Introduction

EduOnMed Project

Problem statement – why this intercultural training is needed

Healthcare provision has become increasingly diverse, from the range of patients accessing services to the considerations that need to be met by practitioners. Diversity manifests on a daily basis: in diverse habits and forms of communication (shaking hands, eating habits, contraception, fasting, expression of feelings, concepts of the body). It proves relevant for many core questions health care staff have to pose themselves when treating patients:

• Does my patient understand the illness?
• Can I confidently distinguish cultural / personal or clinical motives behind the patient’s behaviour?
• Am I aware of cultural taboos that can affect his/her reception of the treatment proposed?
• Does my institution allow me to adapt to the patient’s cultural / religious prescriptions?
• How can I deal with linguistic barriers?
• Which information do I have to give the patient for him/her to feel safe?

When not addressed properly by trained professionals, challenges arising from the work with heterogeneous patients can result in the refusal of treatment, under-treatment or maltreatment, and the potential for discrimination. For a long time, health care education in Europe has focused primarily on conveying medical knowledge to students and training specialized skills and methods deemed necessary for performing the job as a surgeon, a nurse, a paramedic, etc. What has been lacking within this approach is an emphasis on social and communicative skills needed for encountering patients as well as for working together with colleagues in teams. Furthermore, health care education in Europe rests heavily on a biomedical model of health, in which disease is indicated by bodily malfunctions and is to be diagnosed according to scientific methods of measuring and assessing the body’s inner 5 workings. Within this approach, patient backgrounds, their individual characteristics, but also their belonging to certain social groups, have not been on the forefront of practitioners’ minds. Even though medical concepts have begun to change over the last decades, putting more emphasis on individualised medicine and patient-centred approaches, health care students across Europe are still rarely confronted with a comprehensive training of intercultural competences needed for diversity-oriented health care work. Professionals already working in the health care sector are often lacking time and institutional impetus to further develop their intercultural competences. As a result, staff members tend to lack intercultural competencies; awareness of intercultural competence has not been raised to its full extent, especially in rural areas. The Healthy Diversity curriculum offers 7 training modules to health professionals aiming to further develop their intercultural skills, which offer flexibility and can be chosen and adapted according to the healthcare system, existing knowledge of the participants and their busy schedules.

Current context of healthcare for refugees and migrants in Greece, Italy and Spain

Situation in Greece

Since 2014, more than 1,250,000 refugees and migrants have arrived in Greece. Τhe restrictions that had been imposed in the wake of the coronavirus pandemic have led to a reduction in migration flows to the EU. However, the number of arrivals started to increase again in 2021 and 2022, partly due to Russia’s aggressive invasion in Ukraine. A quantitative research published by the Greek Ministry of Migration, indicates that the flow of arrivals had increased by 56% in January 2022, corresponding to those of January 2021. Migrant and refugee populations are a particularly vulnerable social group, and often face an increased risk of social exclusion. Equal access to health care and effective medical access for refugees and migrants is a key factor for their integration and the prevention of inequalities. Αlongside, 37% of the refugees and migrants admitted to our country last year are children which are exposed to persistent protection risks due to inadequate security and conditions. Similarly, people who have applied for asylum and are awaiting confirmation of their recognition as asylum seekers have access to health care only in emergency situations. Μeanwhile, many refugees do not have access to covid vaccinations due to administrative, policy or documentation reasons, while lack of information may also create difficulties with regards to accessing covid vaccination. In Greece, migrants who are legally residing in the country have the same rights as Greek citizens in terms of access to healthcare. However, a large percentage of the migrant population expresses that health services do not meet all their needs, with the main reasons being long waiting times in hospitals, difficulty in communicating with health professionals, costs of care and medicines, the complexity of the system and lack of knowledge of available health services. These are compounded by cultural differences and socio-economic status, which make it difficult to access appropriate information and medical services. Still, among health professionals there still exists a lack of awareness regarding the complex needs of migrants, also with regards to medication. Such way, the large influx of migrant populations in Greece has highlighted the need for preparedness, to meet the immediate and long-term medical needs of people. In this context, the adequate education and awareness-raising of health professionalsis are essential to combat discrimination in health care in order to uphold every person’s fundamental right for access in healthcare.

Situation in Italy

For what concerns arrivals at the sea border, Italy continues to play a role in indirect push-backs by providing the Libyan authorities with the means and technologies to improve sea tracing. In 2021, 67,477 persons had disembarked in Italy, almost doubling the number of arrivals of 2020 (34,154) and an even more relevant increase when compared to 2019 (11,471) and 2018 (23,370). However it is considerably lower than the arrivals of 2017 (119,369). The main nationality of people disembarked remained to be the Tunisians, who were 15,671 in total. Over 31,500 came from Libya, more than 20,000 from Tunisia, 13,000 from Turkey and 1,500 from Algeria. At least 32,425 persons, in 2021, were returned to Libya (already over 3 thousand as of March 19, 2022). Problems continued to be reported in accessing the procedure, both at the borders, due to reported pushback practices and to the use of quarantine ships as de facto administrative detention facilities/hotspots in main cities. This situation has been mainly caused by non-uniform practices in different areas of the country and to the long waiting time that lodging an application entails. In 2021, 56,388 asylum requests were registered in Italy, compared to 21,200 in 2020. The number of children seeking asylum also increased to 10,053, compared to 4,687 of 2020.7 The main countries of origin of the applicants were Pakistan, Bangladesh, Tunisia, Afghanistan and Nigeria. Τhere were 52,987 first instance decisions (compared to 40,800 in 2020). An increase in the recognition of protection statuses was noticed; 44% (compared to 28% in 2020) of these decisions led to a protection status (32% international protection, and 12% special/ protection status). In general, the approach to migrant health is understood as access to services at the time when an illness or emergency appears. Short attention has been given to the need of providing prevention programs that facilitate the possibility of undergoing vaccinations or follow-up screenings. In addition to bureaucratic barriers, the migrant population often encounters language and cultural barriers. The difficulty in understanding the Italian language limits the ability of the migrant population to express their needs and requirements, and prevents them from understanding what services are available to them. The operators’ lack of knowledge about the customs, beliefs and approaches to medicine proper to the patients’ backgrounds prevents them from deeply understanding who is being treated and their reasons, why they refuse a diagnosis or follow recommended treatment. This is especially the case from a gender perspective, so that depending on the countries of origin it may happen, for example, that a woman may prefer not to be seen by a male doctor. In general, it’s necessary to have cultural mediators that can deal with resolving the language gap but also of mediating in cultural terms in order to be able to dialogue with the patient, taking into consideration the beliefs and traditions that guide the migrant in the course of treatment is of fundamental importance. In order to facilitate access to services, it is important that health and social workers are also trained to better manage the needs and requirements of migrant users. Operators should be trained to welcome and manage helping relationships as a necessary prerequisite for efficient service delivery, giving the capacity to understand the person and establish a fruitful relationship with them in order to provide personalized and quality care pathways. Trainings should also be aimed at delving into the methods of traditional country-of-origin medicine and also elements of ethnopsychiatry, as well as gender medicine, in order to understand that culture, gender and socioeconomic status are determinant variables to be considered in the care relationship with the patient.

Situation in Spain

Resident population in Spain increased by 34,110 persons during 2021 and stood at 47,432,805 inhabitants on 1 January 2022. The number of foreigners increased by 49,612 persons during 2021, reaching 5,417,883 on 1 January 2022. Among the main foreign nationalities, the largest increases corresponded to the Italian population (19,093 more than the previous year), Colombian (18,203) and Venezuelan (11,481). This phenomenon of immigrant population reception makes it necessary to address a series of new issues that affect all public sectors, especially the health sector. Health care in Spain for foreigners is regulated by the Organic Law on the Rights and Freedoms of Foreigners in Spain and their Social Integration, which establishes that “foreigners have the right to health care under the terms set out in current legislation on health care”. Thus, the main aim of the latest royal decree-law launched by the government is to restore universal public health care, free of charge, so that anyone living in Spain, whether a national or a foreigner, can go to a hospital in the event of a health problem. Full health care in Spain for foreigners means that anyone, regardless of their situation, whether they have a residence permit or not, can be treated in a public health center. However, there are a number of measures for accessing the health system. Among these measures is the need to prove residence in Spain for more than 90 days. This prevents foreigners who have their own medical coverage in their country of origin from accessing the public health system. However, undocumented immigrants also have access to health care, although they need a report from the social services certifying that they do not have the minimum resources. With regard to the purchase of prescription drugs, this group must pay the same amount as Spaniards with an income of less than 18,000 euros, i.e. 40% of the total. In any case, it should be noted that the immigrant population suffers from difficulties in accessing the health system for different reasons: because they are unaware of the administrative procedures required for access; because they are unaware that some health services exist; because they lack the necessary economic resources to access others; because of incompatible working hours due to long working hours; or because they have difficulties in communicating with health system staff, either due to language problems or cultural issues (Chauvin, Parizot & Simonnot, 2009). For this reason, we need a provision that offers efficient and quality care to the whole population, including migrants. The health system needs a reorientation of care through a model that responds to the experiences, expectations and health needs of a very diverse society (Karl-Trummer, Novak-Zezula & Metzler, 2010).