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. All au ho s collec ed na ional
da a and a e gua an o s o he da a in hei coun y; hey commen ed on
successi e d a s o he manusc ip and app o ed i s inal e sion.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Recei ed: 14 Ma ch 2011 Accep ed: 13 Sep embe 2011
Published: 13 Sep embe 2011
Re e ences
1. WHO: Heal h o Mig an s - The way o wa d. Repo o a global consul a ion.
Mad id, Spain, 3-5 Ma ch 2010 2010.
2. OECD: In e na ional Mig a ion Ou look 2010.
3. In e na ional O ganiza ion o Mig a ion: Wo ld Mig a ion Repo : Managing
Labou Mobili y in he E ol ing Global Economy. Gene a 2008.
4. UNCHR: The Righ o Heal h. Fac shee 31 OHCHR-WHO; 2008 [h p://www2.
ohch .o g/english/issues/heal h/ igh /], accessed on 22/01/2011.
5. Coope H, Smaje C, A be S: Use o heal h se ices by child en and young
people acco ding o e hnici y and social class: seconda y analysis o a
na ional su ey. BMJ 1998, 317:1047-1051.
6. Reijne eld SA: Repo ed heal h, li es yles and use o heal h ca e o i s
gene a ion immig an s in he Ne he lands: do socioeconomic ac o s
explain hei ad e se posi ion? Jou nal o Epidemiology & Communi y
Heal h 1998, 52:298-304.
7. Pa el S: In e cul u al consul a ions. Language is no he only ba ie . BMJ
1995, 310:194.
8. Ahmad WI, Bake MR, Ke nohan EE: Race, e hnici y and gene al p ac ice.
B J Gen P ac 1990, 40:223-224.
9. Langwell KM, Mose JW: S a egies o Medica e heal h plans se ing
acial and e hnic mino i ies. Heal h Ca e Financ Re 2002, 23:131-147.
10. Smaje C: Equi y and he e hnic pa e ning o GP se ices in B i ain. Social
Policy & Adminis a ion 1998, 32:116-131.
11. S onks K, Ra elli AC, Reijne eld SA: Immig an s in he Ne he lands:
equal access o equal needs? J Epidemiol Communi y Heal h 2001,
55:701-707.
12. Smaje C, G and JL: E hnici y, equi y and he use o heal h se ices in he
B i ish NHS. Soc Sci Med 1997, 45:485-496.
13. 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