The migrant health clinic – A good practice in Denmark

• Diversity management/Organizational perspective.
• Intercultural communication and skills/Competence perspective.
• Diversity management and intercultural skills/Organisational and competence perspective

In terms of categorization, the clinic serves a double aim. Firstly, the goal is to deliver special healthcare services, where the staff members are trained to demonstrate intercultural understanding and to handle intercultural communication towards citizens of other ethnic-cultural backgrounds. Secondly, the clinic functions as a lock into the  general hospital departments and wards, thus in itself pointing to the general need for diversity awareness and the need to meet patients and relatives of other ethnic-cultural origins on equal terms with ethnic Danish citizens. The Migrant Health Clinic hereby in itself represents an example of diversity management towards patients and relatives as well as professional staff.

• Local Healthcare centre
• Home nursing service
• Outpatient Treatment service
• Nursing home
• Municipal Health Authorities
• NGOs & private health project
• Hospital sector
• Emergency ward
• Medical ward
• Surgical ward
• Psychiatric ward
• Hospice

• Proffesional/patient
• Proffesional/relative
• Proffesional/profesional
• Patient/relative

The main target groups:

The Migrant Health Clinic s aimed specifically at ethnic minority patients who are characterized by complex health issues and problems. Thus, the clinic does not offer general healthcare services to citizens with a migrant and/or refugee background. The patients, who are referred to the clinic, must have a special and recognized need for one or more of the following criteria:

• The need for a hospital-based interdisciplinary and transversal specialist examination and assessment for a proper anamnesis
• Significant and long-term compliance problems
• Multiple and serious social and somatic complex of symptoms that cannot immediately be handled solely and thoroughly in the primary healthcare sector
• Need for a coordinated action from hospital, general practice, municipal services in terms of healthcare, social care, linguistic support etc
• Need for follow-up specialist examinations involving several hospital departments and wards
• Need for a coordinating body to optimize the total examination, anamnesis and treatment process

Before the referral to the Migrant Health Clinic, many patients were previously examined by GPs and even hospital wards without obtaining a clear and sufficient picture and anamnesis of their disorders and adequate treatment needs.

Furthermore, more than a half of all patients suffer from post-traumatic stress disorder and other diseases related to this.

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Other relations involved in or affected by the good practice:

• All tasks in the clinic are carried out by a team of physicians, nurses and social advisers / social workers. The permanent staff currently consists of 4 doctors, 4 nurses, 2 social workers and a secretary. The permanent staff does not include psychologists. However, the clinic has good experience in recruiting psychologist students as trainees and in internships.

• In addition to the internal day-to-day collaboration, the staff members in the clinic are in ongoing contact with healthcare professionals in other departments and wards in the Odense University Hospital. As part of the external contact to other departments and wards, the staff members in the clinic developes intercultural teaching-learning materials on intercultural understanding and communication. Furthermore, the staff teaches psychology students in intercultural psychology – on a voluntary basis.

• Medical students, psychologist students, social and nursing students have the opportunity to attend an internship at the clinic.
• Students in internships are acquainted with the clinical work under the supervision of the permanent staff members and sometimes also under the supervision of external psychologists. In summary, internships and external collaborative contacts helps to increase awareness of the intercultural aspects and specific needs among ethnic minority patients suffering from a complex of health problems and social, cultural, linguistic and even economical challenges.

The overall aim:

The overall aim and main goal for the Migrant Health Clinic is to provide equal access to adequate medical examination and treatment for a group of citizens who – from a complexity of social, economic, cultural, personal and not least health reasons – are particularly vulnerable and at particular risk of not receiving the somatic and mental clarification and treatment that they need.

According to Danish health legislation, all citizens – regardless of gender, age and origins – should have equal access to healthcare. Equal access is also supported by both national legislation and international conventions on equality treatment and anti-discrimination. Therefore, the requirement for equal access to healthcare holds a very strong position in the Danish health system. However, practice has shown – and still reveals – that equal treatment requirements are not always observed for ethnic minority citizens, especially from non-Western countries who arrived to the country as migrants or refugees. This is due to several complex factors. Language and communication challenges play an important role. Insight into culture-related differences in terms of perceptions and concepts of illness as well as differences in diagnostical systems and treatment traditions also play a significant role.

The Migrant Health Clinic was founded as a response to those challenges generally related to the ethnic minorities´ access to health services.

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Concrete objectives:

Based on the overall aim and as a starting point, the Migrant Health Clinic intended to meet a number of concrete objectives:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

• First and foremost, the clinic should pave the way for a specialized, need-oriented and more qualified health service for migrants and refugees characterized by a complexity of diffuse and multiple symptoms – who would be referred from the local and primary healthcare system, especially from local GPs.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

• Secondly, the clinic was also started from the objective of achieving a better clinical, professional and holistic understanding of the complex health problems and patterns among this special group of patients, who are burdened with a luggage of war experience and horrors, distrust to systems, language barriers and no clear overview of own life situation, own illness and own future.

Objective 3): to optimize the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

• Thirdly, a key assignment for the clinic was from the very beginning to build and enhance the contact and professional collaboration with GPs in the regional area, thus to ensure that GPs would refer patients in the target group to the clinic in order to have a qualified and specialized examination of the patients and a professional sparring on diagnoses, adequate treatment plans, communication with the patients etc.

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

• Fourthly, another key perspective would be to strengthen the awareness of intercultural needs and competence requirements within both the primary and secondart heath sector among general practitioners and hospital staff.

Objectice 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Fifthly, the clinic would provide professional analyses and documentation of current findings and learning points in order to contribute to the professional awareness and the professional improvement of equal access and adequate examination and treatment for ethnic minorities in the healthcare system.

The conceptual approach:

The holistic approach indicates that, in addition to the intercultural clinical skills, the Migrant Health Clinic also built up a comprehensive knowledge and insight into the mechanisms of unequal access to the healthcare system, as illustrated through a high number of individual cases. Furthermore, it becomes clear how the inequality in access to health services is caused by specific organizational and competence issues within the hospital structure as well as by broader cross-sectional issues in terms of “silo thinking”, lack of collaboration etc.

Methodology and activities:

The Migrant Health Clinic does not offer medical treatment, however ensures that the patients are thoroughly examed on basis of the holistic approach to symptoms and suffering – hereby also passed over to further relevant examination by other specialists in hospital wards or private clinics hwhen the individual situation requires so. The holistic examination is the result of the interdisciplinary collaboration between the clinic´s doctors, nurses, social workers and interpreters in cases, where expertise interpretation is necessary from both a communicative and medical point of view. Based on results from further examination, the clinic will finally decide on an adequate treatment plan, which will be communicated to the patient´s local GP. From this point, the GP will take over the responsibility for the further implementation of the treatment plan, possibly with guidance from the Migrant Health Clinic. In some cases, the further treatment may call for hospitalisation.

As part of the holistic and interdisciplinary approach, patients are also guided and helped in questions concerned with other issues and purely health issues, for instance social issues and challenges connected with everyday life.

Medical and societal insight hand in hand in the holistic approach to patient´s life stories

Each patient referred to the clinic is examined and also assessed from 2 different criteria:

• how can the individual patient’s progress be improved and how can the patient’s compliance to the treatment plan be improved and maintained in order to ensure that the patient actually acts in accordance with the treatment plan.in terms of correct medication etc
• what can the healthcare system learn from the identified problems in the individual patient’s anamnesis, regarding specific medical problems and reactions as well as overall findings of an unfamiliar nature.

Based on the holistic principle, the the clinic staff conducts the examination of the patient in terms of both somatic, psychological, social and personal challenges and problems. Thus, doctors, nurses, social workers etc are entering in an interdisciplinary examination approach. As part of the examination process, the patients are also informed thoroughly about the healthcare system and instructed in how to use the system appropriately in the future.

The intended results:

In accordance with the objectives, the intended results can be described as follows:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Result accordingly: to offer special and holistic examination to migrant and refugee patients by referral from local GPs or possibly by hospital wards.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Result accordingly: to collect, enhance and qualify the empirical, clinical and professional insight into migrant and refugee health and disease profiles, as provided through the holistic examinations of patients from the target group

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Result accordingly: to disseminate and spread the knowledge of the clinic to general practitioners all over the region – and in fact all over the country – and also to all wards in the University hospital in which the clinic is anchored

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

Result accordingly: to develop and conduct intercultural training courses for healthcare professionals throughout the healthcare system in the region and in other parts of the country

Objective 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Result accordingly: to ensure that the clinic´s work and results are evaluated and to conduct other analyses on clinical topics which currents appear to be of special relevance for all healthcare professionals

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The success indicators for the good practice results:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Result accordingly: to offer special and holistic examination to migrant and refugee patients by referral from local GPs or possibly by hospital wards.

Indicator: a flow of referrals of patients from the target group, as evidence for the relevance of the clinic´s special mission and services 

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Result accordingly: to collect, enhance and qualify the empirical, clinical and professional insight into migrant and refugee health and disease profiles, as provided through the holistic examinations of patients from the target group

Indicator: significant improvement of the diagnoses process for patients in the target group compared to previous contact to the healthcare system

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Result accordingly: to disseminate and spread the knowledge of the clinic to general practitioners all over the region – and in fact all over the country – and also to all wards in the University hospital in which the clinic is anchored

Indicator: significant feedback from GPs on the value and relevance of the collaboration with the Migrant Health Clinic

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

Result accordingly: to develop and conduct intercultural training courses for healthcare professionals throughout the healthcare system in the region and in other parts of the country

Indicator: conducting a broad practice of training courses and other educational activities focused on the communication and training of intercultural issues 

Objective 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Result accordingly: to ensure that the clinic´s work and results are evaluated and to conduct other analyses on clinical topics which currents appear to be of special relevans for all healthcare professionals

Indicator: documentation through a number of evaluations, analysis reports, presentations and other kinds of dissemination activities

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The results so far of the good practice:

For the learning purpose, the following shows a selection and exemplification of some results of the hospital-based coordination of disease courses among migrant and refugee patients, as conducted for a decade by the Migrant Health Clinic at the University Hospital in the City of Odense:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Indicator: a flow of referrals of patients from the target group, as evidence for the relevance of the clinic´s special mission and services

Results so far:

According to the Danish health legislation, all citizens regardless of origins and other differences must have equal access and equality in health. This may be the case from a formal perspective, where treatment in the public health system is free, thereby claiming equality. However, the Migrant Health Clinic was founded on the empirical experience that ethnic minority citizens generally don’t have equal access in practice, due to a large number of organisational and competence factors which directly or indirectly prevent them from using the healthcare system on equal terms with the majority population. Of course, this is also the case for some other citizen groups, due to economical, social, cultural, normative and personal factors.

In summary, the improvement of equal access for migrants and refugees to proper health investigation and treatment has been a main result indicator from the very beginning.

During the first 5 years, the Migrant Health Clinic treated more than 1000 patients. The treatment and effects are well documented, both by the clinic itself and by external experts. The total number of patients has not been listed in recent years. However, there is reasons to believe that the number increased significantly during the  next 5 years, as the knowledge about the clinic has been widely spread through both medical and social magazines and articles.

Furthermore, in 2013, the Migrant Health Clinic in Odense gave rise to the establishment of yet another Migrant Medical Health Clinic in the Capital area, anchored at the Hvidovre Hospital. Until this day, the model has not been transferred to other regions. The establishing of similar clinics was never a specific goal for the Migrant Health Clinic. However, already at an early stage, the clinic started to recommend a transfer to other regions, as it very soon became clear that there is a great need and demand for this kind of service.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Indicator: significant improvement of the diagnoses process for patients in the target group compared to previous contact to the healthcare system

Results so far:

Through the extensive search and high number of patients, the clinic over the years built up extensive knowledge of 1) specific causes of inequality within professional specialities, 2) broader hospital-specific causes for inequality amd 3) cross-sectorial reasons for inequality in healthcare. The clinic provided an ongoing research and systematic collection of experience in terms of clinical findings and intercultural learning points from practice. Undoubtedly, ethnic minority patients, in addition to the more obvious linguistic and cultural barriers, can also help to explain more basic and transversal general inequalities in health with consequences for patients´ safety.

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Indicator: significant feedback from GPs on the value and relevance of the collaboration with the Migrant Health Clinic

Results so far:

In order to optimize the collaboration between the Migrant Health Clinic and local GPs in the primary healthcare sector, in 2014, regional fundings were allocated to expand the resources in this collaboration.

Furthermore, in January 2015, the Migrant Health Clinic conducted a study among doctors/GPs who referred patients to the clinic. Close to 150 GPs in the region responded to a long list of questions regarding the collaboration with the clinic on migrant and refugee patients characterized by a complexity of health-influential problems. The majority of the GPs in this research would confirm that the establishment of the clinic has resulted in an increased and enhanced contact and exchange of medical professional knowledge, thus improving the coordination and overview of diagnoses and treatment plans for migrant and refugee patients with complex medical needs and requirements linked to GPs as well as hospital wards.

Objective 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Indicator: documentation through a number of evaluations, analysis reports, presentations and other kinds of dissemination activities

Results so far:

During the first decade, the Migrant Health Clinic provided a comprehensive documentation for the lack of equal access among ethnic minority citizens to common welfare and healthcare services – despite a widespread need connected to complex health and well-being issues. The documentation is based on various forms of communication and dissemination such as comprehensive scientifically oriented reports, articles and evaluations alternating with overall or thematic presentations, videos, lectures, training courses etc. This documentation took form of a systematic provision of learning-teaching materials such as lectures, presentations, videos, assessment reports and other reports etc. for dissemination and teaching-learning purposes.

The intended effect:

The intended effects reflect the intended results in the sense that the effect is focused on the learning and changing impact of the objectives and results:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Intended result: to offer special and holistic examination to migrant and refugee patients by referral from local GPs or possibly by hospital wards.

Intended effect: a better and more satisfactory recovery process among patients in the target group.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Intended result: to collect, enhance and qualify the empirical, clinical and professional insight into migrant and refugee health and disease profiles, as provided through the holistic examinations of patients from the target group

Intended effect: a qualified and more professional medical-methodological approach and diagnosis process to patients in the target group.

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Intended result: to disseminate and spread the knowledge of the clinic to health professionals all over the region and all over the country.

Intended effect: More precise anamneses and diagnoses and more adequate and efficient treatment plans for patients in the target group based on the coordination and collaboration across GPs and the Migrant Health Clinic.

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

Intended result: to develop and conduct intercultural training courses for healthcare professionals throughout the healthcare system in the region and in other parts of the country

Intended effect: Increased awareness and recognition of special needs and requirements in the target group as well as better methods and tools among health professionals to handle intercultural encounters in a respectful and equalizing manner.

Objective 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Intended result: to ensure that the clinic´s work and results are evaluated and to conduct other analyses on clinical topics which currents appear to be of special relevance for all healthcare professionals

Intended effect: analytical and reflective approach to each patient and examination process, thus to derive and document learning points from a holistic perspective.

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The success indicators for the good practice effect:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Intended effect: : a better and more satisfactory recovery process among patients in the target group.

Indicator: Positive experience of improved health and life quality from patients in the target group.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Intended effect: a qualified and more professional medical-methodological approach and diagnosis process to patients in the target group.

Indicator: Enhanced professional knowledge about health issues and recovery challenges among patients in the target group.

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Intended effect: More precise diagnostics and more adequate and efficient treatment plans for patients in the target group based on the coordination and collaboration across GPs and the Migrant Health Clinic.

Indicator: Better quality in the CPs treatment plans for patients in the target group.

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

Intended effect: Increased awareness and recognition of special needs and requirements in the target group as well as better methods and tools among health professionals to handle intercultural encounters in a respectful and equalizing manner.

Indicator: Increased intercultural understanding, competence and communication in the healthcare system on all structural and organizational levels.

Objective 5): to provide and disseminate documentation of new knowledge and experience in terms of ethnic and culturally related health issues and intercultural needs

Intended effect: analytical and reflective approach to each patient and examination process, thus to derive and document learning points from a holistic perspective.

Indicator: Analytical documentation with a strong transfer quality.

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The effect so far of the good practice:

For the learning purpose, the following shows a selections and exemplification of some effects of the hospital-based coordination of disease courses among migrant and refugee patients, as conducted by the Migrant Health Clinic:

Objective 1): to establish a special medical and clinical offer for migrants and refugees within the framework of the ordinary healthcare system

Indicator: Positive experience of improved health and life quality from patients in the target group.

Effect so far:

The clinic collected evidence that approx. 2/3 of the patients improved their health situation on basis of the coordinated and holistic approach to the examination and further proposals for treatment plans. For instance, there is generally a decrease in drug consumption and a decrease in the use of public welfare benefits, an interaction that are rarely proven otherwise. There is a decrease in emergency cases among the clinic patients from the time before they are referred to the clinic to afterwards.

According to GP respondents, their referrals of patients to the clinic improve the compliance among many patients, even though some GPs raise attention to the fact that some patients still are difficult to influence in terms of medical instructions and agreements.

Objective 2): to gain new clinical understanding of a special group of patients with comprehensive and complex needs

Indicator: Enhanced professional knowledge about health issues and recovery challenges among patients in the target group.

Effect so far:

As documented in the ongoing documentation practice in the Migrant Health Clinic, the holistic examination practice has an important detection effect in terms of revealing of the complex cause factors behind migrant´s illness and multiple symptoms.

For instance, based on the experience from the first years of the practice, one intended task was to examine the interaction between, on the one hand, patients´ linguistic barriers and lack of interpretation services  – and, on the other hand, the occurrence and frequency of adverse effects and complications in the patient’s disease. Not surprisingly, inadequate interpretation ​​inhibits communication and thus the sober treatment. Correct and qualified interpretation can be seen as part of the general intercultural communication. Although interpretation mostly is regarded as a purely linguistic issue and tool, many examples from the clinic´s daily work have  suggested that a misinterpretation may have severe consequences for the examination, for the diagnosis and consequently for the medical treatment. Not the least, the misinterpretation may disturb the patient´s feeling of being recognized, respected and understood. The experience confirms that patients, who do not feel recognized, become increasingly passive and loose the attitude of being actively involved and also responsible in their own recovery process. In one of the first major evaluations of the Migrant Health Clinic, it was concluded that in many cases interpretation was not used in consultations with ethnic minority patients, which also indicates that health professionals do not adequately respect the great importance of both linguistic and bodily communication for the proper understanding and recognition of the patients’ situation.

In summary, the lack of understanding of the patients individual cognitive competence may imply that patients do not get the opportunity to express themselves about their own feelings and experiences in terms of symptoms, illness, pain. Perhaps, the patients are not familiar with conceptions such as “highest completed education level”, when they are asked about their contextual situation. Lack of insight into the contextual terms and concepts may create confusion and embarrassment – and often lead to a passive attitude from the patient in the short conversation.

One of the central findings in the clinic is the effect of the socalled “grayzone language“.  The concept of grayzone language has been widely used to describe how professional language and communication often gives rise to a hierarchical positioning between the health professional and the migrant patient.  Grayzone language often conveys a socioeconomic hierarchy, where the patient´s general conceptual and cognitive knowledge of patients becomes an important prerequisite for the communication with the professionals. For many ethnic minority patients, the grayzone language has an additional dimension, as the cultural differences increase the linguistic and conceptual hierarchy.

Finally, as an effect of the clinic’s comprehensive and valid empirical findings, it has been emphasized that  more written and visually explanatory information materials can qualify and strengthen a dialogical and equal communication between health professional and migrant patients. This may also apply to information material in foreign languages ​​about common diseases, types of study and treatments and hospitalization procedures, medicine, prescription requirements etc

Objective 3): to promote the trans-sectional collaboration with general practitioners/GPs in the local primary health sector

Indicator: Better quality in the CPs treatment plans for patients in the target group.

Effect so far:

In 2015, a research was conducted in order to investigate the impact of the Migrant Health Clinic´s work as assessed from the GPs perspective. Generally, the assessment testified that the Migrant Health Clinic over the years had an interdisciplinary and intersectional collaborative effect. The assessment showed that the referrals of migrant and refugee patients and the follow-up contact between the clinic and the GPs in itself represents a strengthened intersectional collaboration across a specialized hospital ward – the clinic – and the primary health sector and the general practitioners in this part of the total healthcare system. The importance of this collaboration in terms of a group of patients with specific and unexplored health profiles is strongly underlined, when almost 90 pct of the GP respondents declare that the referral and contact to the Migrant Health Clinic significantly improved their overview of the patent´s illness and health situation.

The GPs were asked to reflect on a number of questions such as:

• Do the Migrant Health Clinic ease your work in terms of your contact to the ethnic minority patients whom you referred to the clinic?
• Do you experience fewer visits to the consultation after your referrals of the patients?
• Do you generally experience better compliance among the patients whom you referred to the clinic?
• Do you feel that you have a better overview of the patient´s problems after the referral?
• Is it easier for you to have a dialogue with the patients after the referral?
• Do you need more education in terms of ethnic minorities´ health?
• Do you receive adequate information and feedback from the clinic? Etc.

According to the respondent GPs, the contact and collaboration with the Migrant Health Clinic contributed to a significant quality improvement in the general practice. Thus, almost 60 pct of the GP respondents confirmed that the contact to the Migrant Health Clinic and the referral of migrant and refugee patients to the holistic examination at the clinic facilitated the GPs´ subsequent contact to the patients, thus having a positive and qualifying impact on the multiple disease profile, the diagnostic understanding and hence the ongoing treatment. Another 10 pct of the GPs have given a positive answer to this question, however emphasize that the positive impact does not include all referred patients in this group.

In summary, a majority of the GP respondents confirm that the contact to the Migrant Health Clinic and the referral of patients have a positive influence, thus improving the understanding of the patient´s complex symptoms and thereby providing a more adequate and qualified treatment hereafter.

Objective 4): to establish and offer education and training focused on intercultural understanding and requirements to ensure equal access

Indicator: Increased intercultural understanding, competence and communication in the healthcare system on all structural and organizational levels.

Effect so far:

One crucial intended effect was about strengthening the medical and human understanding and insight into the actual disorders and diseases of ethnic minority patients among the local GPs who generally refer patients to the Migrant Health Clinic. The GPs are often inclined to give up further understanding or even reject those patients´ symptoms and pain as “ethnic pain” – due to lack of communicative and intercultural tools to communicate with the patients about their living conditions, pains and symptoms as part of a proper investigation.

Previous reviews suggest that the Migrant Health Clinic to a certain extent has a methodological impact on health professionals in terms of increasing intercultural awareness and improvement of intercultural communication on both a local GP level and a hospital level. In the above mentioned research among GPs from 2015, just over half of the GP respondents stated that the referral contributed to a better dialogue with the referred patients. It is, however, noteworthy that almost as many GPs in the research rejected that such a development had taken place. This would also be the case for GPs who generally expressed a very positive attitude to the clinic.

The ambiguity in this answer may be a reflection of the fact that intercultural communication and competence takes more than a short-term contact to improve. It takes proper and even long-term education and training.

The current political mainstream position in terms of special treatment of migrant patients and special training for health professionals (and other professionals) may contribute to the continuous lack of profound intercultural skills in the healthcare system, as also pointed out by the Migrant Health Clinic (see below). The idea of letting ”the normal system cope with it” is unfortunate as the ordinary healthcare system neither has the frame nor the expertise to address patients characterized by a “cocktail” of complicated health‐issues and linguistic barriers. It is necessary to establish a function within the healthcare system to encounter and help these patients on really qualified and professional terms – which cannot be expected from even a modern, efficient and highly specialised healthcare system.

In addition, a survey-based research among Danish health professionals in hospitals in 2012 showed that almost 90 pct of the responding nurses, doctors, health assistants and porters at 2 hospitals in the Capital Area often or occasionally experienced barriers to patients with a different ethnic background than Danish – with particular emphasis on language barriers. However, lack of intercultural knowledge about patient´s cultural background and also patient’s lack of knowledge about the Danish health system were likewise perceived as barriers. This is noteworthy given the fact that intercultural competence and communication has been on and off the agenda in the Danish Health system for almost two decades.

In summary, one of the most  important effects of the Migrant Health Clinic is that the clinic  through its mission and through the collaboration with the general practitioners has demonstrated how intercultural skills are not just some extra qualifications that may be helpful occasionally in the healthcare services. On the contrary, the clinic exposed the fact that intercultural skills must be regarded as professional and methodological skills that all health professionals should manage to a certain level.

Effective mechanisms supporting the achievement of results and effect:

Special migrant clinics improves proper healthcare services for migrant and refugee citizens:

There is a general goal of providing equal and free access to healthcare services for all citizens. Formally, both the primary and secondary healthcare sector are open for everyone. However, the healthcare system is generally characterized by a increasing specialization and advanced divisions which may leave many patients without a proper knowledge and understanding of where to find the right experts. Especially patients with insufficient language competences are easily rejected, which is also the case for patients with vague symptoms and diffuse disorders. Many ethnic minorities would fit into this description, and thus in many situations, they do not receive the proper care and treatment that they are entitled to on equal terms with other citizens.

Mainstream services are often highlighted as a methodology to ensure equal access, whereas specialized units and offers at the same time are rejected as sources to increase inequality. Thus, the mainstream discourse tends to  conceal the fact that ethnic minority citizens are basically disadvantaged and unequally positioned as a starting point in terms of knowledge about the healthcare system and in terms of opportunities to use their general access to the system. The more specialized and advanced the healthcare system becomes the more difficulties to access for citizens in disadvantaged positions.

Therefore, the special centres or clinics like the Migrant Health Clinic represents an effective gate to the healthcare system, handling the expertise to investigation in an equal dialogue with the patients and, on this basis, handling a qualified visitation to other parts of the hospital system or primary healthcare sector etc.

The use and value of “cultural x-rays” improves the medical standard and efficiency towards patients with ethnic minority backgrounds

Cultural differences, religion, ethnic pain and unqualified interpreters are some of the ”cognitive shortcuts” doctors and nurses utilize in order to avoid providing the service which they are required to perform. Experiences from the Migrant Health Clinic however, show that the “cultural x‐ray” is the best clinical tool: who is

the person with the disease and what does it imply for this person to have this disease. Headscarves, skin color and stereotypical conceptions of ethnical minorities have no place in the selection of diagnostics and treatment.

Language‐barriers are critical and present a risk for patient‐security. Language‐barriers lead to delay in diagnosis, prescription errors, including pharmacies and in regular practice and patients derive grave side‐effects and serious complications. Video‐interpretation is the professional tool, which should be the national standard, with

twentyfour‐hour operations and the need for interpreter‐assistance should not be decided by a secretary on the basis of a foreign‐sounding name or economic, political or personal, irrelevant grounds, as is the current instance.

Systematic education and post graduate training in clinical ethnic and intercultural competences

• Post graduate training in clinical ethnic competences has proven effective and has a high stand on the clinic agenda. The key point is that intercultural-ethnic competences should not be a general offer delivered by “random” providers on the general teaching-training market. These competences should, in fact, be integrated in all formal and mandatory education and curricula – or at least mandatory post graduate training for professionals in the healthcare and social care – and also integrated in the area of social and health sciences. Thus, the Migrant Health Clinic strongly suggested that systematic training in intercultural communication should be mandatory as postgraduate training and even as a part of the general health educational system.

Reflections and recommendations based on the previous practice: 

• On behalf of many years of experience from the Migrant Health Clinic, it is recommended that similar clinics are established in each Danish region as an integrated part of the general regional healthcare efforts and possibly anchored in the University hospitals. Until now, only 2 regions are hosting this kind of clinic.
• Faults and events caused by language and linguistic barriers should be recorded systematically similar to other activities within the health service – whether or not interpretation was provided from external actors and providers.
• Doctors and other healthcare professionals generally have a need for clinical knowledge about ethnic-cultural related illness as well as a broader need for intercultural communicative competences. Despite many training initiatives in different contexts and institutional frameworks, there still remains a widespread need for the establishment of proper and adequate training services targeting healthcare professionals, preferably as permanent and integrated parts of the formal healthcare and social educations and postgraduate teaching-learning activities. Clinical knowledge includes the insight into ethnic-culturally related approaches to illness and also linguistic expressions for certain diseases and symptoms etc.
• Hospitals should develop guidelinies that unequivocally describe the requirements for doctor-patient interviews as well as requirement for qualified patient´s information dedicated patients and relatives who do not master the language on a level that allows reading and understanding. It should be required from all healthcare institutions that all patients, regardless of ethnic-cultural and linguistic prerequisites, systematically are offered  the same opportunities to acquire knowledge about the structures and organization of health institutions, about care, diseases, treatments, procedures linked to outpatient clinics and hospitalizations etc. This should also include interpreters corps´ with the necessary linguistic skills as well as a proper insight into health professional issues.

As reflected and proposed in the report: “Misunderstood symptoms, serious misconceptions and unintended incidents involving ethnic minority patients with language barriers” (in Danish language), by Morten Sodemann, The Migrant Health Clinic in Odense University Hospital, Denmark