2.5 Descriptive information on the study population of Phase 1
Of the 24 participants with migration background in Phase 1, 10 identified as female, 12 as male and two as gender nonconforming. There were 11 students, 12 refuges, three of which were both students and refugees, and the remaining four were LGBTQ+ persons. An overview of all participants of Phase 1 can be found in Table 1.
Table 1 Characteristics of the study population – Phase 1 (Migrants)
All participants reported problems that could be related to their mental health. The students in particular described higher stress and feelings related to the pandemic situation such as loneliness, and anxiety. One of them reported risky alcohol consumption. Five individuals, mostly from the LGBTQ+ group, spoke of depression, while one of them mentioned panic attacks. One of this group and two male refugees were undergoing psychotherapy for depression or post-traumatic stress disorder. Most of the refugees, particularly females, did not directly talk about mental health issues, although all of them expressed symptoms such as insomnia, worries, or sadness.
2.6 Descriptive information on the study population of Phase 2
Table 2 Characteristics of the study population – Phase 2 (Health professionals experienced in mental healthcare)
As can be seen in Table 2, the health professionals all had varied work experiences and patient groups. Five of them were psychological psychotherapists, one was a family physician, and one was a psychiatric specialist. One of the health professionals worked in an acute psychiatry clinic for migrant youth, two in their own practice, one in a refugee-specific organization, and three in a university clinic. Only the family doctor worked in a rural area; the others were in the centre of Munich. Four health professionals received academic training in public mental health. Two of them were researching the role of primary care in mental health access with one specialising in psychoeducation, while another one had publications on the male gender roles in Muslim families. Three of the seven health professionals interviewed had a migration background, while only one was male. Finally, the expert who attended the data analysis validation meeting was a female psychiatrist who had migrated and worked at a university.
2.7 Determinants of migrants’ mental healthcare access
Based on the analysed interviews, the determinants of migrants' mental healthcare access were categorized into five dimensions. Their relationship to each other and to culture and language is shown in Figure 2.
2.7.1 Dimension 1. Ability to perceive mental health problems
Knowledge about mental health
Participants' knowledge of mental health varied widely. Younger participants, particularly those under the age of 30, reported mental health as a component of overall health and even correlated their own mental health with physical symptoms such as weight loss or gain, migraine, hypertension, rashes, or immunological diseases. On the other hand, there was one student who suggested that his depression could recover in a very short period of time.
“Health is two different things: physical health and mental health. […] And for mental health, I think that would require a lot more conscious effort, especially if you have any underlying issues that you still haven't identified. If you're not coping well, you would probably have to sit down and think as to what is going wrong. […]. So, these two things have to come together. Just because they're physically healthy doesn't mean you're mentally healthy and vice versa.” – P01
“For me, the depression thing, that's like almost every part of my life, but, you know, that depression could be recovered like in ten seconds. So if you get if you get a mail from Harvard University, that you got approved by the PhD program from them, then you can be recovered from the depression, like in the blink of an eye.” – P05
Others, particularly older participants and female refugees did not see the connection and did not talk about mental health at all. Most of the health professionals explained that many migrants are less aware of their mental health and thus often do not recognize when they need help. This often results in mental health conditions manifesting in physical symptoms, making it even more difficult to detect them.
"How do illnesses manifest themselves in different cultural circles? For example, there are cultures where depression classically manifests itself with physical complaints. That they have very strong whole-body pain, fatigue, exhaustion. And then you have to pay more attention to these symptoms." – Medical specialist for psychiatry and psychotherapy
Stigma of mental problems
Some male participants described stigma about mental problems. Among them, two reported that mental illness is considered taboo in their home country. Another one expressed feelings of shame regarding his own mental problems. They all saw the stigma associated with mental health as a reason why they or others would not talk about their struggles. Men were less likely to admit their mental health problems, according to two of the male participants.
“In Korea it's really hard to get any advice about the depression. So, they tried to hide it. […] If I am depressed, I try to hide it to my parents or my friends. I try to overcome it by myself.” – P05
The psychiatrist, the psychotherapist with his own practice and one psychotherapist working in a primary care project confirmed that mental illnesses are stigmatized, particularly among migrants. Therefore, many do not acknowledge having problems and needing external help, which is especially true for men owing to their traditional gender role of being “strong”.
“Actually, there are problems, they seek help, but there is a stigma. I remember last year a suicide [...] of a teenager. A year ago, she has not expressed suicidal thoughts, but then one day we heard she is already dead [...]. Then family needed many support because in one day they have lost their daughter, but family has said [...] no, they have not said anything [...]. No, they have not accepted any therapy offer.” – Youth psychotherapist
2.7.2 Dimension 2. Ability to seek mental healthcare
Knowledge about healthcare system and care options
Only three people mentioned mental health treatment options that they were aware of. However, one of them thought psychotherapy was prohibitively expensive and was unaware that it is covered by insurance in Germany. Another participant reported being denied an appointment due to a missing insurance document. The lack of knowledge about the German healthcare system was mentioned by the health professionals as a barrier to seeking help. The family physician and one psychotherapist working in a primary care project emphasized that there is too little awareness about insurance and cost coverage of psychotherapeutic services. Additionally, there was a lack of knowledge about different treatment options. According to the psychiatrist, and the psychotherapist with research experience in primary care and psychoeducation, this was also largely due to the language barrier.
"The knowledge about treatment services. Yeah I think that's so random still, whether they learn about something or not." – Psychotherapist with research experience in primary care and psychoeducation
Social support
The participants mentioned that having a social network and support system could have a significant influence on migrants' ability to seek care options. Five participants described situations in which acquaintances or members of their community helped them with health-care issues This could help in overcoming communication problems during doctor’s visits and making it easier to locate appropriate providers. Two of the three participants receiving psychological treatment stated that they found their therapist through another migrant's recommendation. The psychotherapist with research experience in primary care and psychoeducation working with refugees also shared her experience of how a personal contact with a refugee home led to her psychiatric clinic accepting multiple patients from the facility.
The statements of the migrants and health professionals indicated that organizations and volunteers could also provide support in seeking care when there was no social network. Some refugees reported receiving support from social workers in their shelters, which helped in a variety of situations, such as assistance with insurance issues and doctor’s appointments, as well as support with translation or childcare. However, this was not the case for most participants, as they reported receiving no assistance. Some of them were aware of social organizations, but they either were not offered help at all or only got support for issues unrelated to their health. Several participants added that because of limitations imposed during the COVID-19 pandemic, support from organizations had disappeared. In addition, lack of language competency was a commonly mentioned impediment to social assistance, which was confirmed by the health professionals. The psychotherapist with research experience in primary care and working experience with refugees emphasized the lack of support in refugee shelters, particularly for mental health issues. Moreover, the family physician and the psychotherapist working in a psychosocial treatment centre stated that support is especially important for women, who are frequently hindered from accessing healthcare due to the responsibilities for their children. One of the health professionals provided the example below.
“Just a young patient who is here with a disabled child and a school child, so with a disabled kindergarten child, alone from Lebanon now here. There is family, living at a distance, maybe 10 km, but she lives here alone in a council flat, or in a room, and does not speak the language.” – Family physician
2.7.3 Dimension 3. Acceptability of mental health services
Identity and gender of providers
Prejudice on the side of both migrants and providers based on the social identity of the other functioned as a barrier to providers' acceptability. Seven individuals, mainly refugees from Arabian countries and non-white participants, reported a lack of trust in physicians and inhibitions about confiding in them due to fear of not being understood. Especially black participants and LGBTQ+ people described discriminating, racist encounters in the medical setting, which is why they would disregard accessible medical professionals in favour of providers with the same cultural background or ethnicity.
“[…] the doctor's offices where they treated me as if I did not understand German. Like a little child, you then also talk like a little child. Or slowly speaking German. So this, I'm black, which automatically I don't understand German.” – P24
“There are prejudices and racist attitudes on both sides that are never addressed. They come and tell me, for example, most migrants of Turkish origin, but also others: The Germans would not understand us. They don't understand our culture. Then I ask: What is your culture? [...] Yes, when we have family conflicts, violence in the family. Yes, I don't understand violence either. I would not accept violence in the family either. [...] That's what they are afraid of, that's why they don't go [...]. And they explain that with ‘my culture’.” – Psychotherapist with own practice
Many health professionals confirmed the existence of reservations and prejudices on both sides, adding that migrants preferred providers with the same cultural background because they were afraid of being misunderstood, or even of being judged. These concerns were frequently exacerbated by a language barrier. According to the health professionals working with refugees, these concerns are not unfounded, because German providers are sometimes overwhelmed with patients with migration background and may refuse them out of fear of doing something wrong because of their often trauma-related, complex disease patterns. Some had difficulties to empathize with their patient's different cultural background and experiences or even discriminatory prejudices.
Almost all health professionals added that both men and women from other cultures may find it difficult to see a doctor of the opposite sex: Men were more likely to question the competence of female providers, whereas women found it harder to open up to men.
“There are sometimes problems: men-women communication. That perhaps men from perhaps patriarchal cultures had difficulties with female doctors and then somehow try to meet them and then perhaps to also always talk with a male colleague.” – Medical specialist for psychiatry and psychotherapy
2.7.4 Dimension 4. Availability and affordability of mental health services
Insurance and bureaucracy
Health professionals reported that many migrants had trouble arranging medical appointments, mainly owing to the language barrier. The refugees experienced the most challenges. Several of them described major bureaucratic hurdles they were confronted with, because they did not have a health insurance, making it very difficult to make appointments or obtain reimbursement for drug costs.
“So the people who are supposed to go to the doctor […] they are supposed to pick up a health certificate from the asylum office or asylum matter or social welfare office, so pick up and then they are allowed to go to the family doctor. So and that takes time with the bureaucracy and it's also such crap. What if they are sick? Then they should first get this shit and then they can go, right? [...] so they need to, if they're also depressed and, so also don’t procure these things on their own, like a sick note to pick up, then I don't know.” – P18
According to the psychiatrist, family physician, and psychotherapist working at a psychosocial treatment centre, this not only limited patients' ability to access healthcare, but also burdened physicians with extra strain created by patients' inquiries about bureaucratic matters.
“That would also be a classic thing in standard care: A refugee client comes in with five letters and first says: I don't understand them. And then the person in regular care must first try to consider: No, that's not important, that's advertisement, ah there we have something from the health insurance.” – Psychotherapist working at a psychosocial treatment centre
Based on the opinion of most of the health professionals, the inability to pay for medical services also primarily affected individuals lacking health insurance, and therefore refugees and asylum seekers. For everyone else in Germany, this was not a hurdle. All participants with health insurance equally did not perceive the expenses associated with doctor visits and medication as an obstacle to receiving healthcare.
Capacity of care options
All health professionals highlighted the insufficient availability of psychotherapeutic or psychiatric treatment spaces. They indicated lengthy waiting periods, ranging from six months to two years.
“And in the last two years, one and a half years, they are looking for therapy spot, counselling spot, there is nothing at all. And I know practices now, they write in their website now: please don't call us again in the next two years until 2024/25.” – Youth psychotherapist
One participant currently undergoing psychotherapy shared his experience of waiting six months to secure a therapy spot. This was acknowledged by the health professionals as a fundamental issue that affected all individuals in Germany. However, it posed even greater challenges for migrants due to limited options in other languages and the excessive demand on specialized services, such as psychosocial counselling for refugees. The health professionals added that capacity was also lowered dramatically as a result of the COVID-19 pandemic.
Yeah, then of course the question is, are there offers, and especially in the native language. So psychotherapists who perhaps do therapy in English, there are already several. But there are very few in Farsi or other languages. And there the rush is of course big and the waiting times get then actually, too [...] they are then very quickly overrun, if there are very many...so, if there is a great need.” – Psychotherapist with research experience in primary care and psychoeducation
Geographical distribution of services
Five health professionals highlighted transportation and the location of treatment facilities as a component of availability. They noted a disparity in therapy spots between urban and rural areas, with fewer suitable options for migrants in rural regions. While rural networking among doctors may offer advantages, according to the family physician, long distances to care facilities and inadequate transportation possibilities posed challenges for migrants. Most of participants reported no such problems owing to residing in the urban region of Munich, but refugees staying in isolated places experienced considerable difficulties.
“I currently have a client, it is not that far away, he comes here in an hour [...] But where he is, there is nothing else. [...] he speaks French and English, so you could expect him to find someone. But he has no chance, and he is highly depressive and severely dissociative. […]. So, that means, it simply needs to be spread much more widely.” – Psychotherapist working at a psychosocial treatment centre
2.7.5 Dimension 5. Appropriateness of mental health services
Providers’ and patients’ understanding of mental healthcare
According to the health professionals, the idea of the treatment of mental illnesses could be influenced by a culturally determined different definition of mental disorders: for some patients with migration background, illness was often regarded as something external, such as bewitchment, which absolves individuals from personal responsibility.
“So before they come to us, they go to their religious places, with amulets, what do I know, incense and this and that. [...] They come, they have the expectation: [...] Someone made me sick. Evil eye has made me sick. And I come to you, and you have to make me well again, because you are an expert. Because you're a doctor or a psychologist. So I don't have to do anything for it.” – Psychotherapist with own practice
Consequently, there could be an expectation that the doctor, akin to a traditional healer, would take on the role of removing the illness. If physicians were not prepared to take this into account during therapy, these differing beliefs and expectations could potentially clash, creating challenges for both the patient and the healthcare provider. One participant also expressed a desire for more alternative medicine, including spiritual components such as shamans.
“Because of course my idea of treatment goes in a completely different direction, when I, as a German, say: post-traumatic stress disorder, of course, trauma. [...] And my client thinks: Actually, I am bewitched. Then I don't need to come up with a trauma confrontation.” – Psychotherapist working at a psychosocial treatment centre
Competence of providers
Provider competence and patient satisfaction emerged as important factors determining the appropriateness of care. Two women and one gender nonconforming participant reported being misdiagnosed or not being taken seriously. The psychotherapist with research experience in primary care and psychoeducation working with refugees emphasized the problem of undiagnosed psychoses among migrants. The other expert working in a primary care project mentioned that many migrant patients feel a lack of understanding. According to both participants and health professionals, the quality of treatment was also heavily influenced by whether the healthcare provider and the patient could communicate in the same language. However, an equal number of LGBTQ+ participants and refugees had positive experiences with their doctors, which often led to a trusting relationship. One of the named psychotherapists confirmed that this was mostly evident with their primary care physicians. According to the psychotherapist working in a psychosocial treatment centre, the next generation of psychotherapists is becoming more adept at treating people from diverse backgrounds. One participant described her psychotherapist as follows:
“My reasons, reason, or cause for my depression she could understand rather better than others.” – P24
The psychiatrist, general practitioner and one psychotherapist additionally emphasized that the amount of time available for patients was a crucial factor in their competence of providing appropriate care. They said that patients with migration experience required more time compared to other patients due to their specific needs, such as dealing with bureaucracy and communication challenges. The psychotherapist working at the psychosocial treatment centre emphasized that, in contrast to standard care, she had enough time for the treatment of her patients:
“One factor we have, is time. The regular care system doesn't have that. So I can just take three hours of therapy to find out exactly those kinds of things. If someone is sitting with a family doctor, it's difficult. He has a maximum of a quarter of an hour.” – Psychotherapist working at a psychosocial treatment centre
2.7.6 Language, Culture, and the interaction between the dimensions of access to mental healthcare
Language is associated with various dimensions of access to mental healthcare, as shown in Figure 2. It exacerbated barriers such as communication with social organizations for the ability to seek, acceptability of providers’ language skills, appropriateness and quality of care, and availability of services in one's own language. The findings also revealed that a person’s ability to perceive is strongly related to their cultural background. Some cultures had a lower level of awareness of mental health than others, similar to how stigmatization of mental illness is frequently influenced by culture. Culture also had an influence on the acceptability and appropriateness, which are thus inextricably linked: The different cultural understanding of mental health among migrants and providers not only posed challenges during therapeutic treatment, but also led migrants to prefer seeking help from alternative sources they perceived as more acceptable. Negative encounters with healthcare providers, whether due to their medical competence or discriminatory experiences, also reduced migrants' acceptance of German healthcare providers. Simultaneously, provider acceptability may improve the relationship between practitioner and patient, and hence appropriateness. For this reason, the framework of migrants’ mental healthcare access in Figure 2 shows a circle rather than the linear process depicted in [24] model.
2.8 Recommendations for action to improve migrants’ mental healthcare access
The analysis of the expert interviews resulted in a list of 17 recommendations under five categories aimed at enhancing the accessibility of mental healthcare services for migrants. These consisted of enhancing the structure, organization, and funding of (mental) healthcare, empowering healthcare providers, facilitating the adaptation to a new healthcare system, enhancing social and organizational support, and taking into account the determinants of health (see Supplementary Table 1, Additional File 1). Then using the approach of Valentijn et al. [32] the recommendations of the categories were classified into the three dimensions of integrated care: the macro, meso, and micro level (Figure 3).
2.8.1 Macro level
The term "macro" level refers to the system-level structure and aims to meet the overall needs of the population ([32]). At this level, the health professionals working with refugees and the ones with a migration background themselves emphasized the importance of equal treatment of migrants regardless of their origin. All health professionals working with refugees stressed the need for better housing conditions for asylum seekers, as well as faster decisions on their residency status. The health professionals agreed that organizations providing support for migrants should be strengthened. According to the health professionals without migration background, equal opportunities in the education and training of medical professions would increase the representation of migrants among healthcare providers bridging language barriers and fostering better patient acceptance. One expert with public health research experience stressed the significance of carrying out further research on the mental health of migrants. As the other experts did not mention this, it was not included in the analysis as a recommendation for action.
2.8.2 Meso level
The meso level involves the coordination and collaboration among different organizations and healthcare providers [32]. All health professionals advocated for better coordination between healthcare and public organizations. Thereby, they emphasized the important role of general practitioners and psychosocial treatment centres. Most of the health professionals stressed including migrant health into the training of all medical professionals to provide culturally appropriate treatment. All health professionals suggested low-threshold care options, such as self-help groups, or digital health applications. The psychiatrist and the psychotherapists conducting research in primary care additionally recommended comprehensive care options for migrants. All health professionals agreed on the significance of interpreters and translations, including their cost coverage by insurance.
2.8.3 Micro level
On the micro level, clinical integration takes precedence with a person-focused perspective, ensuring continuous and tailored care for individuals [32]. Within this study, these encompass recommendations specifically directed towards migrants themselves. The general practitioner and three psychotherapists suggested conducting educational activities aimed at migrants to provide information about the German healthcare system. These health professionals and the psychiatrist also recommended to spread information on mental healthcare providers and treatment options available treatment options. They additionally recommended to strengthen migrant’s mental health awareness. In order to promote the mental health of migrants the health professionals emphasized the importance of social support. Several health professionals suggested implementing intercultural leisure activities as a viable approach. Besides, the health professionals with migration background recommended refocusing schools on fostering personal interests and linguistic development of children from migrant families to promote migrants’ mental health and social integration.