TARGETED HEALTH CARE SERVICES FOR MIGRANTS WHAT ARE THE NEEDS?

Transcription

1 This seminar brief is based on the presentations and discussions at the seminar on Targeted Health Care Services for Migrants held on 26. The seminar was jointly arranged by the Global Health Unit of Copenhagen University Hospital, Rigshospitalet, the Research Center for Migration, Ethnicity and Health (MESU) and Global Health Minders. TARGETED HEALTH CARE SERVICES FOR MIGRANTS WHAT ARE THE NEEDS? Copenhagen, 26 INTRODUCTION Migrants form a considerable part of the Danish population and is a heterogeneous group including refugees, family reunified, adopted children, labour migrants, students and others. Having in mind that this does not apply to all, subpopulations such as refugees, family reunified to refugees and newly arrived migrants from less developed countries have been shown to be vulnerable with regards to having an excess amount of health needs and to encounter barriers to Danish health care services. Two recent developments within migrant health in Denmark call for a debate on the design and main tasks of health care services that are specifically targeted towards vulnerable migrants. Firstly, migrant health clinics in the Southern and Capital By Hanne Winther Frederiksen, PhD Fellow, Danish Research Centre for Migration Ethnicity and Health (MESU), University of Copenhagen regions of Denmark have been established. Secondly, a new bill on health assessments of newly arrived refugees recently came into force.!1

2 Thus, the objectives of the seminar were to gather researchers, clinicians, NGOs and other stakeholders within the field of migrant health, and to facilitate a debate on future perspectives of targeted health care services for migrants. This was the first joint meeting on migrant health in Denmark with representatives from both primary and secondary health care, universities and NGOs from the three major cities. Photo credit: Flavia Testorio We present below the main themes and discussions that came up during the debate, followed by minutes from the five presentations. KEY POINTS There is a need for targeted health care services for migrants. The complaints, symptomology and social issues of the patient population referred to the three present migrant/adoption health clinics are of such complex nature that general health care services find difficulties encompassing the group. Many of the patients in the migrant health clinics are referred at a point in their patient trajectory, where general health services lack the tools to support and encompass their complex disease patterns, including multimorbidity and a mix of psychosocial and somatic complaints. In order to address the complexity of migrants' health and access to health care services, we need a multi-faceted approach. We must enhance the general as well as the more specific diversity competencies, like e.g. cultural competencies among health care providers. In the design of health care services, we need both the inclusive and the targeted services. Interventions must focus both on the individual and the structural levels. Centre(s) of excellence for good practice in health services for migrants might serve as a link between research, practice and political decision making. Special concerns were expressed regarding the group of refugee children and children of dysfunctional or!2

3 traumatized migrants. We need more knowledge on how to identify children at risk; and we need a better understanding of best practice interventions for vulnerable children. Some of the problems described during the seminar might be addressed in the recent bill on health assessments of newly arrived refugees. At present, a working group under the National Board of Social Services is elaborating a systematic description of the objectives and design of the health assessments of newly arrived refugees. Along with a better implementation of the bill, this description might serve as a stepping-stone towards a more systematic diagnosis, treatment and prevention strategy among newly arrived refugees. During the seminar, there were calls for a stronger collaborative organization of specialists within the field of migrant health, many of whom were present at the seminar. It is clear, that together we all possess much knowledge, but we need a stronger voice. It was suggested to form a forum or society for researchers and health service providers involved in migrant health. A migrant health forum/society could decide on a strategy and focus points for e.g. the next five years and could form a stronger voice in the public/political decision making process. Data collection must be systematized and coordinated. This includes strategies for the collection of both retrospective and prospective data. Dissemination of scientific knowledge must be ensured through actively engaging in debates at the scientific, policy and layperson levels. SUMMARY OF PRESENTATIONS Professor Allan Krasnik, director of the Research Center for Migration, Ethnicity and Health (MESU) opened the seminar with an overview of current trends within migrant health. He outlined how concerns regarding migrant health are focusing on the health and well-being of migrants, and on the access they enjoy to appropriate health care services that are responsive to diversity.!3

4 Roughly speaking, initiatives that seek to address migrant health can either focus on enhancing the general diversity competencies of health care providers, or they can focus particularly on ethnic minority and migrant specific topics, including 'cultural competencies' of health care providers. The initiatives can either be inclusive or targeted, and can focus on the individual or be more structural in their approach. Therefore, it was discussed: 'Which approach to choose?' The answer was a simple 'Yes to all'! In order to address the complexity of the problem, we cannot leave out any of the approaches. Further, Allan Krasnik's messages were that there are many common features between health disadvantages in migrant groups and other socially vulnerable groups. Migrants' history with e.g. migration and traumatic experiences before and during flight is specific for the group. But it will be advantageous to coordinate efforts to improve health in migrant populations with interventions that seek to address inequalities in other vulnerable groups. With regard to migrant health research, we need a better understanding of the web of causalities connected to poor health outcomes among migrants; and we must develop effective and appropriate interventions involving user perspectives, keeping a focus on quality, organization and costeffectiveness. EQUAL ACCESS TO HEALTH The next presenter was special consultant Line Vikkelsø Slot from the Danish Institute for Human Rights. She presented a recent report on equal access to general practitioners for ethnic minorities. Source: menneskeret.dk/udgivelser The institute expresses special concerns regarding the use of child interpreters and quality of interpretation. In addressing other problems than the linguistic ones, the institute recommends migrant health clinics to be established in all regions of Denmark, the elaboration of thorough clinical guidelines, better education of health professionals in migrant-related topics and increased!4

5 attention on the identification of psychological traumas among refugees. The full report can be found here (in Danish). MIGRANT HEALTH CLINIC, ODENSE The third presenter was Professor Morten Sodemann from the migrant health clinic at the University Hospital of Odense, Region of Southern Denmark, which has now existed for more than five years. Morten Sodemann shared his experiences and recommendations with us along with a presentation of a newly published Health Technology Assessment (HTA) on hospital based coordination of care for ethnic minority patients. Source: The HTA can be found here (in Danish). The main messages were that the migrant health clinic is necessary and cost-effective and that it addresses shortcomings of today's health care system. Besides, the vulnerable migrant patient is not very distinct from other vulnerable patients, but is struggling with a large amount of problems, which challenges encounters with the health care system and puts up barriers to beneficial patient trajectories. At the migrant health clinic, the following factors are seen as particular barriers:! Increased division into medical specialties which are sometimes experienced as arbitrary for patients with multimorbidity, and which are often badly coordinated across specialties Lack of communication across health care sectors Frequent transitions between specialties and sectors resulting in loss of data and a following demotivation among patients Language barriers Limited social network among migrant patients, meaning few people to interpret and discuss symptoms with, and less resources to negotiate rights to health care services Economic constrains resulting in low adherence to prescribed medication Lack of general practitioners in some rural areas and areas with high density of migrants Hence, the migrant health clinic is not merely engaged in direct patient encounters, but also in activities related to!5

6 cross sectoral communication, education of health professionals and the use of technology assisted encounters such as video interpretation and video consultations. Conclusively, it was argued that targeted migrant health clinics are cost-effective due to fewer hospitalizations and lower expenditure on social benefits. We now have a large amount of knowledge regarding health problems and barriers to health care services for migrants. Therefore, future research should focus on the gap between knowledge and the political process which leads to its implementation into practice. MIGRANT HEALTH CLINIC, HVIDOVRE Fourth presenter was clinical director Helge Kjersem from the migrant health clinic, the University Hospital Hvidovre, the Capital Region. The clinic has now been up and running for a little more than a year. There are many similarities between the two clinics, but they are also distinct due to local circumstances. HVIDOVRE MIGRANT HEALTH CLINIC A systematic registration of the approximately 200 patients shows: <5 % employed >3/4 % consultations with interpretation 80 % female patients. 40 % from refugee producing countries (the majority Middle Eastern, a few from Vietnam & Somalia) 60 % labour migrants (Turkey, Morocco, Pakistan) At Hvidovre, the patient population consists of around 60 % labour migrants and 40 % refugees, including their families, which is probably a higher share of labour migrants than in Odense. The problems these patients present are closely connected to a poor integration process and social isolation. Many labour migrants immigrated during the 70's and 80's, but have been living a culturally and linguistic secluded life. Patients present heterogenic, and often complex, complaints, including multimorbidity and psychosomatic disorders. 25 % with classical PTSD symptoms 75 % with symptoms related to lack of physical activity Pain Depression Diabetes Mellitus Muscular atrophy Low compliance! Socially secluded and dependent on family members' help!6

7 Referral to the clinic have often been on grounds of the complexity of the problems, where standard services lack tools to disentangle the web of psychosomatic and social problems and ends up 'giving up' on the patient. This calls for multidisciplinary teamwork with the involvement of e.g. physiotherapists, psychiatrists and social workers at a specialized level as well as in the municipalities. There is a need for rehabilitation and mutual adjustment of aims with regard to the treatment plan. The clinic is therefore building its activities on multidisciplinary and cross sectorialnetworking. Conclusively, a concern regarding the children of traumatized, secluded and ill parents was expressed. These children are likely to carry a burden too heavy for children to bear. It is experienced that in general patients who are parents are reluctant to talk about worries regarding their children, probably because of fear the social authorities will interfere. The children are at risk of secondary traumatization without having access to the support needed. We therefore need more knowledge regarding the identification of children who are vulnerable and regarding best practice for the support of the children. NEED FOR A MIGRANT HEALTH CLINIC IN AARHUS The fourth presenter was medical specialist Christian Wejse from the Department of Infectious Diseases, Aarhus University Hospital. He presented the ongoing work to establish a formal migrant health clinic in Aarhus, and described patient encounters and trajectories that were comparable to those of Odense and Hvidovre. Hence, differences in the patient population in Aarhus, Odense and Hvidovre are unlikely to explain the fact there is yet no clinic targeted vulnerable migrant patients in Aarhus. Though there is a need and a will, there are still no exact plans with regard to the clinic. Again, politics rather than needs tend to be defining for the design of health care services. But here are ongoing initiatives to overcome these!7

8 barriers and establish the first migrant clinic in Jutland, covering a significant part of the migrant population in the country. HEALTH ASSESSMENTS OF ADOPTED CHILDREN The fifth and last presenter was medical consultant Anja Poulsen from the Pediatric and Adolescence Department, Copenhagen University Hospital, Rigshospitalet. The clinic has a small unit, specialized in health assessments of newly arrived adopted children. The unit, founded in 2009, has received 245 children of which the majority has been of African or East Asian origin. The health assessments of these children have systematically been registered; and though there are differences, health problems among adopted children might reflect the health problems seen among refugee children. Initially, we were reminded about the following facts:! 40 % of refugees are children asylum seekers in Europe <18 years Many of whom are traumatized Therefore, there is a need for a structured reception practice and a need for doctors, social workers, psychologists etc. with specialist knowledge regarding the challenges of this particular group of vulnerable children. A systematic registration of findings among the adopted children showed that a large share (43 %) arrived with parasitosis and a few carried other infections (latent TB, hepatitis A & B and syphilis). The mental health of the adopted children is systematically being assessed by a specialized psychologist. Accordingly, even though adopted children are in general healthy and live with socially competent and 'strong' parents, there is a need for a structured and specialized health assessment on arrival. On the grounds of experiences with the screening programme for adopted children, it is concluded that structured health assessments are necessary for the future!8

9 health of newly arrived vulnerable children from countries with another disease spectrum and less developed health care system; even more so for children arriving as refugees or through family reunification programmes. Photo credit: Javier López Morton DISCUSSION The discussion after the presentations reflected that it is still an open question whether health assessments of newly arrived refugees and their families are best carried out by specialists or in general practice. The design, conduct and structured collection of knowledge of health assessments are time consuming and at times a specialist task. But building the initiative into the primary sector facilitates detection, follow-up and routined handling of general public health issues. Additionally, building it into the primary sector may facilitate refugees future navigation in the general health care system and the introduction to general practitioners. On the other hand, specialists with competencies in migrantrelated topics, e.g. specific disease patterns, cultural competencies, the use of interpreters etc. in specific centres, facilitate a more focused contact to the health care system. Handling of the health assessment by specialist may also overcome some of the barriers related to difficult interpretation of test results, vaccination regimes, screening for trauma etc. A few specialized clinics performing health assessments could serve as knowledge centers, collecting findings in a formalized way, that could be used in the development of future evidence based health assessment packages. Good referral opportunities to relevant third parties are important; be it medical specialists, trauma rehabilitation, social workers, physiotherapists, or other agencies in both primary and secondary sectors. Regardless of which option is chosen coordination is crucial.!9