Empirical analysis I: Interviews with providers National report Denmark & Sweden Edited by: Tine Baatrup, sociologist Kirstine Simony, bs.c. sociology Mhtconsult ApS May 2009 Funded by the European Commission, DG Health and Consumers, Public Health Nationally funded by Fonds Gesundes Österreich (Austria) and The Netherlands Organisation of Health Research and Development (ZONMW) (Netherlands). Coordinated by Forschungsinstitut des Roten Kreuzes, Austria
Table of contents 1. Introduction 3 1.1. General introduction of the project 3 1.2. Methods 4 1.3. Health promotion in Denmark and Sweden 8 1.4. Migrants in Denmark and Sweden 15 1.5. Health promotion providers and interventions 18 2. Participation of migrants in the health promotion interventions (provider/intervention level) 23 2.1. Actual participation of migrants in the interventions 23 2.2. Hindering or conducive factors on the intervention level 32 3. Policies of organisations to improve participation of migrants (organisational level) 45 3.1. Organisational policies 45 3.2. Hindering or conducive factors on the organisational level 47 4. Governmental policies to improve participation of migrants (institutional level) 51 4.1. Governmental policies 51 4.2. Hindering or conducive factors on the institutional level 53 5. Conclusions 55 5.1. Provider/intervention level 56 5.2. Organisational level 64 5.3. Institutional level 65 6. Summary 67 References 70 Appendix 76 2
1. Introduction This chapter introduces the Healthy project and gives a short presentation of health promotion initiatives in Denmark and Sweden. The providers who are interviewed with regard to this project are presented here, as are the specific methods used in the formulation of this analysis report. 1.1. General introduction of the project Background information Poorer health. Unhealthier lifestyle. Longer absences owing to illness. That is the picture of the health of migrants compared to the Danish majority. And both physical and psychological health factors are poorer. Between 12 and 17 percent of all migrants are affected by diabetes, compared to 2 percent of the general population. While one in ten ethnic Danes suffer from anxiety or depression, this is the case for one in four migrants. The same pattern is present with regard to back problems, osteoarthritis and gastric ulcers (Ny I Danmark, 03 2008, p.15). The overall health status of migrants is remarkably poorer than that of the general population. This is related to the fact that migrants are more exposed to factors which may have a negative impact on health, such as poverty, poor living conditions, restricted access to the labour market and health services etc. As a consequence migrants belong to the most vulnerable and exposed social strata in society, and require special consideration in public health strategies (Healthy, Description of the Action). Additionally, a lack of information, combined with communication problems, create barriers for their access to health promotion interventions. Thus, equal access as well as the quality of the general health services, are essential factors for enhancing the health level of migrants. This does not only apply to health care services, but also to prevention strategies and health promotion interventions. 3
About Healthy Healthy is a European project, which is carried out to abet general efforts to promote more inclusive health promotion initiatives in the EU countries. The project is a trans- European cooperation supported by the EAHC (Executive Agency for Health and Consumers), the health and consumer administration of the EU. Apart from Denmark, the participating countries are Germany, Holland, Austria, Italy, Slovakia, Estonia and the Czech Republic. The aim of the project, apart from a broad information purpose, is to make a number of recommendations, which can contribute to making health promotion initiatives more inclusive for migrants. This is the first occasion in Denmark in which a project systematically analyses the barriers for migrant inclusion in health promotion interventions. The purpose is to collect knowledge of these barriers, both from the migrants themselves and from the personnel who are the providers in health promotion interventions. The final recommendations of the project will therefore on the one hand relate specifically to each country, and on the other hand also include recommendations which can be drawn from good practice in the participating countries, and which can be successfully transferred to other countries. It should be noted here that these recommendations might also be relevant for the inclusion of other vulnerable groups in society. However, this report focuses on migrants only. 1.2. Methods This knowledge of the barriers of migrants access to health promotion interventions will be collected through interviews, through analyses, through cooperation with an advisory board, through attendance at conferences as well as through other avenues. The methods used in the making of the analysis are literary analysis and qualitative interviews. In the following these two methods are shortly described. 4
Literary analysis The literature involved in the study has been accumulated through informational searches on the Internet. Key words were the Danish and Swedish words for health, health promotion, disease prevention and migrants as well as other health and migration related termini. This search was done in larger search engines as well as in the database of the Royal Danish Library. Moreover, information was gathered from various relevant websites targeting health workers and other groups which work with health in a professional capacity. Likewise, information was collected from newsletters from both health and integration sector organisations, at the local, regional and national government level. The collected literature was read and systematised, in order to employ it in various chapters in the report. This collection of relevant research and information, was performed for both Denmark and Sweden, but has been most exhaustive in relation to Denmark, due to the previous knowledge already held by Mhtconsult regarding social integration in Denmark. As such, the study also makes use of knowledge collected through other research projects performed by Mhtconsult. The qualitative interview A total of 30 semi-structured qualitative interviews were conducted. 18 interviews with providers of health promotion initiatives were performed in Denmark and 12 interviews in Sweden. These were all conducted by telephone. The lack of attention to inclusion of migrants found in the health promotion interventions in Sweden (see section 1.3.) has affected the results of this study, in that the Swedish providers have lacked a focus on migrants, and generally have felt incapable of formulating opinions on this issue. Based on this, the information gathered from the Swedish interventions in this study is marked by a level of uncertainty. With a small selection of only 30 providers in two countries, the results of this study cannot be seen as representative. The study can therefore mainly be used for identifying tendencies concerning the inclusion of migrants in health promotion interventions. 5
Informants All informants have been selected systematically, and according to the common selection criteria in order to make the results of all project partner s countries comparable: All should be general, local providers of health promotion and following the participatory empowering approach: What can you do for yourself and how could health promotion support you? (Baric, L & Günter, C. (1999): Gesundheitsförderung in Settings. Verlag für Gesundheitsförderung G., p.12). The interventions should be targeting the general population, but also interventions targeting migrants specifically should be included, in order to gain knowledge about specific approaches. The providers included must have practical experience with health promotion work (hands-on experience), or a good overview and understanding of the health promotion initiatives in the organisation (managerial experience) (Healthy, Description of the Action). The majority of the providers represents local government or publicly funded interventions, as health promotion in Denmark and Sweden is primarily performed in a municipal/local government context, and is usually performed with public funding. Hence, only two of the investigated interventions are private, and these also receive public funding. Therefore, there is an imbalance between public and private interventions, which is representative of the way this area is organised in Danish and Swedish society. An attempt was made at including a broad selection of health promotion initiatives, in order to represent different types of institutions and organisations in Denmark and Sweden. This should ensure that the broadest possible spectrum of information concerning the field of investigation is included in the study. Migrant and native users of health promotion interventions often belong to more vulnerable society groups (see part 2.1), why these groups of society are overrepresented in the report. However, as the inclusion of migrants, with a particular focus on the vulnerable migrant groups, is the concern of this report, we do not find this imbalance problematic for the recommendations based on the report. 6
The majority of the migrant users of the health promotion interventions come from non- Western countries, why the included providers will base their statements on experiences with these migrants. Furthermore, a balance between hands-on staff and management level personnel was attempted, so that half of the providers interviewed have hands-on experience and the other half have management experience. Another selection criteria was that the providers should be geographically dispersed, and both represent urban and rural areas. The performed interviews focused thematically on the barriers for the inclusion of migrants in health promotion initiatives through the following guiding research questions: 1. Do migrants participate in health promotion activities? 2. What are hindering and conducive factors for participation of migrants in health promotion initiatives? What is the influence of images of health/disease on the use of health promotion initiatives? 3. Which strategies and solutions are used to improve access of migrants? Methodology for the analysis The investigation of the access of migrant groups to health promotion initiatives is based on a hermeneutical analytical method, where the interpretation alternates between an atomistic analysis and a holistic perspective between part and whole (Gilje et al, 2002, p.178). Categorisation of the data material takes as its starting point an existing conceptual structure, which signifies that the categorisation starts with already identified concepts, drawn from the previously determined structure of the interviews and the report. These concepts provide the overall structure for the analysis, which contains interpretation at an interventional, organisational and institutional level. 7
1.3. Health promotion in Denmark and Sweden Health promotion in Denmark: Organisation and responsibility The public system in Denmark is based on a welfare model, where all citizens regardless of background and means have equal access to health promotion, prevention, treatment etc. In order to ensure that this welfare model can be implemented, all public services are free of charge, and everyone is entitled to free interpreter services if needed. With regard to health promotion interventions, the publicly funded measures and initiatives are thus prevalent rather than private and civil sector initiatives. The following model illustrates the general organisation of the Danish system: 8
Graph 1: The Danish Health System Government Ministry of Health and Prevention The National Board of Health 5 Regions 98 Municipalities Somatic hospital service Promotion of health Mental health treatment Rehabilitation Dentists Home care / visits Prevention Prevention of abuse Practitioners Dental care for kids Physiotherapists, chiropractors, podiatrist Health visitor Health Care Centers Health service for schools Health insurance 9
In Denmark, the national government holds the overall responsibility for the health care system. As such, the Ministry of Social Affairs is responsible for the development of health care policy especially targeting vulnerable groups such as the elderly, handicapped and socially marginalised groups. The five Danish regions or counties are responsible for hospitals, general practitioners, psychologists etc. The 98 Danish municipalities have, under the new municipality law of January 2007, received the responsibility for health promotion and preventative efforts. At a national level, the interventions in both the regions and the municipalities are regulated by the Ministry for Health and Prevention, which is further advised by the National Board of Health. In connection with the new municipality law and the subsequent restructuring, the Ministry for Health and Prevention initiated a project concerning the establishment of health care centres in the municipalities. 18 of the 98 municipal authorities received funding for the creation of health care centres: In connection with the municipal reform, which was enforced in January 2007, the municipal governments were advised to attempt to create health care centres as a new organisational framework for health related tasks. (Due et al., 2008, p.147). As an extension of this, a study from 2008 shows that 42 percent of the Danish municipalities at the time of research already had a health or prevention centre in operation (ibid, p. 49). The law does not demand that the preventive health effort is performed through health care centres, although this is a model chosen by many local authorities (ibid, p. 8). Based on the structure described above, the provision of health promotion interventions in Denmark takes place in cooperation between regions and municipalities. National cooperation and goals In several cases, private and public actors work together towards reaching socially vulnerable groups. This allows for a more effective use of existing resources. There is a longstanding Danish tradition for cooperation across sectors, and even though the majority of health care work is performed by public institutions, there are advantages from involving 10
civil society actors. Thus, there are several examples, where local authorities cooperate with local sports clubs, voluntary associations, housing associations and others. The Danish efforts are also characterised by the fact that Denmark is a relatively small country. For example, geographical distances are so small that cooperation across regions can be established relatively straightforwardly. However, despite its small size, the Danish society contains everything from big-city municipalities with a high concentration of migrants in specific council housing areas, to sparsely populated outer municipalities, with a very low concentration of migrants. The interventions in - and the types of cooperation between - these very different areas is therefore established, not only based on the needs of the individual citizen, but also with reference to the geographical area in which the person lives. Migrants in health promotion initiatives Migrants constitute a socially vulnerable group in society today, and there is a need for special efforts directed at this group in health promotion initiatives. Several Danish health care centres in big-city areas do incorporate a focus on this target group. Similarly, several interventions have been created over the last few years, which are targeted at migrants. These interventions may be either interventions placed in residential areas with a high concentration of migrant residents, or association initiatives, language school measures or health care centre based activities. Health promotion in Sweden: Organisation and responsibility The Swedish health care system, like the Danish one, is based on a welfare model, where every citizen, regardless of background and means should have equal access to health promotion, prevention measures, treatment and so on. However, a user pays system is implemented. Hence, for an adult above the age of 18, a visit to the doctor costs around 12 EUR, depending on the region, and the hospital fee is around 8 EUR a day 1. For children the health system is free of charge. With regard to health promotion interventions, the 1 There are varying fees depending on what type of consultation/treatment one needs. 11
publicly funded measures and initiatives are prevalent over private and civil sector initiatives. The Swedish health care system is structured in a similar way to the Danish system, in that the Ministry of Social Affairs holds the overall responsibility for the health care system, including health policy. Hence, this Ministry is also responsible for the health promotion areas. The municipalities are responsible for a number of health care activities directed at children, the elderly, handicapped persons and so on, which also includes health care centres. The following model illustrates the structure of the Swedish health care system: 12
Graph 2: The Swedish Health System Government: Ministry of Social affairs Regions (21) Municipalities (290) Justice department Financing, running and control of the health care Health care centres Refugees and immigrants Hospitals Medical treatment: doctors and specialised nurses Dental care Preventive work Rehabilitation Elderly care Psychiatric treatment 13
The health care centre system in Sweden is also similar to the Danish system: The health care centres in Sweden, are a form of medical houses, which provide various health care services. The centres house general practitioners and other professional groups. The health care centres provide services which are also to some extent provided by the outpatient departments at the hospitals. Citizens in Sweden may choose whether they wish to see a doctor in a health care centre or in the outpatient department of a hospital. In the centres the citizens will initially be seen by a nurse, and are then referred to the centre doctor. The nurse can thus to a certain degree relieve the workload of the general practitioner (Indblik, no. 7, 2006). The health care centres in Sweden also focus on health promotion. The Swedish regions are responsible for the operation and control of the health care system, the hospitals and the dental care. Since the Swedish system is similar to the Danish in so many ways, the description of the Swedish system will not be given as much attention as the Danish. This is also connected to the fact that the Swedish data is only used complementarily in the analysis of Healthy. National cooperation and goals Politically, the Swedish aim is that health promotion and prevention initiatives should focus on the entire person that is, they should be holistic in perspective. A direct national guideline is that public institutions are advised to cooperate with civil society actors, in order to ensure an optimal effort towards socially vulnerable groups. Migrants in health promotion initiatives Politically, the differences between the Danish and Swedish efforts are negligible, and the two approaches share a focus on ensuring that socially vulnerable groups (including migrants) are included and that they receive special attention. In Sweden, however, there are no interventions directed specifically at migrants, as this is seen as contributing to a stigmatisation of this group. After a two-year introductory period for migrants, where health 14
promotion and education concerning the Swedish health care system take place, there are no targeted efforts directed at migrants. An important characteristic of the Swedish interventions is their focus on socioeconomic factors. An argument for this focus is that for example the poorer health statistics of the migrants is caused by their inferior socioeconomic conditions rather than their ethnicity (Öhlander, 2004, p.5, Välfärd, 2007). 1.4. Migrants in Denmark and Sweden Migrants in Denmark In February 2006 the total number of immigrants and descendants 2 in Denmark is 452,095, which is equivalent to 8.4% of the Danish population of 5.4 million. This information is based on register data from Statistics Denmark (2006). The group of immigrants and descendants comprises both foreigners and Danish nationals with a foreign background. A total of 40.4% of all foreigners in Denmark are Danish citizens. A very large proportion of the immigrants and descendants in Denmark originate from a non-western country. An estimated 70.8% of the foreigners originate from a non-western country, while the corresponding proportion of foreigners from Western countries is 29.2% (Statistics Denmark, 2004, p.2). Although Denmark is known to be a relatively homogenous nation, immigration is not a new phenomenon. Denmark has in particular had experience with employment seeking migrants. Thus Dutch and Germans, invited by the Danish king, came to do work within the agricultural production in the 1500-1800 hundreds, followed by the Polish migrant workers, who came to seek unskilled, seasonal labour also within agriculture. The general 2 A person is defined a Dane if at least one of his parents is both a Danish citizen and was born in Denmark. It is therefore of no significance whether the person himself is a Danish citizen or was born in Denmark. If the person is not a Dane, he is an immigrant if he was born abroad, and a descendant if he was born in Denmark (Yearbook on Foreigners in Denmark 2004:1) 15
economic upturn throughout Europe after 1945 resulted in an increased growth within the industry and the public sector and a lack of labourers. Therefore employers advertised for employees in countries such as Turkey and former Yugoslavia. The number of guest workers peaked around the 70 s. However, an immigration stop policy was enforced by 1973, setting an end to this immigration. Since this immigration stop policy, family reunification has constituted the majority of the issued legal residencies in Denmark. In 2008 the two main migrant groups in Denmark were the Turkish and the Iraqis, numbering 54,257 and 25,671 respectively. The Turkish originally came as guest workers and the group has since increased due to family reunification. The Iraqis came as refugees 3 primarily after Saddam Hussein came to power and as a consequence of the war against Iran. Lately this number has also increased due to family reunification and due to the present war in Iraq. However, apart from these major migrants groups, Denmark has also experienced migration from a wide range of other non-western countries, such as Lebanon (stateless Palestinians), Somalia, ex. Yugoslavia, Pakistan, Iran, Vietnam and Sri Lanka, to mention a few. The development of the number of immigrants and descendents of working age may have a positive effect on the Danish economy, if immigrants have an employment rate corresponding to that of Danes. However, surveys show that immigrants and descendants have substantially fewer ties with the labour market than Danes (Statistics Denmark, 2006, p.3). The employment rate among immigrants and descendants from non-western countries is 47%, the corresponding employment rate of Danes is 77%. Particularly immigrants and descendants from Iraq have poor labour market ties (ibid.). Immigrants also have a substantially poorer educational level than Danes; an estimated 40% of immigrants have gained professional qualifications, whether in their countries of origin or in Denmark, 66% of Danes have gained professional qualifications (ibid.). As a result of this, the majority of 3 We have chosen to include this group in the study, as the majority of the Iraqis living in Denmark are not granted refugee status in Denmark, but are officially recognised as migrants. In the case of the Iraqis living in Denmark it is difficult to make a clear distinction between refugees and migrants. 16
immigrants in Denmark have low socio-economic status. Apart from this, studies show that the health status of immigrants is poorer than that of the Danes, as described in the introductory section. Migrants in Sweden Currently immigrants in Sweden constitute 12% of the Swedish population of 9 million people. In the 1950s and 1960s, the recruitment of immigrant labour was essential for generating the tax-based expansion of the public sector. Most immigration in the 1950s and 1960s was from neighbouring Nordic countries, with the largest number coming from Finland. However, since the early 1970s, immigration has mainly consisted of refugees and family reunification from non-western countries, particularly from the Middle East and Latin America. In the 1990s Sweden received large numbers of refugees from the former Yugoslavia (www.migrationinformation.org). The two major migrant groups from non-western countries are Iraqis and Iranians constituting 70,117 and 53,982 respectively. Both migrant groups came to Sweden as refugees, and have since increased due to family reunification and the current war in Iraq. Other migrants come from countries such as Somalia, Ethiopia, Turkey, Lebanon and Chile (ibid.). A number of social indicators show that immigrants in Sweden have higher rates of unemployment than Swedes and are more heavily dependent on welfare benefits. Therefore the tendency that immigrants have lower socio-economic status than that of nationals is similar to the tendencies in Denmark. As Sweden has a policy of not registering immigrants, their health status is unknown. However, scholars within the field believe that immigrants in Sweden have poorer health than the general population (Cattacin, 2007, p. 12). 17
1.5. Health promotion providers and interventions In order to provide an overview of the health promotion interventions in Denmark and Sweden, the following paragraph gives a short presentation of the Danish and Swedish interventions included in this project. Types of organizations The majority of providers included in this study are representatives from health care centres in Denmark or Sweden. Moreover, some local residential projects, sports clubs, projects targeting migrants as well as research projects have been included. There is a predominance of public interventions, compared to private interventions, in line with the organisation of the Danish and Swedish health care systems. The following table shows the distribution of organisations: Table 1: Type of organisation - Denmark Types of organizations Number of Interventions Community centre or association Health care centre (Adult) Educational centre (Local) Project Doctor Church related organisation Sports Other associations 3 8 0 5 0 0 1 1 18
Table 2: Type of organisation - Sweden Types of organizations Number of Interventions Community centre or association Health care centre (Adult) Educational centre (Local) Project Doctor Church related organisation Sports Other associations 1 3 0 2 0 0 3 3 As can be seen in the tables, the interventions in Denmark and Sweden are slightly different. Health care centres and local project constitute the majority of the Danish health promotion interventions, whilst the Swedish interventions included in this study are more equally dispersed. Target groups The majority of the interventions in both Denmark and Sweden do not have a specific target group, but are open to all. Eight of the interventions are specifically targeting migrants, some specifically at female or socially marginalised migrants. Two of the Swedish interventions are directed at children. Other interventions have local residents in their area as their target group, but without a specific focus on migrants. One Danish intervention is directed at cancer patients, and one Swedish at persons with a hearing disability. Settings The majority of the interventions are, as previously described, set in health care centres. Furthermore, six interventions are located in housing estates or neighbourhoods. Several of the interventions overlap, in that many Danish and Swedish health care centres are located in local communities, and therefore count the local residents among their participants. Consequently, it has not always been possible to distinguish between different settings. 19
Table 3: Settings - Denmark Settings School Neighbourhood Sports Community Health Other club centre (care) centre Number of 0 4 1 2 8 3 Interventions Table 4: Settings - Sweden Settings School Neighbourhood Sports Community Health Other club centre (care) centre Number of 0 2 3 1 3 3 Interventions Again, these tables show a larger dispersion of the Swedish health promotion interventions, and that a majority of the Danish health promotion interventions are made up of health care centres. Migrants as participants Four out of the 30 providers do not have migrants as participants in their interventions. Three of these are Danish and one is Swedish. Policies towards migrant participation Only three of the providers interviewed for this study had knowledge of the political guidelines concerning participation of migrant participation in health promotion initiatives in their organisation. Out of these three, two knew the specific wording of these policies, and how they were used in practice. The overall picture was that the informants did not have knowledge of guidelines and policies on this topic in their respective organisations. This is the case for both Denmark and Sweden. 20
Types of interventions Table 5: Forms of interventions - Denmark Forms of Counselling Psychological Sports, action Health Social Others interventions and informatiogrammes counselling pro- education health Number of 18 5 14 0 9 1: dental Interventions health Table 6: Forms of interventions - Sweden Forms of Counselling Psychological Sports, action Health Social interventions and informatiogrammes counselling pro- education health Number of 9 2 6 4 5 Interventions Others As can be seen in the frequency tables, the most common intervention in the two countries is that of counselling and information. Hence all the Danish providers offer this type of intervention. In Denmark sports and actions programmes are also quite common, with only four providers not offering this type. Half of the providers also include social health in their intervention programme, and a few offer psychological counselling. In Sweden nine out of 12 providers offer counselling and information as a part of their health promotion intervention. Half of the providers offer sports and action programmes, and less than half offer health education and social health as part of their health promotion initiative. Only two of the Swedish providers offer psychological counselling. The major difference between the forms of interventions in the two countries is the focus on health education in Sweden, which is not offered by any Danish providers. In Denmark there is also a larger focus on sports activities, which only half of the Swedish providers included in this study offer as part of their health promotion interventions. 21
All interventions included in this study take place regularly, and the majority of the interventions take the form of courses and seminars. Half of the providers participate in information events, such as conferences, congresses but also special theme days, dedicated to health and health promotion, which is common in both Denmark and Sweden. Some of the interviewed providers also perform outreach work towards migrants. This, however, is only the case among the Danish providers. 22
2. Participation of migrants in the health promotion interventions (provider/intervention level) This chapter describes health promotion interventions with migrants as their target groups, as well as interventions without migrant participants. The understanding of the target group, as well as their characteristics and specific methods for including them, as these are viewed by the providers, are incorporated in the description. The purpose is to give a general characterisation of the interventions, as well as the target group, from the point of view of the providers. Subsequently, the conducive and hindering factors for the participation of migrants in health promotion interventions, present in the interviews with the providers, are analysed. Based on these results, the chapter finishes with an outline of conducive and hindering factors relating to the content, organisation, methods and other characteristics of the interventions included in this analysis. Denmark has, as the only partner in this project, conducted interviews in two countries, namely Denmark and Sweden. The analysis will distinguish between the Danish and Swedish results where relevant, however due to both the similarity between the two countries, and due to the lack of attention to inclusion of migrants in the Swedish health promotion intervention, more attention will be given to the Danish providers in some parts of this chapter. The conclusions in this chapter are solely based on statements from health promotion providers included in this study. 2.1. Actual participation of migrants in the interventions Denmark As previously described, migrants are present as participants to some degree in 15 out of the 18 Danish health promotion interventions included in this project. Eight of the interven- 23
tions are directed at the general public, while five interventions are specifically directed at migrant groups. One of the interventions are intended for residents of a certain area, while the rest of the interventions have other specific target groups, such as diabetics, cancer patients, children etc. The interventions which have migrants among their participants can be grouped in two overall types: 1. Interventions which are targeted at the general public, and which are focused at a broad health perspective, including physical, psychological and social aspects. 2. Interventions which are targeted at specific groups within migrants, and which typically have a labour market perspective as the primary aim. Among the providers interviewed for the project, the majority fall into the first category. A common trait for these interventions is that they in one way or another focus on reaching migrants with their interventions, even though the intervention as a starting point is directed at the general public. The majority of interventions in this group are health care centres, or activities in residential areas, which focus on reaching socially vulnerable groups. These vulnerable groups are characterised by weaker health profiles, and are generally not pro-active concerning participation in various health promotion interventions available in society (Ny I Danmark, 03 2008, p.15). The health promotion interventions in the first type are all characterised by a holistic approach, where the focus is on the whole person, and particularly on the connection between mental and physical health in the creation of the good life. Amongst the available activities are exercise classes, quit smoking courses, diet advice, cooking classes, theme evenings, individual counselling, follow-ups, information courses, dialogue etc. All of these interventions employ an empowerment and participant-oriented approach, with the aim of providing the individual with control over and responsibility for his or her own health. 24
Regarding the interventions in the second category, the majority are employment projects for migrants in match group 3-5 4 groups with weak integration in the Danish labour market. Over the last few years, these projects have incorporated an increased focus on health promotion elements. This is mainly due to the very low level of unemployment in Denmark, following the economic boom, which led to increased demands for participation in the labour market for all groups in society. Thus, inclusion in the labour market is the main goal for this type of intervention, but in order to reach this goal, and to enable the most vulnerable participants to hold employment, health promotion measures are employed alongside the labour market related initiatives. In this category, the health related activities on offer are somewhat more limited, and mainly include exercise classes, cooking, health assessments, body consciousness, and general information and counselling concerning child rearing, relations, the connection from exercise and diet to health and physical and psychological well-being. The majority of the projects are focused on the idea that body, health and personal developments are prerequisites for the ability to join the labour market, and for a realistic, long-term inclusion in the labour market. The approach in these projects is, in agreement with the projects in the first category, an empowerment and participant-oriented approach where all aspects of the individual s life are included from personal health in the form of exercise, healthy diet, no smoking, to the health of the family in the form of children s well-being, participation in social networks, general integration in society etc. Characterisation of migrant participants 5 According to the interviewed providers, the migrants who participate in the interventions are by and large of poorer health than the general population a point-of-view which is supported by a recent Danish study of the health level of migrants (Singhammer, 2008). Generally, the problems are lifestyle illnesses such as vitamin D deficiency, diabetes, obe- 4 In Denmark five ideal types called match groups are used to order unemployed people s level of connection with the Danish labour market. Match group 1 are educated and are short term unemployed, who will easily find a new job on their own. Match group 5 has no or very weak connection with the Danish labour market, and also deal with other problems than unemployment, ex. bad mental and/or phealth and/or social problems (source: The Danish Ministry of Employment). 5 The characterisation of ethnic minority citizens, provided in this report, is based solely on the experiences and views of the providers. Interviews with the target group have yet to be performed. 25
sity, inactivity or others, as well as psychological problems which are expressed either specifically as PTSD symptoms, or through a general state of anxiety or unhappiness. The latter is reflected in symptoms such as resignation and melancholy, and several providers express the opinion that the group is bordering on depression. Several people express physical pain in different parts of the body, often without any medical explanation. Instead, the providers explain the pain experienced by the target group as psychosomatic symptoms their poor mental condition causes them to develop physical pain. This view is supported by the view of the health condition of migrant groups as presented in the aforementioned study (ibid.), where migrants asses their own health as being lower than the general Danish health level, and which also shows that this group has a higher occurrence of longterm illness, larger strain from illness, and a poorer mental health condition than the Danish population. The target group s perception of illness and health also contributes to this condition. The providers express the belief that the migrant participants generally lack knowledge regarding health and prevention, and that they are, for example, unable to grasp the connection between their own lifestyle and health or illness conditions. The responsibility for individual well-being and health condition is to a large extent placed with God and doctors, rather than with the individual itself. In case of illness and/or pain, this causes the group to expect receiving medicine or being admitted to a hospital, in order to become well again. Further, there seems to be a general understanding that in case of pain, the correct behaviour is to rest and wait for improvement rather than for example exercising and eating healthy. There are cases where the providers have experienced that this group draw misguided conclusions for example that leg pain is due to excessive walking up and down stairs, rather than due to being overweight, or that diabetes can be alleviated by consuming large amounts of lemon. These issues are, amongst other things, connected to educational level and socioeconomic circumstances. Fahimeh Andersen, chief physician at Hillerød Hospital, points out that persons who are illiterate or have a low level of education, understand illnesses 26
differently than the science-oriented doctors (Ministry of Refugee, Immigration and Integration Affairs, Newsletter, no. 3 2008). This difference in mindset, combined with language barriers, thus provides a possibility of misunderstandings and erroneous conclusion. The physical and psychological symptoms according to the providers - are further connected to the fact that this group generally feel unwelcome; they experience problems with being accepted into Danish society. This is a case of lack of social integration, and several providers point out that the health condition of the participants should be explained by a combination of social, mental, physical and cultural issues. In this context, it is important to note that the target groups, who participate in the health promotion interventions included in this study, are characterised by being socially vulnerable. The more well-to-do groups of society, both among migrants and Danish citizens, tend not to make use of the health interventions. Only in the case of interventions targeted at specific patient groups, such as diabetics, cancer patients or patients with Chronic Obstructive Pulmonary disease (COPD), all levels of society are represented. However, in these cases the providers do distinguish between the groups, and divide them into resourceful and less resourceful groups, due to their experience that these groups need different approaches in order to gain a positive effect from the interventions the less resourceful group tends to need a more hands-on, health informing approach. Apart from these similarities, the target group is generally diverse and heterogeneous concerning the parameters age, ethnic origin, Danish language level, and length of residence in Denmark, according to the providers. Age wise, the group stretches from the 20s to the 70s. With regard to origin, most originate from Arabic and Middle Eastern countries as well as Asian countries 6. Concerning Danish language level, the group stretches from illiterate persons to persons fluent in Danish writing. The group contains persons who have had residence in Denmark between 1 to 30 years. 6 In the interviews, the providers list the countries of origin for their participants as Iran, Pakistan, Somalia, Palestine, Turkey, Afghanistan, Bosnia, Vietnam and Burma, but there is a large degree of variation. 27
Reasons for participation Four overall reasons for migrant participation in health promotion interventions can be identified from the interviews with the providers: 1. Interest: According to the providers, some migrant participants are aware that they need to act in order to improve their health, despite their illness and health perceptions. There is an increased focus on health in Danish society, which has caused this group to also pay attention to health issues. 2. Referral/compulsion: Some migrant participants are referred to the health promotion interventions through their doctor or other health care workers, or they are under obligation to participate, for example in the labour market projects, where their participation is compulsory, and absence results in deductions in their cash benefits or jobseekers allowance. 3. Social contact: Some participants employ the interventions as a social gathering place, where people of similar background and situation can exchange knowledge and build networks. In several cases, this network transcends the intervention, in the sense that the participants also meet in a private setting this is also the case across ethnicity. Large sections of the target group are socially isolated, due to lack of social integration and connection to the labour market; for them, participation in the intervention becomes a way out of this isolation an important aspect with regard to health promotion. 4. Considerations for the group/individual: The last reason for participation is found in the way the interventions are organised. The majority take the wishes of different migrant groups into consideration for example by offering gender or nationality segregated classes and also to the individual wishes of the participants. Several of the providers employ a user-participation approach, and aim to involve the participants by for example dealing with themes and issues requested by the participants themselves. Methods of recruitment The interview data indicates that there is an overall need to distinguish between the target groups when it comes to recruitment strategies. The interventions which have success in including migrants in their interventions, recruit migrants through word of mouth, where key 28
actors disseminate the message in their personal network, through outreach workers, text messaging, phoning, text message reminders, and in some cases through making child care available for evening events. These recruitment strategies attest to a very close and personal contact, while the recruitment of other target groups takes place through leaflets, posters and advertising, and to some extent word of mouth more traditional and less personal channels. Once again, this discrepancy relates to the difference between resourceful and less resourceful groups, as recruitment of socially vulnerable groups requires this close personal relation, centred on the creation of trust and safety a condition which can be assumed to be linked with their vulnerable position, where many have experiences of failure of the system or of society to help them in one way or another. The recruitment strategy is therefore, to some degree, shaped by the social position of the target group, rather than their ethnicity as such. Interventions with lack of participation The few interventions in this study, which have a very low participation of migrants, all share the common denominator that they pay little attention to such groups, both in recruitment and in the organisation of the intervention. Most state that they are planning efforts in this area, but have yet to realise these efforts. There is a general agreement as to the reasons behind this lack of participation: It is necessary to put extra effort into recruiting and retaining this group, partly due to lack of knowledge of the system and the existing offers herein, as well as the group s high degree of isolation according to the providers, they lack mobility and are generally reluctant to leave well-known areas. One intervention stands out, in that it employs a focus on non-discrimination in the sense that the different needs of various groups are not taken into consideration, but rather the aim is to establish an offer which holds a broad appeal. A potential risk is present here, in the classic discrepancy between non-discrimination and non-consideration: an intervention aimed at a broad appeal will always be aimed at the majority group, i.e. the most homoge- 29
nous group. The minority is thus implicitly required to adapt to the needs of the majority population if they wish to make use of the available interventions. It can be argued that a possible consequence of this assimilation approach is further segregation. Actual participation of migrants in health promotion interventions Sweden In the Swedish interventions migrants are present as participants in 11 out of the 12 health promotion interventions included in this project. Three of the interventions are directed at the general public, while four interventions are specifically directed at migrant groups. A further two of the interventions are intended for residents of a certain area, while the rest of the interventions have other specific target groups, such as children and people with hearing disabilities. The Swedish interventions in the health promotion areas are markedly different to the Danish interventions on an ideological and political level. While the 18 Danish interventions involved in this study include only one intervention focused on non-discrimination in the sense described above, this seems to be the case for the majority of Swedish interventions. A researcher from the faculty for Health and Society at Malmö University describes the Swedish approach as follows: The system stigmatises. There is a strong Universalistic tradition for this idea of non-discrimination, which leads to a disregard for the existence of differing needs. There is no knowledge of the scope of the problem, as there are few projects directed at migrants, but only at companies, at work environment etc. ( ) The problem is ignored, it does not exist. This is the largest barrier, there is reluctance. It is a tradition, which makes it difficult to get rid of. The Swedish institutions are unsuitable for dealing with migration related issues. There is a fear of discriminating. For example, the translation of materials into other languages is new. Before, this issue was not discussed, due to a fear of drawing attention to people. To distinguish was bad ( ) Universalism is not a bad idea, but in this case it becomes a limitation one size doesn t fit all! You have to take the individual into account. (Interview with researcher at Malmö University). This approach is apparent in the interviews with the providers in several ways: 30
There is no specific focus on migrant groups in the recruitment or organisation of the interventions. Rather, the interventions are targeting vulnerable groups in general, as is also the case with the Danish interventions. The noticeable difference between the two countries is that the Swedish interventions do not distinguish migrants from other profiles in the group of socially vulnerable persons. People are categorized according to which social group they belong, not according to ethnicity. The providers have difficulties describing the migrant groups who participate. They declare that the migrants do not differ from the Swedish majority group concerning illness and health perceptions, needs, and other issues but this may be due to the lack of focus on this group. The Swedish interventions which specifically target migrants, give the same characterisation of the group as given by the Danish providers. There is no focus on establishing an employee group with mixed ethnic heritage, and supplementary training of the staff regarding intercultural competencies, or the like, is also not prioritised. The findings in the interview data confirm the point made by the Swedish researcher in the quote above: that referring to or talking about ethnicity is taboo. This taboo might result in lack of articulation of cultural differences or indifferences and thereby cultural misunderstandings. Thus the researcher points out that a considerable issue in Sweden is that health care personnel ask irrelevant questions to their migrant participants. According to the researcher, lack of cultural understanding also has the potential of leading to prejudice, why education and information are essential for reaching the goal, which in the case of Sweden is inclusion and a normalisation of migration. The consequence may be, as mentioned above, that the interventions end up treating everyone as identical rather than equal, with a consequent risk of segregation in contrast to the view expressed by several of the Danish providers, namely that non-discrimination requires treating people differently. It is necessary to treat the individual based on his or her specific needs, and on his or her own terms. Special treatment in Sweden appears to be limited to interpretation support, translation of information materials and gender segre- 31