Cross-sectoral collaborations to improve refugee mental health in Denmark – Exploring the patients' perspectives
2. Project period:
January 2021 – May 2025
Henriette Laugesen Attardo, MSc Public Health, PhD student
4. Supervisors and collaborative partners:
- Principal supervisor, Jessica Carlsson Lohmann, MD, PhD, Head of Research at CTP
- Primary co-supervisor, Morten Skovdal, PhD Psychology, Associate Professor, Section of Health Services research, University of Copenhagen
- Co-supervisor, Åsa Audulv, PhD Nursing, Associate Professor, Department of Nursing, Umeå University
- Collaborative partner, Maja Bruhn Kristiansen, MD, PhD student, CTP
Refugees demonstrate a high prevalence of posttraumatic stress disorder with 31% being a commonly reported number (1). In addition to the psychological stress caused by past trauma and flight, a wide array of post-migration stressors can complicate everyday life and severely impact mental health (2–5). Common post-migration stressors are navigating the health and social systems, housing, language barriers, finances and social benefits, unemployment, insecure residency status, limited network and worries about family living in unsafe conditions (6,7). However, in Denmark, most stressors are primarily delt with through interventions and initiatives manged by municipalities, not the health care sector. To bridge this gap and take on a more holistic approach to mental health treatment, collaborative meetings are currently being widely implemented in the Capital Region of Denmark. This is done despite little knowledge about its effectiveness and what types of collaborative initiatives work for whom and I what context (8).
The qualitative research on the refugees' perspectives that has already been conducted tends to investigate challenges, facilitators and barriers to health care access and treatment (9). Refugees' experiences with participation in cross-sectoral initiatives that try to address post migration stressors as part of mental health treatment are left unexplored despite the acknowledgement of the stressors' impact on mental health. Knowledge about the expectations, experiences and perspectives of refugees and, how that compares to the perspectives of professionals are central to improving and advancing mental health treatment med refugees (10).
The aim of this project is to investigate the refugee patient perspective on cross-sectoral collaborative meetings to inform future clinical practice so that refugees receive collaborative mental health treatment in accordance with their needs, expectations and wishes.
Interpretive Description formulated by Sally Thorne (2016) will guide this longitudinal qualitative study. Interpretive Descriptions aims to answer questions of relevance to a clinical discipline, typically investigating the patient perspective; peoples experiences during encounters, challenges and transitions, the influence of the surrounding organisational and social context, what factors influence service provision and decision making as well as attitudes, beliefs and perceptions of health-related topics (11). One of key points in Interpretive Description is that results stemming from inquiries situated in a complex clinical context should ideally be able to inform clinical understanding and potentially yield application implications (11).
22 patients (refugees or family re-unified to a refugee) who are unemployed, diagnosed with PTSD, receiving treatment at CTP as part of a randomized controlled trial
22 municipal employment counsellors
35 mental health clinicians
6.2 Description of data and data collection:
Participant observation, subsequent informal conversations and semi-structured interviews will be applied for this project. Participant observation will take place during the three collaborative meetings and three preparative sessions for each patient. During observations, attention will be brought exploring 'what is happening' as well as the broader situation by looking at the different social arenas that come together, when professionals from different sectors and patients participate in the collaborative meetings. After each collaborative meeting, engaging in informal conversations with the patients will be attempted to explore initial thoughts and reactions to what has just happened. Field notes will be jotted down both during and after the collaborative meetings and informal conversations. In order to understand the broader situation, informal conversations will also be carried out with mental health clinicians and municipal employment counsellors to get their perspectives on the involvement of the patients during the collaborative meeting, the interaction and value of the collaborative meeting. Individual interviews are carried out with refugee patients at two points in time; at the end of the PTSD treatment and approximately six-ten months after treatment and contact with CTP has ended. Looking beyond the course of mental health treatment and including follow-up interviews is highly relevant because post-migrations stressors can be on-going (12). During these interviews, the patients' views upon cross-sectoral service provision are explored and their opinion on the relevance of collaborative meetings is studied. This is thought to be an important part of discovering how and why the intervention might be feasible and well suited for some patients but not for others. The interviews also investigate to what extent the collaborative meetings can facilitate empowerment, ownership and continuity of care for refugee patients, and when this might happen. In addition, patients are asked about their everyday life and well-being to broaden the scope of the research and look at the whole situation, not just the process of collaborative meetings as part of mental health treatment. The multiple interviews along with informal conversations make it possible to explore how the patients' experiences and perceptions of the collaboration might change and evolve over time, and it can shed light on how the patients' everyday lives might change due to important decisions and clarifications regarding the social stressors or other circumstances.
Interpretive Description as a qualitative research approach does not point to a specific type of analysis, but typically uses a thematic coding focusing on identifying patterns in the empirical material (13). If relevant, data analysis might also be conducted by drawing up analytical maps as explained by Adele Clarke – especially the type of map referred to as a 'Relational map' (14). Using maps as an analytical tool can provide a researcher with the ability to In go 'beyond the knowing subject' and approaching and mapping complexities, differences and contradictions in the surrounding situation on a meso level instead of zooming in on the individual stories (14). In the field of cross-sectoral service provision, several actors representing different organizations, agendas and interests are present. Using Interpretive Description in combination with situational analysis in this PhD project, attention can be brought to understanding refugee patients' experiences of cross-sectoral service provision and how they are embedded in a larger structure and overall social situation that will ultimately condition their lived experiences.
6.4 Application/acceptance from the Danish Data Protection Agency, the National Committee on Health Research Ethics:
The project has obtained permission from the Danish Data Protection Agency (P-2019-0327) and it has been assessed by the National Committee on Health Research Ethics.
8. Expected findings:
This project is expected to produce valuable knowledge about the refugee patient perspective on cross-sectoral service provision – specifically the potential of collaborative meetings and the influence it might have on mental well-being, continuity of care and patient involvement in the co-production process of health care. With these findings, we expect to know more about why and in what situations collaborative meetings arranged as part of mental health treatment is a well suited approach to reduce the impact of post migration stressors and in turn ensure a positive treatment outcome and better well-being.
9. Dissemination of findings:
Findings will be disseminated in three scientific articles published in peer reviewed scientific journals. Additionally, findings will be presented at several national and international conferences as well as discussed as part of workshops and after-work meetings arranged for mental health clinicians and municipal employees.
- Carlsson J, Sonne C. Mental Health, Pre-migratory Trauma and Post-migratory Stressors Among Adult Refugees. In: Morina N, Nickerson A, editors. Mental Health of Refugee and Conflict-Affected Populations: Theory, Research and Clinical Practice. 1st ed. Cham, Switzerland: Springer Nature Switzerland AG; 2018.
- Chen W, Hall BJ, Ling L, Renzaho AM. Pre-migration and post-migration factors associated with mental health in humanitarian migrants in Australia and the moderation effect of post-migration stressors: findings from the first wave data of the BNLA cohort study. The lancet Psychiatry. 2017 Mar;4(3):218–29.
- Hynie M. The Social Determinants of Refugee Mental Health in the Post-Migration Context: A Critical Review. Can J Psychiatry. 2018 May;63(5):297–303.
- Hou WK, Liu H, Liang L, Ho J, Kim H, Seong E, et al. Everyday life experiences and mental health among conflict-affected forced migrants: A meta-analysis. J Affect Disord. 2020 Mar;264:50–68.
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- Joshi C, Russell G, Cheng I-H, Kay M, Pottie K, Alston M, et al. A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination. Int J Equity Health. 2013 Nov;12:88.
- Schweitzer R, Vromans L, Brough M, Asic-Kobe M, Correa-Velez I, Murray K, et al. Recently resettled refugee women-at-risk in Australia evidence high levels of psychiatric symptoms: individual, trauma and post-migration factors predict outcomes. BMC Med. 2018 Dec 1;16.
- Alderwick H, Hutchings A, Briggs A, Mays N. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health. 2021;21(1):753.
- Nowak AC, Namer Y, Hornberg C. Health Care for Refugees in Europe: A Scoping Review. Int J Environ Res Public Health. 2022 Jan;19(3).
- Kiselev N, Pfaltz M, Haas F, Schick M, Kappen M, Sijbrandij M, et al. Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. Eur J Psychotraumatol. 2020 Feb 4;11(1):1717825.
- Thorne S. Interpretive Description. 2nd ed. New York: Routledge; 2016.
- Turrini G, Purgato M, Acarturk C, Anttila M, Au T, Ballette F, et al. Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2019 Aug;28(4):376–88.
- Thorne S. Interpretive description: qualitative research for applied practice. 2nd ed. New York: Routledge; 2016.
- Clarke AE, Friese C, Washburn RS. Situational Analysis - Grounded Theory After the Interpretive Turn. 2nd ed. Thousand Oaks: SAGE Publications, Inc.; 2017.