The effect of patient origin and relevance of contact on patient and caregiver satisfaction in the emergency room

Do Danish medical students feel prepared to deliver healthcare to patients with backgrounds different from their own? A cross-sectional survey

BACKGROUND

Migrant and ethnic minority populations in Europe are growing, leading to a demand for health systems and health educations to accommodate the growing diversity. Research indicates that health professionals feel inadequately prepared to care for diverse populations, and medical education has gaps in addressing these issues. The aim of the study is to explore whether Danish medical students and newly graduated physicians feel prepared to meet the needs of the increasingly diverse populations.

METHODS

An online survey was emailed to students in the four medical Master's programs in Denmark and to newly graduated physicians in clinical internships. Data was collected spring 2023. Descriptive statistics reported overall numbers, and multivariate logistic regression was used to model the association between survey answers and the background variables: semester, gender/sex, parent's education, self-identified ethnicity.

RESULTS

Many medical students and newly graduated physicians feel unprepared to care for patients of backgrounds different from their own. For all items women reported feeling more unprepared than men. Among the medical students and newly graduated physicians with enough clinical experience to answer the question, 34.2% reported feeling helpless at times or often in the past year when treating culturally different patients. Men were less likely than women to report feeling helpless (OR = 0.42; 95% CI 0.28 to 0.64); and self-identified ethnic minorities were 2.59 times more likely than Danish/European medical students and newly graduated physicians to report feeling helpless (95% CI 1.32-5.07).

CONCLUSION

Our findings indicate shortcomings in medical students and newly graduated physicians feeling of preparedness to provide care to patients of backgrounds different from their own. These findings can assist medical education management with identifying curriculum gaps.

Caregivers with limited language proficiency and their satisfaction with paediatric emergency care related to the use of professional interpreters: a mixed methods study

OBJECTIVES

Communication is a main challenge in migrant health and essential for patient safety. The aim of this study was to describe the satisfaction of caregivers with limited language proficiency (LLP) with care related to the use of interpreters and to explore underlying and interacting factors influencing satisfaction and self-advocacy.

DESIGN

A mixed-methods study.

SETTING

Paediatric emergency department (PED) at a tertiary care hospital in Bern, Switzerland.

PARTICIPANTS AND METHODS

Caregivers visiting the PED were systematically screened for their language proficiency. Semistructured interviews were conducted with all LLP-caregivers agreeing to participate and their administrative data were extracted.

RESULTS

The study included 181 caregivers, 14 of whom received professional language interpretation. Caregivers who were assisted by professional interpretation services were more satisfied than those without (5.5 (SD)±1.4 vs 4.8 (SD)±1.6). Satisfaction was influenced by five main factors (relationship with health workers, patient management, alignment of health concepts, personal expectations, health outcome of the patient) which were modulated by communication. Of all LLP-caregivers without professional interpretation, 44.9% were satisfied with communication due to low expectations regarding the quality of communication, unawareness of the availability of professional interpretation and overestimation of own language skills, resulting in low self-advocacy.

CONCLUSION

The use of professional interpreters had a positive impact on the overall satisfaction of LLP-caregivers with emergency care. LLP-caregivers were not well-positioned to advocate for language interpretation. Healthcare providers must be aware of their responsibility to guarantee good-quality communication to ensure equitable quality of care and patient safety.

Satisfaction With Primary Care Among the Foreign-Born and the General Population in Finland: A Survey-Based study

Foreign-born people have been found to be less satisfied with health care than native populations across countries. However, studies on differences in satisfaction with treatment between different foreign-born groups are lacking. This study explores differences in satisfaction with primary health care between the foreign-born population from different regions of origins and the general population of Finland. The study uses survey data on foreign-born population (n = 2708) and general population (n = 6671) living in Finland who report using health services. Satisfaction with experienced respect for privacy during treatment, benefit of treatment and smoothness of treatment are predicted by region of origin using logistic regression. Almost all foreign-born groups were less likely to consider treatment appointments beneficial as compared to the general population. Some foreign-born groups (people from Southeast Asia and South and Central Asia) were more satisfied with smoothness of care compared to general population. People from East Asia were less likely than the general population to consider that their privacy had been respected during the examinations and treatment. While we made the positive finding of high overall satisfaction with treatment, we also found important differences between groups. In particular, appointments were found less useful among the foreign-born population. Perceived unusefulness of treatment might lead to underuse of health care, which might result in accumulation of untreated health problems. The results point toward potential development points in the health care system. Addressing these issues might help decrease health disparities between population groups.

Adaptation of the All Aspects of Health Literacy Scale (AAHLS) for Karen refugees: factor analysis

Health literacy has been identified as a significant predictor of healthcare utilization among refugee and immigrant communities. Considering its potential impact on their health outcomes, accurately measuring levels of health literacy among limited English proficiency (LEP) populations is an important area of investigation. This study examined the psychometric properties of a modified version of the All Aspects of Health Literacy Scale (AAHLS), based on Nutbeam's model of health literacy, using an exploratory factor (EFA) and confirmatory factor (CFA) analysis among a sample of Karen refugees, an ethnic minority group from Burma. Results of the EFA confirmed a 3-factor model in our sample. CFA results indicated good model fits, demonstrating a promising use of the AAHLS in assessing health literacy among Karen refugees. The findings of this study support the validity of using this measure among this population and suggest some necessary adjustments to incorporate factors unique to the refugee experience that may affect the interpretation and application of items in the AAHLS. Further replication using other LEP samples is necessary to confirm the psychometric properties of the AAHLS and its ability to assess health literacy using Nutbeam's theoretical model of health literacy.

Satisfaction with access to health services among foreign-born population in Finland: a survey-based study

BACKGROUND

Many European studies have shown migrants to be less satisfied with health care and find it less accessible than the general populations. The aim of this study was to compare satisfaction with access to health care between migrants from different regions of origin and the general population of Finland.

METHODS

This study uses data from two comprehensive survey samples on health and wellbeing of the foreign-born and the general population living in Finland. Three aspects of satisfaction with health care access were measured and predicted by region of origin using logistic regression.

RESULTS

Foreign-born population was slightly more dissatisfied with all aspects of the access to health care as compared to the general population. In all aspects of access, migrants from the Middle East and Africa were least likely to be satisfied.

CONCLUSIONS

As the satisfaction with access was lowest among migrant groups which are likely to have higher needs for at least some health services in comparison to the general population, these results are alarming. More research is needed to identify the potential development points in the health care system of Finland.

Knowledge and attitudes of U.S. medical students regarding the care of Asian American patients: a cross-sectional survey study

BACKGROUND

Asian Americans (AsAm) are a rapidly growing population in the U.S. With this growing population, U.S. healthcare providers must be equipped to provide culturally competent care for AsAm patients. This project surveyed U.S. medical students on their knowledge of and attitudes towards AsAm to assess predictors of readiness to care for AsAm patients.

METHOD

This cross-sectional study surveyed medical students who had completed at least one clinical rotation. The survey was distributed online to nine medical schools throughout the U.S. The survey measured self-rated knowledge of, comfort with, cultural competency (CC) towards, and explicit biases towards AsAm patients. The first three domains were analyzed in a multivariate regression model including sociodemographic characteristics and past clinical, curricular, and social experiences with AsAm. Explicit bias questions were reported descriptively.

RESULTS

There were 688 respondents. Asian race, AsAm-prevalent hometown, AsAm-related extracurricular activities, Asian language knowledge, and having taken a population health course predicted increased AsAm knowledge. Social interactions with AsAm increased comfort with AsAm patients. Increasing year in medical school, more frequent exposure to AsAm patients on rotations, and prior travel to an Asian country were predictors of increased CC toward AsAm. Importantly, having completed a CC course was a significant predictor in all domains. In terms of explicit bias, students felt that AsAm patients were more compliant than Caucasian patients. Students also believed that Caucasian patients were generally more likely to receive self-perceived "preferred" versus "acceptable" care, but that in their own clinical experiences neither group received preferred care.

CONCLUSION

Experience with and exposure to AsAm prior to and during medical school and CC courses may increase medical student knowledge, comfort, and CC with AsAm patients. Standardized and longitudinal CC training, increased simulations with AsAm patients, diverse student recruitment, and support for students to engage in AsAm-related activities and interact with AsAm may improve CC of future physicians towards AsAm patients and possibly other minority populations.

Use of Health Services and Unmet Need among Adults of Russian, Somali, and Kurdish Origin in Finland

Equal access to health care is one of the key policy priorities in many European societies. Previous findings suggest that there may be wide differences in the use of health services between people of migrant origin and the general population. We analyzed cross-sectional data from a random sample of persons of Russian (n = 692), Somali (n = 489), and Kurdish (n = 614) origin and the Health 2011 survey data (n = 1406) representing the general population in Finland. Having at least one outpatient visit to any medical doctor during the previous 12 months was at the same level for groups of Russian and Kurdish origin, but lower for people of Somali origin, compared with the general population. Clear differences were found when examining where health care services were sought: people of migrant origin predominantly visited a doctor at municipal health centers whereas the general population also used private and occupational health care. Self-reported need for doctor's treatment was especially high among Russian women and Kurdish men and women. Compared to the general population, all migrant origin groups reported much higher levels of unmet medical need and were less satisfied with the treatment they had received. Improving basic-level health services would serve besides the population at large, the wellbeing of the population of migrant origin.

What Does It Mean for a Case to be 'Local'?: the Importance of Local Relevance and Resonance for Bioethics Education in the Asia-Pacific Region

Contemporary bioethics education has been developed predominately within Euro-American contexts, and now, other global regions are increasingly joining the field, leading to a richer global understanding. Nevertheless, many standard bioethics curriculum materials retain a narrow geographic focus. The purpose of this article is to use local cases from the Asia-Pacific region as examples for exploring questions such as 'what makes a case or example truly local, and why?', 'what topics have we found to be best explained through local cases or examples?', and 'how does one identify a relevant local case?' Furthermore, we consider the global application of local cases to help extend the possible scope of the discussion, opening new avenues for the development of practical bioethics educational materials. We begin with a background description and discussion of why local cases enhance bioethics education, move to an overview of what is currently available and what is not for the region, and then outline a discussion of what it means to be local using example cases drawn from Hong Kong, Australia, Pakistan, and Malaysia. We are not creating a casebook but rather constructing by example a toolbox for designing active and dynamic learning cases using regional diversity as contextualised cases with generalised principles.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context

OBJECTIVE

Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice.

DESIGN

Systematic review and meta-synthesis of published findings from qualitative studies.

DATA SOURCES

Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched.

ELIGIBILITY CRITERIA

Studies employing qualitative methods published in English.

SETTINGS

EDs in high-income countries.

PARTICIPANTS

ECPs included doctors, nurses and paramedics.

TOPIC OF ENQUIRY

Staff views on migrant care in ED settings.

DATA EXTRACTION AND SYNTHESIS

Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice.

RESULTS

Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants.

CONCLUSION

ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

Patterns of complementary and alternative medicine use among Arab immigrants in Denmark: A qualitative study

Aims: The aim of this study was to explore patterns of complementary and alternative medicine use among Arab immigrants in Denmark, in order to increase insight into the hidden practices of this ethnic group. Methods: In this study, 21 Arab immigrants in Denmark were interviewed in Arabic. A purposive strategic sample was recruited from mosques, a healthcare center and by snowballing. Semi-structured interviews were conducted, then audiotaped and transcribed. The analysis was conducted according to Malterud's principles for systematic text condensation and guidelines for qualitative research. Results: Different types of complementary and alternative medicine, referred to as Arabic and Islamic medicine, were used including dietary practices; spiritual healing and cupping therapy, which were mainly used for acute diseases, painful conditions and what so-called jinn-related diseases. Conclusions: Arabic and Islamic medicine is a special form of complementary and alternative medicine, used by some Arab immigrants, which appears to be deeply embedded in their health beliefs within cultural and religious contexts. Healthcare providers should be familiar with diverse health practices and beliefs in order to provide culturally sensitive care and improve the quality of care delivered to ethnic minority patients with different religious backgrounds.

Know where to go: evidence from a controlled trial of a healthcare system information intervention among immigrants

BACKGROUND

Immigrants may face problems with accessing the Danish healthcare system due to, for example, lack of knowledge of how to navigate it, which may cause inappropriate healthcare-seeking. Danish municipalities provide a mandatory introduction and language programme for newly arrived immigrants, but no information on the healthcare system is offered. This study investigated what effects information about the Danish healthcare system may have on the hypothetical healthcare-seeking behaviour of newly arrived immigrants and their actual healthcare use.

METHODS

A prospective intervention study of 1572 adult immigrants attending two language schools in Copenhagen was carried out. Two intervention groups received either a course or written information on the Danish healthcare system, respectively, while the control group received neither. Survey data included three case vignettes on healthcare-seeking behaviour (flu-like symptoms, chest pain and depression) and were linked to registry data on sociodemographic characteristics and healthcare use in the year to follow. Logistic regression and binomial regression analyses were performed.

RESULTS

Appropriate hypothetical healthcare-seeking behaviour was reported by 61.8-78.8% depending on the vignette. Written information showed no effect on immigrants' hypothetical healthcare-seeking behaviour, while the course showed a positive effect on hypothetical healthcare-seeking behaviour for flu-like symptoms (adjusted odds ratio [AOR] = 1.71, 95% confidence interval [CI] = 1.01-2.91, p-value = 0.0467), but not on chest pain or depression. The interventions did not affect immigrants' actual healthcare use; all groups made lower use of health care services in the following year compared with the year where the study took place, except for the use of dental care which remained stable.

CONCLUSIONS

Information on the healthcare system embedded in the language school programme has the potential to facilitate immigrants' access to healthcare. Yet, the results underscore the need for further refinement and development of educational interventions, as well as ensuring adequate utilisation of healthcare services by other means. Multi-dimensional and multi-sectional efforts are important for integration issues within healthcare in Europe.

TRIAL REGISTRATION

Health-seeking behaviour among newly arrived immigrants in Denmark ISRCTN24905314 , May 1, 2015 (Retrospectively registered).

Ignorance is not bliss: The effect of systematic information on immigrants' knowledge of and satisfaction with the Danish healthcare system

AIMS

Suboptimal healthcare utilisation and lower satisfaction with the patient-doctor encounter among immigrants has been documented. Immigrants' lack of familiarity with the healthcare system has been proposed as an explanation for this. This study investigated whether a systematic delivery of information affected immigrants' knowledge of and satisfaction with the Danish healthcare system.

METHODS

A prospective, randomised intervention study of 1158 adult immigrants attending two language schools in Copenhagen was conducted. Two intervention groups received written information or a 12-hour course on the Danish healthcare system, while a control group received nothing. Survey data included self-assessed knowledge, true/false questions on access and questions relating to satisfaction with the healthcare system. Data were linked to socioeconomic registry data. Logistic regression analyses were performed.

RESULTS

The course improved knowledge of who to contact in the event of an accident (odds ratio (OR) = 2.67, 95% confidence interval (CI) = 1.56-4.59) but not in the event of illness. Further, it positively affected correct answers for nine out of 11 questions on the healthcare system (varying from OR = 1.87, 95% CI = 1.08-3.24 to OR = 3.11, 95% CI = 1.58-6.11). Written information positively affected correct answers for three out of 11 questions, but negatively affected one out of 11 compared with the control group. Neither intervention affected immigrants' satisfaction with the healthcare system.

CONCLUSIONS

Knowledge of the healthcare system is necessary for optimal healthcare-seeking behaviour. The results may form the basis of national and international changes in immigrant reception and optimise immigrants' contact with the healthcare system.

Use of emergency care services by immigrants—a survey of walk-in patients who attended the Oslo Accident and Emergency Outpatient Clinic

BACKGROUND

The Oslo Accident and Emergency Outpatient Clinic (OAEOC) experienced a 5-6% annual increase in patient visits between 2005 and 2011, which was significantly higher than the 2-3% annual increase among registered Oslo residents. This study explored immigrant walk-in patients' use of both the general emergency and trauma clinics of the OAEOC and their concomitant use of regular general practitioners (RGPs) in Oslo.

METHODS

A cross-sectional survey of walk-in patients attending the OAEOC during 2 weeks in September 2009. We analysed demographic data, patients' self-reported affiliation with the RGP scheme, self-reported number of OAEOC and RGP consultations during the preceding 12 months. The first approach used Poisson regression models to study visit frequency. The second approach compared the proportions of first- and second-generation immigrants and those from the four most frequently represented countries (Sweden, Pakistan, Somalia and Poland) among the patient population, with their respective proportions within the general Oslo population.

RESULTS

The analysis included 3864 patients: 1821 attended the Department of Emergency General Practice ("general emergency clinic"); 2043 attended the Section for Orthopaedic Emergency ("trauma clinic"). Both first- and second-generation immigrants reported a significantly higher OAEOC visit frequency compared with Norwegians. Norwegians, representing 73% of the city population accounted for 65% of OAEOC visits. In contrast, first- and second-generation immigrants made up 27% of the city population but accounted for 35% of OAEOC visits. This proportional increase in use was primarily observed in the general emergency clinic (42% of visits). Their proportional use of the trauma clinic (29%) was similar to their proportion in the city. Among first-generation immigrants only 71% were affiliated with the RGP system, in contrast to 96% of Norwegians. Similar finding were obtained when immigrants were grouped by nationality. Compared to Norwegians, immigrants from Sweden, Pakistan and Somalia reported using the OAEOC significantly more often. Immigrants from Sweden, Poland and Somalia were over-represented at both clinics. The least frequent RGP affiliation was among immigrants from Sweden (32%) and Poland (65%).

CONCLUSIONS

In Norway, immigrant subgroups use emergency health care services in different ways. Understanding these patterns of health-seeking behaviour may be important when designing emergency health services.

Migrants' and professionals' views on culturally sensitive pre-hospital emergency care

This study was designed to explore the views of migrants and professionals on culturally sensitive pre-hospital emergency care in order to adapt such care to migrants' needs. Interviews were conducted with 41 migrants who had received direct (as a patient) or indirect (as a significant other) pre-hospital emergency care. Furthermore, 20 professionals in the field of pre-hospital emergency care were interviewed. The content analysis showed five distinguishable categories based on the statements by the migrants and six categories based on the statements by the professionals. While migrants gave priority to basic proficiencies of first responders such as 'social/emotional competencies' and 'communication skills', the professionals considered '(basic) cultural knowledge', 'awareness' and 'attitude' the most important. Furthermore, migrants provided practical indications, e.g. regarding areas of cultural knowledge, whereas professionals seemed to view the issue of culturally pre-hospital emergency care from a more theoretical perspective. The issues of the culturally sensitive pre-hospital emergency care itself, as well as the varying points of view of the two groups interviewed, resulted in eight recommendations for culturally sensitive pre-hospital emergency care.

Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study

BACKGROUND

Healthcare obtained abroad may conflict with care received in the country of residence. A special concern for immigrants has been raised as they may have stronger links to healthcare services abroad. Our objective was to investigate use of healthcare in a foreign country in Turkish immigrants, their descendants, and ethnic Danes.

METHODS

The study was based on a nationwide survey in 2007 with 372 Turkish immigrants, 496 descendants, and 1,131 ethnic Danes aged 18-66. Data were linked to registry data on socioeconomic factors. Using logistic regression models, use of doctor, specialist doctor, hospital, dentist in a foreign country as well as medicine from abroad were estimated. Analyses were adjusted for socioeconomic factors and health symptoms.

RESULTS

Overall, 26.6% among Turkish immigrants made use of cross-border healthcare, followed by 19.4% among their descendants to 6.7% among ethnic Danes. Using logistic regression models with ethnic Danes as the reference group, Turkish immigrants were seen to have made increased use of general practitioners, specialist doctors, hospitals, and dentists in a foreign country (odds ratio (OR), 5.20-6.74), while Turkish descendants had made increased use of specialist doctors (OR, 4.97) and borderline statistically significant increased use of hospital (OR, 2.48) and dentist (OR, 2.17) but not general practitioners. For medicine, we found no differences among the men, but women with an immigrant background made considerably greater use, compared with ethnic Danish women. Socioeconomic position and health symptoms had a fairly explanatory effect on the use in the different groups.

CONCLUSIONS

Use of cross-border healthcare may have consequences for the continuity of care, including conflicts in the medical treatment, for the patient. Nonetheless, it may be aligned with the patient's preferences and thereby beneficial for the patient. We need more information about reasons for obtaining cross-border healthcare among immigrants residing in European countries, and the consequences for the patient and the healthcare systems, including the quality of care. The Danish healthcare system needs to be aware of the significant healthcare consumption by immigrants, especially medicine among women, outside Denmark's borders.

Migrant participation in Norwegian health care. A qualitative study using key informants

Background Little is known about how migrants adapt to first-world public health systems. In Norway, patients are assigned a registered general practitioner (RGP) to provide basic care and serve as gatekeeper for other medical services. Objectives: To explore determinants of migrant compliance with the RGP scheme and obstacles that migrants may experience. Methods: Individuals in leadership positions within migrant organizations for the 13 largest migrant populations in Norway in 2008 participated in this qualitative study. Semi-structured interviews, with migrants serving as key informants, were used to elucidate possible challenges migrant patients face in navigating the local primary health-care system. Conversations were structured using an interview guide covering the range of challenges that migrant patients meet in the health-care system. Results: According to informants, integration into the RGP scheme and adequacy of patient-physician communication varies according to duration of stay in Norway, the patient's country of origin, the reason for migration, health literacy, intention to establish permanent residence in Norway, language proficiency, and comprehension of information received about the health system. Informants noted as obstacles: doctor-patient interaction patterns, conflicting ideas about the role of the doctor, and language and cultural differences. In addressing noted obstacles, one strategy would be to combine direct intervention by migrant associations with indirect intervention via the public-health system.