Author's response to reviews Title: Providing Medical Care for Undocumented Migrants in Denmark: What Are the Challenges for Health Professionals? Authors: Natasja K Jensen (naje@sund.ku.dk) Marie Norredam (mano@sund.ku.dk) Tania Draebel (tdr@sund.ku.dk) Marija Bogic (marija.bogic@eastlondon.nhs.uk) Stefan Priebe (s.priebe@qmul.ac.uk) Allan Krasnik (alk@sund.ku.dk) Version: 2 Date: 15 May 2011 Author's response to reviews: see over
Reviewer: Anne Rytter Hansen Minor Essential Revisions 1) Results, paragraph "Access to primary care". The sentence "If the GPs agreed to treat the undocumented migrant, the majority of partcipants expressed that there would be no difference in the medical traetment they could perform themselves in the clinic..." is unclear. What is being compared to when writing "no difference in the medical treatment"? Is it "no difference between the GPs" og "no difference from other settings" or? Reply: The wording has been changed to make the point come across more concisely. The meaning of the sentence is that the GPs report that the medical care they can give without involving external diagnostic facilities is the same as for other patients. It is seen in relation to the next paragraph that describes problems in relation to using external facilities. This has been highlighted in the text. 2) Discussion, paragraph "Quality of care". The sentence "We report that undocumented migrants have a delay in seeking medical care..." sounds very conclusive in the light that it seems to be based on one ER physicians statement.i recommend rephrasing. Reply: The wording has been changed to highlight that this finding is only based on the comments from one physician in our study. 3) Discussion, paragraph "Influence on health professionals", second paragraph, first sentence. It is unclear what is meant by "the provision of care is in the margins of the Danish health care system". Does it mean that the provision of care for undocumented is not an integrated part of the Danish health care system? Reply: The meaning of this sentence has been elaborated in the manuscript. 4) Discussion, paragraph "Implications of legislation and policy", third paragraph.provide reference for request to and response by the National Board of Health. Reply: The reference has been inserted. Discretionary Revisions 1) Results, paragraph "Access to primary care". After the sentence "There was a difference in how willing the GPS were to treat this group of patients" an example of this provided. Also providing an example of the opposite case would make good sense in order for the reader to compare. Reply: An extra quote has been inserted to give an example of a GP who is more reluctant to offer treatment. 2)Discussion, paragraph "Influence on health professionals" Could you title the paragraph something else/more precise? For example "Consequences for health professionals" or "How health professionals are affected". Reply: The title has been changed to Consequences for health professionals. 3) Discussion, paragraph "Methodological considerations". I suggest keeping the sentence "As previously mentioned, another explanation may be that we interviewed only those last in the chain of providing care" and erasing the next two sentences as this has already been explained. Reply: The sentences have been kept in the text despite the suggestion. This is because it is judged as very important to explain that the undocumented migrants may never have been able to reach a doctor when seeking treatment. Furthermore, this is a point put forth by reviewer number two as a methodological weakness and therefore the two sentences are still in the manuscript. Level of interest: An article of importance in its field Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. I declare that I have no competing interests 1
Reviewer: Chiara Bodini MAJOR COMPULSORY REVISIONS 1.A more detailed background analysis on the immigration phenomenon in Denmark would be useful to frame the discourses that follow. How many regular immigrants are there? Where do they come from? What do recent immigration trends in Denmark tell us (is it a recent phenomenon? Has it changed its characteristics/impact on the everyday life of the population? How is the phenomenon framed in the public debate/media?)? These aspects should be described before the second paragraph in the "Background" section. Reply: A paragraph on the Danish migration history has been inserted in the background section. It has been judged to be too extensive for the purpose of this article to touch upon all of the suggested questions above, but an introduction to the migration history during the last 50 years is now included. 2.As partially noted also by the authors, the choice of interviewing only doctors (ER doctors and GPs) has several limitations, including: - not taking into account the perspective of immigrants and service users - not considering all the other professionals involved, including nurses, administrative front office staff, etc. - as far as GPs are concerned, it is unclear whether they have actually ever seen irregular immigrants among their patients, as many sentences reported refer to the case in a mere hypothetical/speculative way (and, for this same reason, the interviews with managers of psychiatric residential units were not included in the analysis) I would suggest to move the Methodological considerations section in which all these issues should be considered and explained in detail before the discussion. Reply: a) It has now been elaborated in the section on methodological considerations that the perspective of undocumented migrants themselves and other categories of health care professionals than physicians is not accounted for in the study. b) The general practitioners interviewed have experience with treating undocumented migrants. The majority from treating patients in their own practice, but if not from their practice they have experience from other parts of the health care system. This has now been specified in the methods section. c) The section on methodological considerations has now been moved as suggested. 3. It is not too clear from the text how are GPs linked to the national health system; this aspect should be clarified in order to better understand the reported issues around financial implications of treating irregular immigrants. Reply: a paragraph presenting the most important features of the Danish health care system has been inserted into the background section. MINOR ESSENTIAL REVISIONS Tables 1-3 are named as Box 1, 2, 3 in the text. Reply: the wording has been changed. DISCRETIONARY REVISIONS 1.I would like to ask to the authors whether a review of the literature from fields "other than health" (such as Sociology and Anthropology) has been conducted. Doctors are part of the community, are there studies that tell us what the perceptions of Danish society are towards immigrants, and particularly irregular immigrants? Which motivations underpin their coming to/staying in Denmark, and how are these perceived by the general population? This background contextualisation would be extremely helpful in order to interpret the finding of the interviews correctly. Reply: A section on the perception of immigrants in the Danish population have now been inserted into the background section based on sociological literaterature. In addition, a section reflecting recent discussions 2
amongst health professionals and medical organizations in the Danish Medical Bulletin has now been inserted in the discussion in the section of consequences for health professionals. 2.From a methodological point of view, I would like to give the following suggestion: if interviews are aimed at finding out what really happens, it would have probably been better to ask the interviewees about their actual experiences and not (only) about what they would have done, as this framing of the question elicits speculative answers that may be less reliable or far from actual practices. Reply: Including the vignettes has been a way to elicit how health professionals would respond and act in a concrete situation. It is still possible for them to draw on their experiences in providing care when giving their answers. Level of interest: An article of limited interest Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. I declare that I have no competing interests. Reviewer: Hans Wolff Title: Providing Medical Care for Undocumented Migrants in Denmark: What Are the Challenges for Health Professionals? General: The study aimed to describe how health professionals navigate and how they experience providing treatment for undocumented migrants in the Danish health care system. The major finding is that undocumented migrants experience unequal access to primary care facilities and that great uncertainties exist amongst health professionals concerning administrative and medical management of these. Several barriers are identified. The study is important because trying to identify barriers to access to health care in DK where undocumented migrants have no formal access to care. The strength of the article could be improved by: Essential Revisions: 1. Give more detailed information about the health care professional (age, sex, % with experience of consultations with undoc. Migrants, urban/rural practice, migrants among the doctors,?) Reply: Information on urban area, sex and migrant background have been included. We tried to obtain information on experience with treating migrant patients, but as this is not registered the estimates are very inaccurate and not valid enough to include in the article. 2. Include some information about the sociodemographic profile of undocumented migrants in Denmark in the Introduction. Reply: To our knowledge, no information is available concerning sociodemographic profile of undocumented migrants in Denmark, but this has been elaborated in the background section. 3. If available, give some sociodemographic information about patient profile in contact with the GP and ER doctors. Reply: See question 1. Only very rough estimates were available in relation to immigrant patients and the overall data collected on patients are too superficial to be relevant for the purpose of this article. In addition, due to different organization of general practices it would require a very elaborate description simply to explain how many patients a general practitioner sees in a year. 3
4. The ID 53 who mentions his thoughts about Ukraine is puzzeling. I understand that this GP expresses a clear (negative) judgement about undoc. migrants. Negative judgement might be an important barrier: the GP who judges that the undoc migrant should not be here, has no right, may profit of the system, of the Dains??? Maybe you have other statements in this direction? Please try to discuss this point because it is an important barrier not only among GP but frequently among administrative personal at front desks! Reply: Negative judgments is certainly a problem in relation to barriers hindering access to care. This has now been elaborated in the section on methodological considerations in the discussion. However, in the interviews this study is based on it is not found to be a prevalent statement amongst the health professionals. Therefore, it is not brought forth as a theme in the results section. 5. Page 14: but will also lead to problems for health professionals when providing care for these migrants. will seems too strong. I suggest may. Explain one or two problems which may occur. Reply: The wording has been changed and a new transition further leads to the next section on quality of care in the discussion. 6. Page 17: Although undocumented migrants may still experience other barriers in access to health care services, granting them official rights to health care is a significant political statement. Explain why tis is a a political statement! Granting basic human rights is not necessarily a political statement. It could also be interpreted according to the respect of basic human rights. Reply: Explanation and explicit stating of the relationship human rights is now provided in the text. 7. Revise the language. A lot of the could be dropped: Eg: p. 19 at the bottom: the health prof in question viewed the access Reply:The specific example have been rephrased, but in relation to the use of could in the text the language has been adjusted by a proof reader in English. Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published Statistical review: No, the manuscript does not need to be seen by a statistician. I declare that I have no competing interests 4