Access to mental health for asylum seekers in the European Union. An analysis of disparities between legal rights and reality

'Through a kaleidoscope': A Foucauldian discourse analysis of Belgian policy regarding patients with a migration background and depression in general practices

A higher prevalence of depression is found among patients with a migration background within the Belgian population. Nevertheless, this group is underrepresented in ambulant and residential mental health care services. Since general practitioners (GPs) have a crucial gatekeeping role, this led some researchers to investigate the possibility of a provider bias influencing GPs' assessment and referral of depressed patients with a migration background. However, GPs' accounts may be influenced by wider professional discourses present at the policy level, which are inevitably linked to institutions regulating the conduct of GPs. Therefore, this study applied a Foucauldian discourse analysis (a) to identify broader professional discourses in Belgian policy documents regarding patients with a migration background and depression in general practices, (b) to examine how patients with a migration background are discursively positioned and (c) to investigate which different balances of power in the relationship between GPs and patients with a migration background are demonstrated in the identified discourses. We identified three recurring discourses: (a) the othering discourse, (b) the health literacy discourse, and (c) the person-centred discourse. Our analysis demonstrated that the former two discourses illustrate the perpetuation of a biomedical discourse. While the last discourse is aligned with a counter-discourse associated with the person-centred care model in health care. Consequently, our analysis demonstrated the construction of a contradictory discursive framework throughout the various policy documents on which GPs might rely when speaking about patients with a migration background suffering from depression.

Victimization of Applicants for International Protection Residing in Belgium: Sexual Violence and Help-Seeking Behavior

BACKGROUND

Sexual violence (SV) literature on applicants for international protection (AIPs) shows that they are at high risk of victimization. The study objectives are to provide an exploratory overview of the occurrence of SV in AIPs in Belgium and their help-seeking behavior (HSB). This overview is crucial to develop prevention strategies and care paths focusing on providing adequate care to AIP SV victims in Belgium.

METHODS

Quantitative data from structured interviews with AIPs (n = 62) triangulated with qualitative data from in-depth interviews with AIP SV victims (n = 11) served to explore the nature and impact of SV in AIPs in Belgium and their HSB.

RESULTS

A total of 83.9% of respondents have experienced SV. A total of 61.3% were victimized within the past year. Victimization seems more gender-balanced than in the general population. AIPs link SV to their legal status and their associated vulnerable situation. HSB upon SV was very limited in this sample. Help-seeking barriers interfering with the decision-making process to consult (in)formal resources were identified.

CONCLUSIONS

AIPs in Belgium are at high risk of SV. Despite the impact of SV on AIPs' lives, HSB upon SV is rare. The provision of age-appropriate sexual education and development of policies that will reduce help-seeking barriers is needed.

Mind the Gate: General Practitioner's Attitudes Towards Depressed Patients with Diverse Migration Backgrounds

This study aims to examine (a) whether there are differences in general practitioners' (GPs) attitudes towards native Belgian patients, patients of foreign descent and asylum seeking patients who all express symptoms of major depression, and (b) whether these differences depend on GPs' experience with cultural competency training and interethnic contact. Using a video vignette study among 404 Flemish (Belgium) GPs, we find evidence of a provider bias. While GPs regard a patient of foreign descent as less trustworthy and less able to adhere to medical recommendations than a native Belgian patient, they also hold more pessimistic views on a potential recovery of an asylum seeking patient. In addition, we find that cultural competency training might alter GPs' attitudes of asylum seeking patients in a positive way. Summarized, our research highlights the need to target stereotypes among GPs for interventions designed to reduce migration-based disparities in healthcare use and health status.

A qualitative exploration of post-migration stressors and psychosocial well-being in two asylum reception centres in Belgium

Purpose

Prolonged exposure to daily stressors can have long-term detrimental implications for overall mental health. For asylum seekers in European Union transit or destination countries, navigating life in reception centres can represent a significant burden. The purpose of this study was to explore post-migration stressors during residency in reception centres, and to formulate recommendations for adequate service provision in Belgium.

Design/methodology/approach

Research was conducted in two reception centres in Belgium. A total of 41 in-depth interviews were carried out with asylum seeker residents (n = 29) and staff (n = 12). Purposive recruitment was used for asylum seekers (for variation in length of centre residency and family status) and staff (variation in job profiles). Interviews were conducted in English, French or with a translator in Arabic or Dari. Interviews were audio-recorded, transcribed verbatim and manually coded using thematic analysis.

Findings

Asylum seekers face significant constraints with regard to their living conditions, including total absence of privacy, overcrowding and unhygienic conditions. These act as continuous and prolonged exposure to daily stressors. Several barriers to accessing activities or integration opportunities prevent meaningful occupation, contribute towards eroded autonomy and isolation of asylum seeker residents. Inadequate capacity and resources for the provision of psychosocial support in reception centres leads to a sense of abandonment and worthlessness.

Originality/value

Analysis indicates that structural and practical challenges to adequately support asylum seekers are rooted in policy failures necessary for appropriate resourcing and prioritization of preventative measures. Such deliberate decisions contribute towards state deterrence strategies, eroding both individual well-being and manufacturing a crisis in the systems of support for asylum seekers.

Experiences of psychotherapists working with refugees in Germany: a qualitative study

BACKGROUND

Despite a high burden of mental health problems among refugees, there is limited knowledge about effective mental health care provision for this group. Although substantial efforts in understanding the complexity of cross-cultural psychotherapy - which in the context of this study we use to refer to therapy with client and therapist of different cultural backgrounds - have been made, there remains a dearth of research exploring barriers for effective cross-cultural psychotherapy. This study aimed at narrowing this gap in knowledge by exploring major challenges encountered by psychotherapists in cross-cultural psychotherapy and strategies which have proven useful in overcoming such challenges.

METHODS

We employed a qualitative study design, conducting semi-structured in-depth interviews with 10 purposely selected psychotherapists working with refugees in Germany. Respondents were from varying theoretical background and had varying levels of experience. Data were analyzed using a thematic approach, following a mix of deductive and inductive coding.

RESULTS

Respondents reported three main challenges in their cross-cultural practice: different or unrealistic expectations of clients towards what psychotherapy would offer them; challenges grounded in different illness explanatory models; and communication challenges. In dealing with these challenges, respondents recommended psychoeducation to overcome issues related to problematic expectations towards psychotherapy; "imagining the real", identifying "counter magic" and other client-appropriate resources to deal with issues related to clients' foreign illness attributions; and translators in dealing with communication barriers, though the latter not univocally.

CONCLUSIONS

Results show that psychotherapy with refugees can be very successful, at least from the psychotherapist perspective, but also poses significant challenges. Our findings underline the importance of developing, testing, and institutionalizing structured and structural approaches to training psychotherapists in cross-cultural therapy at scale, to accommodate the rising mental health care need of refugees as a client group.

Assessing Provider Bias in General Practitioners' Assessment and Referral of Depressive Patients with Different Migration Backgrounds: Methodological Insights on the Use of a Video-Vignette Study

Although the prevalence of common mental health conditions such as depression and anxiety, is higher among people with a migration background, these groups are generally underrepresented in all forms of institutionalized mental health care. At the root of this striking discrepancy might be unequal referral by health care practitioners. In this article we describe the development of a quasi-experimental video vignette methodology to assess potential forms of unequal diagnosing, treatment and referral patterns, based on clients' migration background and asylum status. The presented methodology also allows to explore whether potential differences are related to provider bias, i.e. underlying attitudes and expectations held by general practitioners. Potential assets and drawbacks of this methodology are discussed in detail.

Efficient identification of mental health problems in refugees in Germany: the Refugee Health Screener

Background: A substantial number of refugees present with mental disorders. This appears particularly acute in the currently increasing refugee populations in Europe. Although EU guidelines demand the identification and support of vulnerable individuals such as survivors of trauma, no adequately validated and comprehensive mental health screening instruments for refugees residing in Europe currently exist. Objective: We studied the feasibility, validity, and reliability of the Refugee Health Screener-15 (RHS-15) - a time-efficient and easy-to-implement screening developed by Hollifield et al. (2013) - as a self-rating and interview instrument. Methods: A sample of refugees from different countries (N = 86), representative of those who had arrived around the turn of the year 2015/2016 in Germany, filled in the RHS-15 on their own. A semi-structured clinical interview was later conducted with a random subsample (n = 56). Results: Fifty-two percent of the refugees examined screened positive in the RHS-15, thus indicating current mental health problems. The RHS-15 showed a good feasibility, reliability, and validity in both the self-rating and the interview version. It detected clinically relevant mental health problems when PTSD, depression, anxiety, or somatization problems were present. A shorter 13-item version proved to be equally valid. Conclusions: Together with previous research on the RHS in refugees living in the US, this suggests that the RHS is a time-efficient and accurate instrument that is able to detect common mental health problems in a wide range of refugees. Prospectively, the RHS could be used as an instrument for identifying vulnerable refugees, for example, by integrating it in the initial medical examination in the host community, thereby initiating support.

Disparities in health and access to healthcare between asylum seekers and residents in Germany: a population-based cross-sectional feasibility study

OBJECTIVES

To assess disparities in health and healthcare between asylum seekers (AS) and residents in Germany as a proof of concept using European Core Health Indicators (ECHI).

DESIGN

Population-based cross-sectional feasibility study.

PARTICIPANTS

All AS (aged 18 years or above) registered in three counties in Germany during a 3-month study period (N=1017). Cross-sectional data on the resident population were taken from the German Health Interview (2008-2011, N=8152), and the European Union Statistics on Income and Living Conditions (2012, N=23,065).

OUTCOME MEASURES

Self-reported health status and healthcare access (utilisation and unmet medical need) in line with ECHI.

METHOD

Inequalities in health and access to healthcare were quantified both by crude and age-stratified/sex-stratified ORs with 95% CI using cross-tabulations.

RESULTS

A total of N=156 AS (15.34%) participated in the study. Compared with residents, AS were significantly more likely to report a bad health status (OR=1.72 (1.23 to 2.41)), activity limitations (OR=1.97 (1.39 to 2.79)) or (only younger age groups) any chronic morbidity (18-24 years: OR=6.23 (2.62 to 14.57); 25-49 years: OR=2.05 (1.23 to 3.37)). AS had significantly lower odds for consulting any physician (OR=0.1 (0.07 to 0.16)) or general practitioners (OR=0.44 (0.31 to 0.62)), but higher odds for hospital admissions (OR=2.29 (1.54 to 3.34)), visits to psychotherapists (OR=4.07 (2.48 to 6.43)) and unmet needs (OR=3.74 (2.62 to 5.21)). The direction of healthcare-related associations was consistent across all strata despite variation in magnitude and statistical significance.

CONCLUSIONS

Quantifying disparities between AS and the resident population by means of selected ECHI proved to be feasible. The approach yielded first quantitative evidence for disparities in health and access to healthcare in the German context. Further research is needed to generate representative estimates, for example, by including AS in national health monitoring programmes.