Cross-border migration has been increasing steadily over the past decade, leading to an increase in ethnic diversity in Western countries. The expansion of the European Union has also spurred cross-border migration of the EU citizens within the union. Migration and health status have a strong association. Migrant patients, due to their low socioeconomic status, often have poor health outcomes. Additionally, the health care services available to the local population are usually less suited to address the specific health needs of the migrants (World Health Organization (WHO) par. 2). Migrants are prone to various health risks during their migration. In this regard, they require adequate and appropriate health care services to improve their health outcomes. Health promotion is another important way of improving migrant health.
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The health literacy of migrants is often low, which limits their ability to utilize the services offered by the existing health care system. In addition, most health care facilities cannot provide culturally sensitive care. In most cases, community hospitals are the primary facilities that migrants can visit for medical care. The rise in migrant patient populations implies that hospitals must develop new services and interventions to accommodate the growing ethnic diversity of their patients.
The Migrant Friendly Hospital (MFH) is a European initiative that seeks to “identify, develop, and evaluate” health interventions targeting migrants immigrating to the European Union (MFH Project Group par. 2). Its first aim is to improve the capacity of hospitals to offer efficient health care services and health literacy to immigrants entering the EU. The MFH initiative also aims to develop healthcare quality standards, establish migrant-friendly hospital settings, and provide health care services and routines that are responsive to the needs of immigrants and ethnic minorities.
The MFH initiative brings together a sample of hospitals from 12 EU member states that participate in a “quality development process” to make them migrant-friendly facilities. The outcomes of the project provide a framework for policies on migrant health care services in other European hospitals. The aim of this paper is to evaluate the MFH initiative, analyze its key features, and assess its contribution to a re-orientation of the health service in the EU.
Definition of a Migrant and Types of Migrants
A migrant can be defined as a person who moves into or out of a country or region, forcibly or voluntarily (WHO par. 7). Globally, the population of migrants is rising because of political and religious conflicts. Migration encompasses movements across borders, whether international or local. People can migrate between continents, countries, or regions. In 2007, WHO put the number of migrants at 175 million globally (par. 3). Migrants fall into different groups based on their status. The migrant groups include “migrant workers, long-term and short-term immigrants, internally displaced people, refugees, asylum seekers, and victims of human trafficking” (WHO par. 11). The migrants’ access to health care differs based on these statuses.
International migrants can be grouped into four categories based on the reasons for their migration. Economic migrants or workers move to a foreign country to seek better economic opportunities (WHO par. 4). Economic migrants often move from poorer countries or regions to more developed ones. In contrast, political migrants are people who are forcibly evicted from a country or region due to war, regional conflicts, or discriminatory laws that limit the rights of ethnic or religious minorities (WHO par. 7). Political migrants move to stable countries to escape persecution or discrimination.
People can also migrate to escape sudden environmental changes. Environmental migrants seek haven in other regions to escape environmental effects, such as long-term floods or earthquakes. Such environmental changes affect their way of life, forcing them to emigrate. The number of environmental migrants is projected to increase because of climate change (WHO par. 9). People also relocate to reunite with their family members residing in foreign nations. This may include fiancés, children, spouses, or siblings. Racism, xenophobia, and other forms of intolerance can also force victims to emigrate.
The MFH Initiative: The Evidence Base for Its Introduction
The MFH project was established to address migrant health challenges by enhancing the capacity of participating hospitals to serve culturally diverse groups. The pilot hospitals were drawn from the twelve EU member states. Italy’s Health Authority of Reggio Emilia initiated the idea of a migrant-friendly hospital. The project was launched in 2002, bringing together different types of hospitals in the EU, including “metropolitan university teaching hospitals, public and private hospitals, and community hospitals” (Hudelson et al. 108). Some of the participating hospitals were involved in serving ethnically diverse patients before joining the project.
The hospitals involved in the MFH project worked collaboratively with experts and international partners in conducting a needs assessment and identifying intervention areas for the project. As a result, three specific action areas were identified, namely, “improving interpreting services, providing migrant-friendly information, and staff training on cultural competence” (Hudelson et al. 110). To become migrant-friendly, hospitals were required to implement evidence-based interventions in the identified problem domains. European benchmarks and resources were availed to the hospitals implementing the project.
The evidence for the project’s interventions in the three action areas came from a needs assessment involving partner organizations’ staff and management. A comprehensive review of studies examining the health challenges of migrants provided additional evidence for the MFH project’s interventions. The literature review identified four categories of interventions for the health problems affecting migrant groups, namely, “communication, responsiveness, empowerment, and monitoring” (MFH Project Group par. 3). Interventions focusing on management structures and services were proposed to make health care more migrant-friendly.
The review identified communication as a major challenge in the provision of quality health care services to migrant patients. Language barriers were found to affect health care communication. It was also found that language barriers affect the “accessibility of care, the quality of care provided, patient satisfaction, and health outcomes” (Bischoff et al. 509). This shows that minority patients who cannot speak the language used by the hospital staff are likely to receive suboptimal care due to incorrect diagnostic testing, even when a trained interpreter is used. Hampers and McNulty establish that, in a pediatric emergency unit, because of communication barriers, migrant pediatric patients undergo more diagnostic tests than other patients do (112).
Research evidence also indicates that migrant patients receive inadequate medication due to cultural beliefs and language barriers (Hampers and McNulty 113). Communication constraints also hamper medical follow-up, patient adherence, and patient reporting. The systematic review identified three main strategies for overcoming the communication barriers. First, hospitals should hire more professionals who speak the migrant languages to promote health care communication efficiency. The second strategy involves using a mediator or an interpreter to translate the content of health care communication. The third approach is to educate patients to express themselves in the local language.
Research evidence shows that existing health services are less responsive to migrant health needs. Responsive interventions are those that address the health needs of migrants. Interventions, such as the provision of interpreter services, empower migrant patients and attain responsiveness (Castaneda 833). They empower the patient by addressing his or her communication needs. Responsiveness to the health care needs of migrants is essential in improving their health outcomes. The review found that, previously, the health care services provided by European hospitals were less responsive to the needs and attributes of minority patients. According to Cortis, the needs of migrants differ depending on their “migration history, legal and political status, experiences, literacy level, and language proficiency”, among others (56).
Health care systems often respond to the needs of culturally diverse patients using a universalistic or particularistic approach. In a universalistic approach, hospitals provide homogeneous interventions to all citizens while in a particularistic one, specific interventions are offered to particular ethnic or social groups (Cortis 52). Understanding the patient’s cultural background is critical in providing health care that is responsive to his or her needs. In this regard, cultural competence is an essential skill for providers serving migrant patients.
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Migrant-friendly hospitals involve the participation of the migrants in identifying the community health needs and resources. The participatory approach ensures that the health care offered is responsive to the cultural and language needs of the migrants, which enhances patient satisfaction. As a result, migrants play a leading role in assessing their needs and developing interventions (Krajic et al. 12). This empowers migrant patients to be responsible for their own health.
Unlike responsiveness, which centers on provider activities, empowerment focuses on factors specific to the patient. It seeks to improve health care communication and literacy to promote treatment outcomes and address professional dominance. Empowered patients become pro-active partners in a therapeutic relationship. They exercise power over processes and actions that affect their health (Krajic et al. 14). Empowerment enhances the involvement of individuals and groups in improving social and community health. It entails an educational process that equips people with appropriate self-management skills to be more responsible for their physical and social health.
Despite the rise in cultural diversity in European societies, baseline data on the social changes occasioned by migration is insufficient. Demographic data of migrants are essential in the integration of their health needs in the health care system. However, as the review established, only anecdotal data on migrant demographics and epidemiology exists. As such, there is a need for research to monitor the effectiveness and assess the effects of health care interventions targeting migrants. Research findings indicate that migrant patients receive suboptimal care compared to the rest of the population (MFH Project Group par. 6). Their low socioeconomic status means that they cannot afford quality health care services. Thus, there is a need to address the health care disparity to ensure that migrants receive optimal care.
Research findings further indicate that migrant patients are less likely to receive specialist care when being treated for colorectal and prostate cancer, cardiovascular disease, and mental illness compared to the majority of patients (MFH Project Group par. 15). In this view, monitoring migrant health needs, health care interventions, quality of care received, and social support services offered by hospitals is essential.
Key Features of the Program
The MFH initiative was initiated in 2002 and involved a large number of ‘pilot’ hospitals within the EU. Project teams were created in each of the participating hospitals to promote and coordinate the activities of the initiative. A needs assessment involving partner institutions, staff, patients, and administration was done followed by a literature review on the health challenges affecting migrant groups. Four intervention areas were identified, namely, “communication, responsiveness, empowerment, and monitoring” (MFH Project Group par. 1). The review provided evidence based on the efficacy of these interventions.
The projects implemented at the migrant-friendly hospitals are oriented to reflect the core mission of the MFH and its three principles. The project’s first principle is to promote diversity and equitable treatment of migrants. The second principle of the project is to identify the health needs of migrants and provide responsive health care services. Its third principle is to compensate for the health inequalities caused by cultural diversity.
In 2004, the project team created a survey tool MFQQ questionnaire to assess the quality of migrant-friendly hospital programs. The MFQQ instrument evaluates the quality of health care services in line with the migrant-friendly principles. The tool is useful in evaluating hospital services, such as “interpreting services, culturally sensitive services like hospital food and religion” (Jaeger et al. 662). It also evaluates the quality management structures, such as the incorporation of migrant-friendly principles into staff training programs (MFH Project Group par. 8). The MFQQ assessment tool was used in 2004 to identify problems affecting migrant health outcomes. Based on their results, three interventions or subprojects are being implemented. These include the improvement of interpreting services, provision of migrant-friendly information, and cultural competency training of the workforce.
Improvement of Interpreting Services
Due to language barriers, clinical communication between the providers and migrant patients is often hampered. This prevents migrant patients from receiving adequate information regarding their condition. Similarly, language barriers make it difficult for clinicians to obtain relevant information from the client during physical assessment. The MFH needs assessment indicated that communication and language barriers present a serious challenge to the provision of migrant-friendly services (Kerrish et al. 411).
This subproject involves nine hospitals each from a different EU member state. Among the measures adopted to promote clinical communication include “telephone interpreting, intercultural mediation, face-to-face interpreting, and written material” (Bischoff par. 8). The central aims are to improve clinical communication, overcome language barriers, and educate migrant patients on the available health care services.
Provision of Migrant-friendly Information
The MFH project notes that maternal and child health care services for migrants are insufficient. Migrant health problems mostly affect mothers and children (Bischoff par. 4). Appropriate interventions focus on empowering the mother through education on available pre-and post-natal care. Empowerment increases the mothers’ health literacy level, enabling them to be proactive in seeking maternal care services.
Through this subproject, the MFH partners have developed training programs to empower migrant mothers. Six EU hospitals have developed health information brochures and films to provide migrant-friendly information to mothers and families (Cortis 55). They have also designed short training programs to educate migrant women on maternal and prenatal care. Additionally, evaluation tools and measures have been formulated to assess the quality of the courses.
Cultural Competence Training
The needs assessment established that the clinical staff lacked cultural competence, which hampered clinical communication. The assessment identified “cultural unawareness, misunderstandings, and prejudices” as the factors affecting efficient clinical communication (Taylor 137). Evidence from the literature review indicated that staff training on cultural competence could improve clinical outcomes.
The staff training courses implemented in MFH hospitals focus on improving the cultural awareness and skills of the hospital staff. The aim is to enhance the capacity of hospitals to care for diverse patient groups. Nine hospitals are taking part in this subproject. The tools that are used to evaluate the programs include fact sheets and implementation modules (Bischoff par. 6).
The Contributions of the MFH Initiative
The project offers guidelines on how MFH hospitals can provide culturally sensitive care. It also gives broad recommendations on migrant-friendly care. MFH hospitals have incorporated migrant issues into their policies, mission, and services. The hospitals also collect and analyze migrant-specific information.
Migrant-friendly health care organizations have implemented structures and processes that improve the outcomes of migrant issues (Saladin et al. 21). MFH hospitals usually recruit staff with different backgrounds to improve their capacity to address migrant issues. Their medical care services involve a patient-centered approach. They also offer language assistance and interpretation services to improve clinical communication. They also train their staff on cultural competency. The MFH initiative identifies the different action areas that can make a hospital more migrant-friendly. These include improvement in clinical communication, responsive hospital policies, patient empowerment, and migrant epidemiological data surveillance.
Improvement in Clinical Communication
One major contribution of the MFH initiative is in the area of clinical communication. To overcome language barriers that affect the effectiveness of clinical communication, hospitals utilize patient family or relatives as informal interpreters. In a Swiss survey, Bischoff et al. found that minority patients from Tamil and Albania use their relatives as interpreters when communicating with the clinical staff (509). Besides family members, hospitals employ trained interpreters to help in clinical communication.
Another strategy hospitals use to overcome language barriers is encouraging health providers to learn the minority language. Hospitals implement initiatives to hire bilingual and multilingual professionals who can speak the minority languages (Hampers and McNulty 110). High patient satisfaction is associated with the services of the multilingual staff working at a hospital (Bischoff et al. 512). In addition, referrals decline because the asylum seekers can communicate with the clinical staff in their native languages. A major contribution of the MFH project relates to the hospital’s commitment to providing trained interpreters to minority patients. This allows non-English speakers to access quality care that is available to the rest of the population.
Culturally Sensitive Services
The MFH project has also contributed to the development of hospital policies that promote responsiveness. Responsiveness at the institutional level entails the adoption of an open approach that takes into account cultural diversity and individual differences (Krajic et al. 281). Health providers use the patient-centered approach to establish the impact of migration history on migrant health, their help-seeking tendency, and their views about the treatment received. Migrant-friendly hospitals also use a history-taking questionnaire to determine the patient’s perspective and perception of the health care providers, illness, religion, food customs, social network, and occupation, among others. This information is essential in the provision of holistic care to migrant patients.
In the MFH project, health professionals are trained on “cultural competency, public health, and community-oriented primary care” to make them more responsive to migrant health needs (Krajic et al. 284). The aim is to strengthen the physicians’ role in community health through community-based clinics. A patient-centered approach also allows physicians to learn to appreciate cultural diversity and overcome cultural stereotypes. Cultural competency training is another strategy health care organizations use to promote responsiveness.
Krajic et al. write that to achieve greater accountability, organizations must develop benchmarks for cultural competency (283). Thus, responsiveness is an essential skill both at the organizational and individual levels. It entails training staff on cultural competency and implementing structures and facilities that support culturally sensitive care. Hospitals have developed culturally appropriate programs for weight loss, cervical cancer screening, diabetes education, mental illness, and AIDs awareness targeting migrant patients.
Patient Empowerment Initiatives
Migrant-friendly hospitals focus on empowering patients to assume greater responsibility for their health (Karl-Trummer and Krajic 41). One intervention used to empower migrant patients is by increasing the representation of migrants in health care. Increasing cultural diversity in health care improves the accessibility of quality medical care to the migrant population (Karl-Trummer and Krajic 44). This has to lead to improved patient satisfaction and better health outcomes. Hospitals also give professional interpreting services as a way of strengthening clinical communication.
Hospitals also take into account the religious and spiritual beliefs of the patient in designing an appropriate plan of care. According to Mueller, Plevak, and Rummans, religious involvement has profound health benefits to the patient, such as preventing cardiovascular diseases and promoting healthy practices (229). Health providers ensure that the plan of care is tailored according to the patient’s spiritual beliefs and values. Community hospitals also provide programs that train migrants on self-care. Such hospitals also recruit their staff from the community to serve as interpreters. The community worker model is an example of initiatives used to promote care delivery within communities (Mueller, Plevak, and Rummans 231). In this model, the hospital staff is recruited from the local community to lead programs that target the community. All these initiatives empower the migrant community to address its health needs.
Migrant Health Surveillance
The MFH initiative has enhanced the surveillance systems for migrant health needs and interventions. One of its recommendations is that hospitals should “collect and disaggregate data related to migrants” (Saladin et al. 23). Surveillance helps evaluate the impacts of the hospital programs on migrant health and assess the quality of care offered. By establishing a network of hospitals, the MFH initiative promotes quality care standards and accountability. It provides benchmarks and performance indicators that hospitals rely on to improve the quality of migrant health care.
Because of the MFH initiative, migrant-friendly hospitals collect and report data on patient variables such as ethnicity and migrant type (Castaneda 834). Such kind of data is essential in evaluating health disparities among different populations. Appropriate care and support services can be provided to the migrants based on the hospital surveillance data.
Hospitals also monitor the socioeconomic indicators of the patients. Besides ethnicity, age, and sex, hospitals collect data on occupation, level of education, and marital status, among other factors. These factors have a big influence on the health status of migrants. Migrants cannot access quality care because of their low socioeconomic status. Therefore, monitoring of socioeconomic indicators is useful in health promotion activities targeting migrant communities.
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