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Background: Different service characteristics are known to influence mental health care delivery. Much less is known about the impact of contextual factors, such as the socioeconomic circumstances, on the provision of care to socially marginalized groups. The objectives of this work were to assess the organisational characteristics of services providing mental health care for marginalized groups in 14 European capital cities and to explore the associations between organisational quality, service features and country-level characteristics. Methods: 617 services were assessed in two highly deprived areas in 14 European capital cities. A Quality Index of Service Organisation (QISO) was developed and applied across all sites. Service characteristics and country level socioeconomic indicators were tested and related with the Index using linear regressions and random intercept linear models. Results: The mean (standard deviation) of the QISO score (minimum = 0; maximum = 15) varied from 8.63 (2.23) in Ireland to 12.40 (2.07) in Hungary. The number of different programmes provided was the only service characteristic significantly correlated with the QISO (p < 0.05). The national Gross Domestic Product (GDP) was inversely associated with the QISO. Nearly 15% of the variance of the QISO was attributed to country-level variables, with GDP explaining 12% of this variance. Conclusions: Socioeconomic contextual factors, in particular the national GDP are likely to influence the organisational quality of services providing mental health care for marginalized groups. Such factors should be considered in international comparative studies. Their significance for different types of services should be explored in further research.

Background: Providing mental health care to socially marginalized groups is a challenge. There is limited evidence on what form of mental health-care generic (i.e. not targeting a specific social group) and group-specific services provide to socially marginalized groups in Europe. Aim: To describe the characteristics of services providing mental health care for people with mental disorders from socially marginalized groups in European capitals. Methods: In two highly deprived areas in different European capital cities, services providing some form of mental health care for six marginalized groups, i.e. homeless, street sex workers, asylum seekers/refugees, irregular migrants, travelling communities and long-term unemployed, were identified and contacted. Data were obtained on service characteristics, staff and programmes. Results: In 8 capital cities, 516 out of 575 identified services were assessed (90%); 297 services were generic (18–79 per city) and 219 group-specific (13–50). All cities had group-specific services for the homeless, street sex workers and asylum seekers/refugees. Generic services provided more health-care programmes. Group-specific services provided more outreach programmes and social care. There was a substantial overlap in the programmes provided by the two types of services. Conclusions: In deprived areas of European capitals, a considerable number of services provide mental health care to socially marginalized groups. Access to these services often remains difficult. Group-specific services have been widely established, but their role overlaps with that of generic services. More research and conceptual clarity on the function of group-specific services are required.

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

Aim: This study examines the accessibility of addiction treatment within services providing mental health care and support for people from socially marginalized groups in deprived urban areas across EU countries. Methods: Services providing mental health care and support in deprived areas of 14 EU capital cities were assessed with a questionnaire. We analysed the availability and accessibility of those services providing addiction treatment for people from six groups: the long-term unemployed, the homeless, street sex workers, asylum seekers and refugees, irregular migrants and people from travelling communities. Results: While 30% of all the assessed services provided addiction treatment, in 20% of services, addiction was a criterion for exclusion. Among services providing addiction treatment, 77% accepted self-referrals, 63% were open on weekends or in the evening, 60% did not charge any out-of-pocket fees, 35% provided access to interpreters, and 28% ran outreach activities. These results varied substantially among EU capitals. Conclusion: Access to addiction treatment for socially marginalized groups varies across Europe. Some of the models identified may constitute barriers to treatment. Developing care delivery models that facilitate access for vulnerable populations should be a priority for national and European policies.

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

BACKGROUND:Irregular migrants (IMs) are exposed to a wide range of risk factors for developing mental health problems. However, little is known about whether and how they receive mental health care across European countries. The aims of this study were (1) to identify barriers to mental health care for IMs, and (2) to explore ways by which these barriers are overcome in practice. METHODS:Data from semi-structured interviews with 25 experts in the field of mental health care for IMs in the capital cities of 14 European countries were analysed using thematic analysis.RESULTS:Experts reported a range of barriers to mental health care for IMs. These include the absence of legal entitlements to health care in some countries or a lack of awareness of such entitlements, administrative obstacles, a shortage of culturally sensitive care, the complexity of the social needs of IMs, and their fear of being reported and deported. These barriers can be partly overcome by networks of committed professionals and supportive services. NGOs have become important initial points of contact for IMs, providing mental health care themselves or referring IMs to other suitable services. However, these services are often confronted with the ethical dilemma of either acting according to the legislation and institutional rules or providing care for humanitarian reasons, which involves the risk of acting illegally and providing care without authorisation. CONCLUSIONS:Even in countries where access to health care is legally possible for IMs, various other barriers remain. Some of these are common to all migrants, whilst others are specific for IMs. Attempts at improving mental health care for IMs should consider barriers beyond legal entitlement, including communicating information about entitlement to mental health care professionals and patients, providing culturally sensitive care and ensuring sufficient resources.

As a result of the deinstitutionalisation of psychiatric service users, fragmentation in mental health care delivery systems has become a public mental health issue in many Western countries. Research indicate that it should be addressed at the system level. Leutz described three levels of care integration: linkage, coordination, and full integration. Within a European cross-national research on mental health in socially marginalised groups, we used several measures from Social Network Analysis to describe those three levels of care integration across inter-organisational networks of mental health and social care agencies. The study revealed gaps in the implementation of all three levels of care integration: levels of linkage (density) and coordination (centrality) were low across all networks, there were few fully integrated services, and these services were generally positioned in peripheral positions. We suggest that these social network indicators are relevant to compare integration models across different welfare systems.

Background: Socially marginalised groups tend to have higher rates of mental disorders than the general population and can be difficult to engage in health care. Providing mental health care for these groups represents a particular challenge, and evidence on good practice is required. This study explored the experiences and views of experts in 14 European countries regarding mental health care for six socially marginalised groups: long-term unemployed; street sex workers; homeless; refugees/asylum seekers; irregular migrants and members of the travelling communities. Methods: Two highly deprived areas were selected in the capital cities of 14 countries, and experts were interviewed for each of the six marginalised groups. Semi-structured interviews with case vignettes were conducted to explore experiences of good practice and analysed using thematic analysis. Results: In a total of 154 interviews, four components of good practice were identified across all six groups: a) establishing outreach programmes to identify and engage with individuals with mental disorders; b) facilitating access to services that provide different aspects of health care, including mental health care, and thus reducing the need for further referrals; c) strengthening the collaboration and co-ordination between different services; and d) disseminating information on services both to marginalised groups and to practitioners in the area. Conclusions: Experts across Europe hold similar views on what constitutes good practice in mental health care for marginalised groups. Care may be improved through better service organisation, coordination and information.

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

Background: European Member States are facing a challenge to provide accessible and effective health care services for immigrants. It remains unclear how best to achieve this and what characterises good practice in increasingly multicultural societies across Europe. This study assessed the views and values of professionals working in different health care contexts and in different European countries as to what constitutes good practice in health care for immigrants. Methods: A total of 134 experts in 16 EU Member States participated in a three-round Delphi process. The experts represented four different fields: academia, Non-Governmental Organisations, policy-making and health care practice. For each country, the process aimed to produce a national consensus list of the most important factors characterising good practice in health care for migrants. Results: The scoring procedures resulted in 10 to 16 factors being identified as the most important for each participating country. All 186 factors were aggregated into 9 themes: (1) easy and equal access to health care, (2) empowerment of migrants, (3) culturally sensitive health care services, (4) quality of care, (5) patient/health care provider communication, (6) respect towards migrants, (7) networking in and outside health services, (8) targeted outreach activities, and (9) availability of data about specificities in migrant health care and prevention. Although local political debate, level of immigration and the nature of local health care systems influenced the selection and rating of factors within each country, there was a broad European consensus on most factors. Yet, discordance remained both within countries, e. g. on the need for prioritising cultural differences, and between countries, e. g. on the need for more consistent governance of health care services for immigrants. Conclusions: Experts across Europe asserted the right to culturally sensitive health care for all immigrants. There is a broad consensu

BACKGROUND: European Member States are facing a challenge to provide accessible and effective health care services for immigrants. It remains unclear how best to achieve this and what characterises good practice in increasingly multicultural societies across Europe. This study assessed the views and values of professionals working in different health care contexts and in different European countries as to what constitutes good practice in health care for immigrants. METHODS: A total of 134 experts in 16 EU Member States participated in a three-round Delphi process. The experts represented four different fields: academia, Non-Governmental Organisations, policy-making and health care practice. For each country, the process aimed to produce a national consensus list of the most important factors characterising good practice in health care for migrants. RESULTS: The scoring procedures resulted in 10 to 16 factors being identified as the most important for each participating country. All 186 factors were aggregated into 9 themes: (1) easy and equal access to health care, (2) empowerment of migrants, (3) culturally sensitive health care services, (4) quality of care, (5) patient/health care provider communication, (6) respect towards migrants, (7) networking in and outside health services, (8) targeted outreach activities, and (9) availability of data about specificities in migrant health care and prevention. Although local political debate, level of immigration and the nature of local health care systems influenced the selection and rating of factors within each country, there was a broad European consensus on most factors. Yet, discordance remained both within countries, e.g. on the need for prioritising cultural differences, and between countries, e.g. on the need for more consistent governance of health care services for immigrants. CONCLUSIONS: Experts across Europe asserted the right to culturally sensitive health care for all immigrants. There is a broad consensus

Health services across Europe provide health care for migrant patients every day. However, little systematic research has explored the views and experiences of health care professionals in different European countries. The aim of this study was to assess the difficulties professionals experience in their service when providing such care and what they consider constitutes good practice to overcome these problems or limit their negative impact on the quality of care.

Background: Health services across Europe provide health care for migrant patients every day. However, little systematic research has explored the views and experiences of health care professionals in different European countries. The aim of this study was to assess the difficulties professionals experience in their service when providing such care and what they consider constitutes good practice to overcome these problems or limit their negative impact on the quality of care. Methods. Structured interviews with open questions and case vignettes were conducted with health care professionals working in areas with high proportion of migrant populations in 16 countries. In each country, professionals in nine primary care practices, three accident and emergency hospital departments, and three community mental health services (total sample = 240) were interviewed about their views and experiences in providing care for migrant patients, i.e. from first generation immigrant populations. Answers were analysed using thematic content analysis. Results: Eight types of problems and seven components of good practice were identified representing all statements in the interviews. The eight problems were: language barriers, difficulties in arranging care for migrants without health care coverage, social deprivation and traumatic experiences, lack of familiarity with the health care system, cultural differences, different understandings of illness and treatment, negative attitudes among staff and patients, and lack of access to medical history. The components of good practice to overcome these problems or limit their impact were: organisational flexibility with sufficient time and resources, good interpreting services, working with families and social services, cultural awareness of staff, educational programmes and information material for migrants, positive and stable relationships with staff, and clear guidelines on the care entitlements of different migrant groups. Problems a

Aims. There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems’ Effect on the Quality of Mental Health Care in Europe) project

Comparing mental health systems across countries is difficult because of the lack of an agreed upon terminology covering services and related financing issues. Within the European Union-project REFINEMENT, international mental health care experts applied an innovative mixed “top-down” and “bottom-up” approach following a multistep design thinking strategy to compile a glossary on mental health systems, using local services as pilots. The final REFINEMENT glossary consisted of 432 terms related to service provision, service utilisation, quality of care and financing. The aim of this study was to describe the iterative process and methodology of developing this glossary.

Introduction: Mental health care is a critical area to better understand integrated care and to pilot the different components of the integrated care model. However, there is an urgent need for better tools to compare and understand the context of integrated mental health care in Europe. Method: The REMAST tool (REFINEMENT MApping Services Tool) combines a series of standardised health service research instruments and geographical information systems (GIS) to develop local atlases of mental health care from the perspective of horizontal and vertical integrated care. It contains five main sections: (a) Population Data; (b) the Verona Socio-economic Status (SES) Index; (c) the Mental Health System Checklist; (d) the Mental Health Services Inventory using the DESDE-LTC instrument; and (e) Geographical Data. Expected results: The REMAST tool facilitates context analysis in mental health by providing the comparative rates of mental health service provision according to the availability of main types of care; care placement capacity; workforce capacity; and geographical accessibility to services in the local areas in eight study areas in Austria, England, Finland, France, Italy, Norway, Romania and Spain. Discussion: The outcomes of this project will facilitate cooperative work and knowledge transfer on mental health care to the different agencies involved in mental health planning and provision. This project would improve the information to users and society on the available resources for mental health care and system thinking at the local level by the different stakeholders. The techniques used in this project and the knowledge generated could eventually be transferred to the mapping of other fields of integrated care.