Introduction: Delivery of health care to immigrants is an emerging field of interest. Immigrants are frequently characterised by health outcomes that are inferior to those of other groups with regard to morbidity and mortality. In addition, health professionals report difficulties associated with the encounter with immigrant patients.
Material and methods: A Delphi process with eight Danish experts from the field of immigrant health was performed as part of an EU project. The objective of the Delphi process was to investigate expert opinion on "best practice in the delivery of healthcare to immigrants". Initially, 60 factors were suggested by the experts. Next, these factors were summarised into 32 factors that the experts were invited to rate and, if possible, agree on.
Results: The top 11 factors identified in the Delphi process were access to interpreters, quality of interpretation, ensuring medication compliance, having sufficient consultation time, coherence of offers, interdisciplinary collaboration, allocation of resources, the role of the practitioner, acknowledgement of the
Immigrants often present disease profiles that differ from those of the native-born populations of which they form part , and although their results were not fully consistent, several studies have reported inferior health outcomes among immigrants in terms of morbidity and mortality [2-4]. Furthermore, immigrants often struggle with language difficulties and health illiteracy [5, 6], and several Danish studies have documented that health professionals may experience difficulties with this group of patients [7, 8]. In order to improve the delivery of care to immigrants, the objective of the present study was to investigate expert opinions on best practices in the delivery of health care to immigrants.
MATERIAL AND METHODS
This study was performed as part of an EU project on European Best Practices in Health Services for Immigrants in Europe (EUGATE). It presents the findings from Denmark, focussing on a substudy of the EUGATE involving a Delphi process on the delivery of care to immigrants. The Delphi process is a consensus method used to extract knowledge in areas where scientific evidence is conflicting or lacking. The aim of the method is to determine the extent to which experts agree on a given issue and – to the extent possible – to resolve any disagreement through a controlled feedback process .
A strategic sample of experts was selected. To be considered an expert, participants were to have immigrants as a focus area in their job position (non-governmental organisation (NGO) employee, policy maker or academic) or to work as general practitioner or medical staff at a health centre in an area with a high density of immigrants. All of the included experts have been working with immigrant health for a number of years and have contributed significantly to elucidating the area through academic publications or other public dissemination efforts targeting immigrant patients on the basis of their direct experience. A total of eight experts including academics (two), NGOs (one), policy makers (two), and health professionals (three) were contacted and all agreed to participate. Six experts were from the greater Copenhagen area and two from the outskirts of Aarhus and Odense, respectively.
Data were collected via e-mail correspondence from June 2008 to January 2009. The experts were first invited to list up to ten factors that in their opinion constituted "best practices in the delivery of healthcare services to immigrants" focusing on immigrants who a) had arrived in Denmark within the past five years, b) were between 18-65 years of age, c) had a regular income, and d) did not originate from a developed country with a similar language. Initially, 60 factors were suggested and these factors were summarized into 32 by the researcher (NKJ).
First, the experts rated each factor on the summarized list on a scale from one to five. Next, to achieve the highest possible level of consensus, experts with ratings differing more than one point from the average group rating were invited to reconsider their ratings and revise, where relevant. Six experts were asked to reconsider one factor, and two experts were asked to reconsider three factors. Experts thus achieved a consensus on 29 of the 32 factors. We intended to present the top ten factors, but as several factors achieved identical average ratings, 11 factors are presented in the following.
The top 11 factors selected by the participating experts concerning delivery of healthcare to immigrants in Denmark are presented in Table 1. The most important factor was access to interpreters, followed by quality of interpretation and ensuring medication compliance, which were both ranked second. The experts stressed that interpretation should be available to all patients who feel a need for this, and that quality interpretation services are needed. The related factor of telephone interpretation as a supplement to other services was ranked ninth by the experts. Having sufficient time in the consultation was ranked fourth. The experts explained the need for extra consultation time with immigrant patients with reference to a number of factors such as the need to understand a culture different from the health professional’s own or an increased need to explain things orally.
The factors coherence of services and interdisciplinary collaboration were ranked fourth and seventh, re-spectively. This emphasizes the need for collaboration between the health and the social sector. The experts expressed that immigrant patients may have considerable social problems in addition to their health problems, and as these patients often cannot cope with the burden of contacting various public authorities, there is an additional need to coordinate any casework relating to this patient group. Furthermore, there was consensus among the experts concerning the need for a political focus on the area of immigrant health, and allocation of resources was also ranked fourth.
The remaining factors in the top 11 of best practices included the role of the health professional and acknowledgement of the individual patient. Both have reference to the importance of the encounter between the professional and the patient and underline that it is important that the health professional is familiar with their immigrant patients’ backgrounds. Education of health professionals and students shows that health professionals often feel insecure about how to deal with immigrant patients; thus, the need to support health professionals and to prepare them for such encounters was emphasized.
The results clearly show that best practices in the treatment of immigrant patients is an area that merits special attention.
Interpretation was found to play an important role in the evaluation of best practices in the delivery of health care to immigrants. This indicates the importance placed by experts on patient-health professional communication. It has often been reported that there is a need for professional interpretation to avoid misunderstandings and serious clinical mistakes [10, 11]. As from June 2011, immigrants who have resided in Denmark for more than seven years will no longer be entitled to cost-free interpretation services unless very specific circumstances exist . The Medical Association in Denmark states that the implementation of this act will entail problems for a patient group of 10,000-15,000 people and that the use of relatives as interpreters will lead to an increase in the above-mentioned risks . Given the emphasis our experts placed on the need for interpretation, the strategy chosen does not seem tenable and may entail poorer patient-provider communication and a poorer health outcome.
It has previously been stressed that in the Danish context, there is a need for system-level measures – such as a special fee for the use of interpreters during consultation – when responding to the needs of immigrant patients in general practice . Such measures have subsequently been implemented and when a qualified interpreter assists during the consultation, the general practitioner receives a pay supplement . However, other potentially time-consuming problems such as the need to build an understanding of other cultures and an increased need to explain things orally should be considered in the future organisation of health care services.
The experts also stressed the need for collaboration within and between the health care and the social sector; a need that springs from the existing lack of coherence. Patients with few resources often bring social problems to their general practitioner instead of to their social worker . This issue is not limited to immigrant patients, but may occur even more frequently in this group due to lack of familiarity with the systems.
Ensuring medication compliance is assessed to be important for the delivery of healthcare services to immigrants. Ensuring compliance is a general problem in quality assurance, but it becomes particularly important in relation to marginalised groups. It has previously been reported that non-western immigrants are more vulnerable to medication noncompliance . Contrary to this, a Swedish study concluded that immigrants are more compliant than natives, but more often feel that they lack someone to confide in and may be in greater need of emotional support . The immigrant group in the latter study mainly consists of European immigrants, which may account for the difference observed in these findings.
The role of health professionals
Training of health professionals and students involving migrant-specific diseases and cultural competencies was also considered important for best practice. The need for training of health professionals in the communication, culture and disease patterns of immigrants has previously been reported. In a Danish study, the health professionals’ behaviour differed across cultures and immigrant groups due to factors such as lack of knowledge, insecurity, stereotyping and prejudice, and it was concluded that educational interventions are needed [7, 19]. Likewise, health professionals may struggle with uncertainty and apprehension when taking care of patients with a different ethnic background and they may therefore unintentionally contribute to ethnic disparities in healthcare . This becomes even more important in the context of the emphasis that the experts placed on the role of the healthcare professionals in the encounter with the patient, as they need to risk asking the patients about conditions they do not understand. Furthermore, a Danish study of the meeting between general practitioners and immigrant patients concluded that it is essential for the general practitioner to focus on the individual and his or her current expectations rather than relying on any preconceived ideas of the relation between the health professional and the immigrant patient .
The Delphi process has been widely used in health research. However, the validity of the Delphi method has been debated; specifically, it has been contended that it entails a risk of creating collective ignorance. Therefore, it cannot replace more rigorous scientific methods, but the method is still considered useful, when employed soundly, for the extraction of knowledge where conflicting evidence exists .
It is a strength of the study that the experts included had different educational backgrounds and held job positions at the policy-making, administrative and operational levels of Danish healthcare as well as in the academic world. The inclusion of immigrant patients to allow the target group to express their views could have further strengthened the experts’ findings through triangulation; however, this was not a part of the EU project’s design.
Given that we have defined delivery of health care services specifically to immigrants as the topic of the Delphi process, we have influenced the focus of the study. However, the initial definition of themes within this topic was left completely to the experts. Nevertheless, a certain degree of interpretation has been involved in synthesizing information when summarising the factors.
One of the experts expressed concern about the definition of immigrants employed in the present study as only persons who had arrived in Denmark within the past five years were included. The tightening of the Danish immigration laws in recent years has caused a shift in the main immigrant donor countries, and the experts felt that there was not sufficient room to describe the group of immigrants who have stayed in Denmark for a longer period and who are facing more challenges in the practice setting. As data were collected in the context of an EU project, it was not possible to change the definition. We met the critique by emphasizing that the experts were to pay extra attention to the definition of immigrants. However, it seems likely that some of them have based their answers on a more general understanding of the concept of immigrants.
It is worth noticing that there was a very high degree of consensus between the Danish experts despite their different backgrounds and job positions, which strengthens the findings of our study.
The Delphi process can be a valuable tool for the study of expert opinion in a given area when the objective is to take into account the ratings of a number of experts working in the same area. Thus, this type of study may serve to establish a consensus among experts and thereby guide policy initiatives. Given the emphasis experts placed on interpreters in the delivery of health care to immigrants, the introduction of self-payment for interpretation services which will come into force as from June 2011 seems paradoxical. It is likely that the group of immigrants who has been in the country for more than seven years and still have not learned the Danish language will consist of persons in socially vulnerable situations. Consequently, there is a risk of further marginalising a group of immigrants who are already having difficulties. This legislative measure is intended to serve as an incentive to stimulate integration, but, in practice, it may have just the opposite effect. Another structural condition affecting the delivery of health care to immigrants includes the duration of consultations. A more flexible planning and financing of the work in general practice, e.g. the introduction of prolonged consultations for vulnerable persons as needed, including for some immigrants, would allow the health professional and the individual patient to overcome any cultural barriers encountered.
Correspondence: Natasja Koitzsch Jensen, Forskningscenter for Migration, Etnicitet og Sundhed, Afdeling for Sundhedstjenesteforskning, Institut for Folkesundhedsvidenskab, Københavns Universitet, Øster Farimagsgade 5, 1014 København, Denmark. E-mail: email@example.com
Accepted: 25 April 2010
Conflicts of interest: None
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