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

RESEARCH ARTICLE Open Access Good p ac ice in heal h ca e o mig an s: iews and expe iences o ca e p o essionals in 16 Eu opean coun ies S e an P iebe 1* , Sima Sandhu 1 , Sónia Dias 2 , And ea Gaddini 3 , Tim G eacen 4 , Elisabe h Ioannidis 5 , Ul ike Kluge 6 , Allan K asnik 7 , Majda Lamkaddem 8 , Vincen Lo an 9 , Rosa Puigpinósi Rie a 10 , A ila Sa a y 11 , Joaquim JF Soa es 12 , Mindaugas S ankunas 13 , Ch is a S aßmay 14 , K is ian Wahlbeck 15 , Ma a Welbel 16 , Ma ija Bogic 1 Abs ac Backg ound: Heal h se ices ac oss Eu ope p o ide heal h ca e o mig an pa ien s e e y day. Howe e , li le sys ema ic esea ch has explo ed he iews and expe iences o heal h ca e p o essionals in di e en Eu opean coun ies. The aim o his s udy was o assess he di icul ies p o essionals expe ience in hei se ice when p o iding such ca e and wha hey conside cons i u es good p ac ice o o e come hese p oblems o limi hei nega i e impac on he quali y o ca e. Me hods: S uc u ed in e iews wi h open ques ions and case igne es we e conduc ed wi h heal h ca e p o essionals wo king in a eas wi h high p opo ion o mig an popula ions in 16 coun ies. In each coun y, p o essionals in nine p ima y ca e p ac ices, h ee acciden and eme gency hospi al depa men s, and h ee communi y men al heal h se ices ( o al sample = 240) we e in e iewed abou hei iews and expe iences in p o iding ca e o mig an pa ien s, i.e. om i s gene a ion immig an popula ions. Answe s we e analysed using hema ic con en analysis. Resul s: Eigh ypes o p oblems and se en componen s o good p ac ice we e iden i ied ep esen ing all s a emen s in he in e iews. The eigh p oblems we e: language ba ie s, di icul ies in a anging ca e o mig an s wi hou heal h ca e co e age, social dep i a ion and auma ic expe iences, lack o amilia i y wi h he heal h ca e sys em, cul u al di e ences, di e en unde s andings o illness and ea men , nega i e a i udes among s a and pa ien s, and lack o access o medical his o y. The componen s o good p ac ice o o e come hese p oblems o limi hei impac we e: o ganisa ional lexibili y wi h su icien ime and esou ces, good in e p e ing se ices, wo king wi h amilies and social se ices, cul u al awa eness o s a , educa ional p og ammes and in o ma ion ma e ial o mig an s, posi i e and s able ela ionships wi h s a , and clea guidelines on he ca e en i lemen s o di e en mig an g oups. P oblems and good ca e componen s we e simila ac oss he h ee ypes o se ices. Conclusions: Heal h ca e p o essionals in di e en se ices expe ience simila di icul ies when p o iding ca e o mig an s. They also ha e ela i ely consis en iews on wha cons i u es good p ac ice. The deg ee o which hese componen s al eady a e pa o ou ine p ac ice a ies. Implemen ing good p ac ice equi es su icien esou ces and o ganisa ional lexibili y, posi i e a i udes, aining o s a and he p o ision o in o ma ion. * Co espondence: [email p o ec ed] 1 Uni o Social and Communi y Psychia y, London and he Ba s School o Medicine and Den is y, Queen Ma y Uni e si y o London, Newham Cen e o Men al Heal h, London, E13 8SP, UK Full lis o au ho in o ma ion is a ailable a he end o he a icle P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 © 2011 P iebe e al; licensee BioMed Cen al L d. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/2.0), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Backg ound Mig a ion o Eu opean coun ies has inc eased since 2000 [1]. Es ima es sugges ha in 2005, 8.5% o he EU popula ion consis ed o mig an s, wi h an addi ional 5.6 million a i ing be ween 2005 and 2009 [2]. A cen al challenge o Eu ope, wi h i s inc eased p opo - ion o mig an s, is he p o ision o accessible, equi able, and good quali y heal h se ices o all. Mos esea ch on heal h ca e o mig an s has ocused on access and use o se ices by mig an s, wi h much o he li e a u e coming om he US [3,4], Canada [5], Spain, [6-8], Denma k [9], he UK [10] and Sweden [11,12]. S udies sugges ha mig an s expe ience unequal access o ca e [13], and ou line he complexi y o heal h ca e en i lemen s o mig an s [14-16]. This s udy did no add ess he p oblems o accessing ca e, bu he quali y o ca e p o ided o mig an s once hey a e in a se ice, an issue which has ecei ed compa a- i ely less a en ion in he li e a u e, bu is o cen al impo ance o millions o mig an s who a e ea ed in heal h se ices ac oss Eu ope e e y day. Nume ous heal h ca e p o essionals in di e en Eu opean coun ies ace he challengeo p o iding hebes possibleca e omig an pa ien s, and many o hem ha e a weal h o expe ience [17,18]. Ye , he e has been li le sys ema ic esea ch explo ing hei iews and expe iences on wha hey see as he p oblems and wha hey ega d as good p ac ice. This s udy explo ed he iews and expe iences o hose heal h ca e p o essionals in di e en ypes o se - ices ac oss Eu ope, who p o ide ca e o mig an s on a daily basis. The aim was o assess wha p oblems hey expe ience in hei se ice, and wha hey iew as good p ac ice o o e come hese p oblems o limi hei nega- i e impac on he quali y o ca e. Me hods Rec ui men and Sampling As pa o he EC unded p ojec ‘Bes P ac ice in Heal h Ca e Se ices o Immig an s in Eu ope’ (EUGATE) [19] in e iews we e conduc ed wi h heal h ca e p o essionals in 16 Eu opean coun ies (co e ing mo e han 85% o he EU popula ion) o iden i y hei expe iences and iews o p o iding heal h ca e o mig an s. To ensu e he pa icipan s had su icien expe ience o p o iding heal h ca e o mig an s, each pa icipa ing coun y was asked o iden i y and ec ui pa icipan s om a eas whe e mig an popula ion le els we e pa i- cula ly high. The plan was o ocus on he h ee dis ic s in each capi al, o ano he u ban con ex , wi h he high- es p opo ion o immig an s. A e ined de ini ion o mig an s was used o aid classi- ica ion o a eas high in mig an g oups. Mig an s we e de ined as pe sons who we e bo n ou side he coun y o cu en esidence, and who we e aged be ween 18 and 65 yea s. In line wi h EU di ec i es; egula immi- g an s (e.g. labou immig an s), e ugees, asylum seeke s, ic ims o human a icking, and illegal/undocumen ed immig an s we e all encapsula ed in his de ini ion. Once a eas we e iden i ied, o each o he h ee dis- ic s in each coun y, pa icipan s we e ec ui ed om h ee p ima y ca e p ac ices (i.e. 9 pe coun y, o al n = 144), and one each om an acciden and eme gency hospi al depa men (3 pe coun y, o al n = 48), and a communi y se ice o pa ien s wi h men al illnesses (3 pe coun y, o al n = 48). In selec ing p ima y ca e p ac ices we aimed o include hose wi h he highes numbe o mig an pa ien s o , in he absence o such da a, he bigges ones in he a ea. Whils usually he e was only one A&E depa men in each a ea, o commu- ni y men al heal h se ices we aimed o selec he la - ges one in he gi en a ea. The lis o selec ed a eas and heal h se ice in all 16 coun ies a e shown in Table 1. We app oached he selec ed se ice and asked o an in e iew, p e e ably wi h a p ac i ione wi h he la ges expe ience in p o iding heal h ca e o mig an s in he se ice. The decision as o who was o be in e iewed in he s udy was made by he se ice. The In e iews Face- o- ace in e iews we e conduc ed be ween 2008 and 2010. A s uc u ed in e iew schedule was de el- oped in English and pilo ed in each pa icipa ing coun- y. Based on he expe iences o he pilo phase, he schedule was e ined and inalised. The inal e sion o he schedule was ansla ed in o he languages o he pa icipa ing coun ies. I was p esen ed in wo pa s. The i s pa o he in e iew ocused on open ques- ions abou gene al expe iences, in pa icula p oblems and s eng hs in p o iding heal h ca e o mig an s wi hin he se ice. The second pa consis ed o open- ended ques ions abou pa ien s ep esen ed in h ee case igne es. These cases we e modi ied o sui he h ee ypes o se ices (p ima y ca e, A&E, and commu- ni y men al heal h) and aimed o speci y di e ences and simila i ies in ea men o mig an s in compa ison o indigenous popula ions (as can be seen in he ex om he igne es below). P ima y Ca e Illegal immig an A male, 28 yea s old, coming om [inse coun y], p esen s wi h pain when u ina ing and has a sligh e e . He does no speak any language ha he doc o unde s ands. He has no insu ance, no iden i- ica ion and no esidency pe mi . Re ugee A e ugee woman, 39 yea s old, om [inse coun y], p esen s wi h headache, anxie y, sleeping P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 2 o 12 p oblems and s omach ache. She has e y li le com- mand o he language o he hos coun y. She b ings he 12 yea s old daugh e along, who speaks he lan- guage o he hos coun y e y well. Labou immig an A [inse na ionali y] woman, 40 yea s old, labou immig an , widow, wi h wo chil- d en 10 and 15 yea s old, asks o medica ion o he lowe back pain. She speaks he language o he hos coun y easonably well, is wo king legally in a cleaning company and wan s o go back o wo k u gen ly. Acciden & Eme gency Depa men Illegal immig an The pa ien a i ed in he hos coun- y as an illegal immig an abou 1 yea ago. He is 25 y s o age and o [inse a coun y] o igin. He does no speak any language ha he A&E s a unde s ands and p esen s wi h an in ense lowe abdominal pain. Re ugee The emale pa ien is 19 y s o age and a i ed om [inse a coun y] 10 mon hs ago. She has e ugee s a us and speaks only [inse language o o igin] and a ew wo ds o English. She is in he i h mon h o p egnancy and has a se ious complica ion (p e-eclampsia). Sheis eluc an obeexaminedbyamaledoc o . Labou immig an The male pa ien is 35 y s o age anda i ed om[inse a coun y] wo yea s ago. He has a egula esidence pe mi . He was b ough o A&E by he police because o his agg essi e beha iou ollow- ing hea y d inking. He su e ed ex e nal head inju ies in a igh . He is ully conscious and accessible o examina ion. Men al Heal h Se ices Illegal immig an The pa ien a i ed in he hos coun- y as an illegal immig an abou 1 yea ago. She is 25 y s o age and o [inse na ionali y] o igin. She does no speak he language o he hos coun y, has no social con ac s and appea s se e ely dep essed. Re ugee The male pa ien is 22 yea s o age, came o he hos coun y om [inse coun y] a yea ago and has e ugee s a us. He speaks a ew wo ds o he language o he hos coun y. He appea s o ha e pe sis en audi o y hallucina ions and eels pe secu ed. Table 1 Sampled coun ies and co esponding heal h se ice a eas Coun y Selec ed Ci ies Selec ed P ima y Ca e A eas Selec ed Men al Heal h Ca e A eas Selec ed A & E A eas AUSTRIA Vienna Rudolsheim-Fün haus, O ak ing, & B igi enau. Rudolsheim-Fün haus, O ak ing, & B igi enau. Leopolds ad , O ak ing, & B igi enau. BELGIUM B ussels Sain Josse, Schae beek, & Molenbeek Sain Josse, Schae beek, & Molenbeek Sain Josse, Schae beek, & B ussels Ci y DENMARK Copenhagen Nø eb o, Valby, Bispebje g, B øndby, Albe slund, & Rødo e A eas wi hin Bispebje g Hospi al, H ido e Hospi al, & Glos up Hospi al Bispebje g Hospi al, H ido e Hospi al, & Glos up Hospi al FINLAND Vaasa, Pie a saa i, O a ais, Malax Vaasa, Pie a saa i, & O a ais, Vaasa, Pie a saa i, & Malax Vaasa, Pie a saa i, & O a ais, FRANCE Pa is 18 h &19 h A ondissmen s o Pa is & Aube illie s o Seine-S -Denis Depa men 18 h &19 h A ondissmen s o Pa is & Aube illie s o Seine-S -Denis Depa men Bicha , La iboisie e, & La Rose aie GERMANY Be lin Tie ga en, Wedding, & K euzbe g Tie ga en, Wedding, & K euzbe g Tie ga en, Wedding, & K euzbe g GREECE A hens Va i, Vy onas, Gala si, Th akomakedones, & Ele sina Cen al A hens Voula & Th akomakedones HUNGARY Budapes Te éz á os, E zsébe á os, Kőbánya, Zugló, & Csepel E zsébe á os, Kőbánya, & Pes e zsébe E zsébe á os, Kőbánya, & Pes e zsébe ITALY Rome Dis ic s I, VIII, & XX Dis ic s I, VIII, & XX Dis ic s I, VIII, & XX LITHUANIA Kaunas Nine la ges PHC ou o 11 Alekso as & Zaliakalnis Down own Kaunas, Zaliakalnis, & Silainiai dis ic NETHERLANDS Ams e dam, U ech , Ro e dam, Hague Ams e dam, U ech , & Ro e dam Ams e dam, U ech , & Ro e dam Ams e dam, U ech , & he Hague POLAND Wa saw Moko ow, P aga Poludnie, & S odmiescie Moko ow, P aga Poludnie, & S odmiescie Moko ow, P aga Poludnie, & S odmiescie PORTUGAL Lisbon Amado a, Lou es, & Lisboa Amado a, Lou es, & Lisboa Amado a, Lou es, & Lisboa SPAIN Ba celona Cui a Vella, Eixample, San s Mon juic, & Nou Ba is Cui a Vella, Eixample, & Nou Ba is Cui a Vella, Eixample,& Nou Ba is SWEDEN S ockholm Cen al, Sou h Eas , & Sou h Wes Cen al, Sou h Eas , & Sou h Wes Cen al, Sou h Eas , & Sou h Wes UNITED KINGDOM London Hackney, Towe Hamle s & Newham Hackney, Towe Hamle s & Newham Hackney, Towe Hamle s & Newham P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 3 o 12 Labou immig an The emale pa ien is 45 y s o age and a i ed om [inse coun y] wo yea s ago. She has a egula esidence pe mi , speaks he language o he hos coun y well and su e s om a bipola diso de wi h equen and p olonged manic episodes. The coun y o o igin o he mig an s in he igne es a ied sligh ly be ween coun ies o ensu e ha he o i- gin o he mig an was consis en wi h he demog aphic composi ion o mig an s in he pa icipa ing coun y, so ha he igne es p esen ed a ealis ic scena io o he in e iewees in each coun y. In all o he ways, he case igne es and ques ions we e iden ical ac oss coun ies. Demog aphic in o ma ion and p o essional s anding o he in e iewees we e documen ed and he in e iews we e audio- aped in he majo i y o cases. When his was no possible, esponses we e documen ed in w i ing. In o med consen was ob ained p io o he in e iews, and he s udy was app o ed by ele an e hics commi - ees in coun ies whe e his was equi ed. E hics app o al o he s udy was ob ained in Po ugal h ough he Uni e si y Hospi al S. João. In o he coun ies e hics app o al was no equi ed because no pa ien da a was eco ded, because he s udy was ega ded as se ice e a- lua ion wi hou he need o an e hical e iew. Da a Analysis All o he 240 in e iews we e audio- aped o eco ded in w i ing and ansc ibed e ba im, ensu ing he emo al o any iden i ying in o ma ion o main ain anonymi y. The p epa ed ansc ip s we e subjec ed o hema ic con en analysis [20]. This p ocess was deemed he mos sui able o in e p e ing he ex ual da a in a sys ema ic way, om classi ying codes o iden i ying eme gen hemes. The i s s agewas ocode heda a om heini ial in e iew ansc ip s line-by-line, which was conduc ed in each o he pa icipa ing cen es. The codes and co - esponding ex ual ex ac s we e hen used o de elop a codebook, which was ansla ed in o English, e iewed and inalised amongs he esea che s in all pa icipa ing coun ies. The esul ing codebook consis ed o a lis o codes, accompanied by a b ie and a mo e comp ehen- si e de ini ion, and illus a ed wi h examples. The code- book was u ilised o code he en i e da a co pus, wi h s a egic checks made a e coding o he i s six in e - iew ansc ip s om each coun y. The alidi y o he codes was checked agains he da a ex ac s o asce ain g ounding in he ansc ibed da a. Disc epancies in cod- ing ac oss cen es we e picked up ea ly in he analysis and cla i ied wi h e i ica ions, u he o hose sum- ma ised in he codebook. The second s age o he analy- sis was he clus e ing o codes in o eme gen ca ego ies, which we e hen s uc u ed and g ouped o o m o e - a ching hemes [21,22]. To ensu e he hemes and ca ego ies consis en ly ep esen ed he da a co pus ac oss all pa icipa ing cen es, inal e i ica ion checks we e made be ween each pa icipa ing cen e and he coo dina ing cen e. Da a om all pa s o he in e iew and om all coun- ies we e included in equency coun s o hemes. This nume ical depic ion o con en was used o speci y he equency o he p oblems and good p ac ice compo- nen s and compa e hose equencies ac oss se ices. Resul s Pa icipan s The majo i y o in e iewees we e p ac i ione s (n = 214) including doc o s (156), nu ses (44), psychologis s (7), physio he apis s (4) and social wo ke s (3). The emaining pa icipan s we e ei he adminis a o s o manage s, some o whom we e also quali ied heal h ca e p o essionals (n = 26). Di e ences in u he ea men o mig an s The majo i y o esponden s (74%) asse ed ha , in gen- e al, ea men o mig an s a e he ini ial con ac would no di e om ha o non-mig an pa ien s. When speci ically asked in case igne es abou di e en u he pa hways depending on he immig a ion s a us, o he labou mig an igne e o e wo- hi ds (147 pa icipan s) explici ly said ha he e would be no di - e ence in u he ea men pa hways. Howe e , o e ugees and undocumen ed mig an s only one o wo pa icipan s espec i ely epo ed no di e ence in u he ea men pa hways. P oblem A eas Eigh p oblem a eas we e iden i ied, which a e lis ed in Table 2. These a e comp ehensi e and include all p o- blems men ioned in he 240 in e iews. The p oblems a e he e p esen ed in he o de o he equency o in e iews in which hey ha e been aised. 1) Language ba ie Language and communica ion p oblems we e mos commonly epo ed, wi h equen e e ences made o a‘language ba ie ’be ween p ac i ione s and pa ien s. Conce ns we e exp essed o mig an s’inabili y o communica e hei p oblems due o language di icul- ies, wi h he isk o being misunde s ood and, ul i- ma ely, misdiagnosed. Responden s desc ibed how ex ensi e physical examina ions and diagnos ic es s we e some imes equi ed o compensa e o he inabil- i y o communica e e bally. Adminis a i e p ocedu es we e also p olonged and complica ed h ough poo communica ion. Some in e iewees ou lined associa ed p oblems wi h no o es ic ed access o in e p e ing se ices, which o en esul ed in he use o he pa ien ’schild,o P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 4 o 12 ano he amily membe ansla ing du ing consul a ions. This was especially p oblema ic in sensi i e cases. “The e is o en a signi ican language ba ie . I e e y hing has o be ansla ed, you lose hal he ime. O en a child o g andchild is ansla ing, bu hen you can’ ask pe sonal in ima e hings anymo e. A en yea old gi l can’ ansla e he mens ua ion p oblems o he mo he . Tha ’s eally a p oblem.” (Ne he lands, ID 212, P ima y Ca e) Family membe s may also choose o be selec i e in wha hey ansla e, summa ising o e en censo ing he communica ion be ween he pa ien and he doc o . “When i is a amily membe who comes o ansla e, he ansla es wha he wan s, i ’s only in e p e a- ion...”(Belgium, ID 27, P ima y Ca e) In ol ing a p o essional in e p e e howe e may also come wi h p oblems. Conce ns we e exp essed o how in ol ing a hi d pa y would impac on he pa ien - p ac i ione ela ionship. Thi d pa y in ol emen also led some pa icipan s o be conce ned o e con iden ial- i y issues, especially when he in e p e e was om he pa ien ’s own communi y. 2) Di icul ies in a anging ca e o immig an s wi hou heal h ca e co e age Responden s discussed he di icul ies in p o iding ca e o undocumen ed immig an s, who had no en i lemen s o mains eam heal h ca e se ices. Some p o essionals epo ed ha he en i lemen s o di e en pa ien g oups equi ed cla i ica ion. O he s men ioned ha hey had su icien in o ma ion o know wha ea men s hey could o e , whe e he pa ien could seek u he help, o how he ea men should be unded. Awa eness o he legal si ua ion may pu p ac i ione s in o a dilemma. “Un o una ely, some imes e en legal immig an s a e no co e ed by gene al heal h ca e insu ance. This is a big p oblem o doc o s, because in heo y, unin- su ed pa ien s should co e he cos s o hei ea - men by hemsel es. Bu o mos immig an s i is impossible... And doc o s a e in a si ua ion wi h no good solu ion - om an e hic poin o iew hey should p o ide ea men , om a legal poin o iew - hey shouldn’ .”(Poland, ID 234, P ima y Ca e). Mos in e iewees said ha hey would always p o ide eme gency ca e i equi ed. They desc ibed es ic ed access o labo a o ial es s, scanning and o he specialis pa hways o mig an s wi hou co e age. Some in e ie- wees a emp ed o ci cumna iga e he co e age p oblems by submi ing labo a o y samples in hei own name, p e- sc ibing he pa ien wi h a cheape medicine hey could a o d, o choosing o egis e he pa ien in an al e na- i e manne . Some in e iewees exp essed conce n ha hey would no be able o con ac he pa ien again i es s aised abno mal esul s, o ha mig an s ea ul o depo a ion would isk using ake iden i ica ion o some- one else’s documen s o ecei e ca e. 3) Social dep i a ion and auma ic expe iences O e wo- hi ds o he in e iewees epo ed p oblems a ising om s ess ul expe iences o mig an s. Recen mig an pa ien s we e iewed as being mo e socially ma - ginalised, om poo e backg ounds, unemployed, s ug- gling o lea n a new language, o o in eg a e, and possibly auma ised om expe iences o wa and con lic . “... ha lady om he Congo had he oo sawn o as a o m o o u e. O he hings like ha , mul iple ape, people who ha e had hei lips cu o , o hei whole amilymu de edin on o hem...”(UK, ID 305, P ima y Ca e) Some o hese speci ic socioeconomic s esso s had a di ec impac on ea men . “... he di e ence is, ha he e is mo e [ ea men ] and less p e en ion. Tha I jus can’ pu he on sick-lea e, Table 2 F equency o p oblem a eas epo ed amongs in e iewees by se ice ype Themes Se ice Type (%) To als (%) P oblem A eas P ima y Ca e Men al Heal h A&E All Se ices Language ba ie 137 (95) 45 (94) 46 (96) 228 (95) Di icul ies in a anging ca e o mig an s wi hou heal h ca e co e age 124 (86) 33 (69) 28 (58) 185 (77) Social dep i a ion and auma ic expe iences 101 (70) 41 (85) 26 (54) 168 (70) Lack o amilia i y wi h he heal h ca e sys em 92 (64) 27 (56) 31 (65) 150 (63) Di e en unde s andings o illness and ea men 79 (55) 36 (70) 24 (50) 139 (58) Cul u al di e ences 74 (51) 26 (54) 38 (79) 138 (58) Nega i e a i udes among s a and pa ien s 58 (40) 21 (44) 21 (44) 100 (42) Lack o access o medical his o y 24 (17) 10 (21) 13 (27) 47 (20) P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 5 o 12 ha I can’ ad ise he o change he job - how should she a end a aining, and le he child en s a e, ha is no possible and ha is he di e ence.”(Aus ia, ID 2, P ima y Ca e). Some esponden s held he iew ha esol ing socioe- conomic and legali y issues we e o mo e impo ance o many pa ien s han esol ing heal h p oblems. 4) Lack o amilia i y wi h he heal h ca e sys em A lack o amilia i y wi h he heal h ca e sys em was ega ded as common among ecen immig an s. “A&E se ices a e o en he only ca e access many mig an s ha e - because hey don’ know how he sys- em wo ks.”(F ance, ID 806, A&E). No ully unde s anding he heal h ca e sys em a ec s he ea men a ailable. In e iewees epo ed cases whe e a ailable esou ces and se ices we e unde used by mig an s, because hey we e no awa e o hei exis- ence. Fu he mo e, esponden s discussed ha p e ious expe ience in o he heal h ca e sys ems o en led mig an s o ha e di e en expec a ions o he oles o doc o s and pa ien s. Di e en unde s andings o he pa ien -clinician ela ionship may esul in unce ain y and mis us , i expe iences di e g ea ly om expec a- ion. In e iewees ega ded he ole o doc o s as gi en g ea e p ecedence amongs ce ain mig an pa ien s, who may ha e un ealis ic expec a ions abou he capa- ci y o doc o s o so a ious physical and social p o- blems wi hin sho consul a ions. 5) Di e en unde s andings o illness and ea men Pa icipan s epo ed p oblems linked speci ically o di - e en unde s andings o he gi en illness o a mig an pa ien and he ea men op ions. Exp essions o ae iol- ogy, symp oms, and pain made a diagnosis di icul o es ablish, especially when unde s andings o hese con- cep s g ea ly di e ed be ween he pa ien and p ac i ione . Responden s discussed he challenges in ea ing mig an pa ien s wi h di e en unde s andings o he human body, which occasionally esul ed in pa ien s deciding no o ollow he ecommended ea men , o ag eeing a e some esis ance. “I had his woman om Somalia who said he back was hu ing and he unde s anding o he pain was ha she had some ai which was mo ing om one side o he back o he o he [...] she wan ed me o pe o a e he shoulde so ha he ai could ge ou . I was e y di icul o explain why I jus ga e he able s because he pe cep ion o he body is comple- ely di e en . [...] E en wi h an in e p e e i was e y di icul o explain so we had o ind my ana omy book and show [...] he p oblem wi h he back was wi h muscles and ha he e was no ai he e. She kind o unde s ood hough she did no look comple ely con inced, bu she ook he pills and i helped.”(Denma k, ID 49, P ima y Ca e) 6) Cul u al di e ences Whils he p e ious p oblem was speci ically linked o he unde s anding o he gi en illness and i s ea men , in e iewees epo ed also mo e gene al di e ences in cul u al no ms, eligious p ac ices and cus oms as po en ial complica ions o di ec examina ion and ea - men . In e iewees epo ed conce ns ega ding app o- p ia e engagemen in physical examina ions, p ese ing and espec ing eligious es ic ions on physical con ac and cul u al aboos. “...membe s o Muslim eligious communi ies, he e a e shame ba ie s ha we do no ha e: he husband expec s o a end he ea men session. In ce ain ea men - he a eas o sex, anal egion a e aboo.” (Ge many, ID 101, A&E) While mos se ices we e able o o e ea men om ei he gende i eques ed, o he s we e no . Acco ding o he esponden s, his had on occasion esul ed in pa ien s e using ca e o unwilling o disclose sensi i e in o ma ion. In e iewees no ed ha some Eu opean ea men s and adi ions may be di icul o mig an s o emb ace, pa icula ly when hey in ol e he apies and ea men s ou side o medica ion. “Di e en cul u al alues and belie s make i di icul o he doc o o use psycho he apeu ic p ocedu es” (G eece, ID 122, Men al Heal h). Responden s also discussed cul u al di e ences in e ms o p ac ical issues such as no a ending appoin - men s, u ning-up la e, o seeking consul a ion ou side o opening hou s. O en his was discussed as leading o disappoin men and us a ion, as pa ien s would be asked o make ano he appoin men . The e we e also conce ns o he impac his would ha e on he se ice, wi h delays o o he appoin men s, and a gene al s ain on ime and esou ces. 7) Nega i e a i udes among s a and pa ien s In e iewees epo ed a lack o us o some mig an pa ien s owa ds s a . Dis us owa ds p ac i ione s and in e p e e s o igina ing om coun ies whe e pa ien s p e iously expe ienced poli ical o eligious con lic we e epo ed in his con ex . Ce ain pa ien s we e epo ed as being explici in hei eques s o be seen by ano he membe o s a , o wi hholding in o ma ion, based on hese g ounds. Nega i e a i udes owa ds s a P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 6 o 12 and some imes hos ile beha iou we e la gely a ibu ed o cul u al di e ences, misunde s andings, o he eeling o he pa ien s ha hey we e no being aken se iously. Fea s o disc imina ion we e men ioned in explana- ions o pa ien e icence, o en based on cu en and p e ious socie al expe iences, o opinions epo ed in he media. Howe e , s a beha iou owa ds mig an pa ien s may also pe pe ua e his ea o disc imina ion. “Many mig an s expe ience disc imina ion and ejec- ion wi hin he heal hca e sys em; being sen away, being ea ed unkindly, ea ed as i hey a e s upid, while hey do no unde s and he language. These expe iences a e aken along in he doc o -pa ien ela ionship. I can no ice he dis us o new clien s a hei i s consul a ion wi h me.”(Ne he lands, ID 214, P ima y Ca e). 8) Lack o access o medical his o y Finally, lack o access o a medical his o y was epo ed as p oblema ic, especially o undocumen ed mig an s. I such in o ma ion was a ailable, i was usually in a o - eign language. Responden s u he discussed he com- plica ions associa ed wi h no knowing whe he pa ien s had alle gies, accina ions, o p e ious heal h p oblems. They we e conce ned ha lack o con ac de ails and na ionali y made decisions ega ding consen and nex o kin p oblema ic. Di e ences be ween ypes o se ices Mos p oblems we e simila ly aised in all h ee ypes o se ices. P ima y ca e se ices mo e o en men ioned di icul ies in a anging u he ca e, whils communi y men al heal h se ices pu mo e emphasis on he social s esso s o mig an s and A&E depa men s on di e - en cul u al no ms. Nega i e a i udes and lack o access o medical his o y we e aised as p oblems in 15 coun- ies; he o he p oblem a eas we e aised in all 16 coun ies. Componen s o good p ac ice Se en hemes desc ibing di e en componen s o good p ac ice eme ged and co e ed all componen s men ioned in he in e iews. They a e summa ised in Table 3 and epo ed below in o de o equency. S a emen s on good p ac ice we e conside ed in he hemes indepen- den ly o whe he esponden s men ioned hem as an exis ing s eng h o hei se ice, o a sugges ion o u u e imp o emen s. 1) O ganisa ional lexibili y wi h su icien ime and esou ces Almos all esponden s men ioned aspec s ela ing o o ganisa ional lexibili y, including su icien ime, esou ces and indi idualisa ion o ca e. Many p ac i ione s epo ed booking double ses- sions, especially when an in e p e e was in ol ed, and gi ing mig an pa ien s mo e ime o ensu e ha hey we e hea d and unde s ood. Whe e limi ed ime and esou ces we e epo ed, he esponden s sug- ges ed ha s a could be employed o speci ically manage social and adminis a i e issues, eeing mo e ime o p ac i ione s o see pa ien s in a heal h ca e capaci y. “... o ha e mo e p o essionals wi h ime a ailable o p o ide in o ma ion o hese pa ien s so hey can eel ha hey ha e a place whe e hey can go and ask hei ques ions.”(Po ugal, ID 244, A&E). In e iewees discussed he impo ance o s uc u ing egula s a mee ings o deal wi h he p oblems a ising in heal h ca e o mig an s. Some se ices aced es ic ions on ea ing undocu- men ed mig an s. To o e come his ba ie o u he ca e, sugges ions we e made o seek unding o ea - men om Non Go e nmen al O ganisa ions, sending pa ien s o clinics specialising in p o iding ca e o undo- cumen ed mig an s, p o iding cheap o ee medica ion, gi ing p i a e p esc ip ions, o egis e ing undocumen- ed mig an s in an al e na i e way (e.g. as a ou is ). “I p esc ibe he medicines o my own name, i he pa ien has no money o i .”(Hunga y, ID 146, P ima y Ca e). Table 3 F equency o componen s o good p ac ice epo ed amongs in e iewees by se ice ype Themes Se ice Type (%) To als (%) Componen s o Good P ac ice P ima y Ca e Men al Heal h A&E All Se ices O ganisa ional lexibili y wi h su icien ime and esou ces 138 (96) 48 (100) 48 (100) 234 (98) Good in e p e ing se ices 142 (99) 38 (79) 38 (79) 218 (91) Wo king wi h amilies and social se ices 67 (47) 48 (100) 18 (38) 133 (55) Cul u al awa eness o s a 58 (40) 32 (67) 22 (46) 112 (51) Educa ion p og ammes and in o ma ion ma e ial o mig an s 66 (46) 15 (31) 23 (48) 104 (43) Posi i e and s able ela ionships wi h s a 62 (43) 13 (27) 16 (33) 91 (38) Clea guidelines on ca e en i lemen s o di e en g oups o mig an s 15 (10) 8 (17) 4 (1) 27 (11) P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 7 o 12 In p ac ice many esponden s epo ed ha s a would i s ea pa ien s and hen possibly conside issues o en i lemen and insu ance. Responden s also men ioned ha se ices o mig an s could be imp o ed wi h he use o mo e documen a ion, e en o hose wi h no legal esidency. Recommenda ions we e made o es ablishing da abases wi h medical his o ies. Se e al in e iewees men ioned close geog aphical p oximi y o immig an popula ions as a s eng h o hei se ice. P o iding a local se ice o mig an s educed p oblems associa ed wi h keeping appoin - men s, and he cos o anspo a ion. Responden s spoke o he impo ance o a lexible and indi idualised app oach o mig an s wi hin mains eam ca e, wi h mo e walk-in sessions, open appoin men slo s, and ad ocacy se ices. 2) Good in e p e ing se ice Good in e p e ing se ices we e men ioned in almos all o he in e iews and esponden s we e speci ic in wha was equi ed o a good quali y in e p e ing se ice. “Quali a i e in e p e ing se ices, so ha he in e - p e e knows he medical e minology and also unde s ands he p o essional disc e ion“(Finland, ID 73, P ima y Ca e). They sugges ed ha his could be achie ed h ough p o essional in e p e e s, ecommending imp o ed access o in e p e ing se ices, including he a ailabili y o in e p e e s a he ecep ion poin and acili ies o mul iple languages. The p o ision o a pe manen in- house in e p e ing se ice was discussed by some, as we e same-language he apis s o pa ien s ecei ing alk-based he apies. O he s emphasised imp o ing mig an pa ien s’command o he na ional language as he bes possible long- e m answe o educing language ba ie s. Communica ion h ough a p o essional in e p e e was no always iewed as en i ely help ul. Some in e iewees p e e ed using ela i es o iends as in e p e e s ins ead, because o hei abili y o p o ide mo e comp e- hensi e in o ma ion abou he pa ien , as well as ha ing he pa ien ’s us . Responden s epo ed using he in e - ne o assis in ansla ion, by he use o sea ch engines o web pages wi h medical ad ice and in o ma ion om he pa ien ’s coun y o o igin. 3) Wo king wi h amilies and social se ices Jus o e hal o he esponden s sugges ed collabo a ion wi h social se ices and amilies as impo an o good p ac ice in mig an heal h ca e. Cen al o his heme we e good con ac s wi h social se ices and he sha ing o in o ma ion. In e iewees explici ly men ioned engaging wi h communi y cen es o connec mig an pa ien s o he wide communi y. Some epo ed con ac ing eli- gious leade s and non-s a u o y agencies o assis mig an s in ge ing in ouch wi h hei local commu- ni y. Conce ns we e also aised abou mig an s becoming isola ed. Responden s add essed a emp s made by heal h ca e s a in some se ices o con- ac he pa ien ’s amily o iends, e en i hey we e in ano he coun y. Pa icipan s aised conce ns ha in some cases he pa ien ’s li ing condi ions maybe exace ba ing an ill- ness o limi ing eco e y and discussed ins ances whe e hey had a emp ed o ind solu ions o he pa ien ’s pe sonal and social p oblems. Fo example, some e e ed pa ien s wi h housing p oblems o cha i- ies wi h housing acili ies. O he heal h se ices ha e Ci izens Ad ice Bu eau ad iso s, physio he apis s, cul- u al wel a e ad iso s, and amily ac ion ad iso s o assis immig an s wi h di e en needs in one se ice. Responden s discussed he bene i s o dealing wi h heal h, adminis a i e and legal issues in one place. They epo ed o en o encou age mig an pa ien s o ge in ouch wi h e ugee o ganisa ions, p ojec s o immig an women, language lea ning cen es and o he aining cou ses. 4) Cul u al awa eness o s a Cul u al awa eness was epo ed as impo an o good p ac ice. Some esponden s iewed he aining o s a in di e en cul u al and eligious p ac ices as co e o he deli e y o sa is ac o y and espec ul ca e o mig an pa ien s. Some spoke o de eloping expe ise in he ea men o mig an pa ien s h ough expe ience and exposu e, such as being loca ed in a mul icul u al communi y, o being known as a cul u ally sensi i e se ice. Responden s made speci ic ecommenda ions o opics on cul u al sensi i i y o be co e ed in p ac i- ione aining cou ses and uni e si y educa ion. They u he sugges ed ha cou ses should include in o ma- ion on mig an speci ic diseases, cul u al unde s and- ings o illness and ea men , and in o ma ion pe aining o cul u al and eligious no ms and aboos. “The e a e he lack o knowledge how o wo k wi h his ype o pa ien s. Doc o s a e lacking legal, cul- u al, speci ic medical in o ma ion abou his. I would be good o o ganize a sho aining cou se in his ield.”(Li huania, ID 186, A&E). Acco ding o he esponden s, such knowledge enabled hem o each mo e accu a e diagnoses and p o ide app op ia e ea men s, while mee ing pa ien needs o cul u al accep ance and unde s anding. The p esence o mig an s a was also lagged up as inc eas- ing he awa eness o mig an needs and assis ing wi h P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 8 o 12 unde s anding cul u e and language issues. “I is a g ea s eng h ha we ha e s a o di e en e hnic backg ound. We can lea n om hem once in a while when he e is an episode whe e we hink “wha jus happened he e?”Then i is a gi o ha e an employee who is able o say wha hey hink i is abou . And o en i is. In acu e si ua ions we ha e a language which we need he e and now...”(Denma k, ID 44, Men al Heal h). 5) Educa ional p og ammes and in o ma ion ma e ial o mig an s In e iewees sugges ed ha ins uc i e p og ammes and in o ma ion ma e ial be p oduced o mig an s abou he hos coun y’s heal h ca e sys em. Such in o ma ion was iewed as help ul o mig an s o access app op ia e se ices and seeking e ec i e ea men . Sugges ions we e made o communi y heal h p ojec s, o e ening mee ings, whe e medical s a could explain and educa e mig an s abou how he heal h ca e sys em wo ks, and how o os e a heal hy li es yle. “They should design a welcome p ocess adap ed o immig an people o explain he heal h ca e sys em, counselling e c. Fo example, hey should ha e an in e iew wi h he immig an pa ien s o in o m hem abou he heal h ca e sys em and he se ice oles.”(Spain, ID 265, P ima y Ca e). As one way o p o iding such in o ma ion espon- den s sugges ed he use o lea le s in mul iple languages, explaining he heal h ca e sys em and a enues o acces- sing se ices. Some in e iews el his ook some p es- su e o p ac i ione s, so ha hey would spend less ime explaining he sys em and mo e ime p o iding di ec pa ien ca e. In addi ion, in e iewees pu po ed ha his would educe pa ien disappoin men , as awa eness o wha can be expec ed om each se ice and s a would be unambiguous. Howe e , some esponden s cau ioned ha mig an pa ien s may s ill need assis ance o be guided o lea le s and, whe e li - e acy is an issue, mo e assis ance would be equi ed han jus a lea le . 6) Posi i e and s able ela ionships wi h s a O e a hi d o all esponden s poin ed owa ds posi- i e ela ionships be ween s a and pa ien s, and con i- nui y o ca e as componen s o good p ac ice. They discussed he necessa y ea u es o a posi i e ela ion- ship, which included espec , wa m h, being welcom- ing, lis ening and esponding e ec i ely. Some esponden s spoke o ha ing welcoming policies in place, which ensu ed ha pa ien s a e gi en indi idual a en ion and eased p ocesses o hem whe e possible. The p omo ion o non-judgmen al, open minded and equi able s a was also men ioned in esponses unde his heme. Consis ency o s a was seen as impo an o achie - ing amilia i y and building a posi i e and us ing ela- ionship. “I ha e buil a ela ionship wi h my clien s, and ha e g adually come o know hem. I am a amilia pe - son, and hey know hey can always con ac me. I I am absen , hey can con ac a colleague o mine, wi h whom hey a e also amilia .”(Ne he land, ID 214, P ima y Ca e). Responden s u he epo ed ha seeing a di e en clinician a e e y appoin men had a nega i e impac on pa ien s’expe ience o he se ice, especially when hey had o explain hei medical his o y epea edly in e e y consul a ion. 7) Clea guidelines on ca e en i lemen s o di e en g oups o mig an s Se e al esponden s sugges ed clea e in o ma ion and guidelines on wha ype o ca e di e en mig an g oups a e en i led o. They epo ed he bene i s om cou ses on mig an heal h ca e igh s and o he legal issues. Included unde his heme we e sugges ions o in o - ma ion on how o gain unding o ea ing undocumen- ed mig an s. Some go e nmen s legally allow p ac i ione s o ea undocumen ed mig an s i hei condi ion was li e h ea ening. Howe e , esponden s epo ed ha anspa ency was needed on wha was conside ed a li e h ea ening condi ion. Di e ences be ween ypes o se ices Collabo a ion wi h amilies and social se ices was mo e o en epo ed as impo an in communi y men al heal h se ices, whils he o he componen s o good p ac ice we e aised by in e iewees in he h ee se ice ypes wi h a simila equency. Clea guidelines we e sug- ges ed in 10 coun ies, educa ion p og ammes in 14 coun ies, posi i e ela ionships in 15 coun ies, and all o he good p ac ice componen s in all 16 coun ies. Discussion Main indings In in e iews wi h heal h ca e p o essionals in di e en ypes o se ices ac oss Eu ope, eigh p oblem a eas we e iden i ied in he deli e y o ca e o mig an s. Se en componen s o good p ac ice we e sugges ed o o e - come hese p oblems o limi hei po en ially nega i e impac . P oblem a eas and good p ac ice componen s a e comp ehensi e, i.e. hey co e ed all s a emen s made in 240 in e iews in 16 coun ies. Mos p oblems and good p ac ice componen s we e aised in all coun ies and in mo e han 50% o he in e iews, al hough he speci ic aspec and emphasis o each heme o en a ied P iebe e al.BMC Public Heal h 2011, 11:187 h p://www.biomedcen al.com/1471-2458/11/187 Page 9 o 12