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