Improving Multicultural Patient-Provider Encounters in Danish Mental Healthcare: A Multiple Methods Study on Migrant Patient Satisfaction and the Use of the Cultural Formulation Interview

English summary

Introduction: In resettlement countries, migrants often exhibit more mental health problems compared with non-migrants. Migrants are subjected to structural patterns of socioeconomic disadvantages as well as inequity in access to healthcare and lower quality of care. This is due to formal and informal barriers in health systems that are not sufficiently equipped for a multicultural patient population. Migrant patients report lower satisfaction with health encounters, less trust in providers, less attention to specific predicaments and less involvement in care compared with non- migrants. Providers report lower satisfaction as well as challenges with communication, mutual understanding, diagnosing and care in encounters with migrant patients. Culturally competent providers are more likely to achieve alliance, mutual understanding and treatment-efficacy in multicultural encounters. Accordingly, they contribute to reducing health disparities across cultural groups and to increasing migrant patient satisfaction, involvement and adherence to care. In Denmark, healthcare providers are not trained in cultural competences. Based on the above there is a need to improve multicultural patient-provider encounters in Danish mental healthcare, which was the phenomenon of investigation for this study. Aim: My study and data production were guided by the overall study aims: • From a patient perspective, to investigate migrant patient satisfaction with multicultural patient-provider encounters at a specialised Danish transcultural mental healthcare service, with a focus on factors that shape satisfaction.
• From the perspectives of providers and migrant patients, to explore the use of the evidence- based clinical tool, the Cultural Formulation Interview (CFI), as a possible approach to improve multicultural encounters in Danish mental healthcare.
Methodology: Data were generated at the Competence Centre for Transcultural Psychiatry (CTP) and four other public healthcare services in the Capital Region of Denmark. Migrant patient satisfaction was investigated using a cross-sectional patient satisfaction survey (n= 686) conducted during 2009-2017 at CTP. With logistic regression models, we estimated associations between ‘Overall treatment satisfaction’ and treatment-related factors. The CFI was explored with qualitative methods. Empirical data consisted of 20 recorded CFI sessions, 16 migrant patient interviews, 17 provider interviews, and participant observations. All data were coded with a constructivist Grounded Theory approach. The analyses draw on the theoretical framework of intersubjective recognition and selected theoretical concepts. Findings: Most migrant patients at CTP, n= 497 (82.6%), were satisfied with their treatment. Only half of the participants in the study, n= 311 (48.8%), reported health improvements after having ended treatment. Patients who reported improvements in health were eight times more likely to be satisfied with their mental health treatment, OR = 8.5 (95% CI: [4.0–18.1]). Patients who reported to have had an influence on their treatment, OR= 4.7 [2.4–9.2], and who experienced understanding and respect for their cultural background, OR= 3.4 [1.5–7.6], had higher odds of being satisfied. In the final regression model, age and sex were insignificant. The qualitative findings demonstrated the CFI’s ability to facilitate working alliance and to give providers a more profound and contextually situated understanding of the patient. Further, less experienced providers felt supported by the CFI in investigating cultural issues. However, nine providers had felt discomfort and notions of distance and ‘othering’, when the CFI compelled them to introduce the explanatory framework of culture in a mental health assessment encounter. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which they found to have limited analytical value. Migrant patients described several instances of misrecognition in their life and previous healthcare encounters. I suggest that this contributed to restrain their self-esteem and confidence and was a barrier to the shared decision-making of the CFI and to the patients’ perceptions of worthiness of care. CFI recordings showed how several patients hesitated or seemed insecure in their responses. Nevertheless, patients who were interviewed immediately after their CFI described how they had felt recognised as complex human beings operating in a larger cultural framework. They recounted how the provider curiosity and patient empowerment that was facilitated by the CFI, was vital for their subsequent feelings of dignity, hope and engagement in future care. Conclusion: Implications for practice based on patient satisfaction findings are to enhance patient involvement with all patients regardless of cultural background and to prioritise training in cultural competences and cultural humility for healthcare providers. I demonstrated benefits and pitfalls of using the CFI with migrants in Denmark, where cultural consultation is not an integrated concept in health education programmes and where the notion of culture can be particularly contentious due to negative political rhetoric on multiculturalism. I suggest that the CFI should be introduced with thorough training and supervision in the clinical application of the concept of culture. Recognition is relevant in all types of interaction with patients, but the recognising CFI approach can be particularly justified in mental health encounters with migrants or other marginalised and misrecognised groups, and in the context of assessment encounters where patients are exposed and where access to care is negotiated.