Good Practice in Reaching and Treating Refugees in Addiction Care in Germany – A Delphi Study

doi:10.21203/rs.3.rs-3101791/v1

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Research Article

Good Practice in Reaching and Treating Refugees in Addiction Care in Germany – A Delphi Study

https://doi.org/10.21203/rs.3.rs-3101791/v1

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published 02 Jan, 2024

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Background

Health and adequate access to health care is a human right. Despite both structural and personal risk factors towards substance abuse, refugees continue to face barriers to receive adequate addiction care in Germany, neglecting their human right of adequate health care. The question arises as to how barriers for refugees in reaching addiction services and care can be overcome. In the presented study, strategies for good practices to deconstruct these barriers were identified.

Method

A total of 21experts participated in a three–round, consensus-oriented Delphi-Process. The experts represented five different fields: addiction care services, including specialized programs for women, refugee aid services, academia, policy-making and immigrants’ self-help services.

Results

The Delphi-Process generated 39 strategies of good practice summarized in 9 major categories: Care System, Framework Conditions, Multilingualism, Information and Education, Access, Service-Level, Employee-Level, Employee-Attitudes and Networking.

Conclusion

In order to guarantee human rights regarding health and adequate access to health care for refugees, institutional barriers limiting access to prevention and treatment programs for addictive disorders must be abolished. The identified good practice strategies for Germany, if widely implemented, could contribute to this aim. By opening up prevention and treatment facilities for refugees, other marginalized groups could also benefit. While some of the strategies need to be implemented at the institutional level, political steps are also required at the system level including, e.g. financing of adequate translation services.

Addiction Care

Refugees

Barriers

Access

Good Practice

Drug use

Prevention

According to the United Nations High Commission for Refugees [1], the number of displaced people and refugees worldwide has reached an all-time high of 100 million people in 2022. In Germany, the total number of refugees and asylum seekers has increased over the last decade. In 2021, more than 1.9 million protection seekers[1]^,[2] lived in Germany [2].

Studies show that a significant number of refugees (mis)use drugs (3; 4, 5). Nonetheless, prevalence estimates are heterogeneous and inconsistent, partly because of different definitions around substance use and addiction [6]. Salas-Wright & Vaughn [7] found evidence that refugees in the US are less likely to meet substance use disorder criteria than non-refugees. However, refugees are subject to risk factors for substance (mis)use and addiction ranging from socio-economic issues such as unemployment and poverty, marginalization and discrimination [8, 9], poor living conditions, lack of entitlement to work and family status [10] , to coping with traumatic experiences both in the country of origin, as well as the host country [11, 12].

Health and adequate access to necessary health care is explicitly mentioned in both the constitution of the World Health Organization [13] and in Article 25 of the Universal Declaration of Human Rights [14]. All services should be accessible to all populations, especially to vulnerable populations such as refugees.

However, a systematically decreased utilisation of addiction services [4, 15] and mental health care services in general [16–20] for immigrants and refugees is often discussed. While data focussed on immigrants in general show an underrepresentation in addiction care, a closer look reveals a more heterogeneous picture, with immigrants using cocaine and opioids or seeking treatment for pathological gambling being overrepresented [15, 21]. There is no data available on refugees seeking help in addiction services in Germany, but some data suggest that first generation immigrants – the definition of which includes refugees - use the addiction care system less than second generation migrants [15].

Barriers to the addiction care system are diverse. For decades, immigrants and refugees themselves were considered responsible for barriers to addiction care system mainly [22] based, e.g., on apparent socio-cultural barriers such as fear of stigma, lack of trust in health and social care professionals, as well as negative attitudes towards psychiatry and institutions [5, 23–25]. In recent years, deficits of the care system have increasingly been taken into account [26]. Factors on behalf of care providers such as uncertainty, irritation and triggering of fears and resentments due to unfamiliarity, resistance due to fear of loss of competence as a result of culturalization as well as fear of additional workload due to a particularly “difficult” and “burdened” group, and seeking relief through delegation to special services, all constitute access barriers [27]. Lack of provision of and funding for interpreting services alongside additional expected expenditure due to the need for interpreter services are often seen as a problematic issue with regard to access as well as care delivery [28–31]. Furthermore, perceived discrimination has also been described as a barrier to accessing services [32, 33]. Deimel [34] found that structural barriers limiting access to addiction care depend on residency status. There are various barriers that can impede access to healthcare, including unequal legal entitlements to care and administrative obstacles that make it challenging to obtain care even when there is a legal right to it. For example, separate insurance systems such as a regular insurance card or voucher in German federal states, can add uncertainty over which institution will cover treatment costs [35], preventing refugees gaining proper access.

In order to overcome the abovementioned barriers for immigrants and refugees when accessing (mental) health care in Germany, the multi-layered concept of “intercultural opening” is a guideline considered to be a standard for facilities for reaching and caring for immigrants [26, 36]. Additionally, several European good practice strategies have been identified to aim for reaching and serving immigrants and refugees equally. For instance, Priebe et al. [37] identified in a case vignette study various components of good practice to tackle the barriers and problems evolving among 16 European countries when it comes to delivering care for migrants. Specifically, in mental health services organisational flexibility with sufficient time and resources, working with relatives and social services, and good interpreting services were the three components of outstanding importance. Kluge et al. [38] followed up on these components and further examined the practical implementation of interpreting services in health care. The data revealed almost half of the services interviewed from all over Europe do not to provide any type of interpreting services for patients with language barriers.

Devillé et al. [39] found nine themes consisting of 186 factors representing strategies of good practice in health care in a Delphi-study across 16 EU member states. Common results were the establishment of low-threshold outreach programs, network activities within and outside of the care system, different forms of disseminating information about treatment and prevention within refugee communities as well as different caregivers, and most importantly, easy and equal access to all health care.

There has been little research regarding good practice, including the recommendations mentioned above, in helping refugees to overcome barriers in addiction care. One qualitative study by McCleary et al. [40] showed three themes addressing barriers to successfully referring refugees to substance use treatment in the US. While the will for treating non-English speaking clients must be present, culture and language also have to be considered for successful referral and treatment of refugees. Clients’ preparation for substance use treatment can affect the success of referral and treatment utilization. Finally, coordination and support measures such as case management, alongside close accompaniment to and organisation of appointments, can be necessary for successful referrals. However, previous studies on good practice strategies for reaching and serving refugees did not specifically address addiction services or focused on refugees as a distinct group in outside the US.

The study presented was therefore using a three –round, consensus-oriented Delphi process aiming to produce specific good practice strategies for addiction services to reach and treat refugees in Germany.

[1] Protection seekers are foreigners staying in Germany on the basis of international law, humanitarian or political reasons and are registered in the Central Register of Foreigners (AZR) with the corresponding status under residence law. Terms such as refugees, asylum seekers or persons entitled to asylum are often used as synonyms for people who have fled, but in immigration and asylum law they only describe a specific subset of those seeking protection [2].

[2] The term “refugee” is used synonymously for protection seeker in this paper.

The presented study was part of the PREPARE Consortium (“Prevention and treatment of substance use disorders in refugees”), funded by the German Federal Ministry for Education and Research.

To identify good practice strategies for reaching and serving for refugees in addiction services in Germany, we used an expert-based three–round, consensus-oriented Delphi process [41]. For an overview on the procedure see Figure 1. A similar study design was used by Devillé et al. [39] in order to identify strategies of good practice in health care. The Delphi method is an approach to collecting and creating expert opinions based on their expertise providing a level of consensus with a series of statements [42], that are provided to each expert anonymously in the subsequent round. The approach used involved a panel of experts presenting and rating strategies over three rounds. To achieve a high level of agreement, three rounds are viewed as sufficient [43]. The research was conducted in German. The strategies and questionnaire (see Supplementary Material) were translated into English by two researchers and then reviewed by a native English speaker for the purpose of this publication and research dissemination.

***INSERT Figure 1 Step-by-Step overview on the expert-based three–round, consensus-oriented Delphi process conducted to identify strategies of good practice to reach and treat refugees in addiction care services. Here***

Panel formation

Our aim was to capture a diverse representation of experts working in the fields of refugees and addiction, mental health, policy making as well as key persons working with the target group. While the number of participants varies in Delphi-processes [44], our panel consisted of 22 experts.

The main inclusion criteria for the panel were expertise related to refugees. In order to ensure a broad representation of different viewpoints, the panel was aimed to consist of experts, half of whom have expertise in one of the different German fields of addiction support such as low-threshold street work, injection rooms, counselling centres, hospitals and rehabilitation centres as well as specialized programs for women. This ensured a wide array of views from within different addiction services. The other half included experts from the fields of refugee aid (e.g. employees in shelters), who often are the first to notice substance use among refugees and have experience on how referral to the care system can be managed; from academic researchers to complement knowledge from practice with meta-perspectives on public health approaches and marginalization of refugee; from policymakers to overcome structural barriers and realistic approaches; and from immigrants’ self-organisation and self-help to cover the perspective of those affected themselves.

Identified experts were invited via an email that included a description of the study and an outline of the required contribution. After agreement to participate was gained, the questionnaire was sent via email together with a data protection information sheet and a consent form. Written informed consent was given by each expert before participation in the project. This project was granted human research ethics approval by the Charité – Universitätsmedizin ethics committee (number EA4/164/20).

A total of 51 experts were contacted overall, of whom 22 from across Germany agreed to share their experiences about strategies of good practice regarding the reach out to refugees and provision of addiction care services for them. Eleven had a background in addiction care services, including specialized programs for women, four were working in refugee aid services, two in academia, another two in the field of policy-making and three in immigrants’ self-help services. One expert had to be excluded after the first round due to incomplete answers.

First round of Delphi-process

In the first round between September 2020 and October 2020, experts were asked to list, explain and justify in a free text format up to ten good practice strategies in the field of addiction services for reaching refugees/asylum seekers and providing them with good care (see Fig. 1). Experts were asked to focus mainly on refugees that had arrived 2015 or later and refugees of diverse gender and age.

A review of the collected strategies was subsequently conducted by a team of four researchers experienced in qualitative data analysis. Strategies mentioned by the experts that included more than one strategy for reaching and caring for refugees in addiction services were divided into more selective and discrete strategies. Strategies mentioned by several experts were aggregated, even though different wording was used in reference to the same principles.

To identify, distinguish and aggregate all strategies mentioned, inductive coding with MaxQDA 2020 was performed. Two teams of two researchers each analyzed all answers separate from each other. Each team was instructed to work as follows: firstly, the response of each expert was coded by two researchers independently. Discrepancies between those two coders were then discussed referring to each answering sheet and adjusted in the code system. Finally, the code systems from both teams were compared and integrated. As a result of this three step process in-depth discussions and extensive re-considerations of naming of strategies and grouping took place, resulting in a final code system. Each code included referred to a strategy for reaching and/or serving substance-using refugees. Descriptions of each strategy were derived from associated text sections.

The outcome of the first round of the Delphi process were 48 expert-based good practice strategies for reaching and treating refugees in addiction care. Each strategy included a title and a short explanatory text. The strategies were categorized into nine categories/themes: 1. Care System (8 strategies), 2. Framework Conditions (2 strategies), 3. Multilingualism (7 strategies), 4. Information and Education (3 strategies), 5. Access (4 strategies), 6. Service-Level (11 strategies), 7. Employee-Level (3 strategies), 8. Employee-Attitudes (5 strategies), 9. Networking (5 strategies).

Second round of Delphi-process

The second Delphi round took place from December 2020 to January 2021 as an online survey, hosted by LimeSurvey. Experts were asked to rate the importance of each strategy on a 5-Point-Likert-scale (1=not important, 5= very important). One expert was excluded because of no response in this stage of the process. Thereafter, the mean score was calculated based on the individual ratings of the remaining 21 experts for each strategy.

Third round of Delphi-Process

With the aim of reaching a consensus among the experts interviewed within the third round, each expert was given feedback on their evaluation against the background of the group evaluation in an individual survey tool provided via email. If any expert’s rating differed by more than one point on the 5-Point-Likert-scale from the group mean score of the respective strategy, they were asked to re-consider their rating. Each expert had the option to either adjust the individual rating to the displayed group mean, maintain the original rating, or increase the distance between the own rating of the strategy and the respective group mean. If an expert decided for one of the latter two options, a short explanation was required, which were then used to explain controversial strategies for which no consensus could be found. Finally, any strategy that was rated 4 or higher by at least 80% (n=17) of the experts was considered good practice in terms of reaching and treating refugees in addiction services.

The three–round, consensus-oriented Delphi process identified 39 out of 48 initially proposed strategies as good practice for reaching and serving for refugees in addiction services. The strategies were clustered in nine categories after the first round. Table 1 gives an overview of all strategies combined with number of experts rating each strategy with at least 4 (important) and experts’ mean ratings in terms of importance in Delphi rounds two and three[3]. The final strategies, summarized into categories, are detailed below.

***INSERT Table 1 Overview of all strategies. Bold lines are considered good practice ** with Footnote “Cultural sensitivity as it is used here does refer to a static understanding of culture. It draws back to the need of knowledge about norms, values and attitudes of specific cultures while dismissing heterogeneity and transitions within and between cultures and individuals [45] “HERE****

Care System

The strategies of this category aimed to decrease structural barriers that are not necessarily refugee specific, and to call for an opening of already existing programs for refugees. Three out of eight initially suggested strategies were considered good practice as part of this category by the panel of experts: “Opening all existing addiction services to refugees” (M=4.57; SD=0.81; Mdn= 5), “Overcoming municipality-based support structures” (M=4.38; SD=0.67; Mdn=4,5) and “Ensuring consistency of addiction support services” (M=4.68; SD=0.48; Mdn=5).

Strategies originally assigned to this category not considered good practice were: “Creation of specific services for refugees” (M=4.33; SD=0.86; Mdn=5), “Establishment of services for individual subgroups of refugees” (M=3.95; SD=0.74; Mdn=4,5), “Enabling flexible project development and implementation” (M=4.05; SD=0.80; Mdn=4,5), “Management of requirements planning by policy-makers (federal government, state governments and municipalities)” (M=3.57; SD=0.81; Mdn=4,5)and “Integration of science and practice” (M=3.67; SD=0.91; Mdn=4).

Framework Conditions

Strategies of this category aimed for the meta-level, such as improvement of the conditions of refugees’ everyday lives and their entitlement to use (mental) health care services. Both initially suggested strategies were considered good practice by the experts:“Nationwide equal opportunities for refugees with regard to entitlement of benefits and right of use” (M=4.76; SD=0.44; Mdn=4,5) and “Reduction of structural factors that facilitate or maintain addiction” (M=4.76; SD=0.44; Mdn=4,5).

Multilingualism

Strategies of this category focused on ensuring clear linguistic communication and understanding for two purposes; to ensure the transmission of correct information, and as a signal of openness and welcome. All but the last of these strategies dealt with the implementation of and access to language mediation as well as language mediators and their professionalism. All of the seven originally identified strategies were considered good practice among the experts involved, and included: “Addressing people in their mother tongue as a gesture of welcome” (M=4.29; SD=0.72; Mdn=5), “Nationwide implementation of language mediation in addiction support facilities” (M=4.62; SD=0.50; Mdn=4,5), “Ensuring funding of language mediators” (M=4.57; SD=0.60; GP=20), “Fast and low-threshold availability of language mediators” (M=4.67; SD=0.58; Mdn=4,5), “Professionalism of the language mediators employed” (M=4.62; SD=0.59; Mdn=4,5), “Supervision for language mediators” (M=4.43; SD=0.60; Mdn=4,5), “Multilingualism of documents of the facility process” (M=4.38; SD=0.67; Mdn=4,5).

Information and Education

Strategies of this category dealt with the way information about the addiction support system and about addiction should be designed, presented and passed on.All of the strategies were considered good practice: “Provision of centrally designed, multilingual information on substances, substance use and addiction” (M=4.33; SD=0.86; Mdn=4,5), “Passing on (bundled or centrally designed) multilingual information on addiction-related care services and framework conditions” (M=4.38; SD=0.80; Mdn=4,5), “Outreach information work in the living environment of refugees” (M=4.48; SD=0.68; Mdn=4,5).

Access

Strategies of this category referred to access to refugee populations and how refugees could be reached by addiction support services. The named strategies focused on educating multipliers within the refugee support services as well as key persons or “bridge builders” (peers) from within the community on topics of addiction, addiction care and substance (mis)use. Three of the four strategies first identified were deemed good practice: “Raising awareness of addiction issues among those involved in refugee assistance” (M=4.62; SD=0.59; Mdn=4,5), “Use of key persons as door openers“ (M=4.38; SD=0.74; Mdn=4,5) and “Qualification of and work with "bridge builders” (M=4.29; SD=0.64; Mdn=4). The strategy “Working with relatives” (M=4.68; SD=0.48; Mdn=4) did not reach consensual importance among the experts.

Service-Level

In general, strategies of this category aimed to reduce barriers for refugees within existing services, remove inhibitions, strengthen trust and empower refugees. Ten out of the initially suggested eleven strategies were considered good practice: “Ensuring low-threshold access to addiction support services” (M=4.62; SD=0.74; Mdn=5), “Emphasis on discretion and anonymity” (M=4.67; SD=0.58; Mdn=4,5), “Ensuring participation and active involvement of people affected by addiction in the process of developing services and materials” (M=4.33; SD=0.80; Mdn=4,5), “Participation of refugees in self-help activities”(M=4.52; SD=0.60; Mdn=4,5), “Early intervention for substance use among refugees” (M=4.38; SD=0.92; Mdn=4), “Outreach counseling in the immediate surroundings of refugees” (M=4.38; SD=0.74; Mdn=4,5), “Outreach work in places where drugs are consumed” (M=4.48; SD=0.68; Mdn=5), “Outreach work to build up relationships” (M=4.57; SD=0.68; Mdn=5) “Regularity and durability in the relational work with refugees” (M=4.38; SD=0.80; Mdn=4,5)and “Accompanying clients” (M=4.33; SD=0.66; Mdn=5). Only one strategy (“Creating and maintaining a welcoming environment across all services”) was not deemed good practice(M=3.52; SD=1.03; Mdn=4,5).

Employee-Level

Strategies of this category aimed to promote diversity in terms of migration history and/or non-German (native) language skills in employee teams, and to address acquisition and extension of knowledge of existing refugee-specific legal frameworks. Two out of three strategies were considered good practice: “Promoting diversity in teams” (M=4.67; SD=0.48; Mdn=4,5) and “Trainings for addiction support professionals that addresses the living situation of refugees andPromoting diversity in teams” (M=4.57; SD=0.60; Mdn=4,5). The strategy that did not meet the threshold was “Cultural sensitivity of professionals[4]” (M=3.67; SD=1.20; Mdn=4)

Employee-Attitudes

Strategies of this category focussed on the awareness of addiction service employees towards concepts that seem foreign, or contradict one’s own convictions, and on the development of a professional attitude that involved focussing on each client as a unique case. The strategies additionally exemplify how constantly occurring self-reflection regarding one's own and foreign endings can be achieved. All five of the initially suggested strategies were considered good practice: “Understanding and acceptance of substance use as a coping strategy” (M=4.71; SD=0.46; Mdn=5), “Adopting an appreciative, living environment-oriented attitude” (M=4.67; SD=0.58; Mdn=4,5), “Cross- and transcultural competences in attitude and reflection” (M=4.62; SD=0.59; Mdn=4,5), “Adopting a gender-sensitive attitude” (M=4.29; SD=1.01; Mdn=4,5), and “Coping mechanisms and setting boundaries as a competence of professionals” (M=4.24; SD=0.77; Mdn=4,5).

Networking

Finally, strategies clustered in the category networking outlined the importance of networking on different levels. Networks are established in order to spread information about services, but also to further establish cooperation e.g. common action guidelines. Networking is time-consuming and should thus be considered as a specific target when conceptualising a service.Four out of five initially presented strategies were deemed good practice: “Networking of all stakeholders involved in the care of drug users” (M=4.52; SD=0.60; Mdn=5), “Multidisciplinary networking beyond addiction support services” (M=4.29; SD=0.85; Mdn=4,5), “Considering networking financially and conceptually” (M=4.19; SD=0.81; Mdn=4,5)and the “Establishment of in-depth inter-institutional cooperation” (M=4.29; SD=0.56; Mdn=4,5). A strategy not considered good practice was “Networking with civil society stakeholders”(M=4; SD=0.84; Mdn=4,5)

[3] See Supplementary Material for full length description of strategies.

[4] Cultural sensitivity as it is used here does refer to a static understanding of culture. It draws back to the need of knowledge about norms, values and attitudes of specific cultures while dismissing heterogeneity and transitions within and between cultures and individuals [45].

A total of 39 strategies of good practice in reaching and treating refugees were identified in our three round consensus oriented Delphi-process, with 21 experts working in the fields of refugees and addiction, mental health, policy making and key persons working with the target group.

This study confirms and extends the results of Devillé et al. [39] and Priebe et al. [46]. Our study results also highlight strategies focusing on equal access to health care, low threshold outreach programs both for engagement with and treatment of the target group, networking or collaboration between different services both within and without the specific care system, and provision of information about services and substances as a means of empowering those affected to act in a self-determined manner.

A major difference was the additional relevance of reducing structural, addiction-promoting circumstances refugees are exposed to, which became clear in the context of the strategy “Reduction of structural factors that facilitate or maintain addiction”. Post-migration stressors, especially in the context of the living situation of refugees, but also legal status concerning prospects and possibilities of e.g. work and meaningful activities, facilitate addiction [10, 47] . To enable successful treatment, structural factors embedded in refugees’ social ecology, such as formal access to the job market, family reunification, and residence prospects, have to be addressed [10, 48] . Socio-political solutions to combat marginalisation are needed. Another difference in comparison to other study results [39, 46] is that our results highlighted the need to open up existing services to refugees rather than creating separate special projects and services for refugees, which is the common procedure in Germany. This is especially illustrated by the strategy “Opening all existing addiction services to refugees”. Strategies such as "Ensuring funding of language mediators" aim to enable the opening of existing regular services. The explicit rejection of "special projects" for refugees was also confirmed by the failure to reach consensus as good practice strategies of the initially presented strategies “Creation of specific services for refugees”. Strategies aiming at special projects for refugees promote “othering” defined by Weis [49] as a “process that serves to mark and name those who are thought to be different from oneself”. It is a mean of securing and defining one’s identity through stigmatization and distancing of others in an “us-them” separation, which leads to exclusion and has hence been identified as a barrier for access and delivery of health services [50]. Contrasting our study results and those by Devillé et al. [39], language mediation was not part of the best practice strategies described by Priebe et al. [46]. This could be due to the fact that these authors did not focus exclusively on refugees/asylum seekers. The results of Deville et al. [39] and our own study identified different aspects of language mediation and multilingual material as good practice for better communication and proper treatment. In order to do justice to the great linguistic diversity of refugees – for instance, refugees from 152 countries applied for asylum in Germany in 2022 [51] - the use of language mediation is essential. Non-native German speaking staff cannot cover this diversity.

In Germany, funding of language mediators in health care is often a decision made by health institutions based on their stance towards opening access to non-German speakers by allocating funds [35], and not an entitlement through e.g. health insurance. Straßmayr et al. [24] point out that some care providers have implemented strategies concerning access to help or language mediation either despite (and sometimes against) current legislation, which in turn places care providers in either an ethical or a financial dilemma. This shows a need for change on a policy level to provide legislation that tackles socio-political barriers to accessing healthcare [52].

“Cultural sensitivity of professionals” as it was described as an initially proposed strategy, refers to the need of knowledge about cultural background, culture, value systems and world views of refugees. This does not only build on an static and definite understanding of culture [45], but further contributes to undesirable dynamics of othering. Weis [49] describes othering as the process that “serves to mark and name those thought to be different from oneself”, consequently making it difficult to work with immigrants without sufficient knowledge. According to Akbulut and Razum [53], the analytic lens of othering can help to comprehend group-related differences in health outcomes, as well as inadequate utilization and/or provision of certain health services due to consequences of othering on an individual, institutional and contextual level. Following this train of thought, the initially proposed strategy of “Creation of specific services for refugees” constitutes othering.

In contrast, “Cross- and transcultural competences in attitude and reflection” gained consensus and was considered good practice by the expert panel. The main difference between these strategies is the underlying concept of culture/ cultural difference and background. Prevailing paradigms of culture do not consider it as a static and distinct entity, but as complex, dynamic, and hybrid [45]. Cultural complexity denotes the existence of intricate dynamics, diverse perspectives, and ongoing negotiations within a specific culture. Cultural dynamics and hybridity encompass the temporal and historical aspects of cultural processes, emphasizing their ever-changing, interacting, and interdepending nature. Similarly, Steinhäuser et al. [54] found in a literature review two contrasting concepts of culture as static and dynamic. The static concept views culture as homogenous unit often used interchangeably with country of origin or ethnicity, whereas the dynamic concept of culture considers culture as an individually self-produced hybrid belief system that emerges in a procedural manner and is continuously changeable. Within the latter, geographical experiences, external living conditions, and socio-cultural backgrounds influence the construction of every person’s environment. Applied to the strategies of “Cultural sensitivity of professionals” and “Cross- and transcultural competences in attitude and reflection”, the former requires knowledge of a multitude of backgrounds and origins, which in turn, assumes a static understanding of culture that encompasses all members of a specific cultural background. The latter refers to open-minded curiosity towards other people as well as a self-reflective process, especially in light of one’s own background in the sense of a non-discriminatory attitude. This is, according to Steinhäuser et al. [55], a protracted active process of self-reflection while working with immigrants. The strategies “Creation of specific services for refugees”, “Establishment of services for individual subgroups of refugees” and “Cultural sensitivity of professionals”, which were not ultimately determined to be good practice, refer to a static understanding of culture. The experts we interviewed thus advocated for an open concept of culture.

To our knowledge, this is the first study on good practice strategies in reaching and treating refugees in addiction care in Germany. The findings represent knowledge gathered from different experts from a multitude of fields. By expanding the selection process to experts from fields beyond addiction services, representativeness was addressed as much as possible. Nevertheless, responses always depend on the selection of experts, which can never be fully representative. In future research, a participatory approach with people who are users of the care system should be conducted. The study was conducted in and about Germany; an application to a broader context is, therefore, limited. However, the results are similar to previous internationally conducted studies [39, 46]. While these studies had a broader range of marginalised groups and broader fields of application, the similarities of the results might point at a need to generally aim for inclusive health and addiction care services. Eventually, implementing the strategies of good practice presented serves to reduce genuine barriers to adequate addiction care service provision and utilization, and thus might be beneficial not only for refugees, but also for other marginalised groups.

As part of a different work package of the PREPARE research and intervention consortium, a study on the status of implementation of the identified good practice strategies in the German addiction services was conducted in 2022 and will be published in the future.

The results of this study confirm the available results regarding good practice for marginalized population groups in Europe, most of which stem from studies with small sample sizes. Specifically, “Reduction of structural factors that facilitate or maintain addiction”, “Ensuring funding of language mediators” and “Cross- and transcultural competences in attitude and reflection”. Contextualizing them for the German Addiction care system adds to the growing body of work showing the need to open up (health)services to refugees. The process of opening up institutions for refugees cannot be successful as long as policy framework concerning marginalisation are not adequate.

More research on the implementation of these strategies is necessary in order to validate our findings. Furthermore, reducing barriers and opening up existing services is not adequate as long as long as structures such as funding for language mediation are not implemented. Therefore, on a political level, legislation needs to be adjusted in order to facilitate lasting change, not only in terms of access to health care, but also in terms of health prevention by addressing structural factors that impair equal access to addiction prevention and treatment.

Ethics approval and consent to participate

Research ethics were approved by the ethics committee of the Charité – Universitätsmedizin Berlin (EA4/164/20). All respondents and participants signed informed consent before participation in the study. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and material

The data and material used and/or analyzed for the study presented are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

German Federal Ministry of Education and Research (grant no. 01EF1805B).

Authors’ contributions

Conceptualization, basic methodology and funding acquisition were carried out by AH, SP and IS. PS, the corresponding author, monitored data collection, took care of data curation, adapted and specified methodology as needed, analyzed the data and prepared the original draft of the manuscript. LH was involved in monitoring data collection and data analysis. SP, UK and IS supervised the project and provided feedback. All authors read, edited and approved the final manuscript.

Acknowledgements

We thank all the respondents and participants of the study for their time and for sharing their expertise. We thank Anna Möller for her contribution to the data analysis.

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Table 1 is available in the Supplementary Files section

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Good Practice in Reaching and Treating Refugees in Addiction Care in Germany – A Delphi Study

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