NIVEL Team: Dinny de Bakker, Christos Balliatsas, Derek de Beurs, Tim Schoenmakers, Marieke van Veldhuizen

Michel Dückers Netherlands Institute for Health Services Research (NIVEL)

Barriers and solutions for the

optimization of refugee and migrant

healthcare in Europe

#EFPC2016 RIGA CONFERENCE

MAIN TOPICS

Objective

Methods

Results

Conclusions

2015, September 2016, February

‘Europe is "close to limit" on accepting refugees, EU President Donald Tusk said

Sunday, as he urged the international community to do more to step up resettlement

of those seeking refuge. A growing number of refugees have fled to Europe to escape

instability in Syria, Iraq, Eritrea and Somalia, among other nations.’

- CNN, September 4, 2016

OBJECTIVE

With the ambition to promote the health of refugees and

other migrants, especially those coming from Middle

East and Africa, in the context of short-term arrival, the

main objective of WP3 is:

“to learn from literature and experts on measures and

interventions and the factors that help or hinder their

implementation in European health care settings”

METHODS

Literature review, systematic search in literature

databases (app. 4.000 abstracts, app. 250 full-text articles, app. 85 included publications)

Online survey (81 participants working in 9 countries)

Expert interviews (10 experts)

Information collected between February and May 2016

IMPLEMENTATION FACTORS

(inspired by Flottorp et al. (Imp Sci 2013)

Succesful implementation of

measures and interventions to improve refugee

and migrant health care

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions Incentives

and resources

Capacity for organiza-

tional change

Social and political

environment

BARRIERS AND SOLUTIONS

Barriers

Solutions,

improvement strategies

BARRIERS AND SOLUTIONS: GUIDELINES,

PROTOCOLS, POLICIES, LEGISLATION

Availability, quality and applicability of guidelines and protocols, clarity and

accessibility of documents (and consistency with other documents)

● Unavailability of useful guidelines ● Guidelines are complex, not up-to-date, inappropriate for the target population ● Lack of protocols, policies and restrictive legislation

● Weak institutionalization of policies

● Develop guidelines for unaddressed topics (e.g. entitlement, cross-cultural communication, interpreters/mediators, health surveillance systems) ● Engage stakeholders in development

● Simplify, clarify or adjust existing guidelines, tailor them to local circumstances and level of education of professionals ● Invest in dissemination ● Governments can facilitate feasibility of policies

Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

BARRIERS AND SOLUTIONS:

INDIVIDUAL PROFESSIONAL FACTORS

● Lack of knowledge and awareness about supporting policies, legislation or available services ● No access to medical history ● High workload, complex situations (e.g. people in need not

entitled) ● Bureaucracy ● Fear of stigmatization ● Limited support by authorities ● Cultural norms (e.g. provision of

condoms to unmarried women) ● Fear of losing license ● Time constraints ● Language difficulties ● Unprofessional attitude

(e.g. discriminative, xenophobic)

● Enhance awareness about importance of service provision ● Broadly share knowledge about specific issues (e.g. refugee health needs and problems, cultural issues, traditional health

practices and beliefs, barriers for accessing healthcare, risk factors and treatment effects different ethnic groups ● Train professionals

(e.g. cultural competencies, sensitive issues, trust-building, appropriate attitude) ● Involve stakeholders in development of

training ● Work in multidisciplinary teams ● Integrate psychosocial dimension ● Active outreach and provision of information

● Involve families (e.g. pregnancy) Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

Knowledge, awareness, skills, attitude/beliefs/cultural factors, expectations of outcome,

motivation, perceived barriers, provision of training/information, self-efficacy, staff incentives

BARRIERS AND SOLUTIONS:

TARGET POPULATION FACTORS

Knowledge, awareness, information, skills, attitude/beliefs/cultural factors, outcome expectations,

perceived barriers, self-efficacy, patient incentives, patient needs, refugee specific issues

● Complex medical and social histories of refugees ● Limited knowledge and awareness about disease, illness, health risks and behaviour, available

services, rights to healthcare, health system ● Language problems, illiteracy, low level of education ● Different norms and belief systems concerning health services ● Passive attitude towards treatment ● Limited access to healthcare

(e.g. legal restrictions/entitlement, physical distance, transportation problems, unable to pay for healthcare, long waiting times) ● Low trust in professionals (hide symptoms, fear of discrimination or deportation, reluctance to discuss

sensitive issues like HIV) ● Fear of stigmatization, shame or social repercussions ● Lack of privacy ● Lack of supportive environment

● Educational campaigns to increase acceptability and uptake of health services, guide expectations, for instance via a group

approach that contributes to social network of patients ● Training materials adjusted to the level of understanding and language,

assistance from interpreters ● Make professionals aware of relevant target group expectations to address ● Involve refugees in

development of health care approach to increase quality, acceptability and effectiveness of services ● Availability of childcare

during appointments and walk-in sessions Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

BARRIERS AND SOLUTIONS:

PROFESSIONAL INTERACTIONS

Patient-professional interactions, interpreter services, communication on

organizational level/between stakeholders, collaboration, continuity of care

● Patient-professional interaction (language and communication difficulties, cultural differences incl. norms and beliefs, distrust in relations, time constraints) ● Interpreters/ cultural mediators (informal interpreters: confidentiality, fear of gossip, unfamiliarity with medical vocabulary,

withholding information; formal interpreters: limited availability, confidentiality issues, logistics, costs, time) ● Continuity of care (mobile

target population, uncertain length of stay, lack of adequate information on different organizational levels and between countries, poor patient

registration, professionals lack information, lack of coordination between professionals and services)

● Patient-professional interaction (increase trust and patient compliance by family involvement, shared language, neutral

wording of sensitive issues and cultural sensitivity, longer consultation time, provide translated information ● Interpreters/

cultural mediators (increase availability of formal interpreter services and cultural mediators to avoid miscommunication,

increase trust and quality of healthcare, also via phone and skype) ● Continuity of care (improve information exchange with a medical passport, follow-up of care needs, well-functioning referral system,

good cooperation between reception facilities and health care system to enhance accessibility, continuity of staff and interpreters/mediators, case manager with overview)

Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

BARRIERS AND SOLUTIONS:

INCENTIVES AND RESOURCES

Availability of time, financial means, human resources,

equipment, services, financial resources, incentives

● Lack of resources in terms of time,

financial means, human workforce,

services and equipment

● Reallocation of resources,

cross-national collaboration

and exchange of resources

Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

BARRIERS AND SOLUTIONS:

CAPACITY FOR ORGANIZATIONAL CHANGE

Monitoring and evaluation, division of roles and responsibilities, coordination,

authority of change, prioritization, integration of care, continuity of staff

● Refugees can try to avoid registration or hide

health needs because of distrust or fear ● Lack of capacity

for evaluation or systematic data analysis ● unavailability of

services because of a lack of prioritization and authorization

● Monitoring and evaluation (establish quality assurance systems, evaluate patient compliance and cost-efficacy, strengthen the evidence base; allocate financial means, expertise and time for systematic data

collection, more research into effectiveness of interventions and measures for different populations) ● Coordination of care (realize a

clear division of roles and responsibilities, appoint a leading agency or focal point to improve coordination, involve stakeholders incl. migrant

groups, collaborate with partner organizations ● Continuity of care (invest in local services and in the chain across sites and countries,

integrate sectors e.g. psychiatric and social services, reproductive health services in primary care, and HIV-testing in routine care; commitment of

different stakeholders and agreements; evidence-based advocacy)

Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

BARRIERS AND SOLUTIONS:

SOCIAL AND POLITICAL ENVIRONMENT

Cultural beliefs and attitudes, community involvement/support,

scale of problems, political conditions

● Lack of political will to address health issues and needs of refugees ● Changing political realities/incompatible time frames of policy and practice ● Entitlement and the right to health care ●

Poor living conditions and uncertain prospects of refugees and migrants (mental health risk in itself)

● International cooperation and collaboration, realization of international networks (exchange of expertise linked shared policy-making) ● Active

government involvement ● Outreach and capacity-building at the community level, community involvement ● Make health systems more favourable towards newcomers (advocacy, MIPEX) ● Focus not only on

differences between target populations but also in they have in common ● Invest to reduce stigmatization and xenophobia

Succesful imple-

mentation

Guidelines, protocols, policies,

legislation

Individual professional

factors

Target population

factors

Professional interactions

Incentives and resources

Capacity for organizational

change

Social and political

environment

CONCLUSIONS

Different data sources point at recurring barriers and

potential solutions, regardless of the type of health problem

Development of practical evidence-informed guidelines,

protocols, tools and training materials, tailored to local

circumstances, languages, users and target groups is crucial

However, in order to implement them we need to effectively

address the implementation factors identified!!!!!!!!!

Many of the challenges require solutions exceeding the

country level

TEST IMPLEMENTATION CHECKLIST

(working title ATOMiC: appraisal tool for optimization of migrant healthcare)

APPRAISAL

Implementation conditions to

consider

WHAT

Characteris-

tics of

health care

intervention

FOR

Characteris-

tics of

migrant

target group

HOW.

Professional

interactions

BY

Characteris-

tics of

health care

providers

WITH

Incentives and

resources

WHERE (INT)

Organizational capacity for change

WHERE (EXT)

Social, political and legal factors

DECISION

Proceed with implementation

(Y/N)

Based on

General implementation

literature:

Rogers 1995, 2003;

Greenhalgh et al. 2004;

Weiner 2009

Michie et al. 2011

+

Refugee and other migrant

related implementation factors:

EUR-HUMAN WP3

THANK YOU FOR YOUR ATTENTION