Patientinnenorientierung im Kontext der soziokulturellen Vielfalt im Krankenhaus : Vergleich der Erfahrungen und Wahrnehmungen deutscher und türkischsprachiger Patientinnen sowie des Klinikpersonals zur Versorgungssituation in der Gynäkologie

Immigrantinnen machen in Frauenkliniken deutscher Großstädte bis zu einem Drittel der Patientinnen aus, jedoch liegen kaum Kenntnisse über ihre Versorgungsbedürfnisse vor. Für eine bedarfsgerechte Ausrichtung der Gesundheitsversorgung gewinnt die Berücksichtigung der soziokulturellen Herkunft der PatientInnen auch unter ökonomischen Aspekten an Bedeutung. Um die Versorgungsqualität für Patientinnen unterschiedlicher Ethnizität zu untersuchen, vergleicht diese Studie 262 türkischsprachige und 320 deutsche Patientinnen einer gynäkologischen Klinik in Berlin. Bilinguale Fragebögen und explorative Interviews mit jeweils 50 Patientinnen jeder Gruppe konzentrieren sich auf die Inanspruchnahme niedergelassener GynäkologInnen, Laienwissen über Gesundheit, subjektive Krankheitstheorien, Erwartungen und Zufriedenheit in der Klinik, Verständnis der medizinischen Aufklärung und die Patient-Personal-Interaktion. Die Sichtweisen des Klinikpersonals zur Migrantinnenversorgung werden durch eine Fragebogenbefragung von 69 MitarbeiterInnen und vertiefende Interviews erschlossen. Die Ergebnisse zeigen, dass die existierenden Versorgungskonzepte nicht geeignet sind, soziokulturelle und migrationsbedingte Unterschiede zwischen einheimischen und zugewanderten Frauen (z. B. Deutschkenntnisse, Bildungssituation, Gesundheitswissen) angemessen auszugleichen sondern die Partizipationsmöglichkeiten für Immigrantinnen stark einschränken. Während Patientinnen türkischer und deutscher Herkunft ähnlich hohe Ansprüche an eine gute Versorgung im Krankenhaus haben, werden insbesondere die Erwartungen an ausführliche Information und Aufklärung und eine umfassende psychosoziale Betreuung im Krankenhaus für Immigrantinnen nur unzureichend erfüllt. Bei der Entlassung aus der Klinik sind sie wesentlich schlechter über ihre Erkrankung und die erfahrene Therapie informiert und deutlich unzufriedener mit der Versorgung als die deutsche Vergleichsgruppe. Vor der stationären Behandlung wechseln sie aufgrund von Unzufriedenheit häufiger niedergelassene FrauenärztInnen. Beim Klinikpersonal offenbart sich eine kritische Haltung gegenüber der eigenen Versorgungsleistung, was vor allem auf Zeitmangel, organisatorische Probleme und inadäquate Strukturen für die Kommunikation mit Immigrantinnen zurückgeführt wird. Schwachstellen in der Versorgungsqualität für Immigrantinnen weisen auf konkreten Handlungsbedarf für die Verbesserung der Patientenversorgung und der Arbeitsbedingungen hin. Von der Orientierung der Versorgungskonzepte an unterschiedlichen Bedürfnissen verschiedener PatientInnengruppen und der Entwicklung entsprechender organisatorischer Strukturen (z.B. Dolmetscher, mehrsprachige Informationsmaterialien, interkulturelle Kompetenzen, Gesundheitsförderung) profitieren nicht nur Immigrantinnen sondern auch die MitarbeiterInnen und die Versorgungseinrichtungen selbst.Immigrant women account for up to 1/3 of patients in gynecological and obstetric hospitals in German cities, however very little is known about their health care needs and experiences. For adequate demand oriented and patient centered healthcare services as well as for economic considerations it is increasingly essential to consider the sociocultural background of the utilizers. Sociocultural diversity has changed the job description of hospital staff. To explore the quality of healthcare for patients of different ethnicities, this study compares 320 German patients and 262 patients of Turkish extraction on the same gynecological ward in Berlin. Bilingual questionnaires and explorative interviews with 50 patients of each group focus on previous experiences with gynecological services, patient-expectations and -satisfaction in the clinic, subjective theories of illness, lay knowledge about health, the comprehension of their illness and the medical treatment received and patients' views on the staff/patient relationship. To ascertain the views of clinic personnel, interviews and questionnaires with 69 members of staff were conducted. The results of this study indicate that existing health care concepts are not suitable to compensate sociocultural and migration related differences between Turkish and German women (e.g. proficiency in the German language, educational status, general health education) and that they are particularly detrimental to patient participation of immigrants. High expectations of all patients towards detailed medical information and profound psycho-social care in the clinic are inadequately met in the study group of immigrant women. At discharge they are less satisfied with the health care service and know less about their illnesses and their medical treatment than German patients. Prior to the clinic therapy they significantly more often change their gynecologists due to dissatisfaction. Hospital personnel has a critical view on their own professional performance. Miscellaneous factors such as general organizational problems, lack of time and the fact that healthcare services are insufficiently prepared to correspond adequately to immigrant patients have a negative impact on their job satisfaction. Since the quality of care of immigrant patients is severely impaired, this is an area of great potential for improvement of both patient care and working conditions. Considering immigrants' specific health care needs and implementing corresponding health care concepts (e.g. interpreters, multilingual material, intercultural competence, health promotion) is profitable for immigrant patients, staff and health care services at the same time

Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany

David M, Borde T, Brenne S, Henrich W, Breckenkamp J, Razum O. Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany. PLoS ONE. 2015;10(5): e0127489.Objective The frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants. Methods A standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers' antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status. Results The caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants. Conclusion Unlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history

Reasons for a Lower Rate of Epidural Anesthesia During Birth for Immigrant Women in the Eyes of Medical Staff: A Mixed-Methods Analysis

Various studies have shown that immigrant women in comparison to non-immigrant women of the same parity have lower rates of epidural anesthesia (EDA). Data from two studies on immigrant obstetric care in Berlin, Germany were analyzed to answer the following question: What reasons do the medical staff see for the lower rate of EDA in immigrant women? Between May and August 2017, 34 interviews with obstetricians and midwives in four obstetric clinics in Berlin were conducted on the topic of obstetric care for immigrant women. After anonymizing the more than 20 h of interview material, transcripts were coded with MaxQDa and analyzed according to the qualitative content analysis.The quantitative data is from an online survey conducted between May and October 2017, in all but one obstetric clinic in Berlin with obstetricians and midwives. Regarding the research question, 121 questionnaires could be analyzed. In the online survey, (multiple answers were possible), the top reason for a lower rate of EDA given was mostly fear on the part of the immigrant women (64%). A language barrier, which results in logistic and time constrictions, is mentioned as the second most frequent reason (50%). The explorative analysis of the interviews shows that doctors and midwives regard cultural aspects such as different expectations on the birth experience as a reason for a lower EDA rate. Furthermore, within the medical staff the impression persists that in some cases the companion decides on the behalf of the patient about the application of an EDA, which from time to time is against the wish of the immigrant woman giving birth. In the view of the medical staff, the reasons for a lower rate of EDA during birth for immigrant women were varied. On one side, this is attributed to the wishes of the respective women ("demand") but on the other side this can be attributed to the health care system ("supply"). In the case of a language barrier, the "supply" and the access of EDA for immigrant women is limited and can be then shifted to the German-speaking companion to make a decision regarding EDA ("structural deprivation of self-determination")

Inanspruchnahme von Notaufnahmen durch sog. Mehrfachnutzer/-innen: Ergebnisse einer prospektiven Studie unter besonderer Berücksichtigung des Migrationsstatus

Objectives: Can we identify predictive factors for the group of so-called multiple users (MU; 4 and more uses of an emergency department [ED] in the past 12 months)? Are people with a migration background more likely to be classified in the MU group? Methodology: Included were consecutive patients who visited three EDs in Berlin from July 2017 to July 2018. Using a questionnaire, diseases, reasons for visiting the ED and socioeconomic factors were recorded. Comparisons between migrants (1st generation), their descendants (2nd generation) and nonmigrants were assessed using logistic regression. Results: A total of 2339 patients were included in the evaluation (repeat rate 56%), of which 901 had a migration background. Young women (<30 years), chronically ill, pregnant women, patients with severe complaints and people with (self-assessed) moderate and poor health quality as well as those without medical referral had a greater chance of multiple use of ED. Conclusion: MU burden the already increasing patient volume of ED. However, they represent a heterogeneous group of patients, among whom people with a migration background are not common. Further research is warranted to better understand the factors that lead to frequent use and to develop effective strategies to address the complex health needs of MUs

cross-sectional study

Objective: Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Design: Cross- sectional study. Setting: Three obstetric hospitals in Berlin, Germany. Methods: Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. Results: The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). Conclusions: We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery)

Einfluss der (un)angemessenen Inanspruchnahme klinischer Notfallambulanzen und der verbalen Kommunikation auf die Zufriedenheit von Ärzten mit der Arzt-Patient-Interaktion unter besonderer Berücksichtigung des Migrationshintergrundes

In recent years, utilization of emergency departments (EDs) has increased continuously, both in Germany and internationally. Inappropriate use of EDs is believed to be partly responsible for this trend. The topic of doctor-patient interaction (DPI) has received little attention in research. However, successful DPI is not only important for adherence and treatment success, but also for the satisfaction of medical staff. This non-interventionl cross-sectional study attempts to identify factors influencing physicians' satisfaction with DPIs, with a particular focus on the appropriate utilization of EDs and verbal communication. We carried out tripartite data collection in three EDs of major referral hospitals in Berlin between July 2017 and July 2018. Migration experience, communication and language problems, level of education, and a large gap between physicians' and patients' perceived urgency regarding the utilization of EDs influence the quality of the doctor-patient relationships and interactions.In den letzten Jahren hat die Inanspruchnahme von klinischen Notaufnahmen (KNA) sowohl in Deutschland als auch international kontinuierlich zugenommen. Es wird angenommen, dass unangemessene Inanspruchnahmen von KNA mitverantwortlich für diesen Trend sind. Das Thema Arzt-Patient-Interaktion (API) ist in diesem Zusammenhang in der Forschung bisher wenig beachtet worden. Eine erfolgreiche API ist aber nicht nur für die Adhärenz und den Behandlungserfolg wichtig, sondern auch für die Zufriedenheit des medizinischen Personals. Im Rahmen einer nichtinterventionellen Querschnittsstudie wurden Einflussfaktoren auf die Zufriedenheit von Ärzten mit der API identifiziert, mit einem besonderen Fokus auf der angemessenen Nutzung von KNA und der verbalen Kommunikation. Zwischen Juli 2017 und Juli 2018 wurde in 3 großstädtischen KNA in Berlin eine dreigliedrige Datenerhebung durchgeführt. Migrationserfahrung, Kommunikations- und Sprachprobleme, Bildungsniveau und eine erhebliche Diskrepanz bei der wahrgenommenen Dringlichkeit der KNA-Inanspruchnahme beeinflussen die Qualität der Arzt-Patient-Beziehung und der Interaktion

Recommendations for collecting and analysing migration-related determinants in public health research

Background: According to the definition of the German Federal Statistical Office, about every fourth person living in Germany has a so-called migration background (MB), i.e., the person or at least one of their parents was born without German citizenship. However, MB has been defined differently in many studies. Also, the MB summarises people in different living situations, making differentiated analysis in health science more difficult. This article formulates recommendations for the collection and analysis of migration-related, as well as social and structural, determinants of health. Indicators for capturing relevant determinants of health: As part of the Improving Health Monitoring in Migrant Populations project (IMIRA), the previous approaches to operationalise and measure migration-related determinants were revised based on literature research and exchange formats, such as workshops, meetings, congress contributions, etc. Instead of MB, the country of birth of the respondents and their parents, duration of residence, citizenship(s), residence status, and German language proficiency should be recorded as minimum indicators and analysed as individual variables. Further social and structural determinants, such as socioeconomic position, working and housing conditions, or self-reported discrimination, should be included. Conclusions: In order to describe health inequalities and to specifically identify the needs of people with a history of migration, a mutual and differentiated consideration of migration-related and social determinants of health is essential

Advanced cervical dilatation as a predictor for low emergency cesarean delivery: a comparison between migrant and non-migrant Primiparae – secondary analysis in Berlin, Germany

Breckenkamp J, Läcke EM, Henrich W, et al. Advanced cervical dilatation as a predictor for low emergency cesarean delivery: a comparison between migrant and non-migrant Primiparae – secondary analysis in Berlin, Germany. BMC Pregnancy and Childbirth. 2019;19(1): 1.Background Cesarean rates are higher in women admitted to labor ward during early stages rather than at later stages of labor. In a study in Germany, crude cesarean rates among Turkish and Lebanese immigrant women were low compared to non-immigrant women. We evaluated whether these immigrant women were admitted during later stages of labor, and if so, whether this explains their lower cesarean rates. Methods We enrolled 1413 nulliparous women with vertex pregnancies, singleton birth, and 37+ week of gestation, excluding elective cesarean deliveries, in three Berlin obstetric hospitals. We applied binary logistic regression to adjust for social and obstetric factors; and standardized coefficients to rank predictors derived from the regression model. Results At the time of admission to labor ward, a smaller proportion of Turkish migrant women was in the active phase of labor (cervical dilation: 4+ cm), compared to women of Lebanese origin and non-immigrant women. Rates of cesarean deliveries were lower in women of Turkish and Lebanese origin (15.8 and 13.9%) than in non-immigrant women (23.9%). In the logistic regression analysis, more advanced cervical dilatation was inversely associated with the outcome cesarean delivery (OR: 0.76, 95%CI: 0.70–0.82). In addition, higher maternal age (OR: 1.06, 95%CI: 1.04–1.09), application of oxytocic agents (OR: 0.55, 95%CI: 0.42–0.72), and obesity (OR: 2.25, 95%CI: 1.51–3.34) were associated with the outcome. Ranking of predictors indicate that cervical dilatation is the most relevant predictor derived from the regression model. Conclusions Advanced cervical dilatation at the time of admission to labor ward does not explain lower emergency cesarean delivery rates in Turkish and Lebanese migrant women, despite the fact that this is the strongest among the predictors for emergency cesarean delivery identified in this study

Do social factors and country of origin contribute towards explaining a “Latina paradox” among immigrant women giving birth in Germany?

Zolitschka KA, Miani C, Breckenkamp J, et al. Do social factors and country of origin contribute towards explaining a “Latina paradox” among immigrant women giving birth in Germany? BMC Public Health. 2019;19(1): 181.Background The “Latina paradox” describes the unexpected association between immigrant status, which is often correlated to low socioeconomic status, and low prevalence of unfavourable birth outcomes. Social (e.g. culture, religion) and/or non-social factors related to country of origin are potentially responsible for this paradox. Methods Questionnaire survey of 6413 women delivering in three large obstetric hospitals in Berlin (Germany) covering socioeconomic and migration status, country of origin (Turkey, Lebanon), and acculturation. Data was linked with routine obstetric data. Logistic regressions were performed to assess the effect of acculturation, affinity to religion and country of origin on preterm birth and small-for-gestational-age (SGA). Results Immigrant women with a low level of acculturation (reference) were less likely to have a preterm birth than those who were highly acculturated (aOR: 1.62, 95%CI: 1.01–2.59), as were women from Turkey compared to non-immigrants (aOR: 0.49, 95%CI: 0.33–0.73). For SGA, we found no epidemiologic paradox; conversely, women from Lebanon had a higher chance (aOR: 1.72, 95%CI: 1.27–2.34) of SGA. Affinity to religion had no influence on birth outcomes. Conclusions There is evidence that low acculturation (but not affinity to religion) contributes towards explaining the epidemiologic paradox with regard to preterm birth, emphasising the influence of socioeconomic characteristics on birth outcomes. The influence of Turkish origin on preterm birth and Lebanese origin on SGA suggests that non-social factors relating to the country of origin are also at play in explaining birth outcome differences, and that the direction of the effect varies depending on the country of origin and the outcome

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study

Razum O, Reiss K, Breckenkamp J, et al. Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study. BMJ Open. 2017;7(8): e015913.Objective Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Design Cross-sectional study. Setting Three obstetric hospitals in Berlin, Germany. Methods Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. Results The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). Conclusions We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery)