Final Report Summary - PSYSPOCUC (Meeting the healthcare needs of culturally diverse populations: A psycho-sociopolitical approach to cultural competence in health professionals)
In current context of crisis, uncertainty and progressive impoverishment of an increasing part of the population in Portugal and other Southern European countries, one of the greatest risks is the deterioration of health and the increase of health inequalities, particularly in populations living under conditions of vulnerability and social exclusion. This includes immigrants, their descendants and other groups suffering with particular strength the consequences of the crisis as a result of unemployment, economic instability and the general precarization of working and living conditions. Assuming that health and healthcare are a matter of human rights, the reduction of healthcare disparities is a key challenge.
Substantial evidence shows that migrants and ethnic minorities tend to have worse health and more limited access to quality healthcare when compared to the broader general population (Ingleby, Chiarenza et al., 2012; Ingleby, Krasnik et al., 2012; WHO, 2010). One of the most well-known strategies for reducing healthcare inequalities in contexts of diversity linked to migration is the promotion of cultural competence among professionals and healthcare organizations. Cultural competence has been defined as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency or those professionals to work effectively in cross-cultural situations” (Cross et al., 1989, p. 13). However, lessons learned from research and experiences of implementing “cultural competence” programmes have led to profound debates and criticism about this concept. Currently, there is common concern regarding the need to re-define it, looking for innovative and more comprehensive approaches (Balcazar et al., 2010; Chiarenza, 2012; García-Ramírez et al., 2012; Ingleby, 2011).
The main aim of this research project was to develop an innovative psycho-sociopolitical approach to the analysis and reduction of inequalities in primary healthcare in contexts of diversity linked to migration, which merges the perspectives of community psychology, social psychology and sociology, also incorporating insights from other social sciences. Specifically focused on the Portuguese context, this approach is intended to serve as a basis for proposing strategies and recommendations oriented to better respond to the needs of healthcare users in contexts of cultural and socioeconomic diversity, with a clear accent on the promotion of equity in healthcare. The psycho-sociopolitcal approach proposed emphasizes the role of power asymmetries at diverse ecological levels: personal, relational, organizational, community, socioeconomic, health system, and policy/political level.
A community based participatory approach was adopted, emphasizing collaborative work among researchers and diverse stakeholders in the field of healthcare, such as health professionals, social workers, intercultural mediators in health centres and municipalities, governmental agencies and non-governmental organizations in the field of immigration and health, community organizations, and coordinators of primary healthcare centres and units. The context under study was the Metropolitan Area of Lisbon, characterized by the highest levels of diversity linked to migration in Portugal, concentrating 53’4 % of the total foreign-born population in the country (SEF, 2012).
A multi-method approach was used, combining qualitative and quantitative methodologies. The qualitative phase of the project comprised: (1) interviews with 13 key informants, 11 women and 2 men, with the following profiles: 1 coordinator of a governmental agency in the field of health and migration; 2 representatives of health professionals’ organizations, 3 intercultural mediators and 2 social workers in healthcare organizations; 2 members and 2 coordinators of non-governmental organizations; and 1 community leader; as well as (2) case studies based on in-depth interviews to a double-folded sample of 8 health professionals, 4 doctors and 4 nurses, 1 male and 7 female, 2 foreign-born and 6 native, one of them with immigrant origin; and 32 healthcare users, 22 women and 10 men, aged between 21 and 65 years old, with a homogeneous representation of the main origin countries in the local contexts under study: 6 Cape Verdeans, 7 from other African countries with Portuguese as Official Language (PALOP), 6 Brazilians, 7 descendants (born in Portugal with immigrant parents), and 6 natives.
Case studies were focused on two municipalities within the Metropolitan Area of Lisbon, Amadora and Sintra, characterized by the highest concentration of migrant population, including foreign-born and descendants, in Portugal. A 50 % of the interviews were conducted in each municipality, half in the Healthcare Centre Grouping ACES VII (Amadora), and the other half in ACES X (Cacém-Queluz).
The quantitative phase of the project was also primarily focused on these municipalities and ACES, consisting on a survey to a sample of 253 healthcare users, 175 women and 78 men, aged between 18 and 83 years old; 145 in Amadora, 87 in Sintra and 21 in other municipalities of the Metropolitan Area of Lisbon (Lisbon, Caiscais), again from the main origin countries in these contexts: 69 Cape Verdians, 64 immigrants from other PALOP countries, 43 Brazilians, and 77 natives, 25 of them with African origin.
Needs assessment reveals that the priority needs of healthcare users in the contexts under study are: (1) severe problems of access to medicines - 45.1% of the respondents were not able to buy medicines when needed (sometimes, frequently or habitually) due to the lack of economic resources, and 18.2% frequently or never could buy prescribed medicines; (2) severe problems of access to medical consultations – 41.5% of the respondents were not able to get an appointment with a medical doctor in their health centre when needed (sometimes, frequently or habitually) due to the lack of available consultations, and for a 15.4% this happened frequently or never had a consultation when needed; and (3) problems of access to family doctors – 34.4% of the interviewed do not have a regular family doctor and had to see a different health professional each time they required healthcare.
A similar pattern of needs emerge when only foreign-born healthcare users are considered: (1) 46.6 % could not buy medicines (sometimes, frequently or habitually), and 21.6 % were frequently unable to buy or never can buy prescriptions; (2) 40.9 % could not get an appointment with a doctor when needed due to insufficient availability of consultations; and (3) 43.8 % do not have a family doctor.
Concerning the socioeconomic position of healthcare users in contexts of diversity linked to migration, a 37.9 % of the respondents were unemployed; 63.6 % consider that it is difficult or very difficult to live with their very low income; 49.4 % states not eating enough due to the lack of economic resources (sometimes, frequently or habitually), and 20.5 % do not eat properly frequently or habitually; 41.5 % of the interviewees sometimes turn to food banks due to the lack of economic resources for their basic needs, 18.2 % depends completely on food banks, and 11.5 % need food banks for eating but do not get access to them due to the exceptionally high demand.
At the health system and policy/political level, increasing direct cost of healthcare (moderator fees) impedes a 25 % of the interviewees to afford healthcare when needed (sometimes, frequently or habitually) due to lack of economic resources, with a 20.6 % facing serious difficulties for paying diagnostic tests.
Results also evidence that inequities at the health system level, based on unequal access to family doctors, lead to strong disparities in healthcare quality and interpersonal processes of care. Users with a regular family doctor, particularly those entitled to a Family Health Unit (USF) tend to describe easier appointment procedures and access to consultations; continuity of care based on a long-term personalized doctor-patient relationship; communication based on trust, care, empathy and respect; knowledge of the healthcare user as an individual, in diverse ecological contexts (family, social networks, neighbourhood, workplace, culture, etc.); and fewer levels of perceived discrimination.
On the contrary, users without a regular family doctor, entitled to a Personalized Healthcare Unit (UCSP), usually refer complicated appointment procedures, waiting lists, difficult access; lack of continuity of care, extremely impersonalized doctor-patient relationships; communication based on distrust, prejudice and lack of respect; scarce knowledge of the healthcare user as an individual; interaction based on stereotypes; discrimination, and extreme dissatisfaction with healthcare.
Among foreign-born respondents, only 56.3 % have a regular family doctor, 80.7 % are entitled to a Personalized Healthcare Unit, and only 19.3 % to Family Health Unit, characterized by the highest healthcare quality, based on the indicators examined in the present study. By contrast, up to 87 % of natives users have a family doctor, rising up to 90.4 % when descendants (with immigrant parents) are not considered; 68.8 % of native healthcare users were entitled to a UCSP, and 31.2 % to a USF.
Consequently, a clear pattern of institutionalized discrimination of immigrants is observed in the contexts under study, leading to strong healthcare inequities based on differentiated actual entitlements, favouring access to family doctors and Family Health Units for native users, in noticeable opposition to the principle of universal entitlement that formally defines the Portuguese National Health System.
In conclusion, this research project reveals severe healthcare needs and inequities in the Metropolitan Area of Lisbon, clearly deteriorated in current context of crisis. The analysis of diversity dimensions involved in identified needs allow concluding that the main sources of healthcare inequities in the contexts under study were not culture-related, but strongly based on the socioeconomic position of healthcare users, the lack of economic resources, and the retrenchment of the Welfare State in terms of increasing cuts in public expenditure on healthcare, rising direct costs for users through moderator fees, and strong inequities at the healthcare system level among those with or without a regular family doctor, a need significantly more often observed among immigrant healthcare users.
These results allow questioning the actual universality of the Portuguese National Health System, primarily due to: (1) severe socioeconomic barriers in access to medicines and consultations, and (2) a pattern of institutionalized discrimination of immigrants in their entitlement to healthcare. Recommendations for policy-making emphasize action on these two core lines.
Therefore, we suggest to move from cultural competence, characterized by an over-emphasis on culture linked to ethnicity; to an accent on equity, emphasizing (1) an ecological view of the human being, embedded in contexts characterized by unequal power dynamics at multiple ecological levels (personal, relational, organizational, community, socioeconomic, health system, policy/political), (2) the need to consider multiple dimensions of diversity (socioeconomic position, immigrant status, citizenship, local community context, education, etc.), and (3) a clear commitment to values of social justice.
References
Balcazar, F. E., Suarez-Balcazar, Y., Willis, C., & Alvarado, F. (2010). Cultural competence: A review of conceptual frameworks. In F. Balcazar, Y. Suarez-Balcazar, T. Taylor-Ritzler & C. Keys (Eds.), Race, culture and disability: Rehabilitation science and practice (pp. 281-305). Boston: Jones & Bartlett.
Chiarenza, A. (2012). Developments in the concept of cultural competence. In Ingleby, D., Chiarenza, A., Deville, W., Kotsioni, I. (Eds.), In D. Ingleby, A. Chiarenza, W. Devillé and I. Kotsioni (Eds.), Inequalities in Health Care for Migrants and Ethnic Minorities. COST Series on Health and Diversity, Volume II (pp. 66-81). Antwerp/Apeldoorn: Garant
Cross, T.L. Bazron, B.J. Dennis, K.W. & Isaacs, M.R. (1989). Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Washington D.C.: National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center.
García-Ramírez, M., Hernández-Plaza, S. Albar, M.J. Luque-Ribelles, V. & Suárez-Balcázar, Y. (2012). Building healthcare stakeholder coalitions: A community psychology approach to user involvement for migrant populations. In D. Ingleby, A. Chiarenza, W. Devillé and I. Kotsioni (Eds.), Inequalities in Health Care for Migrants and Ethnic Minorities. COST Series on Health and Diversity, Volume II (pp. 188-204). Antwerp/Apeldoorn: Garant
Ingleby, D., Chiarenza, A., Deville, W., Kotsioni, I. (2012) (Eds.). Inequalities in health care for migrants and ethnic minorities. COST Series on Health and Diversity, Volume II. Antwerp/Apeldoorn: Garant Publishers.
Ingleby, D., Krasnik, A., Lorant, V. & Razum, O. (2012). Health inequalities and risk factors among migrants and ethnic minorities. COST Series on Health and Diversity, Volume I. Antwerp/Apeldoorn: Garant.
Ingleby, D. (2011). Good practice in health service provision for migrants. In B. Rechel, P. Mladovsky, W. Devillé, B. Rijks, R. Petrova-Benedict & M. Mackee (Eds.), Migration and health in the European Union (pp. 227-242). Open University Press: Berkshire.
SEF (2012). Relatório de Imigração, Fronteiras e Asilo 2011. Oeiras: Serviço de Estrangeiros e Fronteiras.
WHO (2010), How health systems can address health inequalities linked to migration and ethnicity, Copenhagen, WHO Regional Office for Europe. From http://www.euro.who.int/__data/assets/pdf_file/0005/127526/e94497.pdf(odnośnik otworzy się w nowym oknie) Accessed 20 January 2011
Contact details:
Dr. Sonia Hernández Plaza, principal investigator: sonia.h.plaza@gmail.com
CESPYD, University of Seville, Spain
Dr. Beatriz Padilla, scientist in charge: padilla.beatriz@gmail.com
CICS, University of Minho, Portugal
Substantial evidence shows that migrants and ethnic minorities tend to have worse health and more limited access to quality healthcare when compared to the broader general population (Ingleby, Chiarenza et al., 2012; Ingleby, Krasnik et al., 2012; WHO, 2010). One of the most well-known strategies for reducing healthcare inequalities in contexts of diversity linked to migration is the promotion of cultural competence among professionals and healthcare organizations. Cultural competence has been defined as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency or those professionals to work effectively in cross-cultural situations” (Cross et al., 1989, p. 13). However, lessons learned from research and experiences of implementing “cultural competence” programmes have led to profound debates and criticism about this concept. Currently, there is common concern regarding the need to re-define it, looking for innovative and more comprehensive approaches (Balcazar et al., 2010; Chiarenza, 2012; García-Ramírez et al., 2012; Ingleby, 2011).
The main aim of this research project was to develop an innovative psycho-sociopolitical approach to the analysis and reduction of inequalities in primary healthcare in contexts of diversity linked to migration, which merges the perspectives of community psychology, social psychology and sociology, also incorporating insights from other social sciences. Specifically focused on the Portuguese context, this approach is intended to serve as a basis for proposing strategies and recommendations oriented to better respond to the needs of healthcare users in contexts of cultural and socioeconomic diversity, with a clear accent on the promotion of equity in healthcare. The psycho-sociopolitcal approach proposed emphasizes the role of power asymmetries at diverse ecological levels: personal, relational, organizational, community, socioeconomic, health system, and policy/political level.
A community based participatory approach was adopted, emphasizing collaborative work among researchers and diverse stakeholders in the field of healthcare, such as health professionals, social workers, intercultural mediators in health centres and municipalities, governmental agencies and non-governmental organizations in the field of immigration and health, community organizations, and coordinators of primary healthcare centres and units. The context under study was the Metropolitan Area of Lisbon, characterized by the highest levels of diversity linked to migration in Portugal, concentrating 53’4 % of the total foreign-born population in the country (SEF, 2012).
A multi-method approach was used, combining qualitative and quantitative methodologies. The qualitative phase of the project comprised: (1) interviews with 13 key informants, 11 women and 2 men, with the following profiles: 1 coordinator of a governmental agency in the field of health and migration; 2 representatives of health professionals’ organizations, 3 intercultural mediators and 2 social workers in healthcare organizations; 2 members and 2 coordinators of non-governmental organizations; and 1 community leader; as well as (2) case studies based on in-depth interviews to a double-folded sample of 8 health professionals, 4 doctors and 4 nurses, 1 male and 7 female, 2 foreign-born and 6 native, one of them with immigrant origin; and 32 healthcare users, 22 women and 10 men, aged between 21 and 65 years old, with a homogeneous representation of the main origin countries in the local contexts under study: 6 Cape Verdeans, 7 from other African countries with Portuguese as Official Language (PALOP), 6 Brazilians, 7 descendants (born in Portugal with immigrant parents), and 6 natives.
Case studies were focused on two municipalities within the Metropolitan Area of Lisbon, Amadora and Sintra, characterized by the highest concentration of migrant population, including foreign-born and descendants, in Portugal. A 50 % of the interviews were conducted in each municipality, half in the Healthcare Centre Grouping ACES VII (Amadora), and the other half in ACES X (Cacém-Queluz).
The quantitative phase of the project was also primarily focused on these municipalities and ACES, consisting on a survey to a sample of 253 healthcare users, 175 women and 78 men, aged between 18 and 83 years old; 145 in Amadora, 87 in Sintra and 21 in other municipalities of the Metropolitan Area of Lisbon (Lisbon, Caiscais), again from the main origin countries in these contexts: 69 Cape Verdians, 64 immigrants from other PALOP countries, 43 Brazilians, and 77 natives, 25 of them with African origin.
Needs assessment reveals that the priority needs of healthcare users in the contexts under study are: (1) severe problems of access to medicines - 45.1% of the respondents were not able to buy medicines when needed (sometimes, frequently or habitually) due to the lack of economic resources, and 18.2% frequently or never could buy prescribed medicines; (2) severe problems of access to medical consultations – 41.5% of the respondents were not able to get an appointment with a medical doctor in their health centre when needed (sometimes, frequently or habitually) due to the lack of available consultations, and for a 15.4% this happened frequently or never had a consultation when needed; and (3) problems of access to family doctors – 34.4% of the interviewed do not have a regular family doctor and had to see a different health professional each time they required healthcare.
A similar pattern of needs emerge when only foreign-born healthcare users are considered: (1) 46.6 % could not buy medicines (sometimes, frequently or habitually), and 21.6 % were frequently unable to buy or never can buy prescriptions; (2) 40.9 % could not get an appointment with a doctor when needed due to insufficient availability of consultations; and (3) 43.8 % do not have a family doctor.
Concerning the socioeconomic position of healthcare users in contexts of diversity linked to migration, a 37.9 % of the respondents were unemployed; 63.6 % consider that it is difficult or very difficult to live with their very low income; 49.4 % states not eating enough due to the lack of economic resources (sometimes, frequently or habitually), and 20.5 % do not eat properly frequently or habitually; 41.5 % of the interviewees sometimes turn to food banks due to the lack of economic resources for their basic needs, 18.2 % depends completely on food banks, and 11.5 % need food banks for eating but do not get access to them due to the exceptionally high demand.
At the health system and policy/political level, increasing direct cost of healthcare (moderator fees) impedes a 25 % of the interviewees to afford healthcare when needed (sometimes, frequently or habitually) due to lack of economic resources, with a 20.6 % facing serious difficulties for paying diagnostic tests.
Results also evidence that inequities at the health system level, based on unequal access to family doctors, lead to strong disparities in healthcare quality and interpersonal processes of care. Users with a regular family doctor, particularly those entitled to a Family Health Unit (USF) tend to describe easier appointment procedures and access to consultations; continuity of care based on a long-term personalized doctor-patient relationship; communication based on trust, care, empathy and respect; knowledge of the healthcare user as an individual, in diverse ecological contexts (family, social networks, neighbourhood, workplace, culture, etc.); and fewer levels of perceived discrimination.
On the contrary, users without a regular family doctor, entitled to a Personalized Healthcare Unit (UCSP), usually refer complicated appointment procedures, waiting lists, difficult access; lack of continuity of care, extremely impersonalized doctor-patient relationships; communication based on distrust, prejudice and lack of respect; scarce knowledge of the healthcare user as an individual; interaction based on stereotypes; discrimination, and extreme dissatisfaction with healthcare.
Among foreign-born respondents, only 56.3 % have a regular family doctor, 80.7 % are entitled to a Personalized Healthcare Unit, and only 19.3 % to Family Health Unit, characterized by the highest healthcare quality, based on the indicators examined in the present study. By contrast, up to 87 % of natives users have a family doctor, rising up to 90.4 % when descendants (with immigrant parents) are not considered; 68.8 % of native healthcare users were entitled to a UCSP, and 31.2 % to a USF.
Consequently, a clear pattern of institutionalized discrimination of immigrants is observed in the contexts under study, leading to strong healthcare inequities based on differentiated actual entitlements, favouring access to family doctors and Family Health Units for native users, in noticeable opposition to the principle of universal entitlement that formally defines the Portuguese National Health System.
In conclusion, this research project reveals severe healthcare needs and inequities in the Metropolitan Area of Lisbon, clearly deteriorated in current context of crisis. The analysis of diversity dimensions involved in identified needs allow concluding that the main sources of healthcare inequities in the contexts under study were not culture-related, but strongly based on the socioeconomic position of healthcare users, the lack of economic resources, and the retrenchment of the Welfare State in terms of increasing cuts in public expenditure on healthcare, rising direct costs for users through moderator fees, and strong inequities at the healthcare system level among those with or without a regular family doctor, a need significantly more often observed among immigrant healthcare users.
These results allow questioning the actual universality of the Portuguese National Health System, primarily due to: (1) severe socioeconomic barriers in access to medicines and consultations, and (2) a pattern of institutionalized discrimination of immigrants in their entitlement to healthcare. Recommendations for policy-making emphasize action on these two core lines.
Therefore, we suggest to move from cultural competence, characterized by an over-emphasis on culture linked to ethnicity; to an accent on equity, emphasizing (1) an ecological view of the human being, embedded in contexts characterized by unequal power dynamics at multiple ecological levels (personal, relational, organizational, community, socioeconomic, health system, policy/political), (2) the need to consider multiple dimensions of diversity (socioeconomic position, immigrant status, citizenship, local community context, education, etc.), and (3) a clear commitment to values of social justice.
References
Balcazar, F. E., Suarez-Balcazar, Y., Willis, C., & Alvarado, F. (2010). Cultural competence: A review of conceptual frameworks. In F. Balcazar, Y. Suarez-Balcazar, T. Taylor-Ritzler & C. Keys (Eds.), Race, culture and disability: Rehabilitation science and practice (pp. 281-305). Boston: Jones & Bartlett.
Chiarenza, A. (2012). Developments in the concept of cultural competence. In Ingleby, D., Chiarenza, A., Deville, W., Kotsioni, I. (Eds.), In D. Ingleby, A. Chiarenza, W. Devillé and I. Kotsioni (Eds.), Inequalities in Health Care for Migrants and Ethnic Minorities. COST Series on Health and Diversity, Volume II (pp. 66-81). Antwerp/Apeldoorn: Garant
Cross, T.L. Bazron, B.J. Dennis, K.W. & Isaacs, M.R. (1989). Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Washington D.C.: National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center.
García-Ramírez, M., Hernández-Plaza, S. Albar, M.J. Luque-Ribelles, V. & Suárez-Balcázar, Y. (2012). Building healthcare stakeholder coalitions: A community psychology approach to user involvement for migrant populations. In D. Ingleby, A. Chiarenza, W. Devillé and I. Kotsioni (Eds.), Inequalities in Health Care for Migrants and Ethnic Minorities. COST Series on Health and Diversity, Volume II (pp. 188-204). Antwerp/Apeldoorn: Garant
Ingleby, D., Chiarenza, A., Deville, W., Kotsioni, I. (2012) (Eds.). Inequalities in health care for migrants and ethnic minorities. COST Series on Health and Diversity, Volume II. Antwerp/Apeldoorn: Garant Publishers.
Ingleby, D., Krasnik, A., Lorant, V. & Razum, O. (2012). Health inequalities and risk factors among migrants and ethnic minorities. COST Series on Health and Diversity, Volume I. Antwerp/Apeldoorn: Garant.
Ingleby, D. (2011). Good practice in health service provision for migrants. In B. Rechel, P. Mladovsky, W. Devillé, B. Rijks, R. Petrova-Benedict & M. Mackee (Eds.), Migration and health in the European Union (pp. 227-242). Open University Press: Berkshire.
SEF (2012). Relatório de Imigração, Fronteiras e Asilo 2011. Oeiras: Serviço de Estrangeiros e Fronteiras.
WHO (2010), How health systems can address health inequalities linked to migration and ethnicity, Copenhagen, WHO Regional Office for Europe. From http://www.euro.who.int/__data/assets/pdf_file/0005/127526/e94497.pdf(odnośnik otworzy się w nowym oknie) Accessed 20 January 2011
Contact details:
Dr. Sonia Hernández Plaza, principal investigator: sonia.h.plaza@gmail.com
CESPYD, University of Seville, Spain
Dr. Beatriz Padilla, scientist in charge: padilla.beatriz@gmail.com
CICS, University of Minho, Portugal