritising cultural differences, and between countries, e.g. on the need for more consistent governance of health care services for immigrants.ConclusionsExperts across Europe asserted the right to culturally sensitive health care for all immigrants. There is a broad consensus among experts about the major principles of good practice that need to be implemented across Europe. However, there also is some disagreement both within and between countries on specific issues that require further research and debate.

Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries

PurposeWhile there has been systematic research on the experiences of immigrant patients in mental health services within certain European countries, little research has explored the experiences of mental health professionals in the delivery of services to immigrants across Europe. This study sought to explore professionals’ experiences of delivering care to immigrants in districts densely populated with immigrants across Europe.MethodsForty-eight semi-structured interviews were conducted with mental health care professionals working in 16 European countries. Professionals in each country were recruited from three areas with the highest proportion of immigrants. For the purpose of this study, immigrants were defined as first-generation immigrants born outside the country of current residence, including regular immigrants, irregular immigrants, asylum seekers, refugees and victims of human trafficking. Interviews were transcribed and analysed using thematic analysis.ResultsThe interviews highlighted specific challenges to treating immigrants in mental health services across all 16 countries including complications with diagnosis, difficulty in developing trust and increased risk of marginalisation.ConclusionsAlthough mental health service delivery varies between and within European countries, consistent challenges exist in the experiences of mental health professionals delivering services in communities with high proportions of immigrants. Improvements to practice should include training in reaching appropriate diagnoses, a focus on building trusting relationships and measures to counter marginalisation.

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.

Health care for irregular migrants: pragmatism across Europe. A qualitative study

BackgroundHealth services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries.ResultsSemi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this.ConclusionsThe needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

BackgroundRefugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.MethodsThe study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.ResultsOne of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.ConclusionGeneral practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

Conceptual equivalence of WHOQOL-HIV among people living with HIV in Ethiopia

PurposeThe WHOQOL instruments are intended for cross-cultural studies of quality of life (QoL) but African countries have been poorly represented in its development. This study aimed to explore the conceptual equivalence of WHOQOL-HIV in Ethiopia.MethodsThe fieldwork included home visits, interviews, and focus group discussions with HIV patients and caregivers.ResultsWe found that although WHOQOL-HIV includes many relevant facets, its applicability has several limitations in the Ethiopian setting. The most salient shortcomings of the instrument relate to the Social, Environmental and Religion/Spirituality/Personal Beliefs domains of the instrument. Themes not captured by the instrument include family responsibilities, disease disclosure, exclusion from common resources, basic needs, adequate food, and job opportunities. In addition, several of the tool’s facets such as dependence on medicine seem less relevant. Also, the role of religion is more complex than captured in WHOQOL-HIV. We found that the tool is based on an individualist focus, which tends to overlook the social context of the patient.ConclusionWe conclude that the conceptual equivalence of WHOQOL-HIV is only partially attained for use in Ethiopia. The findings from this qualitative study are used in the further process of developing and validating a QoL instrument for use in Ethiopia.

The use of dialogue tools to promote dialogue-based and person-centred patient education for people with type 2 diabetes

Objectives To explore educator experiences of implementing dialogue tools in practice to engender participatory patient education. Methods Data were collected through qualitative interviews with 31 educators and 20 ethnographic observations of group-based education sessions at eight education sites. Data were analysed using systematic text condensation and the theoretical concepts of script and de-script. Three dialogue tools including ‘My Illness and Me’, ‘Goals and Plan’s and ‘Wheel of Change’ were selected for analysis because they were used most frequently. The tools are intended to support educators in facilitating participatory patient education. Results Consistent with the intended purpose of the dialogue tools, educators reported that the dialogue tools helped engender participatory education in the form of reflection and dialogue among participants regarding living with diabetes. However, educators also reported instances of discrepancies between the tools’ intended purpose and their actual use because some participants found it difficult to relate to the tools. Discussion The application of dialogue tools to engender participatory patient education is highly dependent on educators’ and participants’ understanding and use of dialogue tools in practice. This implies that substantial educator skills are needed to facilitate dialogue and participation in patient education.

Patient Experienced Continuity of Care in the Psychiatric Healthcare System—A Study Including Immigrants, Refugees and Ethnic Danes

Aim: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. Method: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Results: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. Conclusions: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

Post-migratory risk factors and asylum seekers’ mental health

The purpose of this paper is to examine if the post-migrational risk factors, namely length of stay and number of relocations, are associated with asylum seekers’ mental health.,The review includes seven main studies published later than 2006 examining the effect of the asylum procedure on the mental health of asylum seekers. The articles were identified through the search databases PubMed, Embase and PsycINFO. A systematic search strategy based on the concepts of Patient, Intervention, Comparison, and Outcome has laid the groundwork for the findings of relevant articles.,Two out of three articles investigating the association between number of relocations and mental health among asylum seekers observed an effect on mental health. Three out of six studies found associations between length of stay in asylum centres and poor mental health. The overall assessment of the studies indicates an effect of the post-migrational risk factors.,The included studies vary in study populations, outcome measures and methodical soundness.,The review suggests that length of stay in asylum centres and the number of relocations should be considered as risk factors for poor mental health of asylum seekers and, hence, considered in the organisational procedures in the asylum process.,To the best of the authors’ knowledge, this is the first review to specifically examine the literature on the association between the post-migratory risk factors, number of relocations and length of stay, in asylum centres and mental health among non-detained asylum seekers in Europe.