Vincent Lorant

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.

Equity in prevention and health care

Study objective: There is an increasing body of evidence about socioeconomic inequality in preventive use, mostly for cancer screening. But as far as needs of prevention are unequally distributed, even equal use may not be fair. Moreover, prevention might be unequally used in the same way as health care in general. The objective of the paper is to assess inequity in prevention and to compare socioeconomic inequity in preventive medicine with that in health care. Design: A cross sectional Health Interview Survey was carried out in 1997 by face to face interview and self administered questionnaire. Two types of health care utilisation were considered (contacts with GPs and with specialists) and four preventive care mostly delivered in a GP setting (flu vaccination, cholesterol screening) or in a specialty setting (mammography and pap smear). Setting: Belgium. Participants: A representative sample of 7378 residents aged 25 years and over (participation rate: 61%). Outcome measure: Socioeconomic inequity was measured by the HIwvp index , which is the difference between use inequality and needs inequality. Needs was computed as the expected use by the risk factors or target groups. Main results: There was significant inequity for all medical contacts and preventive medicine. Medical contacts showed inequity favouring the rich for specialist visits and inequity favouring the poor for contacts with GPs. Regarding preventive medicine, inequity was high and favoured the rich for mammography and cervical screening; inequity was lower for flu immunisation and cholesterol screening but still favoured the higher socioeconomic groups. In the general practice setting, inequity in prevention was higher than inequity in health care; in the specialty setting, inequity in prevention was not statistically different from inequity in health care, although it was higher than in the general practice setting. Conclusions: If inequity in preventive medicine is to be lowered, the role of the GP must be fostered and access to specialty medicine increased, especially for cancer screening.

Appropriateness of use of medicines in elderly inpatients: qualitative study

Abstract Objectives To explore the processes leading to inappropriate use of medicines for elderly patients admitted for acute care. Design Qualitative study with semistructured interviews with doctors, nurses, and pharmacists; focus groups with inpatients; and observation on the ward by clinical pharmacists for one month. Setting Five acute wards for care of the elderly in Belgium. Participants 5 doctors, 4 nurses, and 3 pharmacists from five acute wards for the interviews; all professionals and patients on two acute wards for the observation and 17 patients (from the same two wards) for the focus groups. Results Several factors contributed to inappropriate prescribing, counselling, and transfer of information on medicines to primary care. Firstly, review of treatment was driven by acute considerations, the transfer of information on medicines from primary to secondary care was limited, and prescribing was often not tailored to elderly patients. Secondly, some doctors had a passive attitude towards learning: they thought it would take too long to find the information they needed about medicines and lacked self directed learning. Finally, a paternalistic doctor-patient relationship and difficulties in sharing decisions about treatment between prescribers led to inappropriate use of medicines. Several factors, such as the input of geriatricians and good communication between members of the multidisciplinary geriatric team, led to better use of medicines. Conclusions In this setting, improvements targeted at the abilities of individuals, better doctor-patient and doctor-doctor relationships, and systems for transferring information between care settings will increase the appropriate use of medicines in elderly people.

Deprivation and mortality: the implications of spatial autocorrelation for health resources allocation.

This paper aims at investigating whether the relationship between mortality and socio-economic deprivation is affected by the spatial autocorrelation of ecological data. A simple model is used in which mortality (all-ages and premature) is the dependent variable, and deprivation, morbidity and other socio-economic indicators are the explanatory variables. Deprivation is measured by the Townsend index; the other socio-economic variables are the median income, unequal income distribution (Gini coefficient) and population density. Morbidity is estimated on the basis of hospital admission rates and overweight prevalence. Spatial autocorrelation is measured by the Morans I coefficient. All mortality and morbidity variables have significant, positive, and moderate-to-high spatial autocorrelation. Two multivariate models are explored: a weighted least-squares model ignoring spatial autocorrelation and a simultaneous autoregressive model. The paper concludes that spatial autocorrelation has a significant impact on the relationship between mortality and socio-economic variables. Future ecological models intended to inform health resources allocation need to pay greater attention to the spatial dimension of the data used.

Substantial use of primary health care by prisoners: epidemiological description and possible explanations.

Objectives: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. Design: Retrospective cohort study of a sample of prisoners’ medical records. Setting: All Belgian prisons (n = 33). Patients: 513 patients over a total of 182 patient years, 3328 gneral practitioner (GP) contacts, 3655 reasons for encounter. Main results: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. Conclusion: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

Socio-economic differences in psychiatric in-patient care

Objective:  We seek to investigate socio‐economic differences in psychiatric in‐patient care regarding admission, treatment and outcome.

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.

Involuntary commitment in psychiatric care: what drives the decision?

BackgroundPsychiatric commitment laws have been reformed in many European countries. We assessed the relative importance of the different legal criteria in explaining involuntary commitment under the Belgian Mental Health Act of 1990.MethodPsychiatric assessments were requested for 346 patients living in Brussels who were randomly selected from a larger group and were being considered for involuntary commitment. A retrospective study of these patients’ files was carried out.ResultsMore than half of the requests for involuntary commitment were turned down. The lack of a less restrictive alternative form of care was the criterion most crucial in decisions in favour of commitment. Alternative forms of care were more likely to be unavailable for psychotic individuals, foreigners, and patients not living in a private household.ConclusionInvoluntary commitment is mainly due to the inability of the mental health care system to provide more demanding patients with alternative forms of care.

Decomposing socioeconomic health inequalities

This Hints & Kinks paper describes a technique enabling quantification of the contributions of determinants to socioeconomic inequality in health. This technique, differing from an analysis investigating the determinants of average health levels, has received considerable attention from health economists (van Doorslaer and Gerdtham 2003; van Doorslaer and Jones 2003; van Doorslaer et al. 2004; Wagstaff et al. 2003) but only more recently from epidemiologists as well (Harper and Lynch 2007; Lynch 2006; Hosseinpoor et al. 2006). This paper employs the relative concentration index (RCI), described in Konings et al. (2009), to summarize relative inequality across the entire socioeconomic distribution. The RCI of a continuous health outcome y results from a relative concentration curve, which graphs on the x-axis the cumulative percentage of the sample, ranked by an indicator of socioeconomic position such as education or income beginning with the poorest. The y-axis then indicates the cumulative percentage of the health outcome corresponding to each cumulative percentage of the distribution of the socioeconomic indicator. Figure 1 provides an example of a concentration curve, where the health variable is childhood malnutrition in Ghana in 2003. It shows that the level of malnutrition accumulates faster among the poor than among the better-off because the line is above the diagonal. The RCI is defined as twice the area between the concentration curve and the line of equality (the 45 diagonal from the bottom-left corner to the top-right). Details on how to compute the RCI can be found in Konings et al. (2009). If yi is linearly modeled, linking a health variable, y to a set of k health determinants, xk, this can be expressed by: yi 1⁄4 a þ X

Good practice in mental health care for socially marginalised groups in Europe: a qualitative study of expert views in 14 countries

BackgroundSocially marginalised groups tend to have higher rates of mental disorders than the general population and can be difficult to engage in health care. Providing mental health care for these groups represents a particular challenge, and evidence on good practice is required. This study explored the experiences and views of experts in 14 European countries regarding mental health care for six socially marginalised groups: long-term unemployed; street sex workers; homeless; refugees/asylum seekers; irregular migrants and members of the travelling communities.MethodsTwo highly deprived areas were selected in the capital cities of 14 countries, and experts were interviewed for each of the six marginalised groups. Semi-structured interviews with case vignettes were conducted to explore experiences of good practice and analysed using thematic analysis.ResultsIn a total of 154 interviews, four components of good practice were identified across all six groups: a) establishing outreach programmes to identify and engage with individuals with mental disorders; b) facilitating access to services that provide different aspects of health care, including mental health care, and thus reducing the need for further referrals; c) strengthening the collaboration and co-ordination between different services; and d) disseminating information on services both to marginalised groups and to practitioners in the area.ConclusionsExperts across Europe hold similar views on what constitutes good practice in mental health care for marginalised groups. Care may be improved through better service organisation, coordination and information.