The encounter between clinicians and migrant patients in the outpatient mental health services in Denmark - A mixed methods study on cultural competences, treatment satisfaction and the Cultural Formulation Interview

​1. Title: 

The encounter between clinicians and migrant patients in the outpatient mental health services in Denmark - A mixed methods study on cultural competences, treatment satisfaction and the Cultural Formulation Interview 

2. Project period: 

August 2015 – August 2018 

3. Investigator: 

Laura Glahder Lindberg, MSc Public Health, PhD student 

4. Supervisors and collaborative partners 

  • Principal supervisor; Jessica Carlsson Lohmann, MD, PhD (Senior Consultant at CTP)
  • Primary co-supervisor; Katrine Schepelern Johansen, PhD, MSc Anthropology (Director of Competence Centre for Dual Diagnosis, Mental Health Centre St. Hans, Roskilde) 
  • Collaborative partner; Signe Lund Skammeritz, MD (CTP) 

5. Background 

In Denmark the level of diversity in the population is increasing due to globalisation, migration and influxes of refugees. Immigrants now make up approx. 8% of the Danish population. The diversity in the general population is also reflected in the constitution of patients in the Danish healthcare system. The increasing number of patients of a different ethnical background conveys new challenges for the healthcare system to adapt their services in order to provide all patients will equal access to good quality of care. Studies show that clinicians experience difficulty in their daily work when having to communicate with, understand, diagnose and treat people of a different ethnic background than Danish (Jensen, 2013; Nielsen et al., 2008). Likewise, ethnic minorities experience less trust and receptiveness as well as more discrimination than ethnic Danes when encountering the healthcare personnel (Esholdt & Fuglsang, 2009). Encounters in the health services can be regarded as asymmetrical because the healthcare personnel has a structural power position as the provider of access to treatment while the patient is in a vulnerable situation due to his or her condition. Therefore, it is important that clinicians are aware of their role and seek to achieve the best possible quality of care by involving the patient in the planning of the treatment (Betancourt, 2004). Psychiatry in particular is faced with challenges due to language barriers and because the presentation, interpretation, understanding and treatment of mental health symptoms vary across cultures (Bhugra et al., 2014; Carta et al., 2005; Kleinman & Benson, 2006). The situation has resulted in a need for solutions to improving the encounter between the health services and minority patients. How can communication be improved, how can a common understanding of the health problem and its solution be reached, how can misunderstandings and mistrust be avoided and how does one ensure that the patient can and will comply with the agreed treatment? 

The answer to the above problems is likely to be found in the notion of ‘cultural competence’. Cultural competence, in relation to mental health clinicians, can be described by a multidimensional model consisting of three dimensions: 1) professional (skills or clinical tools), 2) cognitive (knowledge about different cultures) and 3) affective (respectful and curious attitude) (Mösko et al., 2012). 

Culturally competent clinicians are better equipped to achieve therapeutic alliance and mutual understanding in the patient encounter, which will often improve the treatment-efficacy and increase patient satisfaction (Aggarwal et al. , 2015; Betancourt, 2004). However, there is no formalised training in cultural competence within the Danish health services and internationally, there is a lack of consensus on what the term exactly covers (Bhui et al., 2012) as well as a lack of evidence that cultural competence actually improves the quality of treatment – particularly viewed from a patient perspective (Bhui et al., 2012; Bhui et al., 2007; Kleinman & Benson, 2006; Scarpinati Rosso & Bäärnhielm, 2012). In 1994, the fourth edition of the American diagnostic classification system, DSM-IV, introduced ‘The Outline for Cultural Formulation (OCF)’ which provided a framework for clinicians to organise cultural information relevant to the assessment, diagnostics and treatment of minority patients. The acknowledgement of the importance of culture and the framework itself was much needed at the time and has been applied in several Western countries. However, the use of and research on the OCF has been inconsistent and criticised due to its ambiguities and lack of practical application to a clinical setting. 

Based on two decades of experiences with the OCF, and to address the need for a more systematic and user-friendly clinical tool, an expert group within the field of transcultural psychiatry drew up the interview guide ‘The Cultural Formulation Interview’ (CFI) for the revised 2013 release of the DSM-5 (Aggarwal et al., 2015; Lewis-fernández et al., 2014; Mezzich et al., 2009). With 16 questions, the interview examines how the individual patient perceives his or her problem and also the resources and strains the patient finds in his network, family, faith and cultural identity. Moreover, the CFI covers the perceived barriers with regards to the treatment and the relation with the clinician. The 16 questions make up a tangible clinical tool, which can partly guide a difficult assessment session and partly increase the clinicians’ attention to own cultural skills and the importance of understanding the patient’s perspective. Field trials on the CFI have been conducted in mental health clinics in the United States, Peru, Canada, the Netherlands, Kenya, and India, to explore its feasibility, acceptability, and clinical utility with patients and clinicians (Aggarwal et al., 2015; Aggarwal et al., 2013). There has been no research into the use of neither the OCF nor the CFI in Denmark. 

6. Aims 

At Competence Centre for Transcultural Psychiatry (CTP), Mental Health Centre Ballerup, The Capital Region of Denmark, we have translated the CFI interview guide into Danish. Subsequently, we have adapted and pilot-tested the interview guide so that it fits a Danish context. The CFI supports and operationalises the ideal of patient-centred treatment and the involvement of the social context of the patient. Meanwhile, it corresponds with the current need within the health services for standardised, evidence-based treatment and clinical guidelines. This PhD study will, by studying cultural encounters in mental health care including the use of the CFI, contribute to the requested evidence concerning how cultural competences can improve the patient-clinician encounter and also possibly thereby improve the quality of and adherence to treatment. The study focuses on all aspects of the encounter between the migrant patient and the mental health services. By a thorough assessment of the encounter and subsequent interviews with the partakers, namely the clinicians, the patients and the interpreters, the aim is to extract important elements of the successful encounter and write up recommendations on how such an encounter, and thus the improved treatment, is achieved. The overall aim is to investigate: How are the cultural differences of patients and clinicians in the mental health services understood and managed, and how do these aspects influence on the treatment satisfaction and adherence to the treatment? 

A secondary objective is to test and evaluate the clinical relevance of a Danish translation of the CFI. 

7. Methods 

The PhD study consist of four sub-studies that, in combination, provide a thorough analysis of the cultural encounter between the mental health services and migrant patients, viewed from the perspectives of the clinicians, the patients and the interpreters in a consultation context. Triangulation is done not only at the level of perspective but also at the level of methodology, in which the methods complement each other by generating and testing hypotheses. Both quantitative and qualitative empirical data from questionnaire surveys, qualitative interviews, videos, participant observations and focus groups are used to shed light on skills, satisfaction and challenges in the encounter. Each of the four sub-studies and their corresponding research question is outlined in the table below, and the methodological approaches are described in more detail in the following sections. 

A number of outpatient mental health clinics within the Capital Region of Denmark have been informed about the study and several have shown interest in the testing of the CFI, among others outpatient mental health clinic Ishøj, Ballerup and Bispebjerg-Brønshøj. Together with a MD colleague, the PhD student will run training sessions at the participating clinics on how to conduct the interview. Subsequently, empirical data is generated at the specialised clinic for minority patients, CTP, along with the three outpatient mental health clinics, which are located in catchment areas with a high concentration of citizens with minority background, which ensures adequate experience with the target group. 


​# Sub-study
​Research question
​Empirical data
​Methods
​Analytical perspective
​1 Clinicians 
​Which competences and clinical tools does the clinician employ when working with migrant patients, and can the Transcultural Interview increase acceptance and patient involvement in the treatment?
​Participant observation Focus groups (approx. 3)

Questionnaire survey
​Qualitative analysis in NVivo

Descriptive statistics in Stata
​The Logic of Care (Mol)

Cultural competences
​2 Patients
​How does the individual patient experience the encounter with the outpatient mental health services and what is significant in that person’s understanding of his/her mental problem, the role of the cultural background and the treatment?
​Satisfaction survey (approx. 900)

Semi-structured interviews (approx. 12)
​Descriptive statistics in Stata

Qualitative analysis in NVivo
​Patient satisfaction Experience (Berger & Luckmann)
​3 Interpreters
​How does the interpreter understand the cultural encounter as well as the conveying of illnessrelated and cultural information?
​Focus groups (approx 3)
​Qualitative analysis in NVivo
​Cross-cultural encounters
​4 Consultation
​How are the cultural backgrounds and explanatory models for mental disorders of the patient and the clinician, respectively, expressed in the CFI?
​Video recordings of the CFI (approx. 20)
​Qualitative analysis in NVivo
Clinical encounters (Kleinman) Hybrid Habitus (Lo & Stacey) ​

7.1 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 (ID no. RHP-2014- 028). According to Danish law, only projects involving biological material or medical interventions must obtain permission from the National Committee on Health Research Ethics. Hence, such permission is not required for this type of study. 

7.2 Analysis 

Sub-study #1 

Participant observation and focus group interviews are conducted in the three chosen outpatient mental health clinics and at CTP. All treatment-involved professions that could have use of the CFI are included (doctors, nurses, psychologists, social workers, occupational therapists and physiotherapists). The clinicians’ cultural competences, their use of clinical tools and their perceived challenges in the encounter with migrant patients are examined. Additionally, it is evaluated whether the clinicians consider the CFI as a meaningful and clinically useful tool. A qualitative thematic analysis of the transcribed focus group interviews is conducted and supported by theory on cultural competence along with contextualising field notes. On the basis of analyses of the fieldwork, a questionnaire survey is drawn up and sent out via email to a broader segment of clinicians in the Capital Region’s mental health services in order to map the extent to which the findings are representative. The questionnaire data are analysed descriptively using the statistics software Stata. 

Sub-study #2 

Initially, descriptive statistics analyses of approx. 900 patient satisfaction surveys, concerning influence on the treatment, contact with the clinicians and consideration for the patient’s cultural background, are conducted. Data are collected among all patients at CTP in the period 2008 – 2015. An interview guide for semi-structured qualitative interviews with approx. 12 migrant patients is drawn up on the basis of the results and hypotheses deriving from the statistical analysis of the satisfaction surveys. Informants are continually and strategically selected to ensure diversity and that different perspectives are covered. The selection is aimed at variations in gender, age, education, job situation, faith, previous experience with psychiatric treatment and geographic origin (from the six largest groups of non-Western immigrants: Iraq, Iran, Lebanon/Palestine, Pakistan, Somalia, Turkey and the former Yugoslavia (Nielsen et al., 2014)). The recruitment happens through CTP, where the PhD student is employed and present on a daily basis, as well as at the three outpatient mental health clinics. During the course of the fieldwork, contact is established to selected patients who are then contacted regarding interviews after the analyses of CTP’s satisfaction surveys.

The interviews are transcribed in their full length and are structured thematically using qualitative content analysis (Graneheim & Lundman, 2004) in the computer application Nvivo. Berger & Luckmann’s theory about experience perspectives being central for cultural encounters (Jensen, 2004), will serve as the theoretical framework for the analysis. 

Sub-study #3 

Three focus group interviews, with approx. 5 interpreters in each, are carried out. At a point during the project period, the interpreters must have interpreted a consultation, in which the CFI was used. The interpreters are recruited from the regular team of experienced interpreters at CTP and via the fieldwork. There is a strategic selection of interpreters with regards to variations in gender, age, experience with interpreting work, education, language / country of origin and the duration of residence in Denmark. The focus group interviews are transcribed and analysed using qualitative content analysis (Graneheim & Lundman, 2004) and theory on cross-cultural encounters. 

Sub-study #4 

Along the way during the fieldwork, the PhD student ensures that the clinicians, in individual sessions with approx. 20 migrant patients, make use of and video-record the CFI. Furthermore, the clinician or the PhD student fills in a form with basic demographic background information about the patient. If contextualising and explanatory information is needed during the phase of analysis, the PhD student has been granted permission by the Danish Data Protection Agency to look up the patient’s file in the medical record system OPUS. All video sessions are transcribed in their full length and transverse thematic analyses are carried out. 

Theories on Clinical Encounters and Explanatory Models (Kleinman & Benson, 2006) and also Hybrid Habitus (Lo & Stacey, 2008) are drawn upon because they align with the way of thinking behind the CFI in their attempt to understand how the social world influences, and is influenced by, healthrelated suffering, as well as their focus on the patients’ own explanation and understanding of the health problem. 

8. Expected results 

The project will be carried out across different outpatient mental health clinics, involve personnel across professions and give a voice to the patients around whom the research revolves. Specifically, the study will result in a translated and thoroughly evaluated edition of the acclaimed tool, the CFI, which offers a systematic focus on the patient-centred approach and is expected to be widely used in the Danish health care services. The project will also contribute to the international research field with much needed evidence about the interview’s clinical utility. The liaisons of CTP at transcultural centres in Oslo and Stockholm have requested the translation and it is thus particularly expected that the experiences of this study will be useful in Scandinavia in which health care systems and migrant groups are similar to the Danish. With the knowledge from this project, it will be possible to establish a procedure for a more thorough and accurate assessment and diagnosis of ethnic minority patients with a mental disorder, and create an environment that increases the patient’s acceptance of the treatment. Improved treatment can increase the quality of life of patients and their relatives, and bring about more satisfactory working conditions for mental health clinicians. At the community level, the costs of mental illness in Denmark amount to 55 billion a year when including direct costs of the health services and indirect costs due to lost earnings, interrupted education, social services, increased incidents of somatic disorders and disability-adjusted life years (Borg et al., 2010). With the results, it is possible to achieve health economic benefits, in the form of shorter and more successful courses of treatment, as well as socio-economic benefits, in the form of a faster return to education and the job market and surplus energy for people to take care of themselves and any children. 

9. Dissemination of results 

The PhD thesis will consist of four scientific articles and the results will be presented at Danish and international professional and scientific conferences. In addition, the results will be widely disseminated in the media, articles on Videnskab.dk, from which many newspapers retrieve information about new research, as well as on the website and in the newsletter of the Competence Centre for Transcultural Psychiatry (CTP). In its capacity as a highly specialised clinic, CTP regularly organises after-work meetings for mental healthcare clinicians, social workers, general clinicians and students, where the results will be presented. The participants in the study will in their statement of consent be asked for contact information if they wish to receive a summary of the results. 

10. References 

Aggarwal, N. K., Desilva, R., Nicasio, A. V., Boiler, M., & Lewis-Fernández, R. (2015). Does the Cultural Formulation Interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site. Ethnicity & Health, 20(1), 1–28. doi:10.1080/13557858.2013.857762 

Aggarwal, N. K., Nicasio, A. V., DeSilva, R., Boiler, M., & Lewis-Fernández, R. (2013). Barriers to implementing the DSM-5 cultural formulation interview: a qualitative study. Culture, Medicine and Psychiatry, 37(3), 505–33. doi:10.1007/s11013-013-9325-z 

Betancourt, J. R. (2004). Cultural Competence — Marginal or Mainstream Movement ? The New England Journal of Medicine, 351(10), 953–955. 

Bhugra, D., Gupta, S., Schouler-Ocak, M., Graeff-Calliess, I., Deakin, N. a, Qureshi, a, … Carta, M. (2014). EPA guidance mental health care of migrants. European Psychiatry : The Journal of the Association of European Psychiatrists, 29(2), 107–15. doi:10.1016/j.eurpsy.2014.01.003 

Bhui, K., Ascoli, M., & Nuamh, O. (2012). The place of race and racism in cultural competence: What can we learn from the English experience about the narratives of evidence and argument? Transcultural Psychiatry, 49(2), 185–205. doi:10.1177/1363461512437589 

Bhui, K., Warfa, N., Edonya, P., McKenzie, K., & Bhugra, D. (2007). Cultural competence in mental health care: a review of model evaluations. BMC Health Services Research, 7, 15. 

Borg, V., Nexø, M. A., Kolte, I. V., & Andersen, M. F. (2010). Hvidbog om mentalt helbred, sygefravær og tilbagevenden til arbejde. Copenhagen: Det Nationale Forskningscenter for Arbejdsmiljø. 

Carlsson, J., Sonne, C., & Silove, D. (2014). From pioneers to scientists: challenges in establishing evidence-gathering models in torture and trauma mental health services for refugees. The Journal of Nervous and Mental Disease, 202(9), 630–7. doi:10.1097/NMD.0000000000000175

Carta, M. G., Bernal, M., Hardoy, M. C., & Haro-Abad, J. M. (2005). Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clinical Practice and Epidemiology in Mental Health, 1, 13. 

Esholdt, H. F., & Fuglsang, M. (2009). Etniske forskelle i patienters oplevelser. Copenhagen: Enheden for Brugerundersøgelser, Region Hovedstaden. 

Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–12. doi:10.1016/j.nedt.2003.10.001 

Jensen, I. (2004). The Practice of Intercultural Communication - reflections for professionals in cultural meetings. Journal of Intercultural Communication, 6. 

Jensen, N. K. (2013). Vulnerable migrants in patient-provider encounters. A multiple methods study. University of Copenhagen. 

Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. 

Lewis-fernández, R., Aggarwal, N. K., Bäärnhielm, S., Rohlof, H., Kirmayer, L. J., Weiss, M. G., … Lu, F. (2014). Culture and Psychiatric Evaluation : Operationalizing Cultural Formulation for DSM5, 77(2), 130–154. 

Lo, M.-C. M., & Stacey, C. L. (2008). Beyond cultural competency: Bourdieu, patients and clinical encounters. Sociology of Health & Illness, 30(5), 741–55. doi:10.1111/j.1467- 9566.2008.01091.x 

Mezzich, J. E., Caracci, G., Fabrega, H., & Kirmayer, L. J. (2009). Cultural formulation guidelines. Transcultural Psychiatry, 46(September), 383–405. doi:10.1177/1363461509342942 

Mösko, M.-O., Gil-Martinez, F., & Schulz, H. (2012). Cross-cultural opening in German outpatient mental healthcare service: an exploratory study of structural and procedural aspects. Clinical Psychology & Psychotherapy, 20(5), 434–46. doi:10.1002/cpp.1785 

Nielsen, A., Krasnik, A., & Michaelsen, J. (2008). Hospitalspersonale har forskellige holdninger til indvandrerpatienter. Ugeskrift for Læger, 170(7), 541–544. 

Nielsen, S. S., Jensen, N. K., Kreiner, S., Norredam, M., & Krasnik, A. (2014). Utilisation of psychiatrists and psychologists in private practice among non-Western labour immigrants, immigrants from refugee-generating countries and ethnic Danes: the role of mental health status. Social Psychiatry and Psychiatric Epidemiology, 50(1), 67–76. doi:10.1007/s00127-014- 0916-y 

Scarpinati Rosso, M., & Bäärnhielm, S. (2012). Use of the Cultural Formulation in Stockholm: a qualitative study of mental illness experience among migrants. Transcultural Psychiatry, 49(2), 283–301. doi:10.1177/1363461512442344 

WMA General Assembly. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects (2013). Helsinki, Finland.


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