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

RESEARCH ARTICLE Open Access Heal h ca e o immig an s in Eu ope: Is he e s ill consensus among coun y expe s abou p inciples o good p ac ice? A Delphi s udy Wal e De illé 1* , Tim G eacen 2 , Ma ija Bogic 3 , Ma ie Dau in 4 , Sónia Dias 5 , And ea Gaddini 6 , Na asja Koi zsch Jensen 7 , Ch is ina Ka amanidou 8 , Ul ike Kluge 9 , Ri a Me aniemi 10 , Rosa Puigpinós i Rie a 11 , A ila Sá á y 12 , Joaquim JF Soa es 13 , Mindaugas S ankunas 14 , Ch is a S aßmay 15 , Ma a Welbel 16 and S e an P iebe 3 Abs ac Backg ound: Eu opean Membe S a es a e acing a challenge o p o ide accessible and e ec i e heal h ca e se ices o immig an s. I emains unclea how bes o achie e his and wha cha ac e ises good p ac ice in inc easingly mul icul u al socie ies ac oss Eu ope. This s udy assessed he iews and alues o p o essionals wo king in di e en heal h ca e con ex s and in di e en Eu opean coun ies as o wha cons i u es good p ac ice in heal h ca e o immig an s. Me hods: A o al o 134 expe s in 16 EU Membe S a es pa icipa ed in a h ee- ound Delphi p ocess. The expe s ep esen ed ou di e en ields: academia, Non-Go e nmen al O ganisa ions, policy-making and heal h ca e p ac ice. Fo each coun y, he p ocess aimed o p oduce a na ional consensus lis o he mos impo an ac o s cha ac e ising good p ac ice in heal h ca e o mig an s. Resul s: The sco ing p ocedu es esul ed in 10 o 16 ac o s being iden i ied as he mos impo an o each pa icipa ing coun y. All 186 ac o s we e agg ega ed in o 9 hemes: (1) easy and equal access o heal h ca e, (2) empowe men o mig an s, (3) cul u ally sensi i e heal h ca e se ices, (4) quali y o ca e, (5) pa ien /heal h ca e p o ide communica ion, (6) espec owa ds mig an s, (7) ne wo king in and ou side heal h se ices, (8) a ge ed ou each ac i i ies, and (9) a ailabili y o da a abou speci ici ies in mig an heal h ca e and p e en ion. Al hough local poli ical deba e, le el o immig a ion and he na u e o local heal h ca e sys ems in luenced he selec ion and a ing o ac o s wi hin each coun y, he e was a b oad Eu opean consensus on mos ac o s. Ye , disco dance emained bo h wi hin coun ies, e.g. on he need o p io i ising cul u al di e ences, and be ween coun ies, e.g. on he need o mo e consis en go e nance o heal h ca e se ices o immig an s. Conclusions: Expe s ac oss Eu ope asse ed he igh o cul u ally sensi i e heal h ca e o all immig an s. The e is a b oad consensus among expe s abou he majo p inciples o good p ac ice ha need o be implemen ed ac oss Eu ope. Howe e , he e also is some disag eemen bo h wi hin and be ween coun ies on speci ic issues ha equi e u he esea ch and deba e. * Co espondence: [email p o ec ed] 1 In e na ional and Mig an Heal h, NIVEL (Ne he lands Ins i u e o Heal h Se ices Resea ch), O e s aa 118-124, PO Box 1568, 3500 BN U ech & Uni e si y o Ams e dam, Ams e dam Ins i u e o Social Sciences Resea ch, Ams e dam, he Ne he lands Full lis o au ho in o ma ion is a ailable a he end o he a icle De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 © 2011 De illé 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 The globaliza ion o mig a ion lows, o e ecen dec- ades, has inc eased he mul icul u al di e si y o ou socie ies. Globally, he annual low o immig an s be ween 2005 and 2010 was es ima ed o be a ound 2.7 million, wi h abou 100 million mig an wo ke s in 2009 [1]. Acco ding o he O ganisa ion o Economic Co- ope a ion and De elopmen (OECD), he pe cen age o he o eign-bo n popula ion wi hin he Eu opean Com- muni y in 2008 anged om 4% in Finland o 37% in Luxembou g, wi h an o e all a e age o 8% [2,3]. Heal h ca e se ices in hese coun ies ha e o deal wi h inc easingly cul u ally di e se popula ions. The Wo ld Heal h O ganisa ion (WHO) men ioned in i s Fac Shee n° 31 “The Righ o Heal h“ ha he igh o heal h implies equal and imely access o heal h ca e se ices, he p o ision o heal h- ela ed educa ion and in o ma ion, and he pa icipa ion o he popula ion in heal h- ela ed decisions a na ional and communi y le els [4]. The igh o heal h also implies equi y in access o heal h ca e se ices o equal heal h needs. Heal h ca e se ices should be physically and inancially accessible o all sec o s o he popula ion, including ulne able g oups, and should be deli e ed on he basis o non-disc imina ion. Facili ies, goods, and se ices should espec medical e hics, as well as being gende - sensi i e and cul u ally app op ia e. In o he wo ds, hey should be cul u ally and no only medically accep able. Finally, hey mus be scien i ically app op ia e and o good quali y. In sho , access o heal h ca e is mo e han a legal igh o heal h ca e. Many o he aspec s a e in ol ed. Mee ing he heal h needs o mig an s and e hnic mino i ies is a challenge o heal h ca e se ices. Inequi able a ia ion in he use and accessibili y o heal h ca e se ices o mig an s, indigenous popula- ions, and o he mino i ies in EU coun ies is a ma e o conce n o bo h heal h ca e p o ide s and policy- make s. A subs an ial body o scien i ic li e a u e [5-12] and policy epo s [13-17] ha e documen ed di - e ences be ween mig an g oups and local popula ions in heal h ca e u iliza ion in Eu ope. Mig an s do no always ha e he igh o he se ices hey equi e (e.g. due o hei legal s a us). E en in coun ies whe e access o heal h ca e is gua an eed o all mig an popula ions, hey o en mee wi h obs acles o quali y ca e o : indi idual, socio-cul u al, economic, adminis- a i e and poli ical easons [18,19]. The e is he e o e moun ing p essu e a he Eu opean le el o ensu e equal access o mig an s o social and heal h ca e se - ices, as e lec ed in he Po uguese P esidency o he EU in 2007 o example [20-22]. Go e nmen s a e inc easingly encou aged o de elop policies o educe mig an heal h ca e inequali ies [23]. The h us owa ds ha monisa ion ac oss he EU makes he gene a ion o e idence on wha cons i u es good p ac ice in heal h ca e o mig an s ac oss Eu ope imely, wi h a iew owa ds wide dissemina ion and implemen a ion. The his o y and le el o immig a ion a y be ween Membe S a es, esul ing in di e en le els o expe ience in p o iding heal h ca e o cul u ally di e se popula ions. In coun ies whe e such da a is a ailable, mig an s seem o make lowe use o specialis inpa ien and ou pa ien ca e, wi h g ea e u ilisa ion o eme gency se ices ins ead [24]. Al hough ba ie s o accessing and using heal h ca e se ices ha e been desc ibed in se e al coun ies [25], good p ac ices o dealing wi h hese ba ie s ha e no ye been esea ched in any sys ema ic way ac oss Eu ope. The e has been e en less sys ema ic esea ch on how heal h ca e should bes be deli e ed, once an immig an has en e ed a se - ice. The cu en s udy aimed o assess he iews and alues o p o essionals wo king in di e en heal h ca e con ex s in 16 Eu opean coun ies as o wha cons i u es good p ac ice in heal h ca e o immig an s. Me hods The s udy is pa o he p ojec “Bes P ac ice in Access, Quali y and App op ia eness o Heal h Se ices o Immig an s in Eu ope”(EUGATE). Funded by he Eu - opean Commission, he p ojec collec ed da a in 16 Membe S a es: Aus ia, Belgium, Denma k, England, Finland, F ance, Ge many, G eece, Hunga y, I aly, Li huania, Ne he lands, Poland, Po ugal, Spain and Sweden. De ails and o he indings om he p ojec ha e been desc ibed elsewhe e [26]. The p esen a icle desc ibes esul s om ano he pa o he p ojec , a Delphi p ocess on p inciples o good p ac ice wi h expe s om all 16 coun ies. The Delphi me hod was de eloped as a means o col- lec ing and syn hesizing expe opinion on a gi en issue in he a ea o hei expe ise. Pa icipan s a e chosen o hei expe ise, and a e ensu ed anonymi y wi h espec o hei opinions. In ligh o he eplies o o he pa ici- pan s, hey we e hen encou aged o e ise hei ini ial answe s. The p ocess aimed o b ing he g oup owa ds a consensus. The p ocess also p oduced a se o a gu- men s de ending he di e en poin s o iew, whe he hey we e consensual o disco dan [27]. Th ee ounds a e commonly iewed as su icien o a i ing a a high le el o ag eemen [28]. Fo s eng hs and limi a ions o he Delphi me hod, see Hung e al. [28]. In o de o iden i y p inciples o good p ac ice, eigh expe s in he ield o mig a ion and heal h we e ec ui ed in each o he 16 pa icipa ing coun ies (11 in Belgium and Ge many). Expe s we e chosen p ima ily o hei expe ience and expe ise in he a ea o heal h ca e o mig an s. In each coun y, expe s we e De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 2 o 10 pu posi ely ec ui ed o ensu e ep esen a ion om each o ou di e en backg ounds: academia, he non-go - e nmen al sec o , policy-making and heal h ca e p ac ice (Table 1). No o he c i e ia we e se o ec ui men . F om June 2008 o Janua y 2009 da a we e collec ed ei he : (a) a speci ically c ea ed online so wa e p o- g amme in se en coun ies o (b), whe e esea che s conside ed ha he use o English-language so wa e isked comp omising pa icipa ion o ce ain expe s, ia e-mail co espondence di ec ly wi h expe s. The Delphi p ocess was di ided in o ou ounds ollowing a s anda d p o ocol. The expe s we e i s in i ed o sug- ges up o en s a emen s desc ibing ac o s ha in hei opinion cons i u ed “bes p ac ice in he deli e y o heal h ca e se ices o mig an s”.Theywe easked o ocus on heal h ca e deli e y, om hei pe spec i e, o mig an s who: (a) had a i ed in hei coun y wi hin he las i e yea s, (b) we e be ween 18 and 65 yea s o age, (c) had a egula legal income, and (d) did no o i- gina e om a de eloped coun y wi h a simila language (e.g. a Canadian om Quebec mo ing o Belgium). Fo each ac o , hey we e asked o p o ide a b ie explana- ionas owhy heyconside ed his ac o obe impo an . The o al lis o ini ial ac o s in each coun y was hen e iewed by a minimum o wo esea che s in each local esea ch eam using he ollowing ins uc ions: (i) ac o s ha we e iden ical o using only sligh ly di e en wo ding o desc ibe he same phenomenon we e g ouped in o one ac o ; (ii) ac o s co e ing mo e han one phenomenon we e spli in o mo e disc ee en i ies. Each esea ch eam sough o espec he nuances gi en o he ac o s by he expe s, using he p o ided expla- na ions and aiming o de ine ac o s ha would be Table 1 Backg ound o pa icipa ing expe s a he beginning o he Delphi P ocess in each coun y COUNTRY Academia NGO Policymake P ac i ione AUSTRIA Sociology (3) Poli ical sciences Poli ical sciences (2) Medicine (2) BELGIUM Public heal h Sociology (2) Pedagogy Medicine Social wo k Medicine An h opology Public heal h Medicine (2) DENMARK Psychia y(2) Psychia y Public Heal h Sociologis Public heal h In e nal medicine Medicine ENGLAND Resea che Nu sing Social wo k Medicine (2) Psychia y Occupa ional he apy Psychology FINLAND Social sciences Mas e o A s in Compa a i e Religion Psychia ic nu sing Psychia y Law Psychia y Public heal h Nu sing (2) FRANCE Public heal h (2) Medicine Social wo k Public heal h Psychologis Psychia y Medicine GERMANY Psychia y (3) Poli ical sciences Sociology Medical psychology Psycho auma ology Poli ical sciences NGO ac i is Social sciences Psychia y GREECE Law Public heal h Medicine Heal h economy Psychia y Psychology Medicine (2) HUNGARY Sociology Geog aphy Economical sciences Chemical sciences Social wo ke (2) Medicine (2) ITALY Public heal h Psychia y Psychia y Medicine Psychia y (2) Public heal h Psychia y LITHUANIA Medicine Medical an h opology Medicine Social Sciences/Law Public heal h (2) Gynaecology Medicine NETHERLANDS Sociology Epidemiology Paedia ics Medical an h opology Managemen Public Heal h Medicine (2) POLAND Poli ical sciences Mig a ion s udies Cul u al an h opology NGO Ac i is Law Psychology Medicine (2) PORTUGAL Medicine Sociology Medicine Biochemis y In e cul u al ela ions Nu sing Public Heal h Nu sing SPAIN Human Geog aphy Economical Sciences Medicine (2) Medicine (2) Gynaecology Psychology SWEDEN Public Heal h Psychology Nu sing Nu sing Sociology Psychology Medicine (2) De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 3 o 10 meaning ul o he same expe s du ing he second ound. A he end o his p ocess, each indi idual ac o consis ed o a single summa y s a emen , ollowed by an explana ion composed by he esea ch eam bu using only he commen s p o ided by he expe s hemsel es. In he second ound o he Delphi p ocess, he e ised lis o ac o s, each wi h i s explana ion, was sen back o he expe s who we e asked o a e he impo ance o each ac o on a scale om 1 (no impo an ) o 5 ( e y impo an ). An a e age sco e based on he sco es o he indi idual expe s was calcula ed o each ac o . In he hi d ound, expe s whose a ings a ied by mo e han one poin om he a e age g oup a ing( oundedo ) on any pa icula ac o , we e asked o econside hei a ing on ha ac o in he ligh o he a e age sco e o all expe s in hei coun y. I was speci ically men ioned ha hey had no obliga ion o e ise hei sco e, bu , i hey chose no o e ise i , hey we e asked o explain hei posi ion. Ra ings di e ing by less han one poin om he ounded a e age sco e we e ega ded as con- sensus. Fo he inal da a analysis, indi idual disco dance wi hin coun ies was de ined as an expe gi ing a inal hi d oundsco e ha di e edby3poin so mo e om he ounded a e age sco e o ha coun y. Be ween coun ies, disco dance was de ined as he p e- sence o a good p ac ice ac o in a inal na ional lis ha was in con adic ion wi h a good p ac ice ac o in he inal lis o ano he coun y. Disco dan expe s explained why hey emained wi h hei sco es. In he p esence o pe sis ing wi hin-coun y disco - dance, only one coun y o ganized a ou h ound. This was due o he e icence o ce ain expe s o modi y hei disco dan sco es, ega dless o whe he his mean ha he ac o in ques ion would no longe be in he op en o ha coun y. O he coun ies did no o ga- nize a ou h ound. A e he las ound, he ac o s wi h he en highes a e age sco es in each coun y we e selec ed as he inal lis o ha coun y. In coun- ies whe e se e al ac o s sco ed iden ical o he en h posi ion, mo e han en we e included in he inal lis . Resea ch eams in each coun y discussed he ou comes, conside ing bo h he na ional con ex a he ime o he da a collec ion, and any po en ial easons o disco - dance. Fo he inal analysis, all na ional good p ac ice lis s we e ansla ed in o English whe e necessa y. The inal na ional lis s we e hen compa ed o assess he le el o consensus ac oss Eu ope. Issues o disco dance wi hin and be ween coun ies we e also e iewed. Resul s O he 134 expe s in he 16 coun ies who we e ec ui ed in o he Delphi p ocess, 126 comple ed he las ound. The eigh expe s who d opped ou did so a e he second ound. Da a on pa icipa ing coun ies and he p o essional backg ound o he expe s is p e- sen ed in Table 1. The local e iewing p ocess o emo e epe i ion a each si e p io o ound wo educed hese lis s o be ween 11 and 40 ac o s o each coun y. Final na ional consensus lis s a e he hi d ound included be ween 10 and 16 ac o s wi h he en highes sco es, esul ing in a o al o 186 high sco ing ac o s ac oss all coun ies (Table 2). Consensus The 186 ac o s all in o nine hema ic ca ego ies, which a e summa ized below in o de o equency, and a e de ailed u he in Table 3. The i s eigh hemes igu ed in he inal na ional good p ac ice lis s o mo e han hal o he pa icipa ing coun ies. The hemes ep esen gen- e al p inciples, some gene ic bu wi h speci ic aspec s o mig an s. The nine gene al p inciples we e: •Accessibili y: easy and equal access o heal h ca e (men ioned by all 16 coun ies) This heme was men ioned on consensus lis s o all coun ies as he numbe one p io i y. All coun ies men ioned he need o an easily accessible gene al heal h ca e sys em o all ci izens (Table 3). Al hough hey had ini ially been asked o p opose good p ac ice p inciples o mig an s wi h egula , legal incomes and speaking he local language, expe s om se e al coun- ies also speci ically p io i ised equal access o e ugees and undocumen ed mig an s. •Empowe men o mig an s (15 coun ies) Table 2 Numbe o ac o s o good p ac ice lis ed pe Delphi ound and ange o inal sco es COUNTRY 1s ound 2nd ound Final Sco es AUSTRIA 48 17 11 4.4-4.0 BELGIUM 91 21 10 4.6-4.3 DENMARK 60 32 11 5.0-4.4 ENGLAND 64 28 10 4.9-3.5 FINLAND 50 22 13 4.9-4.0 FRANCE 84 41 16 4.9-4.1 GERMANY 64 30 12 4.8-4.2 GREECE 24 24 10 4.6-4.0 HUNGARY 65 16 10 4.0-3.3 ITALY 80 11 10 4.6-3.8 LITHUANIA 45 35 14 4.8-4.1 NETHERLANDS 54 26 12 4.9-3.9 POLAND 63 31 16 4.8-4.0 PORTUGAL 57 18 10 4.8-4.0 SPAIN 75 14 10 5.0-3.2 SWEDEN 76 30 11 4.9-4.5 De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 4 o 10 Table 3 Majo hemes in he 16 coun y-speci ic, inal ac o lis s Theme Desc ip ion De ails Coun ies men ioning heme Coun ies no men ioning heme in i s 10 Easy and equal access A heal h ca e sys em ha is easy o access o mig an s •Accessibili y on he same e ms as he gene al popula ion: 16 ◦In heal h ca e sys ems wi h ee access, ee access o ca e o mig an s. ◦In insu ance-based heal h ca e sys ems, mig an s should ha e he igh o be insu ed. •Remo e ba ie s o accessing seconda y ca e. •Special heal h se ices should be made a ailable in a eas wi h high mig an popula ions •Se ice hou s should adap o he needs o hei use s, including mig an s. •Se ices should be a o dable: go e nmen s should p o ide he necessa y esou ces and adap legisla ion o achie e his. •In o m heal h p o essionals abou he legisla ion ela ed o he igh s o heal h ca e o mig an s in hei coun y. Empowe men Empowe mig an s wi h ega d o heal h & heal h de e minan s •P o ision o in o ma ion o mig an s in hei own language 15 DK ◦abou hei igh s and he unc ioning o he heal h ca e sys em and social ca e sys em. ◦abou heal h, illness and p e en ion ◦P o ide a special consul a ion he i s ime people access he heal h ca e sys em. •Ou side he heal h ca e sec o : ◦imp o ing access o wo k as well as wo k and li ing condi ions empowe s mig an s and may consequen ly ◦imp o e hei heal h. p o iding oppo uni ies o lea n he language o he hos coun y will acili a e in eg a ion in o he hos coun y and consequen ly also access o heal h ca e. •Pa icipa ion o mig an s and non-go e nmen al o ganisa ions (NGOs) dealing wi h mig an s in he o ganisa ion o heal h ca e se ices. Cul u ally sensi i e ca e Adjus ca e p o ision o cul u al di e ences •Heal h ca e p o ide s should ecei e speci ic aining on cul u al compe encies and communica ion skills. 14 FI, UK •Employ cul u al media o s o heal h ca e p o ide s o mig an descen , •De elop specialised se ices in case o added alue o egula se ices can be demons a ed. •Heal h educa ion and heal h p omo ion messages should ake in o accoun cul u al di e si y. Quali y ca e Gua an ee quali y o ca e •Se ices should conside he pa ien as an indi idual and no s e eo ype hem wi h he cha ac e is ics o he cul u al g oup hey a e pe cei ed o as belonging o. 12 DE, LT, PT, UK •Quali y ca e means aking in o accoun he indi idual’s speci ic medical his o y and social backg ound and gi ing indi idualised psychological suppo and empa hy. •Heal h ca e p o essionals should ake he ime o lis en o pa ien s and check ha bo h pa ies ha e unde s ood each o he . •O he ac o s men ioned: ◦es ablishing us , ◦seeking uly in o med consen , ◦gua an eeing con inui y o ca e De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 5 o 10 Mig an s should be in o med abou hei igh s and he unc ioning o he heal h ca e sys em. This migh in ol e a special consul a ion he i s ime people access he heal h ca e sys em. (Table 3) •Cul u ally sensi i e heal h ca e (14 coun ies) Op imising cul u ally sensi i e ca e se e al speci ic measu es we e p oposed. (Table 3) Al hough mos coun ies’expe s unde lined he need o heal h ca e se ices o ake in o accoun he cul u al o eligious habi s o mig an s, o he s conside ed ha mig an s should be encou aged o unde s and he habi s and cul- u e o local heal h ca e sys ems. •Quali y o indi idual ca e (12 coun ies) Se ices should conside he pa ien as an indi idual and no s e eo ype hem wi h he cha ac e is ics o he cul u al g oup hey a e pe cei ed o as belonging o. (Table 3) •Pa ien -heal h ca e p o ide communica ion (11 coun ies) High quali y in e p e e se ices, ei he in pe son o by elephone, should be easily accessible. (Table 3). •Respec owa ds mig an s (9 coun ies) P ac i ione s should show espec , c ea e us , be in e es ed and add ess pa ien s wi hou p ejudice and wi h an open mind. (Table 3) •Ne wo king and in e disciplina i y (8 coun ies) Mee ing he heal h ca e needs o mig an s equi es Table 3 Majo hemes in he 16 coun y-speci ic, inal ac o lis s (Con inued) ◦adap ing ca e o he pe son’s li es yle and hei capaci y o ecei e and sel -manage ca e Pa ien -heal h ca e p o ide communica ion P o ide in e p e ing and ansla ion •High quali y in e p e e se ices, ei he in pe son o by elephone, should be easily accessible. 11 BE, HU, IT, NL, PT •Se ices should ake in o accoun a ying le els o bo h heal h li e acy and mas e y o he local language. Respec owa ds mig an s Figh disc imina ion & p ejudice, espec di e ences •P ac i ione s should show espec , c ea e us ,bein e es ed and add ess pa ien s wi hou p ejudice and wi h an open mind. 9 AT, BE, DE, EL, IT, PT, UK •Heal h ca e se ices should be deli e ed wi hou xenophobia o any sign o acism. •Heal h ca e p o ide s should be mo i a ed o deli e ca e o mig an s wi h a en ion o hei speci ic needs and p io i ies. •Apolicy agains ac s o disc imina ion in heal h ca e acili ies should be es ablished and implemen ed. Ne wo king in and ou side heal h ca e se ices E ec i e ne wo king, in eg a ed ca e •Ne wo king wi hin heal h ca e se ices and be ween heal h and social se ices 8 AT, BE, DE, EL, FR, HU, LT, SE •In e disciplina i y is a p io i y wi hin heal h ca e se ices. •Coo dina ion be ween p ima y ca e se ices, o be ween p ima y ca e and e ugee-speci ic heal h ca e se ices. •Suppo ing mig an s o de elop hei social ne wo ks •Suppo ing mig an s o pe sons o mig an descen who ca e o o he mig an s. Ta ge ed ou each ac i i ies Ta ge ed ou each p og ammes in p e en ion and ca e •Ou each ac i i ies in heal h educa ion, sc eening, p e en ion and p omo ion wi h di icul o each mig an g oups. 8 AT, BE, DK, FI, LT, NL, PL, SE A ailabili y o da a Da a on mig an s, epidemiology, esea ch •Heal h ca e se ices should be p o ided wi h ele an knowledge on heal h and isk ac o s conce ning he popula ions hey a e dealing wi h. 6 DK, EL, FR, HU, IT, LT, PL, PT, SE, UK •Heal h egis ies ◦should eco d and moni o mig an heal h o acili a e mig an heal h esea ch. ◦should be able o in eg a e pa ien mobili y wi h ull espec o human igh s. De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 6 o 10 ne wo king wi hin heal h ca e se ices and be ween heal h and social se ices. (Table 3) •Ta ge ed ou each ac i i ies (8 coun ies) Ou each ac i i ies in heal h educa ion, sc eening, p e- en ion and p omo ion wi h di icul o each mig an g oups we e men ioned in eigh coun ies. •A ailabili y o da a (6 coun ies) Heal h ca e se ices should be p o ided wi h ele an knowledge on heal h and isk ac o s conce ning he popula ions hey a e dealing wi h. Heal h egis ies should eco d and moni o mig an heal h o acili a e mig an heal h esea ch. (Table 3) I a simila analysis is conduc ed on only he h ee mos impo an p inciples in each coun y, ins ead o en, accessibili y ea u es in ele en coun ies, cul u ally sensi i e ca e in en, communica ion in nine and empow- e men in eigh . All he emaining p io i ies ea u ed among he h ee mos impo an ones, bu in less han hal o he coun ies. Disco dance Disco dance wi hin and be ween coun ies conce ning ac o s expe s conside ed o be impo an was no in equen . O he 120 ound 2 sco es con aining disco - dan sco es, 99 (83%) we e oiced by 13 o he 126 expe s who comple ed he Delphi p ocess in 7 o he 16 coun ies. None o he ou expe ca ego ies (acade- mia, NGO, policy make s, p ac i ione s, and no p o es- sional ca ego y) we e o e - ep esen ed in hese disco dan oices. Final ac o s con aining disco dan sco es we e equen in: G eece (10/12), Aus ia (7/11), UK (7/12) and Po ugal (7/13). Howe e , he disco - dance in hese inal ac o s was all due o one single expe in each coun y, wi h he excep ion o he UK wi h 2 disco dan expe s. No o he coun y had mo e han 3 inal ac o s con aining disco dan sco es. The whole ques ion o mig an -speci ic heal h ca e is seen as a alse p oblem by disco dan expe s in Belgium (" he key di e ence is socioeconomic”), Finland ("e e y- one is cul u ally di e en , no jus mig an s”)and F ance ("pinpoin ing cul u al needs c ea es heal h ca e ghe os”). Wi hin coun y disco dance, as de ined in he Me hods sec ion abo e, emained wi h espec o 15 good p ac ice ac o s in se en coun ies (Table 4). In Aus ia and Belgium, disco dance e en emained in he inal lis o en mos impo an ac o s. In Aus ia, he e was disag eemen on he need o employing s a speak- ing mig an languages, ansla ed in o ma ion ma e ial, and measu es di ec ed a p e en ing and diminishing disc imina ion. In Belgium, disco dance pe sis ed on he impo ance o p o iding speci ic in o ma ion abou heal h insu ance and o he inancial suppo measu es. In Li huania, expe s disag eed abou he need o p o- iding in o ma ion abou he heal h ca e sys em. In F ance and Poland, expe s disag eed abou he need o speci ic epidemiological in o ma ion on a eas wi h high mig an popula ions. F ench expe s also disag eed abou he need o ha ing expe s p o iding ex ensi e aining o heal h ca e p o essionals o be awa e o e h- nic and cul u al issues, wi h opponen s conside ing his o be a ap, a guing ha he mos impo an p inciples o heal h p o essionals a e o ake su icien ime and ha e access o an in e p e e . Ge man expe s disag eed on he need o imp o ing con ex ual socie al ac o s, such as he social accep ance and social suppo o mig an s as ways o imp o ing accessibili y and quali y o heal h ca e. The p esence o a disco dan oice gene ally esul ed in ha ac o ha - ing a signi ican ly lowe inal a e age sco e. This was he case, o example, in Ge many o he ac o con- ce ning he need o heal h ca e p o ide s o e lec on hei own cul u al backg ounds. In he Ne he lands, expe s had highly opposing iews on he need o cus- omized ca e o mig an s, e en on a small-scale, ac ion- speci ic and empo a y basis. In Po ugal, p omo ing posi i e a i udes owa ds mig an s and igh ing agains disc imina ion in heal h ca e p o essionals was excluded om he inal na ional good p ac ice lis due o wo dis- co dan o es (bo h om academics). Disco dance also exis ed be ween he 16 pa icipa ing coun ies. Fo example, cohe en na ional, egional and local go e nance was seen as an ad an age in Belgium and as a disad an age in he UK, whe e poli ical co ec - ness in heal h ca e policy migh ha e c ea ed esis ance and disco d. Discussion Six een Eu opean coun ies, wi h a ying mig a ion his- o ies, pa icipa ed in his esea ch. The na ional con- sensus lis s o p inciples o good ca e ell in o nine hema ic ca ego ies o which he e was a conside able le el o consensus ac oss coun ies. Fou ou o he nine p inciples igu ed in he inal lis s o 12 coun ies, and eigh in he inal lis s o a leas eigh o he pa icipa - ing coun ies. Bes p ac ice should gua an ee easy access o heal h ca e esou ces and equal igh s. Mig an s should be empowe ed o make op imum use o cul u- ally sensi i e heal h ca e se ices. Good p ac ice means quali y indi idual ca e, p o ided when needed and adap ed o mig an s’needs in e ms o : communica ion, a i udes, empa hy and non-disc imina ion. O ganising a Delphi p ocess wi h expe s in 16 di e - en coun ies is a challenge. The s udy did no o se ou o iden i y consensus ac oss all 16 coun ies, bu De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 7 o 10 chose o iden i y consensus lis s a na ional le els. This app oach was conside ed mo e use ul gi en he di e en con ex s o he na ional heal h sys ems. I also acili a ed pa icipa ion, in ha expe s we e able o epo in hei own language, esul ing in mo e de ailed explana ions ega ding he sugges ed ac o s. A limi a ion o his s udy is he ep esen a i eness o he expe s pa icipa ing ineachcoun y.Al hough he p ojec se ou o ec ui expe s om di e en p o es- sional backg ounds, medical doc o s and p o essionals wo king in he ield o men al heal h we e o e - ep e- sen ed in some coun ies. Fu he mo e, expe s in se - e al coun ies we e all based in he capi al ci y, wi h possible implica ions o he gene alisabili y o indings o mo e u al con ex s. The p esence o expe s wi h s ong disco dan iews on pa icula ac o s had an impo an e ec on he ou come o he Delphi p ocess. Fu he mo e, in coun ies wi h limi ed immig a ion expe ience, discussion abou he need o cul u ally sen- si i e heal h ca e was mo e limi ed. In he cu en analy- sis, hese coun ies none heless ecei ed he same weigh as coun ies wi h g ea e expe ience in p o iding heal h ca e o la ge mig an popula ions. Di e ences be ween coun ies’heal h ca e sys ems and social con ex s a e likely o ha e in luenced he selec ion o ac o s. The de elopmen and implemen a ion o mig an heal h policies is a challenging ask o go e nmen s, gi en he highly poli ical na u e o public policy on immig a ion in mos Eu opean coun ies oday [23]. Recen discou se in Eu ope on he necessi y o in eg a ing immig an s, and he esul ing deba e on wha hos socie ies should expec om immig an s h ough his in eg a ion p ocess, may well ha e impac ed on he Delphi p ocess. As esea che s epo ed, issues ha we e highly deba ed wi hin indi i- dual coun ies du ing he ime o da a collec ion, ine i- ably appea ed on he ini ial lis s o bes p ac ice ac o s, e en hough hey o en did no each consensus du ing he Delphi p ocess. O he p ac ices migh ha e been so accep ed and widesp ead in ce ain coun ies ha hey we e aken o g an ed e en by he expe s, did no end up as p io i ies. Fo example, o mal in e p e ing se - ices a e eadily a ailable in he Ne he lands a many le els o he heal h ca e sys em, al hough no necessa ily in e e y single si ua ion in which hey migh be use ul. Recen ly he go e nmen decided o discon inue inan- cing in e p e e se ices o heal h ca e om 2012 on [29]. In he case o Ge many, he e is an on-going deba e wi hin he men al heal h sec o abou he ad an- ages and disad an ages o he apis s wi h he same e h- nic backg ound as he pa ien s compa ed o he apis s using ained in e p e e s [30]. Also he p os and cons o specialized se ices compa ed o cul u ally sensi i e s anda d ca e a e subjec o public deba e in se e al coun ies. In Aus ia, he cu en deba e is less adap ing he heal h ca e sys em o popula ion di e si y, bu s on- ge abou immig an s ha ing o gain Ge man language skills and in eg a ing in o he labou ma ke and he e- o e con ibu e o he heal h ca e sys em [31]. The widesp ead deba e on he in eg a ion o immi- g an s in o Eu opean socie ies may impac on he p o i- sion o language suppo and ansla ed in o ma ion ma e ial o mig an pa ien s. This migh be a eason o why no p inciple on mig an empowe men was ag eed in Denma k [32], whe e in 2011 he go e nmen has in oduced a ee on in e p e e se ices o mig an s ha ing esided in he coun y o mo e han se en yea s [33]. In Belgium, immig a ion con ex s and poli ical iews conce ning immig a ion in a b oad sense, ecep- ion o asylum seeke s and egula isa ion o undocu- men ed mig an s a y be ween egions and egional poli ical ends, hus limi ing he chance o each o e - a ching poli ical decisions [34]. In Poland, which has a sho his o y o immig a ion [32], he deba e is no abou immig a ion i sel , bu mo e abou he quali y o heal h ca e and i s accessibili y o immig an s and espe- cially abou se ices o asylum seeke s. Al hough G eece is cu en ly acing a la ge in lux o immig an s, cul u al media o s and o he acili ies a e s ill no a ail- able as he challenge o immig a ion has s ill o be add essed [32,35]. Table 4 Consensus and disco dance conce ning ac o s o good p ac ice in heal h ca e o mig an s in Eu ope Coun y Fac o s p esen ed a 2 nd ound (n) Consensus 1 2 nd ound Consensus inal (3 d ) ound Fac o s con aining disco dance in inal lis 2 AUSTRIA 17 12% 29% 4 BELGIUM 21 0% 38% 2 DENMARK 32 31% 75% 0 ENGLAND 28 11% 71% 0 FINLAND 22 9% 64% 0 FRANCE 40 12% 61% 2 GERMANY 30 3% 43% 3 GREECE 24 17% 71% 0 HUNGARY 16 6% 81% 0 ITALY 11 9% 82% 0 LITHUANIA 35 14% 49% 1 NETHERLANDS 26 4% 81% 1 POLAND 31 3% 61% 2 PORTUGAL 18 6% 22% 0 SPAIN 14 - 3 80% 0 SWEDEN 30 20% 83% 0 1 Consensus: Pe cen age o expe s’sco es ha a e 1 poin o less om he ounded a e age sco e o each ac o 2 Disco dance: Numbe o sco es ha a e 3 poin s o mo e om he ounded a e age sco e 3 Spain had wo ounds only. De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 8 o 10 Gi en hese g ea ly a ying na ional eali ies, i could be seen as su p ising ha such a b oad Eu opean con- sensus exis s on he need o heal h ca e se ices o ake e hnic cul u al di e si y in o accoun . The igh o equal access o heal h ca e o immig an s, wi hou ba ie s, is ega ded as a p io i y in all pa icipa ing coun ies. A la gemajo i yo expe sag ee ha empowe ingimmi- g an s ega ding heal h and heal h ca e, no he leas by imp o ing communica ion and de eloping cul u ally sensi i e heal h ca e se ices, will acili a e access o and quali y o ca e. An a i ude o espec , us and open- ness wi hou disc imina ion o ms he basis a ound which all o he bes p ac ice p inciples and ac i i ies can de elop. Conclusion The iden i ied p inciples o mig an sensi i e and acces- sible heal h ca e a e no new. Howe e , he esul s o his s udy unde line he cu en b oad consensus in Eu - ope among expe s coming om di e en backg ounds. Se e al o he iden i ied p inciples a e also e lec ed in ecen policy documen s such as The Ams e dam Decla a ion: owa ds mig an iendly hospi als in an e hno-cul u ally di e se Eu ope [36]; he Uni ed King- dom Race Rela ions Ac [25]; amewo ks de eloped unde he Po ugal P esidency o he Council o he Eu opean Union and he Council o Eu ope [20,21]; and he WHO’s Global Consul a ion on Mig an Heal h which ook place in Spain in 2010 [1,25]. I may well be ime o de elop a Eu opean Cha e on he igh o, and he need o accessible, cul u ally sensi i e heal h ca e o all ci izens in Eu ope, whe e e hei o igins. Th ough he Cha e go e nmen s should commi hemsel es o c ea ing and suppo ing all necessa y con- di ions o he de elopmen o cul u ally sensi i e heal h ca e. Al hough, mo e esea ch is needed o de elop he iews o s akeholde s on his ques ion, he p esen con- sensus lis o p inciples o bes p ac ice may be, in ou opinion, a signi ican s ep in his di ec ion. Acknowledgemen s and Funding This s udy is a pa o he EUGATE p ojec unded by he Gene al Di ec o a e o Heal h and Consume P o ec ion o he Eu opean Union (DG-SANCO). Mo e in o ma ion can be ound a : h p://www.euga e.o g.uk. All au ho s would like o acknowledge P o esso Ju a Linde o he con ibu ion o he s udy applica ion and he en i e EUGATE esea ch eam o hei con ibu ions o da a collec ion, managemen and analysis. We also would like o exp ess ou g a i ude o he expe s in each coun y o gi ing hei ime and o hei willingness o sha e hei expe ise. Au ho de ails 1 In e na ional and Mig an Heal h, NIVEL (Ne he lands Ins i u e o Heal h Se ices Resea ch), O e s aa 118-124, PO Box 1568, 3500 BN U ech & Uni e si y o Ams e dam, Ams e dam Ins i u e o Social Sciences Resea ch, Ams e dam, he Ne he lands. 2 E ablissemen public de san é Maison Blanche, 18 ue Rémy de Gou mon , 75019 Pa is, F ance. 3 Uni o Social and Communi y Psychia y, Queen Ma y Uni e si y o London, Newham Cen e o Men al Heal h, London, E13 8SP, UK. 4 Ins i u e o Heal h and Socie y, Uni e si é Ca holique de Lou ain, Clos Chapelle aux Champs 30.05., 1200 B ussels, Belgium. 5 Ins i u o de Higiene e Medicina T opical, Uni e sidade No a de Lisboa, Rua da Junquei a, 96, 1349-008 Lisbon, Po ugal. 6 Laziosani à ASP-Public Heal h Agency o he Lazio Region, Via S. Cos anza 53, 00198 Rome, I aly. 7 Danish Resea ch Cen e o Mig a ion, E hnici y and Heal h (MESU), Sec ion o Heal h Se ices Resea ch, Depa men o Public Heal h, Uni e si y o Copenhagen, Øs e Fa imagsgade 5, DK-1014 Copenhagen, Denma k. 8 Depa men o Sociology, Na ional School o Public Heal h, 196 Alexand as A enue, A hens 11521, G eece. 9 Clinic o Psychia y and Psycho he apy, Cha i é-Uni e si y Medicine Be lin, CCM, Cha i épla z 1, 10117 Be lin, Ge many. 10 Na ional Ins i u e o Heal h and Wel a e (THL), Depa men o Men al Heal h and Subs ance Abuse Se ices, P.O.B. 30, FIN- 00271 Helsinki, Finland. 11 Agency o Public Heal h o Ba celona, Pça. Lesseps, 1, 08023 Ba celona, Spain. 12 Facul y o Heal h Sciences a Nyí egyháza, Uni e si y o Deb ecen, Sós ói ú 31/B, 4400 Nyí egyháza, Hunga y. 13 Depa men o Public Heal h Sciences, Sec ion o Social Medicine, Ka olinska Ins i u e , SE-171 76 S ockholm, and Depa men o Public Heal h Sciences, Mid Sweden Uni e si y, SE-851 70 Sunds all, Sweden. 14 Depa men o Heal h Managemen , Li huanian Uni e si y o Heal h Sciences, A. Micke ičiaus g. 9, LT 44307, Kaunas, Li huania. 15 Ludwig Bol zmann Ins i u e o Social Psychia y, Laza e gasse 14A-912, 1090 Vienna, Aus ia. 16 Ins i u e o Psychia y and Neu ology, Ul. Sobieskiego 9, 02-957 Wa saw, Poland. Au ho s’con ibu ions WD con ibu ed o he s udy design, was in cha ge o s udy implemen a ion and da a analysis, and d a ed he manusc ip . SP designed he s udy p o ocol, was in cha ge o he o e all managemen o he s udy and helped d a he manusc ip . TG pa icipa ed in da a analysis and helped d a he manusc ip . MB suppo ed s udy co-o dina ion. 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Ca ballo M, Mboup M: In e na ional mig a ion and heal h: a pape p epa ed o he Policy Analysis and Resea ch P og amme o he Global Commission on In e na ional Mig a ion. 2005. De illé e al.BMC Public Heal h 2011, 11:699 h p://www.biomedcen al.com/1471-2458/11/699 Page 9 o 10