Study protocol

Project questions

The project addresses four questions:

  1. What are the legislation and directives in European countries regulating health care for immigrants?
  2. What are the views of experts on what constitutes best practice of health care for immigrants?
  3. What are the experiences of practitioners of best practice of health care for immigrants?
  4. What recommendations can be drawn on the findings for best practice of health care for immigrants in Europe?

Methods

The project has three parts of data collection and one final part of synthesizing and interpreting all finding to reach conclusions on recommendations for best practice of health care for immigrants:

  1. A document research of legislation and directives in the participating European countries

    The document research will address legislation and directives regulating health care for immigrants. It will use an inclusive definition of immigrants, ie people who were born outside the country of current residence and are between 18 and 65 years of age.  The focus will be on the quality of the delivery of health care and not on access to it (which is more specifically covered in other DG-SANCO projects).

    The document research will be led by the partner in Italy. It will draw on existing analyses and first summarise European legislation which applies to all EU-countries. Following that a very brief questionnaire will be developed asking each partner for national legislation (excluding regional legislation) that goes beyond European legislation. The questionnaire will begin with a concise explanation of European legislation and ask whether there is national legislation beyond European legislation regulating the delivery of health care, and distinguish between five groups in line with the categories of European directives, ie regular immigrants, irregular immigrants, asylum seekers, refugees, and victims of human being trafficking. Each partner will be asked whether such additional national legislation exists or not. If it does, they will be asked to summarise the content (in English) and reference the document.

  2. Delphi process of expert opinion on what constitutes best health care for immigrants in Europe

    A Delphi process will be organised by the centre in the Netherlands. In each participating country, eight experts from academia, NGOs, policy makers and practitioners (at least three groups represented in each country) will be identified and recruited to participate in the process. Beyond the criterion of expertise and representation of the above groups there are no further inclusion criteria. Yet, partners will document the professional background and current position of each expert.

    In a first step, each partner will send a letter/email to potential partners asking them to participate and explaining the expected workload. The workload is a) first writing down up to ten factors that they feel constitutes best health care for immigrants, b) about six to eight weeks later rating the importance of all factors generated in the given country, and c) about six to eight weeks later another rating of a small number of factors with inconsistent ratings in the first round. Depending on the process there might be one more message asking another rating of a specific factor on which consensus has not been reached. All questions can be answered filling in a questionnaire by email, and the total workload is limited. The invitation letter/message can be accompanied by a letter from the coordinating centre in London, and explain that all experts will be acknowledged in the project report. A template for the wording of all letters will be provided by the centre in the Netherlands.

    In the second step, the Delphi process begins with one question: “What factors constitute best practice of health care for immigrants?” The experts will be asked to focus on the delivery of health care and refer typically to immigrants a) having arrived in the last five years, b) being between 18 and 65 years of age, c) having a regular income, and d) not coming from a highly developed country with the same language (eg an Australian in the United Kingdom). Each expert is asked to write down up to ten factors. Once partners have received the answers they have to ensure that all answers are precise, clear and understandable. In case of vague, very general or unclear answers, the researcher should contact the expert by telephone and clarify the answer until a precise terminology has been reached.

    In a third step, a list with all factors generated in the given country will be put together and circulated among all experts. Experts will be asked to rate the importance of each factor on a scale of one (not important) to five (very important). The answers will be collected and compared. Ratings differing by only one point less will be regarded as consensus.

    In a forth step, the list with all factors will be circulated again. This time, the list will also contain the ratings of the given expert and the average rating of the full expert group in the country (in full scores, eg 3 or 4). If the rating of the expert varies by more than one point from the group rating, he or she is asked to reconsider the rating on that factor and possibly revise it. Answers will be collected, and factors with sufficient consensus identified.
    Only if very little consensus has been achieved after the forth step, the last procedure may be repeated in a fifth step.

    The final list of factors with consensus will then be translated into English and (along with the wording in the original language) sent to the partner in the Netherlands.
  1. Interviews with practitioners in health services

    Primary data collection through interviews with practitioners in health services will be conducted in each country. It will be coordinated by the coordinator in the United Kingdom with support of the partner in Germany.
    In each country a major city will be used for primary data collection (usually the capital).  In each city, three districts administrative districts and/or hospital catchment areas (depending on the organisation of health care system) will be selected. We will select the districts with the highest percentage of immigrants, which will be decided based on available data or informed estimates. In each of the identified districts, three types of services will be identified: a) one Accident and Emergency Department; if there is more than one A&E Department in the district, the largest one will be selected; b) one service providing long-term care for patients with chronic and severe mental illness (most commonly psychotic disorders); this should be a housing service or a team working in the community, in any case a service that is in long-term contact with the patient; if there is more than one suitable service in the district, the largest one will be selected; and c) three primary care services (eg GP practices); in case there are more than three primary care services in the district, the largest ones (to be decided based on available data or estimates) will be selected. If the services of choice cannot be recruited for participation, they will be replaced by another service. The selection and recruitment process will be precisely documented in each country.
    In each of the services, interviewees will be purposively selected. Interviewees will be the people who are supposed to know most about the subject, and always have some practical experience. They will mostly be doctors, but may also be nurses. Their gender, age, professional background, length of time of working in the service, and position in the service will be documented.

    Interviewees will be approached and asked for participation as well as written informed consent if and as required in the given country. For the approach, the coordinating centre will provide a letter explaining the European nature of the study. Interviewees will be acknowledged in the project report. 

    The interviews will have three parts, on a) general information, b) general experiences and c) scenarios based on case vignettes.
    a) The general information will be about specific policies for immigrants, number and characteristics of immigrants in the service (with the distinction as to whether numbers are based on data collection, estimates or totally unknown), data monitoring that specifies immigrants, evaluation/quality management systems for this group, availability of interpreting services, existence of guidelines as well as training of staff in using interpreting support. 
    b) The general experiences will be elicited in structured, open questions on what works well in health care with immigrants, what the problems are, and what suggestions for improvements practitioners have. 
    c) The third part will be three case vignettes, ie one with an illegal immigrant, one with a refugee, and one with a labour migrant (each having arrived in the country within the last two years).  The case vignettes will be followed by a small number of questions. For all vignettes there will be a general question as to whether and, if so, in what way the treatment of the given patient would be different for the treatment of a patient with a similar condition from the indigenous population, what the specific problems are, and how they would be overcome. Moreover, we will ask for further pathways and treatment options for the specific group. This will be followed by up to two case specific questions. These questions will be complemented by a brief rating on how competent staff feel to provide best care for the given patient.

    The interviews will be piloted in each country with one interviewee selected by convenience. The answers documented by interviewers in writing will be translated (crude translation) and sent to the coordinating centre so that feed back can be given on the adequacy of the length, detail and clarity of the documentation of responses.
    If possible, interviews will be audio recorded (preferably digitally) so that they can be re-analysed at a later stage. If this is not possible, the answers of the interviewees to open questions will be documented by the interviewer in writing. In any case, the answers will be subjected to content analysis. The codes and categories for the content analysis will first be generated based on the first material in each country, then communicated and agreed across all participating centres. They can later be revisited and amended. The content analysis will then be completed in each country, before the findings will be synthesised centrally.

  2. Synthesis of findings and conclusions on recommendations for best practice of health care for immigrants in Europe

    In the final part of the project, the findings from the document research, the Delphi process, and the interviews will be synthesised, possibly reanalysed using a more synoptic perspective, and interpreted to inform recommendations for best practice of health care for immigrants in Europe. These recommendations will focus on health care delivery and be directly linked to the evidence as provided in the other parts of the project. The coordinating centre in the UK will lead on this. The other work package leaders and also the other partners will be involved through e-mail and telephone communication - and in the last project meeting - in the discussion of the recommendations. Thus, the recommendations will be developed and specified stepwise. The main recommendations will be general for all European countries.

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