Cross-cultural training program on mental health care for refugees - a mixed method evaluation

(2021) 21:533 McDonald et al. BMC Med Educ https://doi.org/10.1186/s12909-021-02965-5 Open Access RESEARCH Cross-cultural training program on mental health care for refugees - a mixed method evaluation Jordanos Tewelde McDonald1*, Marie Dahlin2 and Sofie Bäärnhielm3 Abstract Background: Refugees tend to have a higher risk of mental ill-health and use mental health services less than the native-born population during their first 10 years in Sweden. Intercultural interactions between refugees and mental health professionals have been described as challenging. Cross-cultural training is proposed as one way to improve care for refugees. Evaluations of such training outcomes are sparse. The overall aim of this study was to evaluate Comprehensive Cross-Cultural Training for mental health care professionals in Stockholm, and to assess training outcomes for participants’ perceived knowledge regarding mental health and care for newly arrived refugee patients, asylum seekers and undocumented refugees. In addition, we analysed the dimensionality of the pre- and post-training questionnaires used. Methods: An embedded mixed-method design was applied. We used pre-and post-training questionnaires (n = 248) and conducted six focus group discussions (FGDs) with mental health professionals after training. Quantitative data was analysed by t-tests and factor analysis, qualitative data was analysed using thematic content analysis. Results: Participants experienced gained knowledge and new perspectives in all aspects covered in the training. Training led to participants restructuring their existing knowledge. Those who had reported experience of refugee patients and working with interpreters pre-training in the past month, had higher ratings of perceived knowledge. Post-training, there were no significant changes in perceived knowledge between those with, and those without, experience of refugee patients and working with interpreters. Factor analysis resulted in 3 factors for the pre-training questionnaire, explaining 71% of the covariance, and 4 factors for the post-training questionnaire, explaining 78% of the covariance. Findings from the post-training FGDs, revealed that refugee patients were described as challenging. Also, that training promoted empathy towards refugees and strengthened participants’ professional role. Conclusions: This cross-cultural training contributed to knowledge development and attitude changes. It was valuable regarding care providers’ professional role. Additional outcomes of the training were that participants not only gained knowledge about refugee mental health care but also restructured their existing knowledge. Keywords: Cross-cultural training, Mental health care, Refugees, Asylum seekers *Correspondence: 1 Department of Global Public Health, Karolinska Institute & Transcultural Centre, Region Stockholm, Solnavägen 4, 11365 Stockholm, Sweden Full list of author information is available at the end of the article Background Given that refugees tend to have a higher risk of mental ill-health [1], along with lower mental health care utilization in Europe [2, 3], there is an urgent need of improvement of mental health services. Intercultural communication and interaction between health care © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. McDonald et al. BMC Med Educ (2021) 21:533 professionals and refugee patients have been described as challenging [4–6] and require knowledge and skills among professionals. Knowledge among professionals makes cross-cultural training for mental health care providers a key factor in improving care for refugees [5–7]. The migration process influences the health of migrants, in particular refugees and asylum seekers [1– 8]. Prevalence of mental disorders such as depression, anxiety, post-traumatic stress, and psychosis is higher among refugees than other migrants and natives [1–3, 7, 9–12]. A Swedish study showed that approximately 33% of the newly arrived refugees from Syria and asylum seekers from Eritrea and Somalia had mental health problems, such as depression and anxiety [13]. Despite the likelihood of higher psychopathology among refugee groups, there are European data suggesting that refugees use less mental health services than the native population [2, 3, 7, 11, 14]. In Sweden, utilization of psychiatric care among migrants is lower than for the Swedish-born population during the ten first years, apart from compulsory care where care consumption is higher [15, 16]. Barriers to mental health care among migrants are seen both on the individual and structural level [1, 2, 5, 8, 11, 12, 14, 15, 17, 18]. Further, barriers both from the perspective of refugees and asylum seekers, as well as from service providers, may contribute to the lower use of mental health care. Regarding refugees and asylum seekers, they face barriers related to language problems, stigma, lack of information about mental health care and lack of cultural sensitivity in the mental health care services [1, 2, 5, 8, 11, 12, 14, 15, 17, 18]. Barriers facing the service providers are linked to lack of competency in intercultural communication [6] and working with cultural variety among this group of patients [5, 6, 17, 18]. Swedish mental health care professionals’ understanding of rights to care for asylum seekers’ and undocumented refugees may be additional barriers [19]. Mental health care for asylum seekers and refugees in Stockholm Sweden has received a great number of refugees and asylum seekers, creating challenges for mental health care to adapt to the need of the newcomers. Between 2000 and 2018, Sweden received 733,827 asylum seekers [20] with a peak in 2015, when approximately 164,000 were seeking asylum. Between 2015 and June 2019, 106,287 unaccompanied minors arrived [20]. Most of the refugees came from Syria, Eritrea, Iraq, Somalia and Afghanistan, countries affected by war, conflict or economic crises [8, 13, 20– (...truncated)