The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems.

AIM: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden. METHODS: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation. RESULTS: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes. CONCLUSIONS: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Nurses' Roles, Responsibilities and Actions in the Hospital Discharge Process of Older Adults with Health and Social Care Needs in Three Nordic Cities: A Vignette Study.

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires the involvement of nurses at multiple levels across the different phases. This study aims to examine and compare what roles, responsibilities and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette-based interview study consisting of three cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). The vignettes represented older patients with medical conditions, cognitive loss and various home situations. The interviews were conducted in the local language, recorded, transcribed and analysed thematically. The findings show that nurses exchanged information with both healthcare (all cities) and social care services (Copenhagen, Tampere). Nurses in all cities, particularly Stockholm, reported to inform, and also convince patients to make use of home care. Nurses in Stockholm and Tampere reported that some patients refuse care due to co-payment. Nurses in these two cities were more likely to involve close relatives, possibly due to such costs. Not accepting care, due to costs, poses inequity in later life. Additionally, organisational changes towards a shift in location of care, i.e., from hospital to home, and from professional to informal caregivers, might be reflected in the work of the nurses through their initiatives to convince older patients to accept home care and to involve close relatives.

The association of neighborhood socioeconomic characteristics with cardiovascular health: A quasi-experimental study of refugees to Denmark.

Neighborhood socioeconomic disadvantage is associated with cardiovascular health, although it is unclear which specific aspects of neighborhoods matter most. We leveraged a natural experiment in which refugees to Denmark were quasi-randomly assigned to neighborhoods across the country during 1986-1998, creating variation in exposure to various aspects of neighborhood disadvantage. The cohort was followed through December 2018. Exposures included neighborhood-level family income, educational attainment, unemployment, and welfare transfers measured in the first neighborhood after arrival to Denmark. Outcomes included cardiovascular risk factors (hyperlipidemia, hypertension, diabetes and anxiety/depression) and cardiovascular disease (acute myocardial infarction and ischemic heart disease). Neighborhood-level income and education were most consistently associated with cardiovascular risk factors, whereas welfare transfers were most consistently associated with cardiovascular disease. Addressing these specific aspects of neighborhood disadvantage could therefore lower the risk of poor cardiovascular health among refugees. Future research is warranted to examine if results are generalizable to other immigrant groups, countries or time periods.

Healthcare professionals' perception of barriers and facilitators for care coordination of older adults with complex care needs being discharged from hospital: A qualitative comparative study of two Nordic capitals.

BACKGROUND: The handover of older adults with complex health and social care from hospital admissions to homebased healthcare requires coordination between multiple care providers. Providing insight to the care coordination from healthcare professionals' views is crucial to show what efforts are needed to manage patient handovers from hospitals to home care, and to identify strengths and weaknesses of the care systems in which they operate. OBJECTIVE: This is a comparative study aiming to examine healthcare professionals' perceptions on barriers and facilitators for care coordination for older patients with complex health and social care needs being discharged from hospital in two capital cities Copenhagen (DK) and Stockholm (SE). METHOD: Semi-structured interviews were conducted with 25 nurses and 2 assistant nurses involved in the coordination of the discharge process at hospitals or in the home healthcare services (Copenhagen n = 11, Stockholm n = 16). The interview guide included questions on the participants' contributions, responsibilities, and influence on decisions during the discharge process. They were also asked about collaboration and interaction with other professionals involved in the process. The data was analysed using thematic analysis. RESULTS: Main themes were communication ways, organisational structures, and supplementary work by staff. We found that there were differences in the organisational structure of the two care systems in relation to integration between different actors and differences in accessibility to patient information, which influenced the coordination. Municipal discharge coordinators visiting patients at the hospital before discharge and the follow-home nurse were seen as facilitators in Copenhagen. In Stockholm the shared information system with access to patient records were lifted as a facilitator for coordination. Difficulties accessing collaborators were experienced in both settings. We also found that participants in both settings to a high degree engage in work tasks outside of their responsibilities to ensure patient safety. CONCLUSIONS: There are lessons to be learned from both care systems. The written e-communication between hospitals and home health care runs more smoothly in Stockholm, whereas it is perceived as a one-way communication in Copenhagen. In Copenhagen there are more sector-overlapping work which might secure a safer transition from hospital to home. Participants in both settings initiated own actions to weigh out imperfections of the system.

Opportunities for transitional care and care continuity following hospital discharge of older people in three Nordic cities: A comparative study.

AIM: To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm. METHODS: Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared. RESULTS: In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm). CONCLUSIONS: Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.

Disability pension among persons with chronic disease: Differential impact of a Danish policy reform.

BACKGROUND: In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type. METHODS: The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated. RESULTS: Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs. CONCLUSION: Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

What is the effect of changing eligibility criteria for disability benefits on employment? A systematic review and meta-analysis of evidence from OECD countries.

BACKGROUND: Restrictions in the eligibility requirements for disability benefits have been introduced in many countries, on the assumption that this will increase work incentives for people with chronic illness and disabilities. Evidence to support this assumption is unclear, but there is a danger that removal of social protection without increased employment would increase the risk of poverty among disabled people. This paper presents a systematic review of the evidence on the employment effects of changes to eligibility criteria across OECD countries. METHODS: Systematic review of all empirical studies from OECD countries from 1990 to June 2018 investigating the effect of changes in eligibility requirements and income replacement level of disability benefits on the employment of disabled people. Studies were narratively synthesised, and meta-analysis was performed using meta-regression on all separate results. The systematic review protocol was registered with the Prospective Register for Systematic Reviews (Registration code: PROSPERO 2018 CRD42018103930). RESULTS: Seventeen studies met inclusion criteria from seven countries. Eight investigated an expansion of eligibility criteria and nine a restriction. There were 36 separate results included from the 17 studies. Fourteen examined an expansion of eligibility; six found significantly reduced employment, eight no significant effect and one increased employment. Twenty-two results examined a restriction in eligibility for benefits; three found significantly increased employment, 18 no significant effect and one reduced employment. Meta-regression of all studies produced a relative risk of employment of 1.06 (95% CI 0.999 to 1.014; I2 77%). CONCLUSIONS: There was no firm evidence that changes in eligibility affected employment of disabled people. Restricting eligibility therefore has the potential to lead to a growing number of people out of employment with health problems who are not eligible for adequate social protection, increasing their risk of poverty. Policymakers and researchers need to address the lack of robust evidence for assessing the employment impact of these types of welfare reforms as well as the potential wider poverty impacts.

Inequalities in extending working lives beyond age 60 in Canada, Denmark, Sweden and England-By gender, level of education and health.

BACKGROUND: Keeping older workers in employment is critical for societies facing the challenge of an ageing population. This study examined the association between types of health conditions and differentials in the probability of employment by level of education among men and women between 60-69 years of age in Canada, Denmark, Sweden and England. METHODS: Data were drawn from the Canadian Community Health Survey, Survey of Health, Ageing and Retirement in Europe and English Longitudinal Study of Ageing. We combined country data, applied logistic regression, adjusted for educational level, and stratified the analysis by sex to calculate the odds ratio (OR) of employment (>15 hours work per week) for persons with physical health conditions, mental health conditions (depression) and physical-mental health comorbidity. RESULTS: The odds of employment among men and women with physical-mental health comorbidity were lower compared to those with no/other conditions (men: OR 0.32, 95% CI: 0.25-0.42, women: OR 0.38 95% CI: 0.30-0.48). Women with low education had lower odds of employment compared to their counterparts with high education (OR 0.66, 95% CI: 0.57-0.76). The odds of employment at older ages was lower in Canada, Denmark and England compared with Sweden (e.g. English men: OR 0.48 95% CI 0.40-0.58; English women OR 0.33 95% CI 0.27-0.41). CONCLUSIONS: The odds of employment beyond age 60 is lower for groups with low education, particularly women, and those with physical-mental health co-morbidities. As such, policies to extend working lives should not be 'one size fits all' but instead consider subgroups, in particular, these groups that we have shown to be most vulnerable on the labour market.

The impact of longstanding illness and common mental disorder on competing employment exits routes in older working age: A longitudinal data-linkage study in Sweden.

OBJECTIVES: Comorbidity is prevalent in older working ages and might affect employment exits. This study aimed to 1) assess the associations between comorbidity and different employment exit routes, and 2) examine such associations by gender. METHODS: We used data from employed adults aged 50-62 in the Stockholm Public Health Survey 2002 and 2006, linked to longitudinal administrative income records (N = 10,416). The morbidity measure combined Limiting Longstanding Illness and Common Mental Disorder-captured by the General Health Questionnaire-12 (≥4)-into a categorical variable: 1) No Limiting Longstanding Illness, no Common Mental Disorder, 2) Limiting Longstanding Illness only, 3) Common Mental Disorder only, and 4) comorbid Limiting Longstanding Illness+Common Mental Disorder. Employment status was followed up until 2010, treating early retirement, disability pension and unemployment as employment exits. Competing risk regression analysed the associations between morbidity and employment exit routes, stratifying by gender. RESULTS: Compared to No Limiting Longstanding Illness, no Common Mental Disorder, comorbid Limiting Longstanding Illness+Common Mental Disorder was associated with early retirement in men (subdistribution hazard ratio = 1.73, 95% confidence intervals: 1.08-2.76), but not in women. For men and women, strong associations for disability pension were observed with Limiting Longstanding Illness only (subdistribution hazard ratio = 11.43, 95% confidence intervals: 9.40-13.89) and Limiting Longstanding Illness+Common Mental Disorder (subdistribution hazard ratio = 14.25, 95% confidence intervals: 10.91-18.61), and to a lesser extent Common Mental Disorder only (subdistribution hazard ratio = 2.00, 95% confidence intervals: 1.31-3.05). Women were more likely to exit through disability pension than men (subdistribution hazard ratio = 1.96, 95% confidence intervals: 1.60-2.39). Common Mental Disorder only was the only morbidity category associated with unemployment (subdistribution hazard ratio = 1.70, 95% confidence intervals: 1.36-2.15). CONCLUSIONS: Strong associations were observed between specific morbidity categories with different employment exit routes, which differed by gender. Initiatives to extend working lives should consider older workers' varied health needs to prevent inequalities in older age.

Too sick to work, too healthy to qualify: a cross-country analysis of the effect of changes to disability benefits.

BACKGROUND: Denmark and Sweden have implemented reforms that narrowed disability benefit eligibility criteria. Such reforms in combination with increasing work demands create a pincer movement where in particular those with moderate health problems might be unable to comply with work demands, but still not qualify for permanent disability benefits, ending up with temporary means-tested or no benefits. This paper examines whether this actually happened before and after the reforms. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) study waves 1-2 and 4-6 in Denmark and Sweden for the age group 50-59 years (N=5384) was used to analyse changes in employment rates and benefits among people with different levels of health before, during and after disability benefit reforms. Interaction between time and health in relation to employment versus permanent or temporary benefits was used as a criterion for whether our hypotheses was confirmed. RESULTS: Overall, employment rates have increased in the age group, but only among the healthy. The OR for receiving temporary or no benefits increased from 1.25 (95% CI: 0.81 to 1.90) before to 1.73 (95% CI: 1.14 to 2.61) after policy reforms for the 29% with moderate health problems and from 2.89 (95% CI: 1.66 to 5.03) to 6.71 (95% CI: 3.94 to 11.42) among the 11% with severe health problems. The interaction between time and health was statistically significant (p<0.001). CONCLUSION: People with impaired health and workability are forced into a life with temporary means-tested or no benefits when pressed by rising work demands and stricter disability benefit eligibility criteria.

Inequalities in employment rates among older men and women in Canada, Denmark, Sweden and the UK.

BACKGROUND: In most developed countries, governments are implementing policies encouraging older persons to work past 65 years to reduce the burden on societies related to disability benefits and pension payments. Despite this push to extend working lives, we know little about who already works past this age and any inequalities that may exist. Our study investigates the employment rates of those aged 65-75 years of age by educational level, health status and sex in Canada (CAN), Denmark (DK), Sweden (SE) and the United Kingdom (UK). Secondly, we aim to relate findings on employment rates to prevailing policies in the different countries, to increase the understanding on how to further extend working lives. METHODS: We used nationally representative cross-sectional survey data from the 2012-2013 Canadian Community Health Survey, 2013/14 Survey of Health, Ageing and Retirement in Europe for Denmark and Sweden and the 2013 English Longitudinal Study of Ageing to examine employment rates for those aged 65-75 years by sex, educational level and health status (having limiting longstanding illness (LLI) or not). RESULTS: Employment rates decline by age, but we see a linear decline in CAN and the UK compared to an initial decline then a plateau of employment rates from 66 to 68 years in DK and SE. Employment rates among persons aged 65-75 years were lower in the UK than in CAN, DK and SE. Among women, employment rates were highest in SE. Women with low education and a LLI had considerably lower employment rates than men with low education and a LLI (employment rates for men ranged from 27% to 12% compared with employment rates for women which ranged from 12% to 0%). CONCLUSIONS: Our results suggest that educational level, sex and health all play a role in extending working lives. The variation in employment rates between the four countries implies that policies do matter, but that social differentials show that policies cannot be 'one size fits all'. Policy-makers must consider different groups (i.e. low-educated women with a LLI) when designing policies to extend working lives.

The use of dialogue tools to promote dialogue-based and person-centred patient education for people with type 2 diabetes.

OBJECTIVES: To explore educator experiences of implementing dialogue tools in practice to engender participatory patient education. METHODS: Data were collected through qualitative interviews with 31 educators and 20 ethnographic observations of group-based education sessions at eight education sites. Data were analysed using systematic text condensation and the theoretical concepts of script and de-script. Three dialogue tools including 'My Illness and Me', 'Goals and Plan's and 'Wheel of Change' were selected for analysis because they were used most frequently. The tools are intended to support educators in facilitating participatory patient education. RESULTS: Consistent with the intended purpose of the dialogue tools, educators reported that the dialogue tools helped engender participatory education in the form of reflection and dialogue among participants regarding living with diabetes. However, educators also reported instances of discrepancies between the tools' intended purpose and their actual use because some participants found it difficult to relate to the tools. DISCUSSION: The application of dialogue tools to engender participatory patient education is highly dependent on educators' and participants' understanding and use of dialogue tools in practice. This implies that substantial educator skills are needed to facilitate dialogue and participation in patient education.

A dialogue-based approach to patient education.

In recent years, the need for person-centered patient education has become evident. To translate this approach into practice, new theoretically and empirically sound methods and models are required. This brief communication introduces a newly developed toolkit that has shown promise in facilitating person-centered education and active involvement of patients. Two health education models constituting the underlying basis for the toolkit are also presented.

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.

PURPOSE: The stressful migration process has been associated with higher vulnerability for mental health problems, implying a greater need for mental healthcare among immigrants compared with native-born. Our objective was to investigate whether potential differences in the use of psychiatrists and psychologists in labour immigrants, immigrants from refugee-generating countries (RGC), and ethnic Danes could be fully explained by mental health status. METHODS: We conducted a nationwide survey in 2007 with 3,573 individuals aged 18-66 comprising ethnic Danes, labour immigrants (Pakistan and Turkey), and immigrants from RGC (Iran, Iraq, Lebanon, and Somalia). Survey data was linked to healthcare utilisation registries. Using Poisson regression, contacts with private practising psychiatrists and psychologists were estimated. Analyses were adjusted for socioeconomic factors and mental health status. RESULTS: Overall, 2.2 % among ethnic Danes, 1.4 % among labour immigrants and 6.5 % among immigrants from RGC consulted a psychiatrist or psychologist. In adjusted analyses, for psychiatrists, compared with ethnic Danes, labour-immigrant women (multiplicative effect = 1.78), and immigrant women from RGC (multiplicative effect = 2.49) had increased use, while labour-immigrant men had decreased use (multiplicative effect = 0.03). For psychologists, immigrant men from RGC had increased use (multiplicative effect = 2.96), while labour-immigrant women had decreased use (multiplicative effect = 0.27) compared with ethnic Danes. CONCLUSIONS: Mental health status had a somewhat explanatory effect on the use of psychiatrists and psychologists. These selected parts of the Danish mental healthcare system seem responsive to health needs across different population groups, particularly for immigrants from RGC. Yet more attention should be given to non-Western labour immigrants to meet their mental health needs.

Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes.

AIM: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. METHOD: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. RESULTS: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. CONCLUSIONS: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

Undocumented migrants have diverse health problems.

INTRODUCTION: In 2008, 1.9-3.8 million undocumented migrants lived in Europe. We aimed to strengthen the evidence base on undocumented migrants' health problems by describing characteristics of undocumented migrant patients in a Danish non-governmental organisation (NGO) health clinic. MATERIAL AND METHODS: All patient files from the period from 24 August 2011 to 28 January 2013 were included in the study. Patient contacts were systematically analysed for age, sex, country of origin, medical referrals, symptoms and diagnoses. Contacts were classified by patient complaints or symptoms based on the International Classification of Primary Care, 2nd Edition (ICPC-2). RESULTS: A total of 830 patients (39.75% women and 60.25% men) visited the clinic, which led to a total of 2,088 visits and 1,384 ICPC-2 classifications. The patients seen had 94 different nationalities. The most common reasons for medical contact correspond well with the pattern seen in general practice and several chronic and severe cases were observed in the NGO clinic. Furthermore, a larger share of pregnant women presented (11.6%) compared with a Danish general practice (5.1%), and these were seen first in a late gestational age on average (16+ weeks). CONCLUSION: Undocumented migrants presented with diverse health problems. Some patients presented with critical disease, and an alarming number of pregnant women did not seek medical care until a late stage, and they did not return for infant care after giving birth. FUNDING: The study was funded by the Institute of Public Health, University of Copenhagen. TRIAL REGISTRATION: not relevant.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark.

BACKGROUND: Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients' refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems. METHODS: The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis. RESULTS: One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms. CONCLUSION: General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

Conceptual equivalence of WHOQOL-HIV among people living with HIV in Ethiopia.

PURPOSE: The WHOQOL instruments are intended for cross-cultural studies of quality of life (QoL) but African countries have been poorly represented in its development. This study aimed to explore the conceptual equivalence of WHOQOL-HIV in Ethiopia. METHODS: The fieldwork included home visits, interviews, and focus group discussions with HIV patients and caregivers. RESULTS: We found that although WHOQOL-HIV includes many relevant facets, its applicability has several limitations in the Ethiopian setting. The most salient shortcomings of the instrument relate to the Social, Environmental and Religion/Spirituality/Personal Beliefs domains of the instrument. Themes not captured by the instrument include family responsibilities, disease disclosure, exclusion from common resources, basic needs, adequate food, and job opportunities. In addition, several of the tool's facets such as dependence on medicine seem less relevant. Also, the role of religion is more complex than captured in WHOQOL-HIV. We found that the tool is based on an individualist focus, which tends to overlook the social context of the patient. CONCLUSION: We conclude that the conceptual equivalence of WHOQOL-HIV is only partially attained for use in Ethiopia. The findings from this qualitative study are used in the further process of developing and validating a QoL instrument for use in Ethiopia.

Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries.

PURPOSE: While there has been systematic research on the experiences of immigrant patients in mental health services within certain European countries, little research has explored the experiences of mental health professionals in the delivery of services to immigrants across Europe. This study sought to explore professionals' experiences of delivering care to immigrants in districts densely populated with immigrants across Europe. METHODS: Forty-eight semi-structured interviews were conducted with mental health care professionals working in 16 European countries. Professionals in each country were recruited from three areas with the highest proportion of immigrants. For the purpose of this study, immigrants were defined as first-generation immigrants born outside the country of current residence, including regular immigrants, irregular immigrants, asylum seekers, refugees and victims of human trafficking. Interviews were transcribed and analysed using thematic analysis. RESULTS: The interviews highlighted specific challenges to treating immigrants in mental health services across all 16 countries including complications with diagnosis, difficulty in developing trust and increased risk of marginalisation. CONCLUSIONS: Although mental health service delivery varies between and within European countries, consistent challenges exist in the experiences of mental health professionals delivering services in communities with high proportions of immigrants. Improvements to practice should include training in reaching appropriate diagnoses, a focus on building trusting relationships and measures to counter marginalisation.

Health care for irregular migrants: pragmatism across Europe: a qualitative study.

BACKGROUND: Health services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries. RESULTS: Semi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this. CONCLUSIONS: The needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.