Exploring the Dimensions of Mental Healthcare Accessibility for Vulnerable Migrant Groups and Actions to Improve Access: A Qualitative Study Conducted in Munich, Germany

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Furthermore, migrants face barriers to accessing mental healthcare. This study aims to explore the dimensions influencing mental healthcare access for migrants in Munich, Germany and to develop recommendations for action. Methods: The study used a two-phase qualitative approach. Phase 1 included individual interviews with 24 migrants from three vulnerable groups (students, refugees, and LGBTQ+ people). Based on the data gathered, seven interviews with health professionals experienced in mental health services for migrants were conducted in Phase 2. The framework from Levesque et al. was applied for analyzing and conceptualization of the dimensions of healthcare access. The health professionals’ proposed actions were grouped based on their respective levels as macro, meso, and micro. Validation was achieved by reviewing the data analysis during a meeting attended by all authors and a professional who was not involved in the interviews. Results: The dimensions of mental healthcare access encompassed: 1) ability to perceive mental problems, including stigma and knowledge about mental health; 2) ability to seek care, encompassing knowledge about the new healthcare system and social support; 3) acceptability of services, involving provider identity and gender; 4) availability and affordability, including insurance coverage, bureaucratic processes, and capacity and geographical distribution of services; 5) appropriateness including providers’ and patients’ understanding of mental healthcare, and providers’ competence. Language and culture exhibited a strong interplay across all dimensions. The analysis yielded 17 action recommendations. Macro-level recommendations target barriers caused by discrimination and inequality. Meso-level recommendations included increased care capacity and coordination and eliminating language and culture barriers in health services. The micro-level recommendations included activities to promote mental health. Conclusion: Migrants face numerous barriers to mental healthcare due to health system and providers in Munich. However, culture and language remain the most important access factors, necessitating social support. Actions pertaining to acceptability, accessibility, affordability, and appropriateness of health services are required to ensure that all individuals, including migrants, have access to mental healthcare. However, improving migrant mental health begins with the removal of structural barriers created by discrimination and inequality at the macro level. Migrants Mental health Access to healthcare Barriers Recommendations for action Qualitative study Figures Figure 1 Figure 2 Figure 3 BACKGROUND Migration is a highly complex experience that has different motives and consequences for each person [1]. Every stage of the migration process can be fraught with difficulties, ranging from poor living conditions or violence in the country of origin and traumatic experiences during migration to adapting to a new culture in the resettlement country [1, 2]. These stressors increase migrants' vulnerability to mental health problems [2, 3]. Furthermore, for the majority of migrants, these stressors are exacerbated by mental health risks associated with gender roles, pre-existing conditions, a lack of language proficiency, precarious living and working conditions, legal status uncertainty, social isolation and loneliness, and discriminatory experiences [1, 4]. Particular groups of people, including refugees, asylum seekers, undocumented migrants, older adults, international students, unaccompanied minors, victims of trafficking, migrant detainees, and LGBTQ+ individuals, are more susceptible to these risks due to the interaction between the various vulnerability mechanisms [1, 2, 4]. A substantial part of migrants experience symptoms such as anxiety, sadness, hopelessness, stress, sleep disturbances or anger as a result of migration [2, 5]. Studies indicate a higher prevalence of common mental disorders, such as depression and post-traumatic stress disorder (PTSD), among migrant populations compared to the general population of the host communities [2, 5–7]. Some migrant groups are also more susceptible to psychotic disorders than the resident population [2, 5, 7]. Migrant populations not only face more mental health issues, but they also have less access to healthcare in general and more specifically for mental health-related problems [3, 4]. Lack of knowledge on services, communication difficulties, stigma, legal restrictions or the absence of culturally sensitive healthcare services are frequently reported barriers of access to mental healthcare for migrants [8–10]. Mental healthcare for migrants in Germany As one of the most popular destination countries in Europe, Germany has accommodated a considerable number of migrants, including a large proportion of refugees and economic migrants [11, 12]. Research on mental disorders among this diverse group is limited in Germany [13, 14], but existing studies on specific migrant populations such as elderly migrants [15], or asylum seekers and refugees [13, 16, 17] suggest an increased burden of conditions like depression or PTSD. The German healthcare system includes statutory health insurance covering 90% of the population and private health insurance covering the remaining 10%. Nearly all people with a migration background are eligible for either statutory health insurance or private health insurance [18]. However, asylum seekers are not included in the regular insurance system and their healthcare is differing between the 16 German federal states. In Bavaria, a state in the south-east of Germany, they must seek approval from the relevant authorities before every doctor's visit to obtain a treatment certificate. Reimbursement is usually limited to acutely treatable conditions, encompassing psychiatric services but mostly hindering access to psychotherapy. Instead, psychotherapeutic treatment is predominantly provided at specialized psychosocial treatment centres [16]. Other migrant groups also encounter barriers to accessing mental healthcare in Germany, leading to their underrepresentation in inpatient psychiatric and psychotherapeutic facilities [13, 19]. Guidelines [20] and position papers [21] were published to improve mental healthcare for migrants, emphasizing early detection of mental problems in migrants, cultural sensitivity in healthcare, the availability of interpreters, and better information for migrants. More recent research focused on the importance of the German healthcare system's intercultural opening, while underlining that too little of the recommendations have been implemented so far [19, 22]. Given the increasing number of refugees in Germany since 2015 [11] and the mental health challenges exacerbated among migrant populations by the COVID-19 pandemic [23], ensuring access to mental healthcare for vulnerable migrants in Germany is crucial. Achieving this goal necessitates an update of the existing action recommendations, particularly since none of these previous guidelines involved the viewpoints of migrants themselves. This study aimed at exploring the facilitators and barriers of migrants' access to mental healthcare from the perspectives of migrants and health professionals in Munich, Bavaria and to derive to conclusions what actions could be taken to improve migrants' access to mental healthcare in Munich and beyond. METHODS 2.1 Study design This qualitative study was conducted in two phases (Figure 1). In the first phase, access to mental healthcare was explored from the perspective of migrants and content analysis was carried out utilizing the framework of Levesque et al. [24]. This framework outlines access to health services in ten dimensions with five considerations from the patient's perspective and five from the provider's perspective. From the provider's perspective, the first dimension is approachability, which corresponds to the ability to perceive on the patient side. Acceptability on the provider's side and ability to seek on the patient's side are related to individual characteristics such as culture and gender that may differ between the two. Provider availability and ability of the patient to reach refer to the local and timely accessibility of healthcare facilities. The seventh and eighth dimensions include the provider affordability and the patient's ability to pay. The final two factors, provider appropriateness and patient ability to engage, influence outcomes of the care. In the second phase, expert interviews were used to validate the research findings, which had been schematized and summarized using a version of the Levesque model. During these interviews, recommendations for action to improve mental healthcare access for migrants were discussed and then categorized and formulated through an iterative coding process. 2.2 Study setting The study took place in the metropolitan area of Munich, a city in Southern Germany and the capital of the state of Bavaria. Owing to its geographical proximity to the country's border, Munich is home to a large share of refugees who are accommodated in a variety of facilities, including state and local refugee shelters as well as arrival centres [25]. In addition, Munich has a robust economy, a sizable employment market and three internationally recognized universities, making it an attractive destination for many migrants. With 18.48% of the population having a migration background and 30.07% being foreign nationals, foreigners constitute to the majority the population [26]. Munich thus plays a significant role in shaping German asylum policies and delivers various forms of aid to refugees and migrants, including one of Bavaria's few psychosocial treatment centres [27]. More than half of the social organizations and initiatives receiving financial support from the city are related to migration [28]. 2.3 Phase 1 – The perspective of migrants Recruitment and study population The study included participants from the German component of the SonarGlobal project, a five-country European Union initiative to investigate the effects of the COVID-19 pandemic on vulnerable populations [29]. Of the 82 people aged 18 and above reached in the SonarGlobal Project, 24 people with migration background who were living in Munich metropolitan area were included in the present study. The criteria for having a migrant background in this project included not being born in Germany, living the first half of one's life outside of Germany, or having both non-German parents. Self-report of a migration background was also considered, and people were included in this group if they reported having a migrant background. Considering accessibility and the possibility of representing multiple vulnerability mechanisms, it was decided to limit the scope of the study population to three distinct groups with migration experiences: 1) LGBTQ+ individuals; 2) international students; 3) asylum-seekers. Three fieldworkers were recruited who were able to connect with these groups through their networks in addition to using the snowball sampling technique. While international students were included in the study, the criterion of having at least one vulnerability factor such as precarious housing, severe financial insecurity, a lack of social support, a higher likelihood of being discriminated against because of their appearance was taken into account. Special attention was given to ensuring variation in terms of age, gender, and ethnicity among the participants. Data collection The Vulnerability Assessment Tool, consisting of a demographic questionnaire and a semi-structured interview guide, was translated into German and Persian and modified for use in Germany during the interviews [29, 30]. Participants were asked during the in-depth interviews about sociodemographic characteristics, such as age, gender, and ethnicity, household features (type of dwelling, ownership of the house, persons living in the household), income and expenses (sufficiency of income, any financial support, healthcare insurance, burden of healthcare expenses), employment (current job, number of working hours, place of work, and the likelihood of a change in all of these within six months), social relationships, health status and access to healthcare. The interviews were conducted by three fieldworkers with previous experience in qualitative methodologies. They received training and ongoing support to use the Vulnerability Assessment Tool. Eighteen interviews were conducted face-to-face, while six were done online. The interviews took place in private settings, with only the interviewer and interviewee present. Due to the COVID-19 pandemic, infection control measures such as masks were used in face-to-face interviews. Of the interviews, ten were conducted in English, eight in Persian, and six in German. The Persian interviews were subsequently translated into English by the interviewer, whose first language was Persian. All interviews took place between April and May 2021. Data analysis The interviews were transcribed as verbatim transcripts by the respective interviewer. The coding was done in a three-part iterative process applying the content analysis approach based on Mayring and Fenzl [31] by using the software MAXQDA. The open codes were developed by ZÖ and MC for the entire dataset of the German SonarGlobal project. The coding process incorporated the field workers' notes from the interviews. SB and ZÖ reviewed the dataset, extracting open codes and data related to mental healthcare through mutual agreement. In the second round, SB refined the list of codes, and established sub-codes. In consultation with ZÖ, the codes and sub-codes were further categorized. The researchers then discussed the categories related to determinants of access to mental care in considering the Levesque's access framework, grouped these categories under domains and visualised their connections. This new designed framework is a version of Levesque's access model that focuses on migrants' access to mental health services. An iterative process was used to assess completeness and validity of this framework by summarizing and discussing the determinants in the interviews conducted during Phase 2. SB translated the German quotes into English, maintaining the original words and syntax, even if it required translating grammatical mistakes. Afterwards, the original quotes and their translations were examined with ZÖ. Because all Persian interviews had already been translated into English, there was no need to translate these quotes. Phase 2 - The health professionals’ perspective and recommendations for action Recruitment and study population Health professionals with at least of one year of practical experience in Germany treating persons with mental health problems and migration background were considered experts. Researchers conducted an internet search to identify psychotherapists, psychiatrists, and family physicians in Munich whose patients were mainly or solely migrants. It was based on the identification of areas with significant migrant populations, particularly inside major urban areas, and on the availability of services in foreign languages. Additionally, the search was expanded by including contacts using snowball sampling. Potential experts were contacted via email and invited to participate in individual interviews. No one refused to participate. A total of seven interviews were conducted until data saturation was achieved. Following the completion of the data analysis, an additional expert was invited to the research team's meeting to validate the results, resulting in a total of eight health professionals. Data collection Health professionals were interviewed to complete and validate the findings of Phase 1, as well as to express their ideas on the potential actions that could improve migrant access to mental healthcare services. These individual interviews were done by SB and ZÖ in German. The interviews began with the health professionals introducing themselves, their professional backgrounds, and their experiences with migrant patients. Following this, health professionals received a 10-minute presentation of the results of Phase 1, using the access framework developed specifically for the mental health of migrants, and were requested for additions and comments on the determinants of access. Then they were openly asked about their recommendations for action. If necessary, the barriers previously discussed were used as thematic guidance. Furthermore, questions on specific issues or migrant groups were posed to the health professionals based on their background and expertise. The interviews lasted approximately 45 minutes each and took place between February and May of 2023. Three of them were conducted through video chat, two at the health professional’s working location, and two at the researcher's office. Data analysis SB categorized the health professionals interview transcripts into the present code and category system of Phase 1 so that the determinants of migrant’s mental healthcare access could be further refined. In addition to the existing ones, new codes and categories were added as needed. Each interview was transcribed and coded immediately after it was conducted. Hence the categories, domains and the access framework designed in Phase 1 were revised in repeated consensus meetings and developed in an iterative process. The participants' perspectives were exemplified in each category using direct quotes. SB translated the health professionals’ quotes into English in coordination with ZÖ. SB ultimately encoded all statements proposed by health professionals to enhance access and mental health. SB and ZÖ categorized these codes, resulting in 17 recommendations across five categories (see Appendix 1). We established three recommendation domains based on five categories adopting Valentjin et al’s [32] approach, which classifies integrated care into macro, meso, and micro levels. We considered recommendations regarding structural vulnerability and causes of inequality at the macro level, recommendations on financing, delivery, and coordination of health services at the meso level, and measures to enhance access and boost resilience of individuals or groups at the micro level. The coding and categorization were supported by multiple consensus meetings, where some of the recommendations could also be grouped into determinants of access. For validity, all results were discussed by the whole research team and presented to an additional psychiatrist, who has patients with migration background, and a professional in public mental health. Collaboratively, the framework of migrants’ mental healthcare access and the categories of the recommendations for action were finalized. The list of recommendations was distributed to the interviewed professionals, but no major changes were necessary following their review. Results 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. DISCUSSION Access to mental health services is a fundamental human right that should apply to all migrants. In this study, in the case of Munich, a Central European city hosting a large number of migrants with different backgrounds, findings were obtained to help better understand the determinants of access to this right from the perspective of migrants and health professionals. Although the study's inclusion of three different migrant groups - international students, refugees, and LGBTQ+ people - has limitations in terms of generalizability, the intersection of different vulnerability mechanisms faced by these groups, such as discrimination, resource insecurity, and precarious housing, has enabled a more in-depth examination of the various aspects of the access issue. The Levesque access framework, which is also commonly employed to conceptualize the access to mental healthcare for migrants [33, 34] was adapted for this particular group and mental health through the iterative process we followed. Based on expert interviews conducted using this modified model, 17 recommendations for improving migrants’ mental healthcare access have been developed, which can also be used by countries and cities in similar situations. 3.1 The Framework for Determinants of Migrants' Access to Mental Health Services The framework developed in this study (Figure 2) summarizes both barriers and facilitators identified by our findings. Unlike the model of Levesque et al., we did not make a distinction between the patient and provider perspectives. Rather, the progression of the various dimensions of our framework shows the shift from the patient side (ability to perceive and ability to seek) to the provider side (acceptability, availability and affordability, and appropriateness), but also their interrelationship. Instead of two separate dimensions of availability and accommodation, and affordability, our model contains a common dimension of availability and affordability, showing that for migrants, the availability of services depends strongly on their cost coverage. Furthermore, we allocated separate sections for language and culture as additional dimensions, recognizing their crucial importance for migrants. Our findings on barriers deriving from the perception of mental health are comparable to those reported in Western nations, including Germany, indicating the effect of stigma [8–10, 35–37]; external stigmas, such as those based gender roles, cause migrants to worry about their social standing, preventing them from recognizing their mental health problems [9, 35, 36]. Culture shapes mental health understanding, as many authors have noted [9, 35, 38]. Immigrants may perceive their mental needs, but their different understandings of mental health compared to European populations may lead them to seek help from other sources [4, 8–10]. Thus, it may be reasonable to expand the access framework’s determinant of knowledge about mental health to “knowledge about the new country’s concept and treatment of mental health” for migrants. This connection is already evident in this study, as culture is a central theme of the framework. Furthermore, other authors also advocated for comprehensive care options that do not rule out non-Western approaches [36, 39, 40]. In agreement with guidelines [19, 41, 42] is focusing on early mental illness detection through organizational support or provider education another recommendation of this study. While Levesque et al. classified social support as a component of the ability to seek [24], our findings revealed that for migrants, social support plays a much larger role. Also, many guidelines and studies advocate for social support to improve the integration and thus the mental health of migrants [7, 8, 10, 21, 38, 39, 42]. Consistent with our findings, other studies indicate that the cultural competence of healthcare practitioners affects their ability to accurately diagnose and treat mental disorders in migrants [5, 9, 10, 19, 43]. Negative or even discriminatory experiences caused by healthcare professionals' incompetence can erode the trust in local providers [9, 36]. Our study suggests that increasing the presence of healthcare providers with a migration background would be beneficial in addressing this issue, along with offering appropriate training for healthcare professionals. This approach was proposed as a way to tackle the language barrier, which was discovered to be linked to almost all aspects of accessibility in this research. Language functioned as both an amplifier of existing problems and as a creator of additional challenges. Several studies [5, 10, 36, 38, 42] support that inadequate communication between doctors and patients can result in inaccurate diagnoses and ineffective treatment. In agreement with this, a key recommendation of this research is to offer interpreters and translations, with the health insurance covering the associated expenses. In contrast to other countries where payment for mental health services can be a significant barrier to affordability for migrants [9, 36, 44], our findings show that in Munich migrants' services are covered by insurance. However, this is not the case for asylum seekers. Consistent with other earlier research [19, 35, 38], our study demonstrates that asylum seekers do not possess health insurance, and non-profit organizations are the sole providers of mental health services for them. On the other hand, in Germany, where mental healthcare capacity is insufficient due to preferences in public funding allocation, and waiting times for the general population are quite long [45, 46], the service availability for asylum seekers are extremely limited [16]. Furthermore, asylum seekers and other migrants face numerous bureaucratic hurdles [17, 35, 40], as this study’s results showed. Our health professionals’ recommendations for addressing these issues include increasing funding for psychosocial treatment centres, improving collaboration between social organizations and the healthcare system, and implementing mental health prevention measures. Furthermore, more low-threshold care options were proposed to improve service geographical distribution, which was emphasized due to the economic barrier created by direct and indirect transportation costs, as reported by other authors [9, 47, 48]. 3.2 Recommendations for action at the macro, meso, and micro levels Valentjin et al. classified integrated care into macro, meso, and micro levels [32]. The recommendations for action suggested in this study are also indicating to macro, meso and micro level interventions (Figure 3). 3.2.1 Macro level The perspective on which system structure is built is extremely crucial. It is well-documented by research that racism, a major structural vulnerability reason, has a significant impact on both mental health and access to healthcare [10, 34, 49]. Bhugra et al. called failure to provide adequate interpretation despite the need for language assistance a form of indirect discrimination [39]. The study's main recommendation is that the system should be free of inequalities and any kind of discrimination. The recommendations regarding basic human rights and social determinants of health presented in this study were reported previously, such as accelerating the process of determining the residency status of migrants [8] and improving the living conditions of asylum seekers [38]. Increasing the number of migrant health workers to promote cultural acceptability, as proposed by Dow [36] and Giacco et al. [8], is one of the study's recommendations. In order to achieve this, the health professionals of this study emphasized the importance of equal opportunities for prospective health service providers with a migration background. It is therefore a recommendation at macro level. Guidelines also called for the expansion of data collection and research to monitor the mental health of migrants and their access to mental health services, and to introduce appropriate policies [39, 41, 42]. German guidelines and action recommendations additionally suggest that the health system's intercultural openness be recognized as a quality aspect of services and examined regularly [19, 37, 50]. Despite being noted in our study, this was not further examined because the health professionals' emphasis was elsewhere due to their specialization of work. 3.2.2 Meso level As our study also showed, better coordination can improve the early detection and care of mental health problems in migrants, as these frequently show as physical symptoms [42]. Many studies and guidelines called for better cooperation to overcome the many bureaucratic barriers asylum seekers and other migrants face [17, 35, 40]. According to our study, psychosocial treatment centers and family physicians should play a more active role in ensuring coordination. As in our study, training healthcare providers, especially general practitioners [8, 10, 21, 35] in cultural competence, sensitizing them for the somatic symptoms in migrants with mental problems, was emphasized in the literature [4, 10, 19, 39, 42, 50]. The experts in our study recommended the provision of interpreters and translations in accordance with the literature, which emphasised covering the costs of interpreters in healthcare settings in addition to ensuring their availability [4, 8, 10, 19, 20, 39, 50]. However, relying solely on interpreters may not always suffice [35, 38]. Some studies advocate for the inclusion of cultural mediators, alongside interpreters [5, 39, 42, 50, 51]. Beyond this, using validated assessment tools in different languages [10, 38, 50] and new technologies to improve communication [8, 38, 42] were suggested in guidelines. Some authors also emphasised considering the acceptability of different treatment approaches and noted that Western treatment modalities, such as talking therapies, may be less appropriate for migrants from certain cultures [9, 36, 39]. Another recommendation for action of this study on the meso level is to incorporate more low-threshold options. Geographically accessible mental health services [39–41], including on-site offers [35] and technology-based interventions [8], are proposed solutions and similar to the ones in our study. 3.2.3 Micro level Educating migrants about mental health can reduce stigma and improve their mental health literacy [10, 35]. In [24] model, mental health literacy is considered a determinant of the ability to perceive and can enhance individuals' awareness of their need for healthcare [24, 34]. As proposed by this study’s findings, it is essential to ensure that mental health education and promotion is provided in a culturally sensitive manner and includes information about the new healthcare system and mental healthcare options [4, 10, 36, 39, 42]. Several studies and guidelines include the promotion of migrants’ mental health as a recommendation for action [8, 10, 20, 38, 42, 52]. Their recommendations also mention school-based programs [10, 38, 42]. Another recommendation at the micro level is stronger social support for migrants. Many guidelines and studies advocate for social support to improve the integration of migrants and thus their mental health [7, 8, 10, 21, 38, 39, 42]. This study's recommendation to foster social support through intercultural leisure activities appears to be novel in this regard. 3.3 Strengths and limitations The study's key strength lies in its two-phase structure, incorporating diverse perspectives that enrich the understanding of factors affecting mental healthcare access and resulting recommendations for action. The findings reflected experiences and viewpoints of vulnerable migrant groups in Phase 1. This research is notable for including international students and LGBTQ+ migrants, which is rare in previous studies on mental healthcare access, allowing for the formulation of both general and group-specific recommendations. However, it is impossible to say that this study is free of methodical limitations. It is essential to recognize the heterogeneity within the group of migrants and consider specific migration-related mental health stressors and needs of individual subgroups. To improve the findings, it would be beneficial to involve additional migrant groups. The interviews took place during the COVID-19 pandemic, possibly influencing the findings due to implemented infection control measures. Research suggests that the pandemic has increased existing disparities in access to mental healthcare [53, 54]. Furthermore, the interview tool was not explicitly developed to address mental healthcare access, leaving the possibility that not all factors of migrants’ mental healthcare access were discussed. However, it was remarkable how much was still revealed about barriers to mental healthcare access, showing the importance of this topic for migrants. Another advantage was the resulting absence of a bias because of socially desired replies. The participation of healthcare professionals as experts in Phase 2 assisted in validating the dimensions reported by migrants, resulting in the development of a new model of migrants’ mental healthcare access. This framework structured guided to define the recommendations for action. Based on the health professionals’ interviews with their different specifications and experiences, comprehensive and action-oriented recommendations were developed. However, for a holistic picture of mental healthcare of migrants, it would be valuable to include experts from disciplines beyond medical professions. CONCLUSION The study's findings indicate that migrants face numerous obstacles when attempting to access mental healthcare services due to being in a new country, such as limited knowledge on care options, a lack of social support, or the burden of bureaucracy. Moreover, limited awareness and stigma surrounding mental health issues can hinder the perception. The lack of acceptability and appropriateness of the providers exacerbates the impact of these barriers. However, each of these issues has a significant cultural and linguistic component. As a result, culture and language should have special places in an access model for migrants' mental health. Being not entitled to health insurance for asylum seekers, the lack of available care options and uneven distribution of services further complicates migrants' access to services. According to our findings, improving migrant mental health access begins with the removal of all structural barriers caused by discrimination and inequality on macro level. Meso level measures include increasing mental healthcare capacity, improving coordination among system components, and implementing measures to eliminate language and cultural barriers, such as improving provider competencies and providing translation services. All of this, however, should be supplemented by measures to promote and raise awareness of mental health for specific groups of migrants on the micro level. DECLARATIONS Ethics approval and consent to participate The study was approved by the Ethics Committee of the Medical Faculty of the LMU Munich as the competent approval authority (reference number 21-0244). Consent for publication Not applicable. Availability of data and materials Individual privacy prevents the public sharing of interview transcriptions. Codes or categories can be shared on request. Competing interests The authors declare that they have no competing interests. Funding The SonarGlobal work was supported by the European Union’s Horizon 2020 research andnnovation programme under grant agreement No. 825671. Authors' contributions SB: Study conception and design, performing the interviews in Phase 2, data analysis, writing the manuscript. ZÖ: Study conception and design of Phase 1 and Phase 2, performing the interviews in Phase 2, data analysis, writing the manuscript. CJS: Study design of Phase 2, validation check for the consistency among final dimensions, categories, codes, quotes, and transcripts, contribution in writing the manuscript. MC: Study conception, data analysis in Phase 1, contribution in writing the manuscript. Acknowledgments We appreciate the effort of the field researchers who conducted the initial data collection, as well as the contributions of all participants in the study at all stages. REFERENCES Bhugra D. Migration and mental health. Acta Psychiatrica Scandinavica. 2004;109:243–58. doi:10.1046/j.0001-690X.2003.00246.x. World Health Organization. Fact sheet: Mental health and forced displacement. 23.01.2023. https://www.who.int/news-room/fact-sheets/detail/mental-health-and-forced-displacement. Accessed 27 Jan 2023. World Health Organization. Fact sheet: Refugee and migrant health. 23.01.2023. https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health. Accessed 27 Jan 2023. 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Tables Table 1 Characteristics of the study population – Phase 1 (Migrants) Participant Group Age Gender Country of origin Years spent in Germany P01 student 23 male Indian 1.5 P02 student 29 female Columbian 3.5 P03 student 23 male Turkish 1.0 P04 student 28 female Eritrean / Saudi-Arabian 1.5 P05 student 27 male South-Korean 1.5 P06 student 25 male Pakistani 1.0 P07 student 27 female Iranian 3.5 P08 student 24 female Bulgarian 5.0 P09 student, refugee 26 male Syrian 5.5 P10 student, refugee 25 male Syrian 5.5 P11 student, refugee 20 female Afghanistan 2.0 P12 refugee 27 female Afghanistan 5.0 P13 refugee 68 female Afghanistan 6.0 P14 refugee 47 male Afghanistan 6.0 P15 refugee 36 female Afghanistan 6.0 P16 refugee 37 male Afghanistan 6.0 P17 refugee 32 female Iranian / Afghanistan 5.5 P18 refugee 35 male Syrian 5.0 P19 refugee 32 male Somalian 5.0 P20 refugee 28 male Afghanistan 2.5 P21 LGBTQ+ 21 male Rumanian 21 P22 LGBTQ+ 30 Gender nonconforming Ugandan 1.5 P23 LGBTQ+ not disclosed gender nonconforming native American born in Germany P24 LGBTQ+ 27 female Kenyan 7.0 Table 2 Characteristics of the study population – Phase 2 (Health professionals experienced in mental healthcare) Health professional Migration background Expertise E01 Yes Researcher in public mental health, youth psychotherapist in training E02 Yes Psychological psychotherapist, own practice E03 No Psychological psychotherapist, researcher in public mental health, working experience with refugees in psychiatry E04 Yes Psychological psychotherapist, researcher in public mental health and the role of primary care E05 No Psychological psychotherapist, working with refugees in a psychosocial treatment centre E06 No Family physician in a rural area where many migrants and refugees are living E07 No Medical specialist for psychiatry and psychotherapy, working in psychiatry, researcher in public mental health E08 Yes Medical specialist for psychiatry and psychotherapy, researcher Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1Recommendationsforactiontoimprovemigrantsmentalhealthcareaccessinfivecategories.docx Title: Supplementary Table 1 Recommendations for action to improve migrants' mental healthcare access in five categories Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4026954","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278056498,"identity":"c1d4fa1e-e6af-4ad1-b113-b2eddf325a01","order_by":0,"name":"Sophia Baierl","email":"","orcid":"","institution":"LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"","lastName":"Baierl","suffix":""},{"id":278056499,"identity":"5189b280-2fa7-45f5-a0d1-57418460548f","order_by":1,"name":"ZELİHA ASLI ÖCEK","email":"","orcid":"","institution":"LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"ZELİHA","middleName":"ASLI","lastName":"ÖCEK","suffix":""},{"id":278056500,"identity":"83af87a6-4818-4447-8b43-d94e735f0623","order_by":2,"name":"Caroline Jung-Sievers","email":"","orcid":"","institution":"LMU Munich","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Jung-Sievers","suffix":""},{"id":278056501,"identity":"a53416e3-9aea-4f1b-8f7d-3c1d33f9d6bf","order_by":3,"name":"Michaela Coenen","email":"data:image/png;base64,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","orcid":"","institution":"LMU Munich","correspondingAuthor":true,"prefix":"","firstName":"Michaela","middleName":"","lastName":"Coenen","suffix":""}],"badges":[],"createdAt":"2024-03-07 15:05:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4026954/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4026954/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52623049,"identity":"b4ea68c8-681d-47f6-ac8f-3bf0b638ac28","added_by":"auto","created_at":"2024-03-13 17:17:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":984072,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of the methodology of the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4026954/v1/8e9194af7cf2e98c903fa79c.jpg"},{"id":52623050,"identity":"09e63aab-c37b-4018-a611-4a94c349b164","added_by":"auto","created_at":"2024-03-13 17:17:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":277648,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdapted framework for the determinants of migrants' mental healthcare access (own presentation) based on the framework of Levesque et al. [24]\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4026954/v1/c8de0494ad7d1203188ba487.png"},{"id":52623051,"identity":"75228957-226b-464e-be6b-ca7d9806a4c5","added_by":"auto","created_at":"2024-03-13 17:17:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":157407,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRecommendations for action to improve migrant’s mental healthcare access on the macro, meso, and micro level\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4026954/v1/161c0cf6a30dfb5433e42cc9.png"},{"id":61795684,"identity":"193870c7-c1ca-4833-ab0a-60b8447aa517","added_by":"auto","created_at":"2024-08-05 16:27:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2635878,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4026954/v1/87dd4b2f-d8b4-4427-b1d7-8a159a8963bb.pdf"},{"id":52623048,"identity":"e867f109-4b24-47ee-8e34-76b9d661c67b","added_by":"auto","created_at":"2024-03-13 17:17:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18210,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTitle: Supplementary Table 1 \u003c/strong\u003eRecommendations for action to improve migrants' mental healthcare access in five categories\u003c/p\u003e","description":"","filename":"SupplementaryTable1Recommendationsforactiontoimprovemigrantsmentalhealthcareaccessinfivecategories.docx","url":"https://assets-eu.researchsquare.com/files/rs-4026954/v1/6b6f9c99a60bffda8098416b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Dimensions of Mental Healthcare Accessibility for Vulnerable Migrant Groups and Actions to Improve Access: A Qualitative Study Conducted in Munich, Germany","fulltext":[{"header":"BACKGROUND ","content":"\u003cp\u003eMigration is a highly complex experience that has different motives and consequences for each person [1]. Every stage of the migration process can be fraught with difficulties, ranging from poor living conditions or violence in the country of origin and traumatic experiences during migration to adapting to a new culture in the resettlement country [1, 2]. These stressors increase migrants' vulnerability to mental health problems [2, 3]. Furthermore, for the majority of migrants, these stressors are exacerbated by mental health risks associated with gender roles, pre-existing conditions, a lack of language proficiency, precarious living and working conditions, legal status uncertainty, social isolation and loneliness, and discriminatory experiences [1, 4]. Particular groups of people, including refugees, asylum seekers, undocumented migrants, older adults, international students, unaccompanied minors, victims of trafficking, migrant detainees, and LGBTQ+ individuals, are more susceptible to these risks due to the interaction between the various vulnerability mechanisms [1, 2, 4].\u003c/p\u003e\n\u003cp\u003eA substantial part of migrants experience symptoms such as anxiety, sadness, hopelessness, stress, sleep disturbances or anger as a result of migration [2, 5]. Studies indicate a higher prevalence of common mental disorders, such as depression and post-traumatic stress disorder (PTSD), among migrant populations compared to the general population of the host communities [2, 5\u0026ndash;7]. Some migrant groups are also more susceptible to psychotic disorders than the resident population [2, 5, 7]. Migrant populations not only face more mental health issues, but they also have less access to healthcare in general and more specifically for mental health-related problems [3, 4]. Lack of knowledge on services, communication difficulties, stigma, legal restrictions or the absence of culturally sensitive healthcare services are frequently reported barriers of access to mental healthcare for migrants [8\u0026ndash;10].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eMental healthcare for migrants in Germany\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAs one of the most popular destination countries in Europe, Germany has accommodated a considerable number of migrants, including a large proportion of refugees and economic migrants [11, 12]. Research on mental disorders among this diverse group is limited in Germany [13, 14], but existing studies on specific migrant populations such as elderly migrants [15], or asylum seekers and refugees [13, 16, 17] suggest an increased burden of conditions like depression or PTSD.\u003c/p\u003e\n\u003cp\u003eThe German healthcare system includes statutory health insurance covering 90% of the population and private health insurance covering the remaining 10%. Nearly all people with a migration background are eligible for either statutory health insurance or private health insurance [18]. However, asylum seekers are not included in the regular insurance system and their healthcare is differing between the 16 German federal states. In Bavaria, a state in the south-east of Germany, they must seek approval from the relevant authorities before every doctor's visit to obtain a treatment certificate. Reimbursement is usually limited to acutely treatable conditions, encompassing psychiatric services but mostly hindering access to psychotherapy. Instead, psychotherapeutic treatment is predominantly provided at specialized psychosocial treatment centres [16]. Other migrant groups also encounter barriers to accessing mental healthcare in Germany, leading to their underrepresentation in inpatient psychiatric and psychotherapeutic facilities [13, 19]. Guidelines [20] and position papers [21] were published to improve mental healthcare for migrants, emphasizing early detection of mental problems in migrants, cultural sensitivity in healthcare, the availability of interpreters, and better information for migrants. More recent research focused on the importance of the German healthcare system's intercultural opening, while underlining that too little of the recommendations have been implemented so far [19, 22].\u003c/p\u003e\n\u003cp\u003eGiven the increasing number of refugees in Germany since 2015 [11] and the mental health challenges exacerbated among migrant populations by the COVID-19 pandemic [23], ensuring access to mental healthcare for vulnerable migrants in Germany is crucial. Achieving this goal necessitates an update of the existing action recommendations, particularly since none of these previous guidelines involved the viewpoints of migrants themselves.\u003c/p\u003e\n\u003cp\u003eThis study aimed at exploring the facilitators and barriers of migrants' access to mental healthcare from the perspectives of migrants and health professionals in Munich, Bavaria and to derive to conclusions what actions could be taken to improve migrants' access to mental healthcare in Munich and beyond.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003e2.1 Study design\u003c/h2\u003e\n\u003cp\u003eThis qualitative study was conducted in two phases (Figure 1). In the first phase, access to mental healthcare was explored from the perspective of migrants and content analysis was carried out utilizing the framework of Levesque et al. [24]. This framework outlines access to health services in ten dimensions with five considerations from the patient\u0026apos;s perspective and five from the provider\u0026apos;s perspective. From the provider\u0026apos;s perspective, the first dimension is approachability, which corresponds to the ability to perceive on the patient side. Acceptability on the provider\u0026apos;s side and ability to seek on the patient\u0026apos;s side are related to individual characteristics such as culture and gender that may differ between the two. Provider availability and ability of the patient to reach refer to the local and timely accessibility of healthcare facilities. The seventh and eighth dimensions include the provider affordability and the patient\u0026apos;s ability to pay. The final two factors, provider appropriateness and patient ability to engage, influence outcomes of the care. In the second phase, expert interviews were used to validate the research findings, which had been schematized and summarized using a version of the Levesque model. During these interviews, recommendations for action to improve mental healthcare access for migrants were discussed and then categorized and formulated through an iterative coding process.\u003c/p\u003e\n\u003ch2\u003e2.2 Study setting\u003c/h2\u003e\n\u003cp\u003eThe study took place in the metropolitan area of Munich, a city in Southern Germany and the capital of the state of Bavaria. Owing to its geographical proximity to the country\u0026apos;s border, Munich is home to a large share of refugees who are accommodated in a variety of facilities, including state and local refugee shelters as well as arrival centres [25]. In addition, Munich has a robust economy, a sizable employment market and three internationally recognized universities, making it an attractive destination for many migrants. With 18.48% of the population having a migration background and 30.07% being foreign nationals, foreigners constitute to the majority the population [26]. Munich thus plays a significant role in shaping German asylum policies and delivers various forms of aid to refugees and migrants, including one of Bavaria\u0026apos;s few psychosocial treatment centres [27]. More than half of the social organizations and initiatives receiving financial support from the city are related to migration [28].\u003c/p\u003e\n\u003ch2\u003e2.3 Phase 1 \u0026ndash; The perspective of migrants\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment and study population\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included participants from the German component of the SonarGlobal project, a five-country European Union initiative to investigate the effects of the COVID-19 pandemic on vulnerable populations [29]. Of the 82 people aged 18 and above reached in the SonarGlobal Project, 24 people with migration background who were living in Munich metropolitan area were included in the present study. The criteria for having a migrant background in this project included not being born in Germany, living the first half of one\u0026apos;s life outside of Germany, or having both non-German parents. Self-report of a migration background was also considered, and people were included in this group if they reported having a migrant background. Considering accessibility and the possibility of representing multiple vulnerability mechanisms, it was decided to limit the scope of the study population to three distinct groups with migration experiences: 1) LGBTQ+ individuals; 2) international students; 3) asylum-seekers. Three fieldworkers were recruited who were able to connect with these groups through their networks in addition to using the snowball sampling technique. While international students were included in the study, the criterion of having at least one vulnerability factor such as precarious housing, severe financial insecurity, a lack of social support, a higher likelihood of being discriminated against because of their appearance was taken into account. Special attention was given to ensuring variation in terms of age, gender, and ethnicity among the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Vulnerability Assessment Tool, consisting of a demographic questionnaire and a semi-structured interview guide, was translated into German and Persian and modified for use in Germany during the interviews [29, 30]. Participants were asked during the in-depth interviews about sociodemographic characteristics, such as age, gender, and ethnicity, household features (type of dwelling, ownership of the house, persons living in the household), income and expenses (sufficiency of income, any financial support, healthcare insurance, burden of healthcare expenses), employment (current job, number of working hours, place of work, and the likelihood of a change in all of these within six months), social relationships, health status and access to healthcare.\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted by three fieldworkers with previous experience in qualitative methodologies. They received training and ongoing support to use the Vulnerability Assessment Tool. Eighteen interviews were conducted face-to-face, while six were done online. The interviews took place in private settings, with only the interviewer and interviewee present. Due to the COVID-19 pandemic, infection control measures such as masks were used in face-to-face interviews. Of the interviews, ten were conducted in English, eight in Persian, and six in German. The Persian interviews were subsequently translated into English by the interviewer, whose first language was Persian. All interviews took place between April and May 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were transcribed as verbatim transcripts by the respective interviewer. The coding was done in a three-part iterative process applying the content analysis approach based on Mayring and Fenzl [31] by using the software MAXQDA. The open codes were developed by Z\u0026Ouml; and MC for the entire dataset of the German SonarGlobal project. The coding process incorporated the field workers\u0026apos; notes from the interviews. SB and Z\u0026Ouml; reviewed the dataset, extracting open codes and data related to mental healthcare through mutual agreement. In the second round, SB refined the list of codes, and established sub-codes. In consultation with Z\u0026Ouml;, the codes and sub-codes were further categorized. The researchers then discussed the categories related to determinants of access to mental care in considering the Levesque\u0026apos;s access framework, grouped these categories under domains and visualised their connections. This new designed framework is a version of Levesque\u0026apos;s access model that focuses on migrants\u0026apos; access to mental health services. An iterative process was used to assess completeness and validity of this framework by summarizing and discussing the determinants in the interviews conducted during Phase 2.\u003c/p\u003e\n\u003cp\u003eSB translated the German quotes into English, maintaining the original words and syntax, even if it required translating grammatical mistakes. Afterwards, the original quotes and their translations were examined with Z\u0026Ouml;. Because all Persian interviews had already been translated into English, there was no need to translate these quotes.\u003c/p\u003e\n\u003ch2\u003ePhase 2 - The health professionals\u0026rsquo; perspective and recommendations for action\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment and study population\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals with at least of one year of practical experience in Germany treating persons with mental health problems and migration background were considered experts. Researchers conducted an internet search to identify psychotherapists, psychiatrists, and family physicians in Munich whose patients were mainly or solely migrants. It was based on the identification of areas with significant migrant populations, particularly inside major urban areas, and on the availability of services in foreign languages. Additionally, the search was expanded by including contacts using snowball sampling. Potential experts were contacted via email and invited to participate in individual interviews. No one refused to participate. A total of seven interviews were conducted until data saturation was achieved. Following the completion of the data analysis, an additional expert was invited to the research team\u0026apos;s meeting to validate the results, resulting in a total of eight health professionals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals were interviewed to complete and validate the findings of Phase 1, as well as to express their ideas on the potential actions that could improve migrant access to mental healthcare services. These individual interviews were done by SB and Z\u0026Ouml; in German. The interviews began with the health professionals introducing themselves, their professional backgrounds, and their experiences with migrant patients. Following this, health professionals received a 10-minute presentation of the results of Phase 1, using the access framework developed specifically for the mental health of migrants, and were requested for additions and comments on the determinants of access. Then they were openly asked about their recommendations for action. If necessary, the barriers previously discussed were used as thematic guidance. Furthermore, questions on specific issues or migrant groups were posed to the health professionals based on their background and expertise. The interviews lasted approximately 45 minutes each and took place between February and May of 2023. Three of them were conducted through video chat, two at the health professional\u0026rsquo;s working location, and two at the researcher\u0026apos;s office.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB categorized the health professionals interview transcripts into the present code and category system of Phase 1 so that the determinants of migrant\u0026rsquo;s mental healthcare access could be further refined. In addition to the existing ones, new codes and categories were added as needed. Each interview was transcribed and coded immediately after it was conducted. Hence the categories, domains and the access framework designed in Phase 1 were revised in repeated consensus meetings and developed in an iterative process. The participants\u0026apos; perspectives were exemplified in each category using direct quotes. SB translated the health professionals\u0026rsquo; quotes into English in coordination with Z\u0026Ouml;.\u003c/p\u003e\n\u003cp\u003eSB ultimately encoded all statements proposed by health professionals to enhance access and mental health. SB and Z\u0026Ouml; categorized these codes, resulting in 17 recommendations across five categories (see Appendix 1). We established three recommendation domains based on five categories adopting Valentjin et al\u0026rsquo;s [32] approach, which classifies integrated care into macro, meso, and micro levels. We considered recommendations regarding structural vulnerability and causes of inequality at the macro level, recommendations on financing, delivery, and coordination of health services at the meso level, and measures to enhance access and boost resilience of individuals or groups at the micro level.\u003c/p\u003e\n\u003cp\u003eThe coding and categorization were supported by multiple consensus meetings, where some of the recommendations could also be grouped into determinants of access. For validity, all results were discussed by the whole research team and presented to an additional psychiatrist, who has patients with migration background, and a professional in public mental health. Collaboratively, the framework of migrants\u0026rsquo; mental healthcare access and the categories of the recommendations for action were finalized. The list of recommendations was distributed to the interviewed professionals, but no major changes were necessary following their review.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e2.5 Descriptive information on the study population of Phase 1\u003c/h2\u003e\n\u003cp\u003eOf 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e Characteristics of the study population \u0026ndash; Phase 1 (Migrants)\u003c/p\u003e\n\u003cp\u003eAll 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. \u003c/p\u003e\n\u003ch2\u003e2.6 Descriptive information on the study population of Phase 2\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e Characteristics of the study population \u0026ndash; Phase 2 (Health professionals experienced in mental healthcare)\u003c/p\u003e\n\u003cp\u003eAs 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.\u003c/p\u003e\n\u003ch2\u003e2.7 Determinants of migrants\u0026rsquo; mental healthcare access\u003c/h2\u003e\n\u003cp\u003eBased on the analysed interviews, the determinants of migrants\u0026apos; mental healthcare access were categorized into five dimensions. Their relationship to each other and to culture and language is shown in Figure 2.\u003c/p\u003e\n\u003ch3\u003e2.7.1 Dimension 1. Ability to perceive mental health problems\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKnowledge about mental health\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants\u0026apos; 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.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Health is two different things: physical health and mental health. [\u0026hellip;] 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\u0026apos;t identified. If you\u0026apos;re not coping well, you would probably have to sit down and think as to what is going wrong. [\u0026hellip;]. So, these two things have to come together. Just because they\u0026apos;re physically healthy doesn\u0026apos;t mean you\u0026apos;re mentally healthy and vice versa.\u0026rdquo; \u003cstrong\u003e\u0026ndash; P01\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For me, the depression thing, that\u0026apos;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.\u0026rdquo; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003eP05\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOthers, 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.\u003c/p\u003e\n\u003cp\u003e\u0026quot;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.\u0026quot; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003eMedical specialist for psychiatry and psychotherapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStigma of mental problems\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome 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. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In Korea it\u0026apos;s really hard to get any advice about the depression. So, they tried to hide it. [\u0026hellip;] If I am depressed, I try to hide it to my parents or my friends. I try to overcome it by myself.\u0026rdquo; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003eP05\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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 \u0026ldquo;strong\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Youth psychotherapist\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e2.7.2 Dimension 2. Ability to seek mental healthcare\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKnowledge about healthcare system and care options\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly 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.\u003c/p\u003e\n\u003cp\u003e\u0026quot;The knowledge about treatment services. Yeah I think that\u0026apos;s so random still, whether they learn about something or not.\u0026quot; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003ePsychotherapist with research experience in primary care and psychoeducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial support\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants mentioned that having a social network and support system could have a significant influence on migrants\u0026apos; 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\u0026rsquo;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\u0026apos;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.\u003c/p\u003e\n\u003cp\u003eThe 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\u0026rsquo;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. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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.\u0026rdquo; \u0026ndash; \u003cstrong\u003eFamily physician\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e2.7.3 Dimension 3. Acceptability of mental health services\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIdentity and gender of providers \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrejudice on the side of both migrants and providers based on the social identity of the other functioned as a barrier to providers\u0026apos; 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. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;[\u0026hellip;] the doctor\u0026apos;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\u0026apos;m black, which automatically I don\u0026apos;t understand German.\u0026rdquo; \u003cstrong\u003e\u0026ndash; P24\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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\u0026apos;t understand our culture. Then I ask: What is your culture? [...] Yes, when we have family conflicts, violence in the family. Yes, I don\u0026apos;t understand violence either. I would not accept violence in the family either. [...] That\u0026apos;s what they are afraid of, that\u0026apos;s why they don\u0026apos;t go [...]. And they explain that with \u0026lsquo;my culture\u0026rsquo;.\u0026rdquo; \u0026ndash; \u003cstrong\u003ePsychotherapist with own practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany 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\u0026apos;s different cultural background and experiences or even discriminatory prejudices.\u003c/p\u003e\n\u003cp\u003eAlmost 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.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Medical specialist for psychiatry and psychotherapy\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e2.7.4 Dimension 4. Availability and affordability of mental health services\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInsurance and bureaucracy \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth 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. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;So the people who are supposed to go to the doctor [\u0026hellip;] 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\u0026apos;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\u0026apos;re also depressed and, so also don\u0026rsquo;t procure these things on their own, like a sick note to pick up, then I don\u0026apos;t know.\u0026rdquo; \u003cstrong\u003e\u0026ndash; P18 \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the psychiatrist, family physician, and psychotherapist working at a psychosocial treatment centre, this not only limited patients\u0026apos; ability to access healthcare, but also burdened physicians with extra strain created by patients\u0026apos; inquiries about bureaucratic matters. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;That would also be a classic thing in standard care: A refugee client comes in with five letters and first says: I don\u0026apos;t understand them. And then the person in regular care must first try to consider: No, that\u0026apos;s not important, that\u0026apos;s advertisement, ah there we have something from the health insurance.\u0026rdquo; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003ePsychotherapist working at a psychosocial treatment centre\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased 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. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCapacity of care options\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll health professionals highlighted the insufficient availability of psychotherapeutic or psychiatric treatment spaces. They indicated lengthy waiting periods, ranging from six months to two years. \u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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\u0026apos;t call us again in the next two years until 2024/25.\u0026rdquo; \u003cstrong\u003e\u0026ndash; \u003c/strong\u003e\u003cstrong\u003eYouth psychotherapist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne 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.\u003c/p\u003e\n\u003cp\u003eYeah, 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.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Psychotherapist with research experience in primary care and psychoeducation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGeographical distribution of services\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive 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.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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. [\u0026hellip;]. So, that means, it simply needs to be spread much more widely.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Psychotherapist working at a psychosocial treatment centre\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e2.7.5 Dimension 5. Appropriateness of mental health services\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProviders\u0026rsquo; and patients\u0026rsquo; understanding of mental healthcare\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording 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.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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\u0026apos;re a doctor or a psychologist. So I don\u0026apos;t have to do anything for it.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Psychotherapist with own practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsequently, 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.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;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\u0026apos;t need to come up with a trauma confrontation.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Psychotherapist working at a psychosocial treatment centre\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompetence of providers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProvider 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.\u003cem\u003e \u003c/em\u003eHowever, 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:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;My reasons, reason, or cause for my depression she could understand rather better than others.\u0026rdquo; \u003cstrong\u003e\u0026ndash; P24\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;One factor we have, is time. The regular care system doesn\u0026apos;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\u0026apos;s difficult. He has a maximum of a quarter of an hour.\u0026rdquo; \u003cstrong\u003e\u0026ndash; Psychotherapist working at a psychosocial treatment centre\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e2.7.6 Language, Culture, and the interaction between the dimensions of access to mental healthcare\u003c/h3\u003e\n\u003cp\u003eLanguage 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\u0026rsquo; language skills, appropriateness and quality of care, and availability of services in one\u0026apos;s own language. The findings also revealed that a person\u0026rsquo;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\u0026apos; 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\u0026rsquo; mental healthcare access in Figure 2 shows a circle rather than the linear process depicted in [24] model. \u003c/p\u003e\n\u003ch2\u003e2.8 Recommendations for action to improve migrants\u0026rsquo; mental healthcare access\u003c/h2\u003e\n\u003cp\u003eThe 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). \u003c/p\u003e\n\u003ch3\u003e2.8.1 Macro level\u003c/h3\u003e\n\u003cp\u003eThe term \u0026quot;macro\u0026quot; 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.\u003c/p\u003e\n\u003ch3\u003e2.8.2 Meso level\u003c/h3\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003ch3\u003e2.8.3 Micro level\u003c/h3\u003e\n\u003cp\u003eOn 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\u0026rsquo;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\u0026rsquo; mental health and social integration.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAccess to mental health services is a fundamental human right that should apply to all migrants. In this study, in the case of Munich, a Central European city hosting a large number of migrants with different backgrounds, findings were obtained to help better understand the determinants of access to this right from the perspective of migrants and health professionals. Although the study's inclusion of three different migrant groups - international students, refugees, and LGBTQ+ people - has limitations in terms of generalizability, the intersection of different vulnerability mechanisms faced by these groups, such as discrimination, resource insecurity, and precarious housing, has enabled a more in-depth examination of the various aspects of the access issue. The Levesque access framework, which is also commonly employed to conceptualize the access to mental healthcare for migrants [33, 34] was adapted for this particular group and mental health through the iterative process we followed. Based on expert interviews conducted using this modified model, 17 recommendations for improving migrants\u0026rsquo; mental healthcare access have been developed, which can also be used by countries and cities in similar situations.\u003c/p\u003e\n\u003ch2\u003e3.1 The Framework for Determinants of Migrants' Access to Mental Health Services\u003c/h2\u003e\n\u003cp\u003eThe framework developed in this study (Figure 2) summarizes both barriers and facilitators identified by our findings. Unlike the model of Levesque et al., we did not make a distinction between the patient and provider perspectives. Rather, the progression of the various dimensions of our framework shows the shift from the patient side (ability to perceive and ability to seek) to the provider side (acceptability, availability and affordability, and appropriateness), but also their interrelationship. Instead of two separate dimensions of availability and accommodation, and affordability, our model contains a common dimension of availability and affordability, showing that for migrants, the availability of services depends strongly on their cost coverage. Furthermore, we allocated separate sections for language and culture as additional dimensions, recognizing their crucial importance for migrants.\u003c/p\u003e\n\u003cp\u003eOur findings on barriers deriving from the perception of mental health are comparable to those reported in Western nations, including Germany, indicating the effect of stigma [8\u0026ndash;10, 35\u0026ndash;37]; external stigmas, such as those based gender roles, cause migrants to worry about their social standing, preventing them from recognizing their mental health problems [9, 35, 36]. Culture shapes mental health understanding, as many authors have noted [9, 35, 38]. Immigrants may perceive their mental needs, but their different understandings of mental health compared to European populations may lead them to seek help from other sources [4, 8\u0026ndash;10]. Thus, it may be reasonable to expand the access framework\u0026rsquo;s determinant of knowledge about mental health to \u0026ldquo;knowledge about the new country\u0026rsquo;s concept and treatment of mental health\u0026rdquo; for migrants. This connection is already evident in this study, as culture is a central theme of the framework. Furthermore, other authors also advocated for comprehensive care options that do not rule out non-Western approaches [36, 39, 40]. In agreement with guidelines [19, 41, 42] is focusing on early mental illness detection through organizational support or provider education another recommendation of this study. While Levesque et al. classified social support as a component of the ability to seek [24], our findings revealed that for migrants, social support plays a much larger role. Also, many guidelines and studies advocate for social support to improve the integration and thus the mental health of migrants [7, 8, 10, 21, 38, 39, 42].\u003c/p\u003e\n\u003cp\u003eConsistent with our findings, other studies indicate that the cultural competence of healthcare practitioners affects their ability to accurately diagnose and treat mental disorders in migrants [5, 9, 10, 19, 43]. Negative or even discriminatory experiences caused by healthcare professionals' incompetence can erode the trust in local providers [9, 36]. Our study suggests that increasing the presence of healthcare providers with a migration background would be beneficial in addressing this issue, along with offering appropriate training for healthcare professionals. This approach was proposed as a way to tackle the language barrier, which was discovered to be linked to almost all aspects of accessibility in this research. Language functioned as both an amplifier of existing problems and as a creator of additional challenges. Several studies [5, 10, 36, 38, 42] support that inadequate communication between doctors and patients can result in inaccurate diagnoses and ineffective treatment. In agreement with this, a key recommendation of this research is to offer interpreters and translations, with the health insurance covering the associated expenses.\u003c/p\u003e\n\u003cp\u003eIn contrast to other countries where payment for mental health services can be a significant barrier to affordability for migrants [9, 36, 44], our findings show that in Munich migrants' services are covered by insurance. However, this is not the case for asylum seekers. Consistent with other earlier research [19, 35, 38], our study demonstrates that asylum seekers do not possess health insurance, and non-profit organizations are the sole providers of mental health services for them. On the other hand, in Germany, where mental healthcare capacity is insufficient due to preferences in public funding allocation, and waiting times for the general population are quite long [45, 46], the service availability for asylum seekers are extremely limited [16]. Furthermore, asylum seekers and other migrants face numerous bureaucratic hurdles [17, 35, 40], as this study\u0026rsquo;s results showed. Our health professionals\u0026rsquo; recommendations for addressing these issues include increasing funding for psychosocial treatment centres, improving collaboration between social organizations and the healthcare system, and implementing mental health prevention measures. Furthermore, more low-threshold care options were proposed to improve service geographical distribution, which was emphasized due to the economic barrier created by direct and indirect transportation costs, as reported by other authors [9, 47, 48].\u003c/p\u003e\n\u003ch2\u003e3.2 Recommendations for action at the macro, meso, and micro levels\u003c/h2\u003e\n\u003cp\u003eValentjin et al. classified integrated care into macro, meso, and micro levels [32]. The recommendations for action suggested in this study are also indicating to macro, meso and micro level interventions (Figure 3).\u003c/p\u003e\n\u003ch3\u003e3.2.1 Macro level\u003c/h3\u003e\n\u003cp\u003eThe perspective on which system structure is built is extremely crucial. It is well-documented by research that racism, a major structural vulnerability reason, has a significant impact on both mental health and access to healthcare [10, 34, 49]. Bhugra et al. called failure to provide adequate interpretation despite the need for language assistance a form of indirect discrimination [39]. The study's main recommendation is that the system should be free of inequalities and any kind of discrimination. The recommendations regarding basic human rights and social determinants of health presented in this study were reported previously, such as accelerating the process of determining the residency status of migrants [8] and improving the living conditions of asylum seekers [38].\u003c/p\u003e\n\u003cp\u003eIncreasing the number of migrant health workers to promote cultural acceptability, as proposed by Dow [36] and Giacco et al. [8], is one of the study's recommendations. In order to achieve this, the health professionals of this study emphasized the importance of equal opportunities for prospective health service providers with a migration background. It is therefore a recommendation at macro level.\u003c/p\u003e\n\u003cp\u003eGuidelines also called for the expansion of data collection and research to monitor the mental health of migrants and their access to mental health services, and to introduce appropriate policies [39, 41, 42]. German guidelines and action recommendations additionally suggest that the health system's intercultural openness be recognized as a quality aspect of services and examined regularly [19, 37, 50]. Despite being noted in our study, this was not further examined because the health professionals' emphasis was elsewhere due to their specialization of work.\u003c/p\u003e\n\u003ch3\u003e3.2.2 Meso level\u003c/h3\u003e\n\u003cp\u003eAs our study also showed, better coordination can improve the early detection and care of mental health problems in migrants, as these frequently show as physical symptoms [42]. Many studies and guidelines called for better cooperation to overcome the many bureaucratic barriers asylum seekers and other migrants face [17, 35, 40]. According to our study, psychosocial treatment centers and family physicians should play a more active role in ensuring coordination.\u003c/p\u003e\n\u003cp\u003eAs in our study, training healthcare providers, especially general practitioners [8, 10, 21, 35] in cultural competence, sensitizing them for the somatic symptoms in migrants with mental problems, was emphasized in the literature [4, 10, 19, 39, 42, 50]. The experts in our study recommended the provision of interpreters and translations in accordance with the literature, which emphasised covering the costs of interpreters in healthcare settings in addition to ensuring their availability [4, 8, 10, 19, 20, 39, 50]. However, relying solely on interpreters may not always suffice [35, 38]. Some studies advocate for the inclusion of cultural mediators, alongside interpreters [5, 39, 42, 50, 51]. Beyond this, using validated assessment tools in different languages [10, 38, 50] and new technologies to improve communication [8, 38, 42] were suggested in guidelines.\u003c/p\u003e\n\u003cp\u003eSome authors also emphasised considering the acceptability of different treatment approaches and noted that Western treatment modalities, such as talking therapies, may be less appropriate for migrants from certain cultures [9, 36, 39]. Another recommendation for action of this study on the meso level is to incorporate more low-threshold options. Geographically accessible mental health services [39\u0026ndash;41], including on-site offers [35] and technology-based interventions [8], are proposed solutions and similar to the ones in our study.\u003c/p\u003e\n\u003ch3\u003e3.2.3 Micro level\u003c/h3\u003e\n\u003cp\u003eEducating migrants about mental health can reduce stigma and improve their mental health literacy [10, 35]. In [24] model, mental health literacy is considered a determinant of the ability to perceive and can enhance individuals' awareness of their need for healthcare [24, 34]. As proposed by this study\u0026rsquo;s findings, it is essential to ensure that mental health education and promotion is provided in a culturally sensitive manner and includes information about the new healthcare system and mental healthcare options [4, 10, 36, 39, 42].\u003c/p\u003e\n\u003cp\u003eSeveral studies and guidelines include the promotion of migrants\u0026rsquo; mental health as a recommendation for action [8, 10, 20, 38, 42, 52]. Their recommendations also mention school-based programs [10, 38, 42]. Another recommendation at the micro level is stronger social support for migrants. Many guidelines and studies advocate for social support to improve the integration of migrants and thus their mental health [7, 8, 10, 21, 38, 39, 42]. This study's recommendation to foster social support through intercultural leisure activities appears to be novel in this regard.\u003c/p\u003e\n\u003ch2\u003e3.3 Strengths and limitations\u003c/h2\u003e\n\u003cp\u003eThe study's key strength lies in its two-phase structure, incorporating diverse perspectives that enrich the understanding of factors affecting mental healthcare access and resulting recommendations for action. The findings reflected experiences and viewpoints of vulnerable migrant groups in Phase 1. This research is notable for including international students and LGBTQ+ migrants, which is rare in previous studies on mental healthcare access, allowing for the formulation of both general and group-specific recommendations. However, it is impossible to say that this study is free of methodical limitations. It is essential to recognize the heterogeneity within the group of migrants and consider specific migration-related mental health stressors and needs of individual subgroups. To improve the findings, it would be beneficial to involve additional migrant groups. The interviews took place during the COVID-19 pandemic, possibly influencing the findings due to implemented infection control measures. Research suggests that the pandemic has increased existing disparities in access to mental healthcare [53, 54]. Furthermore, the interview tool was not explicitly developed to address mental healthcare access, leaving the possibility that not all factors of migrants\u0026rsquo; mental healthcare access were discussed. However, it was remarkable how much was still revealed about barriers to mental healthcare access, showing the importance of this topic for migrants. Another advantage was the resulting absence of a bias because of socially desired replies.\u003c/p\u003e\n\u003cp\u003eThe participation of healthcare professionals as experts in Phase 2 assisted in validating the dimensions reported by migrants, resulting in the development of a new model of migrants\u0026rsquo; mental healthcare access. This framework structured guided to define the recommendations for action. Based on the health professionals\u0026rsquo; interviews with their different specifications and experiences, comprehensive and action-oriented recommendations were developed. However, for a holistic picture of mental healthcare of migrants, it would be valuable to include experts from disciplines beyond medical professions.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe study\u0026apos;s findings indicate that migrants face numerous obstacles when attempting to access mental healthcare services due to being in a new country, such as limited knowledge on care options, a lack of social support, or the burden of bureaucracy. Moreover, limited awareness and stigma surrounding mental health issues can hinder the perception. The lack of acceptability and appropriateness of the providers exacerbates the impact of these barriers. However, each of these issues has a significant cultural and linguistic component. As a result, culture and language should have special places in an access model for migrants\u0026apos; mental health. Being not entitled to health insurance for asylum seekers, the lack of available care options and uneven distribution of services further complicates migrants\u0026apos; access to services. According to our findings, improving migrant mental health access begins with the removal of all structural barriers caused by discrimination and inequality on macro level. Meso level measures include increasing mental healthcare capacity, improving coordination among system components, and implementing measures to eliminate language and cultural barriers, such as improving provider competencies and providing translation services. All of this, however, should be supplemented by measures to promote and raise awareness of mental health for specific groups of migrants on the micro level.\u003c/p\u003e"},{"header":"DECLARATIONS","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Medical Faculty of the LMU Munich as the competent approval authority (reference number 21-0244).\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eIndividual privacy prevents the public sharing of interview transcriptions. Codes or categories can be shared on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe SonarGlobal work was supported by the European Union\u0026rsquo;s Horizon 2020 research andnnovation programme under grant agreement No. 825671.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB: Study conception and design, performing the interviews in Phase 2, data analysis, writing the manuscript. Z\u0026Ouml;: Study conception and design of Phase 1 and Phase 2, performing the interviews in Phase 2, data analysis, writing the manuscript. CJS: Study design of Phase 2, validation check for the consistency among final dimensions, categories, codes, quotes, and transcripts, contribution in writing the manuscript. MC: Study conception, data analysis in Phase 1, contribution in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the effort of the field researchers who conducted the initial data collection, as well as the contributions of all participants in the study at all stages.\u003c/p\u003e"},{"header":"REFERENCES","content":"\u003col\u003e\n\u003cli\u003eBhugra D. Migration and mental health. Acta Psychiatrica Scandinavica. 2004;109:243\u0026ndash;58. doi:10.1046/j.0001-690X.2003.00246.x.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Fact sheet: Mental health and forced displacement. 23.01.2023. https://www.who.int/news-room/fact-sheets/detail/mental-health-and-forced-displacement. Accessed 27 Jan 2023.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Fact sheet: Refugee and migrant health. 23.01.2023. https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health. 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In: Moussaoui D, Bhugra D, Tribe R, Ventriglio AV, editors. Mental health, mental illness and migration. Singapore: Springer; 2021. p. 615\u0026ndash;630.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Regional Office for Europe. Mental health promotion and mental health care in refugees and migrants: technical guidance: World Health Organization. Regional Office for Europe; 2018.\u003c/li\u003e\n\u003cli\u003eLindert J, Schouler-Ocak M, Heinz A, Priebe S. Mental health, health care utilisation of migrants in Europe. Eur. psychiatr. 2008;23:s114-s20. doi:10.1016/S0924-9338(08)70057-9.\u003c/li\u003e\n\u003cli\u003eAdigun S, Barroso C, Mixer S, Myers C, Anderson J. Minding the Gaps: Health Care Access for Foreign-born People in the U.S.: An Integrative Review. J Health Care Poor Underserved. 2021;32:1653\u0026ndash;74. doi:10.1353/hpu.2021.0158.\u003c/li\u003e\n\u003cli\u003eBayerisches Staatsministerium f\u0026uuml;r Gesundheit und Pflege. Erster bayerischer Psychiatriebericht. Munich; 2021.\u003c/li\u003e\n\u003cli\u003eN\u0026uuml;bling R, B\u0026auml;r, T, Jeschke K, Ochs M, Sarubin N, Schmidt J. Versorgung psychisch kranker Erwachsener in Deutschland. Psychotherapeutenjournal. 2014:389\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eKlein J, Knesebeck O. Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review. Int J Equity Health. 2018;17:160. doi:10.1186/s12939-018-0876-z.\u003c/li\u003e\n\u003cli\u003eSatinsky E, Fuhr DC, Woodward A, Sondorp E, Roberts B. Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review. Health Policy. 2019;123:851\u0026ndash;63. doi:10.1016/j.healthpol.2019.02.007.\u003c/li\u003e\n\u003cli\u003eBhugra D, Watson C, Clissold E, Ventriglio A. Migrants, Racism, and Healthcare. In: Moussaoui D, Bhugra D, Tribe R, Ventriglio AV, editors. Mental health, mental illness and migration. Singapore: Springer; 2021. p. 66\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003ePenka S, Schouler-Ocak M, Heinz A, Kluge U. Interkulturelle Aspekte der Interaktion und Kommunikation im psychiatrisch/psychotherapeutischen Behandlungssetting. M\u0026ouml;gliche Barrieren und Handlungsempfehlungen. [Cross-cultural aspects of interaction and communication in mental health care. Barriers and recommendations for action]. Bundesgesundheitsbl. 2012;55:1168\u0026ndash;75. doi:10.1007/s00103-012-1538-8.\u003c/li\u003e\n\u003cli\u003eMachleidt W, Heinz A, editors. Praxis der interkulturellen Psychiatrie und Psychotherapie: Migration und psychische Gesundheit. 1st ed. M\u0026uuml;nchen: Elsevier Urban \u0026amp; Fischer; 2011.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Promoting the health of refugees and migrants: Global Action Plan, 2019\u0026ndash;2023. Geneva; 23.05.2019.\u003c/li\u003e\n\u003cli\u003eAragona M, Barbato A, Cavani A, Costanzo G, Mirisola C. Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health. 2020;186:52\u0026ndash;6. doi:10.1016/j.puhe.2020.06.055.\u003c/li\u003e\n\u003cli\u003eBenjamen J, Girard V, Jamani S, Magwood O, Holland T, Sharfuddin N, Pottie K. Access to Refugee and Migrant Mental Health Care Services during the First Six Months of the COVID-19 Pandemic: A Canadian Refugee Clinician Survey. Int J Environ Res Public Health 2021. doi:10.3390/ijerph18105266.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e Characteristics of the study population \u0026ndash; Phase 1 (Migrants)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipant\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears spent in Germany\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP01\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP02\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eColumbian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP03\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eTurkish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP04\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eEritrean / Saudi-Arabian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP05\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eSouth-Korean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP06\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003ePakistani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP07\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eIranian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP08\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eBulgarian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP09\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent, refugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eSyrian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP10\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent, refugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eSyrian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP11\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003estudent, refugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP12\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP13\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP14\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP15\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP16\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP17\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eIranian / Afghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP18\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eSyrian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP19\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eSomalian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP20\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003erefugee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP21\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003eLGBTQ+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eRumanian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP22\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003eLGBTQ+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003eGender nonconforming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eUgandan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP23\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003eLGBTQ+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003enot disclosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003egender nonconforming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003enative American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003eborn in Germany\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.406940063091483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP24\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400630914826497%\" valign=\"top\"\u003e\n \u003cp\u003eLGBTQ+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.517350157728707%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29652996845426%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.394321766561514%\" valign=\"top\"\u003e\n \u003cp\u003eKenyan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.984227129337539%\" valign=\"top\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e2\u003c/em\u003e\u003c/strong\u003e Characteristics of the study population \u0026ndash; Phase 2 (Health professionals experienced in mental healthcare)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth professional\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMigration background\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpertise\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE01\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eResearcher in public mental health, youth psychotherapist in training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE02\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003ePsychological psychotherapist, own practice\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE03\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003ePsychological psychotherapist, researcher in public mental health,\u0026nbsp;working experience with refugees in psychiatry\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE04\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003ePsychological psychotherapist,\u0026nbsp;researcher in public mental health and the role of primary care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE05\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003ePsychological psychotherapist, working with refugees in a psychosocial treatment centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE06\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eFamily physician in a rural area where many migrants and refugees are living\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.410596026490067%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE07\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.741721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.8476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eMedical specialist for psychiatry and psychotherapy, working in psychiatry, researcher in public mental health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE08\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"NaN%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"NaN%\" valign=\"top\"\u003e\n \u003cp\u003eMedical specialist for psychiatry and psychotherapy, researcher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Migrants, Mental health, Access to healthcare, Barriers, Recommendations for action, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-4026954/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4026954/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The experience of migration is often associated with stressors that affect mental health. Furthermore, migrants face barriers to accessing mental healthcare. This study aims to explore the dimensions influencing mental healthcare access for migrants in Munich, Germany and to develop recommendations for action.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The study used a two-phase qualitative approach. Phase 1 included individual interviews with 24 migrants from three vulnerable groups (students, refugees, and LGBTQ+ people). Based on the data gathered, seven interviews with health professionals experienced in mental health services for migrants were conducted in Phase 2. The framework from Levesque et al. was applied for analyzing and conceptualization of the dimensions of healthcare access. The health professionals’ proposed actions were grouped based on their respective levels as macro, meso, and micro. Validation was achieved by reviewing the data analysis during a meeting attended by all authors and a professional who was not involved in the interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The dimensions of mental healthcare access encompassed: 1) ability to perceive mental problems, including stigma and knowledge about mental health; 2) ability to seek care, encompassing knowledge about the new healthcare system and social support; 3) acceptability of services, involving provider identity and gender; 4) availability and affordability, including insurance coverage, bureaucratic processes, and capacity and geographical distribution of services; 5) appropriateness including providers’ and patients’ understanding of mental healthcare, and providers’ competence. Language and culture exhibited a strong interplay across all dimensions. The analysis yielded 17 action recommendations. Macro-level recommendations target barriers caused by discrimination and inequality. Meso-level recommendations included increased care capacity and coordination and eliminating language and culture barriers in health services. The micro-level recommendations included activities to promote mental health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Migrants face numerous barriers to mental healthcare due to health system and providers in Munich. However, culture and language remain the most important access factors, necessitating social support. Actions pertaining to acceptability, accessibility, affordability, and appropriateness of health services are required to ensure that all individuals, including migrants, have access to mental healthcare. However, improving migrant mental health begins with the removal of structural barriers created by discrimination and inequality at the macro level.\u003c/p\u003e","manuscriptTitle":"Exploring the Dimensions of Mental Healthcare Accessibility for Vulnerable Migrant Groups and Actions to Improve Access: A Qualitative Study Conducted in Munich, Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-13 17:17:38","doi":"10.21203/rs.3.rs-4026954/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38a9d7c7-b239-4f42-9c63-91a696f3f92f","owner":[],"postedDate":"March 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T16:19:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-13 17:17:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4026954","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4026954","identity":"rs-4026954","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}