[The Migration and Health Teaching Network: consolidating and developing education and training]. / Das Lehrnetzwerk Migration und Gesundheit: Aus- und Weiterbildung konsolidieren und weiterentwickeln.

Patients with migration history often encounter barriers to accessing healthcare in Germany, which lowers the quality of care available to them and can affect their overall health. These barriers in access to healthcare are due to both adverse health policies and a lack of migration-related - and diversity-sensitive - content in medical and other health profession teaching. Although most healthcare professionals regularly care for patients with individual or generational migration experience in Germany, teaching content relevant to the healthcare of these patients has not yet been anchored in the curriculum. At best, it is taught in the form of electives or other optional courses.To address this gap, the Teaching Network Migration and Health was created with the goal of promoting the development of human rights-based, diversity-sensitive, and equity-oriented curricula at medical and healthcare professions schools. It aims to (1) connect individuals active in teaching and promote the exchange and collaborative development of teaching materials, (2) use this collective knowledge and experience to develop a model course on migration and health, and (3) develop strategies for the longitudinal implementation of this course into the regular medical and other health professional school curricula. These efforts are flanked by evaluative accompanying research. Anyone interested in joining the network is invited to join and strengthen the network by contacting the authors.

Stepped, evidence-based and integrated care service model vs. usual care for mental disorders: A randomized controlled trial (RECOVER).

Stepped, evidence-based and integrated care service models have the potential to be used as a reference for mental health services. RECOVER aimed to evaluate cost savings, effectiveness, and cost-effectiveness of such a model within a two arm, assessor- and data analysist-blinded RCT in Hamburg, Germany. Participants aged 16-79 years with mental disorders were randomly assigned either to RECOVER or treatment as usual (TAU). Primary outcomes comprised costs, effectiveness (combined symptoms, functioning, quality of life), and cost-effectiveness, hierarchically ordered. Outcomes were evaluated according to the ITT principle, group differences regarding costs with adjusted generalized linear models, effectiveness with ANCOVA models, and cost-effectiveness with the incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curves (CEACs). Between 1/1/2018 and 12/31/2020, n = 891 were finally included (n = 477 in RECOVER, n = 444 in TAU). RECOVER was associated with significantly lower annual total costs (-22 %), health and social care costs (-25 %) and hospital costs (-50 %). Effectiveness analyses showed a significantly better outcome for RECOVER with the fully imputed data . The CEACs descriptively demonstrated that RECOVER was cost-effective with a probability of >95 %. Treatment in RECOVER resulted in substantial cost reductions with better cost-effectiveness. RECOVER can be recommended as a reference model for comprehensive and integrated mental health services.

Interprofessional collaboration to support patients with social problems in general practice-a qualitative focus group study.

BACKGROUND: Social problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions. This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised. METHODS: We carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories. RESULTS: GPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers. CONCLUSIONS: Our stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.

[Diabetes education of Turkish people with low literacy skills: Results of an online survey of training practices]. / Diabetesschulung von türkeistämmigen Menschen mit geringen schriftsprachlichen Kompetenzen - Ergebnisse einer Online-Befragung von schulenden Praxen.

INTRODUCTION: For patients with diabetes mellitus, training is an essential part of therapy. There is a lack of empirical data regarding training experiences for people with a (Turkish) migration background and low literacy skills concerning the established training programmes. The objective of this research was to collect data from general practices based on their experiences in training these particular groups of patients. METHODS: In a quantitative cross-sectional study design, 795 general practices throughout Germany with the additional designation of diabetology were invited via e-mail to participate in a fully structured, standardised online survey. An exploratory data analysis was performed using the statistics software IBM SPSS. RESULTS: Out of 146 participating practices (response rate 18%), 66 (45%) estimated the proportion of patients with migration background in their practice to be more than 20%. Approximately 76% of the practices providing diabetes training (n=119) trained patients of Turkish origin. Forty six percent of these practices estimated the ratio of patients of Turkish origin with low literacy skills to be 10 to 50%. Less than 36% of the practices were aware of suitable training programmes for this target group. Existing programmes were modified to special needs and new materials creatively developed. Additional culturally sensitive and visually enriched materials are needed. Forty two percent of the interviewed practices reported billing difficulties concerning frequently needed individual trainings. DISCUSSION: Training was carried out in different ways due to individual addition or deletion of content elements. There is a lack of evaluated materials that are adapted to the users' cultural background and level of education. In the face of a significantly changed immigration structure, information and materials as well as interpreters for additional languages are increasingly required. CONCLUSION: Further development of evidence-based, multi-lingual, image-based, culturally sensitive and educationally diverse materials and training units and their scientific evaluation is needed. Learning contents adapted to the level of education and promoting cultural sensitivity in the provision of healthcare should be implemented increasingly in the training and continuous professional development of health professionals.

Referrals to secondary care in an outpatient primary care walk-in clinic for refugees in Germany: results from a secondary data analysis based on electronic medical records.

OBJECTIVES: The aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals). DESIGN: Retrospective longitudinal observational study. SETTING: The study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016. PARTICIPANTS: 1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa. PRIMARY AND SECONDARY OUTCOME MEASURES: The endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients' diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin. RESULTS: Referrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were 'eye' (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), 'teeth/gum symptom/complaint or disease' (3.51; 2.52 to 4.9; p≤0.001) and 'urological system/female or male genital' (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral. CONCLUSIONS: In most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.

Study protocol for a randomised controlled trial evaluating an evidence-based, stepped and coordinated care service model for mental disorders (RECOVER).

INTRODUCTION: Healthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care. METHODS AND ANALYSIS: The trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions. ETHICS AND DISSEMINATION: Ethical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications. TRIAL REGISTRATION NUMBER AND REGISTRY NAME: ClinicalTrials.gov (NCT03459664), RECOVER PROTOCOL VERSION: 19 March 2020 (V.3.0).

[Social problems in primary health care - prevalence, responses, course of action, and the need for support from a general practitioners' point of view]. / Soziale Probleme in der hausärztlichen Versorgung ­ Häufigkeit, Reaktionen, Handlungsoptionen und erwünschter Unterstützungsbedarf aus der Sicht von Hausärztinnen und Hausärzten.

BACKGROUND: Very often patients utilize primary care services for health conditions related to social problems. These problems, which are not primarily medical, can severely influence the course of an illness and its treatment. Little is known about the extent to which problems like unemployment or loneliness occur in a general practice setting. OBJECTIVES: What are the most frequent health-related social problems perceived by general practitioners (GPs)? How are these problems associated with GP- or practice characteristics? How do general practitioners deal with the social problems they perceive and what kind of support do they need? MATERIALS AND METHODS: Cross-sectional, postal questionnaire survey with questions derived from "Chapter Z social problems" of the International Classification of Primary Care - 2nd edition. The questionnaire was mailed to available GP addresses in the federal states of Hamburg (n=1,602) and Schleswig-Holstein (n=1,242). RESULTS: N=489 questionnaires (17.2 %) were analyzed. At least three times a week, GPs were consulted by patients with poverty/financial problems (53.4 %), work/unemployment problems (43.7 %), patients with loneliness (38.7 %) as well as partnership issues (25.5 %). Only rarely did GPs report having perceived assault/harmful event problems (0.8 %). The highest frequency of problems was encountered by practices with a high proportion of a migrant population. CONCLUSIONS: Social problems are a common issue in routine primary care. GPs in Northwestern Germany usually try to find internal solutions for social problems but also indicated further interest in institutionalized support. A possible approach to solving these issues are community-based, locally organized networks.

Cultural Competence and Global Health: Perspectives for Medical Education - Position paper of the GMA Committee on Cultural Competence and Global Health.

Introduction: Routine medical care in Germany, Austria and Switzerland is being increasingly impacted by the cultural and linguistic diversity of an ever more complex world. Both at home and as part of international student exchanges, medical students are confronted with different ways of thinking and acting in relation to health and disease. Despite an increasing number of courses on cultural competence and global health at German-speaking medical schools, systematic approaches are lacking on how to integrate this topic into medical curricula. Methodological approach: This paper is based on a structured consensus-building process by a multidisciplinary committee composed of faculty and students. In a first step, a qualitative online survey was carried out in order to establish an inventory of definitions and concepts. After the second step, in which a literature search was conducted and definitions of global health and transcultural and intercultural competence were clarified, recommendations were formulated regarding content, teaching and institutional infrastructure. Based on small-group work and large-group discussions, different perspectives and critical issues were compiled using multiple feedback loops that served to ensure quality. Results: An inventory on the national and international level showed that great heterogeneity exists in regard to definitions, teaching strategies, teaching formats and faculty qualification. Definitions and central aspects considered essential to medical education were thus established for the use of the terms "cultural competence" and "global health". Recommendations are given for implementation, ranging from practical realization to qualification of teaching staff and education research. Outlook: High-quality healthcare as a goal calls for the systematic internationalization of undergraduate medical education. In addition to offering specific courses on cultural competence and global health, synergies would be created through the integration of cultural competence and global health content into the curricula of already existing subject areas. The NKLM (the national competence-based catalogue of learning objectives for undergraduate medical education) would serve as a basis for this.