In the last ten years, the number of displaced people around the world has doubled. Due to wars, violent conflicts, and persecution 82.4 million people worldwide were forced to migrate and abandon their homes, friends, and families of whom 1.23 million refugees found shelter in Germany.[1] With that, the country hosted the fifth-largest number of people displaced across country borders worldwide. [1] For instance, 967546 Ukrainian refugees have been registered in Germany since the war started in February 2022, with a further influx to be expected with the war still going on.[2]
Such high numbers of refugees may pose a challenge for the health care infrastructure of receiving countries such as Germany, as refugees face multiple stressors throughout the process of arriving and resettlement that require access to adequate health care. Aside from traumatic experiences during the flight, especially social stressors such as a lack of support in daily life, rejection or even discrimination can lead to multiple psychological issues that make it necessary to receive treatment.[3],[4],[5],[6] In terms of a downward spiral, refugees’ health may further deteriorate if their health care needs are met insufficiently.[7]
Despite the great need for adequate health care, migrants such as refugees in Germany often report a lack of knowledge about how to access and use health care.[8] It is the responsibility of the government and the federal state offices to ensure treatment and provide refugees with access to appropriate information on the health system in general, on their support options in particular or where to go in order to get help.[9],[10] In everyday life, however, refugees tend to experience rather the opposite. Bureaucratic, complicated, and legally strenuous processes pose a barrier for refugees when trying to obtain adequate information about accessing and utilizing health care services, especially in Germany.[9],[10] Negative experiences with state and/or health authorities, e.g. due to language barriers or distrust can reinforce an already existing lack of information or a reluctance to try accessing health services at all.[8],[11],[12]
If public authorities do not adequately provide refugees with relevant information, members of the host community could serve as gatekeepers and help refugees to become familiar with health care options and appropriate contacts, provided they are aware of the information barriers that refugees often face.[13] With this in mind, it is important to find out, how Germans can help to facilitate refugees’ access to health care services. This includes exploring Germans’ awareness of refugees’ health care information barriers and its antecedents, as increased awareness may provide a bridge to taking supportive action.[13]
Antecedents to awareness and the intention to help may include empathy, positive attitudes, and previous positive contact experiences with people of other cultural backgrounds.[14],[15],[16]. However, there is little research on the interplay of these factors in the context of refugee support.[17],[18] Existing research on refugees has focused on negative attitudes that not only cause and exacerbate refugees’ mental health issues, but may also obstruct their access to health care services.[11],[19],[20] Building on existing research, we therefore used and extended the Empathy-Attitude-Action-model (EAA-model),[14] which specifies antecedents of prosocial action toward members of outgroup, to examine the German receiving community’s awareness of information barriers refugees may face in accessing health care. Specifically, we examined empathy, positive attitudes, and positive contact experiences as positive antecedents of awareness.
Using the Empathy-Attitude-Action-model to examine Germans’ empathy and awareness toward refugees
Batson and colleagues’ EAA-model assumes that empathy toward one member of an outgroup expands to empathy toward the entire outgroup, which should promote positive attitudes towards the outgroup and lead to motivation to help.[14] Thus, outgroup attitudes are suggested to serve as a mediating variable between empathy and prosocial action intentions. Empathy consists of an emotional and a cognitive component.[21],[22] Emotional empathy can be defined as an affective response that is similar or even identical to another person’s emotional state and is based on an understanding of what the person needs to feel better (Eisenberg et al., 1991; 2010).[23],[24] Such understanding corresponds to cognitive empathy in the sense that the perspective of another person in a given situation is consciously taken.[14],[25] In the EAA, attitudes are defined as the overall evaluation of an outgroup and its members, whereas prosocial action can be described as the intention to help.[14] In the context of health care, prosocial action may thus refer, for example, to informational support in terms of advice on organizations or websites that might help with getting an appointment with a specialized therapist.
Since its publication in 2002, the assumptions about the enhancing effect of empathy on positive attitudes towards an outgroup and resulting prosocial behavior, as specified in the EAA-model, have been confirmed by numerous studies with children and adolescents in the context of intercultural contact, including contact between members of the receiving society and refugees; studies with adults are sparse yet also yielded confirming evidence.[14],[17],[20] For instance, previous research has shown that encouraging people to take the perspective of the outgroup (i.e. cognitive empathy) increases emotional empathy, which in turn promotes positive attitudes toward the outgroup.[26] In a study with children in Northern Ireland that looked at their interaction with Syrian refugee children, Glen and colleagues induced empathy and found that attitudes toward the outgroup predicted children’s willingness to help incoming refugee children.[15] In another study with Italian children without migration experiences,[18] intergroup empathy was found to be associated with higher levels of positive attitudes toward immigrant children and with more prosocial behavioral intentions.
These findings underline that the EAA-model is suitable for researching the antecedents of intentions to help refugees. Yet, the model and its core constructs need to be redefined in order to explore host society members’ awareness of the information barriers which refugees face to accessing health care. As a starting point, Germans need to be able to take the perspective of refugees who may have suffered multiple stressful experiences during the arriving and resettlement process, resulting in severe emotional disturbances that require appropriate treatment.[3],[4],[5],[6] Therefore, with regard to empathy, we specifically examined cognitive empathy in our study to assess whether Germans recognize refugees’ socio-emotional support needs as a form of perspective-taking.[25]. The vast majority of receiving society members have no or at most little contact with refugees and thus most likely could not develop emotional empathy.[27],[6]
Given the role of outgroup attitudes when predicting prosocial action, positive attitudes are crucial for peoples’ willingness to offer help to members of the outgroup.[14],[18] Negative attitudes against refugees and their rights, on the other hand, reduce prosocial behavior among members of the receiving society.[20] Positive attitudes towards refugees may thus pose as a counterweight to negative attitudes, and enhance the willingness of ingroup members to provide information on how refugees can use and access health care. Acknowledging refugees’ rights would mean to grant them better access to health services, as the recognition of a legal asylum status grants refugees better access to state/public services such as higher education, health care, etc. (reference). We therefore operationalized Germans attitudes towards refugees through their positive attitudes regarding refugees’ rights.
In addition to redefine the three core constructs, we suggest adapting the EAA-model by including awareness regarding access barriers that refugees face as a prerequisite for prosocial action. As Germans so far reported low to no contact with refugees,[6] actual helping action cannot be measured in a valid way. However, prior research suggests that awareness of access barriers to health care can be seen as an important precondition to the motivation of providing informational support.[13],[28] In our context, Germans as members of the receiving society need to perceive refugees’ information barriers, when trying to use health care services to jump into action and provide information on health care access.[13] Therefore, in line with Batson et al.,[14] we concentrated on Germans’ perception of refugees’ information barriers regarding health care as an antecedent of helping actions as our outcome variable.
Based on the refined EAA-model and the study findings by Yaya et al.,[13] we specified our first hypothesis: We propose that Germans’ cognitive empathy towards refugees is linked to positive attitudes towards them and their rights, and positively connected to the awareness of information barriers, as visualized with bold arrows in figure 1. Accordingly, to perceive refugees information barriers and be able to support them on their way to getting access to health care, Germans first would have to recognize their socio-emotional support needs and acknowledge their rights. We expected greater cognitive empathy among Germans to be linked to a greater awareness of refugees’ information barriers regarding access to health services, directly and indirectly via more positive attitudes regarding refugees’ rights (see figure 1, H1).
The role of positive intercultural contact for empathy and attitude development
In the present study, we propose to extend the EAA-model by including previous positive intercultural contact experiences as a relevant antecedent in the model, as they have been found in previous studies to significantly predict empathy, attitudes, and awareness toward socio-cultural outgroups, and the intention to help these outgroups.[16],[29] However, it is not yet known whether positive contact with people of different cultural backgrounds enhances perceptions of information barriers, and whether this effect is direct or mediated by empathy or outgroup attitudes, as suggested by the EAA-model. Previous studies primarily examined the effects of cross-ethnic friendships and empathy on attitudes towards culturally or ethnically diverse groups and on participants’ motivation to engage in helping behavior. For instance, in a study with children from different ethnic backgrounds, Aboud and colleagues found that intergroup contact was associated with positive attitudes towards children with a different ethnic background.[29] Studies conducted among children with and without a migration background in Germany and Italy found similar results.[18],[30] In addition, and in support of the EAA-model, Vezzali et al. found that positive attitudes could lead to an increase of motivation to act helpfully.[18] Johnston and Glasfords study with adults of different ethnicities confirmed associations between empathy and outgroup prosocial intentions mediated by attitudes.[31]
However, research on contact between refugees and members of the receiving society is sparse,[18] likely because the vast majority of adults in the receiving society report having little or no contact with refugees.[27] Therefore, we decided to assess previous positive intercultural contact experiences with people from different cultural backgrounds in general, as positive experiences with one socio-cultural outgroup are positively linked to empathy, supportive attitudes, awareness, and intentions to help other socio-cultural outgroups.[6],[18]
Extending the EAA, we therefore propose in our second hypothesis that prior positive contact with people of different cultural backgrounds serves as a relevant antecedent, which shows positive and direct associations with cognitive empathy, positive attitudes and awareness of refugees’ information barriers (see Figure 1, H2). Therefore, previous positive intercultural contact should help Germans to perceive greater socio-emotional support needs of refugees to a greater extent, improve their attitudes toward refugees’ rights, and enable them to develop greater awareness of refugees’ information barriers when accessing health services. Further, we expect indirect associations between having positive contact with people of different cultural backgrounds and with the awareness of information barriers via cognitive empathy and positive attitudes. Figure 1 shows the extended EAA-Model. Empathy, attitudes, and prosocial action as core constructs of the original EAA-model are shown in grey, with action masked out because we did not examine this variable in the present study. Instead, we included awareness of information barriers, and further, intercultural contact as an antecedent, which are shown in white. The light grey frames illustrate the outgroup context of each variable.
Figure 1
Extended EAA-model including awareness positive contact with people of different cultural background as an antecedent.
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Note. Dark gray shapes are variables from the original EAA model, white shapes are extensions of the original model, the light gray frames represent the respective outgroup, and the arrows visualize the expected positive relationships according to H1 and H2.