Assessing the Demand for Peer Mentorship Among Refugees and Migrants: Insights From a Qualitative Focus Group Study
Abstract
Objective: This qualitative study aimed to explore the tasks, competencies, and qualifications necessary for an upcoming peer mentor program to support patients with refugee and migrant backgrounds in navigating the healthcare system and their daily lives. The study aimed to uncover the expectations of social workers and healthcare professionals regarding peer mentors and the program.
Methods: The study used focus group interviews and individual interviews with healthcare professionals and social workers. Data were analyzed using a hermeneutic phenomenological approach and Malterud’s text condensation. In the study, we consider individuals with refugee, migrant, and asylum seeker backgrounds equally.
Results: Two main themes emerged: “Patients at risk of being lost in transition” and “Expectations and role of Peer Mentors.” The first theme highlighted the challenges that migrants face in navigating the healthcare and social sectors due to language barriers and complex systems. The second theme emphasized the importance of peer mentors as cultural bridge builders, supporting patients’ understanding of Danish society and the healthcare system and addressing their unique needs.
Conclusions and Implications for Practice: The study emphasizes the vulnerability of migrants and the potential benefits of a peer mentor program. The findings highlight the need for a well-designed program that provides training and support to peer mentors, facilitates sector collaboration, and addresses the complex challenges faced by migrants.
1. Background
Denmark, similar to other European countries, has experienced a notable influx of migrants and refugees from non-Western nations due to ongoing wars and conflicts. The presence of individuals from diverse cultural, religious and linguistic backgrounds, relocating to countries far from their homelands, often leads to higher levels of fear, mistrust, and insecurity when accessing healthcare services in their host country [1]. A comprehensive review conducted in 2018 establishes that migration laws, policies, and the negative portrayal of refugees in the media contribute to the development of an underlying atmosphere of racism, mistrust, and even hostility toward migrants within both healthcare services and society. This, in turn, significantly affects their well-being and overall health status [1]. Consequently, migrants may develop a lack of trust in healthcare and social systems, thus complicating their collaboration and interactions with healthcare and social professionals.
Encounters among refugees, asylum seekers, migrants, and the social and healthcare sectors frequently involve various ethical dilemmas [2, 3]. A review from Spain [4] highlights that the main obstacle faced by social workers involved in refugee support is the lack of time, which impedes the provision of individualized care. Furthermore, the study reveals that information plays a pivotal role in social intervention. Dilemmas often arise in relation to resource management, and the complexity of the situation, compounded by language barriers, affects the duration of the intervention [4].
Misunderstandings arising from language barriers between healthcare professionals and patients, as well as differences in cultural beliefs and behaviors about health, can lead to misinterpretations and misconceptions [5, 6]. For instance, in certain cultures, openly expressing disagreement with a doctor or sharing one’s emotions is deemed culturally inappropriate [7]. Consequently, miscommunication may lead to patients abandoning healthcare and social services or not complying with the recommendations provided by professionals. Consequently, the implementation of evidence-based approaches tailored to patient needs, along with the delivery of culturally competent care by healthcare professionals, can improve the retention rates of healthcare services [8].
With inadequate staffing levels, healthcare systems struggle to meet the complex and diverse needs of those patients who require specific and complex care. Long waiting times for medical attention, reduced quality of care, and compromised patient safety are some of the consequences [9]. Vulnerable populations, such as migrants and refugees, face heightened risks [10]. The lack of sufficient healthcare personnel also impedes preventive measures and health education initiatives. Addressing this shortage requires comprehensive strategies, including recruitment and retention efforts, investments in healthcare education, and the promotion of collaboration with informal peers and relatives.
A scoping review that examined peer support interventions for Type 2 diabetes revealed the need for specially trained individuals or peers who can provide support to migrants or refugees “face to face,” treating them with dignity and respect, considering their vulnerable backgrounds and situations [11]. Specialized peers have been described in a German study as individuals possessing cultural empathy, cultural competencies, skills to overcome personal biases, cultural preparation, and a deep understanding of diverse cultures [12]. Another study by Jain suggests that involving peer educators who have a genuine desire to help others can help migrants manage long-term health conditions. Peer educators, characterized by their natural empathy for individuals from different cultures, religions, and languages, have a significant impact on the health decisions and behaviors of migrants [13]. Moreover, serving as a peer educator can have a positive impact on the educators themselves, fostering personal growth and reinforcing their own knowledge and skills [14].
In a Danish context, a study highlights positive effects of peer mentoring on myocardial infarction patients’ rehabilitation; this peer mentor intervention demonstrated improved transitions between hospital and home, as it resulted in a high rate of cardiac rehabilitation attendance among patients, alongside an improvement in their quality of life [15]. However, there is sparse literature of peer mentor programs in Denmark.
Furthermore, previous studies indicate that patients facing various challenges often struggle during transitions between the hospital and home or municipal services. However, there is limited literature specifically examining these transitions for refugees and migrants, who may encounter unique barriers such as language, cultural differences, and unfamiliarity with healthcare and social systems. Health professionals and social workers also face challenges in supporting these patients due to gaps in communication and coordination across sectors.
Recognizing these gaps in the literature, our study aimed to identify the specific needs and expectations for a future peer mentor role to better support refugee and migrant patients during these critical transitions and enhance the continuity of care.
2. Methods
2.1. Design and Scientific Framework
The study used qualitative focus groups and individual interviews as methods, using a hermeneutic phenomenological approach [16]. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used as a scientific guideline to ensure rigor and transparency in all steps of the study [17].
From a healthcare perspective, hermeneutic phenomenology [16, 18] allows researchers to explore subjective experiences of the encounter with migrants and refugees to the healthcare system, including their interactions with patients, their understanding of health and treatment, and their access to necessary care. This deep dive into their experiences facilitates the identification of gaps in healthcare care delivery and opportunities for more culturally sensitive and accessible care. Simultaneously, from a social work perspective, this approach aimed to shed light on the sociocultural and economic challenges that could complicate the transition from hospital to home for patients.
The commitment of the methodology to bracketing, or leaving out preconceptions, ensures an authentic exploration of these experiences, free from researchers’ biases [16]. This was crucial in fostering an environment where participants could share their experiences openly, ensuring that their voices were heard and understood within the actual contexts. Moreover, the reflective dialog of hermeneutic phenomenology was instrumental in bridging the gap between research and practice. This dialog was used to enrich the research findings with deep and contextually grounded insights [16].
2.2. Participants
The first focus group comprised six healthcare professionals, including nurses, physicians, and social workers, affiliated with a migrant health clinic at a Danish university hospital. The second focus group included three social workers employed in a job center within the primary sector. Additionally, three individual interviews were conducted with professionals based in the same city as the job center social workers. In total, 12 participants were involved, none declined or dropped out (Table 1).
| ID number | Employment | Gender | Education | Interview methods |
|---|---|---|---|---|
| F1a | Migrant health clinic | F | Social worker | Focus group interview |
| F1b | F | Nurse | ||
| F1c | F | Physician | ||
| F1d | M | Physician | ||
| F1e | F | Nurse | ||
| F1f | F | Physician | ||
| F2a | Municipality | F | Social worker | Focus group interview |
| F2b | F | Social worker | ||
| F2c | F | Social worker | ||
| I1a | Municipality | F | Occupational therapist | Individual interviews |
| I1b | F | Occupational therapist | ||
| I1c | F | Occupational therapist | ||
- Note: Overview of participants, their ID number, workplace, gender, and professional background. The additional information about the participants will not be disclosed due to concerns about sensitive personal data.
Participants were selected using purposive sampling to ensure a range of professional backgrounds and experiences. Inclusion criteria required participants to have experience working with refugees and migrants transitioning from hospital to home/municipality. All participants had extensive experience working with migrants and refugees over several years (Table 1). We contacted participants by telephone, except for those at the migrant health clinic, who were contacted face to face.
2.3. Data Collection
All interviews were conducted between November and December 2021. Two authors participated in each focus group LD/DN and DN/LT, respectively, with one acting as the interviewer and the other as the moderator [19]. The interviews were held at the participants’ workplace by their own choice and were conducted only once.
The focus groups aimed to gather various professional perspectives on the challenges their patients with minority background face during their treatment journeys and transition from the hospital to the municipality. In the study, we consider individuals with refugee, migrant, and asylum seeker backgrounds equally. Discussions centered on the qualifications and responsibilities of peer mentors. To ensure all perspectives were included, we further conducted three individual interviews. These interviews also focused on the participants’ experiences and their views on the qualifications necessary for peer mentors to help patients from minority backgrounds manage health-related situations in their daily lives. The interviews were conducted using an interview guide (Table 2) developed based on the existing literature and the authors’ own experiences in the field.
| 1. Introduction and background | The purpose of the interview and confidentiality. |
|---|---|
| Participants introduce themselves, including their professional background and experience working with refugees and migrants. | |
| 2. Understanding the patient’s challenges | What are some of the main challenges that refugee and migrant patients face when transitioning from the hospital to home or community care? |
| 3. The role and expectations of a peer mentor | What do you believe should be the primary role of a peer mentor for refugee and migrant patients? |
| What skills or qualities do you think are essential for a peer mentor to effectively support these patients? | |
| How should a peer mentor assist in bridging cultural and language barriers between patients and professionals? | |
| 4. Navigating the healthcare and social systems | What are the specific tasks or activities that a peer mentor could help patients with in terms of health care (e.g., understanding treatment plans and attending appointments)? |
| 5. Building trust and relationships | How can peer mentors address issues related to trauma or PTSD in patients who may have difficulties with trust or communication? |
| 6. Collaboration with healthcare and social care professionals | How should peer mentors collaborate with healthcare and social care professionals to ensure continuity of care? |
| Are there potential challenges in this collaboration, and how might they be addressed? | |
| 7. Final thoughts and suggestions | Is there anything else you believe would help refugee and migrant patients in their transitions that we haven’t covered? |
| Do you have any additional suggestions or expectations for the role of peer mentors in this context? |
We used both focus groups and individual interviews to accommodate participants’ availability. Furthermore, we designed the focus groups to gather diverse professional perspectives in a collaborative setting, while the individual interviews were conducted to ensure that all relevant voices were included when scheduling difficulties prevented full group participation. The combination allowed for both broad group discussions and in-depth individual insights.
All interviews were recorded using a Dictaphone and securely stored online. Transcripts were not returned to participants for further comments; agreements and “fusion of horizons” were achieved during the interviews. The moderator wrote down the field notes during the focus groups, and the notes were later included in the analysis process. We used Microsoft Word to manage the data, and the analysis was conducted as an iterative process involving all authors.
2.4. Health Services in Denmark
All healthcare services in Denmark are provided free of charge, with expenses covered through a complex tax system. Social and health services in Denmark are divided into two sectors: primary health and social care, operated by the local municipality, and secondary health care, including hospitals, operated by the local region.
2.5. Data Analysis
The interview transcripts were transcribed by author LT, carefully reviewed, and subjected to collective discussions. The analysis was guided by Malterud’s text condensation approach [20]. Initially, author LT conducted a pre-analysis of all the transcripts to identify meaningful units. Thereafter, all authors performed the data analysis collaboratively as an iterative process. Subsequently, the preliminary meaning units were thoroughly discussed and analyzed by the entire author group to gain a deeper understanding of the expectations of healthcare professionals regarding the peer mentor program.
Field notes were made by the moderator during the focus groups and were included in the analysis process. Microsoft Word was used to manage the data, and the analysis was conducted as an iterative process involving all authors.
2.6. Ethical Considerations
The data about participants were kept minimal due to ethical considerations. We aimed to protect participants’ anonymity and ensure they would not be easily recognized. Given the specific professional backgrounds of those involved, there was a risk of identification if too much detail was provided. Therefore, we made a conscious decision to limit the amount of identifying information shared to prioritize their confidentiality.
Before they participated in the study, participants received verbal and written information about the project. It was emphasized that participation was voluntary and written informed consent was obtained from all included participants. In addition, the participants consented to the audio recording of their interviews.
All data are securely stored in a protected SharePoint room at the University Hospital to ensure confidentiality. The study received approval from the Data Protection Agency in the Region of Southern Denmark. Furthermore, the Scientific Ethical Committee determined that the study did not require additional formal consent from ethics committees according to Danish legislation.
2.7. Reflexivity
All authors were highly aware of their preconceptions throughout the research process. Two authors, DSN and LT, were experienced nurses and researchers, with extensive knowledge of healthcare practices, while LD brought many years of expertise in cultural communication. This diverse combination of backgrounds enriched the study, allowing the team to approach the data from multiple angles.
Authors LD and DSN had prior professional relationships with some participants from the migrant health clinic. This familiarity allowed for a deeper understanding of the clinic’s context and challenges but required the authors to remain particularly mindful of any potential bias. To mitigate this, the analysis was conducted as a collaborative and iterative process with the entire research team, ensuring that diverse perspectives and interpretations were included to maintain objectivity and rigor in the findings.
Given their awareness of the complexities and challenges in working with refugees and migrants, the authors remained vigilant about avoiding biases and acknowledging preunderstandings. This reflexive approach helped ensure that personal perspectives did not overshadow the data, enhancing the rigor and credibility of the analysis. By actively reflecting on their assumptions, the team aimed to minimize potential blind spots and kept focus on the authentic voices of the participants.
3. Findings
The analysis revealed that peer mentors need a combination of professional and personal skills to effectively support migrant and refugee patients. These skills included the ability to bridge cultural gaps, provide practical guidance, and offer emotional support, especially in navigating complex systems such as healthcare and social services. The findings are organized into two main themes and five subthemes, which highlight the vulnerability of patients during their transitions and the critical role that peer mentors play in offering tailored assistance and fostering trust. This underscores the importance of peer mentors in improving patients’ overall experience, helping them manage the challenges they face while transitioning between different sectors.
- -
Navigating complex transitions
- -
Understanding patient vulnerability
- -
Collaboration gaps between sectors
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Bridging cultural and systemic gaps
- -
Guiding patients through society
3.1. Patients at Risk of Becoming Lost in Transition
This theme focuses on the professional perspectives regarding the challenges migrant and refugee patients face during transitions between healthcare and social services. All professionals emphasized the heightened risk these patients face due to language barriers, posttraumatic stress disorder (PTSD), and social isolation. They discussed the need for strong, trust-based relationships and additional support to prevent patients from being “lost” during transitions.
3.1.1. Navigating Complex Transitions
“They are a non-Danish-speaking group in society, where physical, mental, social, and economic problems are all intertwined. They have given up, the municipality has given up, and the family has given up. Even the doctor has given up” (F1d).
“Sometimes we simply hold their hand and go with them… Sometimes, we sit with them… If they need transportation, we sit with bus schedules and coordinate from here to there, etc. Down to the smallest detail, explaining how things can be done and why they should be possible. (I1c)
“Demanding too much from the patient distances us a lot. The group of citizens we deal with requires a lot of relationship building and trust in each other. So, having the flexibility and being able to filter what is relevant for this particular citizen to know—I believe that would greatly help us. Because often there is a good relationship. The most important thing is the dialogue. We don′t want them to just disappear” (F2a).
“We also tried to educate them, so to speak. If I had to go on a preventive home visit, they had to be home when we arrived, and things like that. Otherwise, it is really difficult to handle… So, we were very clear about it and then kept our fingers crossed for it to work out” (F2c).
3.1.2. Understanding Patient Vulnerability
“I also meet these patients. There are those who are extremely vulnerable… Meaning, they have not processed their traumas. It consumes their entire day, and they cannot make sense of it” (I1b).
“But it is not just PTSD; it is generally when someone is mentally vulnerable and has mental problems… It is about understanding that you cannot always see it. Even if they smile and seem happy, they can still feel bad inside” (F1b).
According to the participants, some of the challenges faced by the patients were more complex due to misunderstandings between the social and healthcare systems. Some patients could be caught between healthcare care and social care because these two systems often lack a common platform to address their needs. Misunderstandings between patients and professionals were attributed, in all focus groups, to different cultural understandings of what it means to be healthy, sick, or ready for work.
“It is a hopelessness and meaninglessness that is very, very difficult for them to cope with. They cannot go back home, they cannot leave, and they are not allowed to stay. However, they have to stay. It is very meaningless. Even legislatively, it seems pointless. Apart from residency, the entire legal complexity surrounding them is incomprehensible” (F1d).
The social vulnerability of the patients was also explained by the differences between their countries of origin and Denmark. In particular, the municipality’s participants highlighted that many patients had previously been able to earn a living in their home country through “small” jobs such as street trading without any oversight from the public sector. In Denmark, however, they encountered a complex tax and financial system that could lead some patients to accumulate unpayable debts.
3.1.3. Collaboration Gaps Between Sectors
“And they have completely lost control over their own lives, right? It is the municipality and legislation that actually determine everything” (F1c).
“Well, we are dealing with different legal frameworks. Different boxes, so to speak. […] If you go to the other side of the street, they also do not want to know anything about the patients, right? It is a problem of specialization. The less you know, the easier it is to be clever, right? And the municipalities’ task is either employment or disability. They are just as specialized as a hospital is” (F1d).
During interviews and focus groups, it was emphasized that organizing network meetings across sectors could help identify the unique needs and challenges of the individual patient, recognizing the need for different competencies and perspectives among colleagues in various specialties, departments, and sectors to improve patients’ trajectories, with peer mentors playing a vital role.
3.2. Needs and Expectations of the Peer Mentor
The professionals all welcomed the idea of a peer mentor program, recognizing the need for such a program to support migrant and refugee patients in the transition from hospital to the municipality. Peer mentors were seen as a possible key in bridging cultural and systemic gaps, helping patients navigate both healthcare and social services, and fostering trust between patients and professionals.
3.2.1. Bridging Cultural and Systemic Gaps
“Yes. I think, in general, in relation to a difficult rehabilitation process for the citizen discharged and needs to be rehabilitated in the municipality, and learn to be independent and make use of the available services, you need a contact person in general” (F2a).
Expectations included the peer mentor’s ability to help overcome language barriers, enabling better communication between patients and healthcare or social workers. Having a common language between the patient and the peer mentor was deemed essential for building relationships and ensuring accurate information transfer without pressure or demands.
3.2.2. Guiding Patients Through Society
“Someone who can function as a kind of dictionary for the patient. Someone who is familiar with Danish society, whom they can ask about various things that are on their minds” (F1e).
Yes, and also knowing that if someone has PTSD, they have difficulty connecting with other people. So, it is not necessarily related to the mentor. However, it is a general fear or difficulty in making contact with new people. (F1c).
“To show that there is a connection between the mind and body and that it benefits the brain to do physical exercises…” (F1d).
Additionally, challenges stemming from different cultural perceptions of time and appointments were frequently cited as major sources of conflict between patients and healthcare or social care professionals. Waiting lists, in particular, were often misunderstood, leading to mistrust and dissatisfaction. Moreover, the expectation of booking appointments rather than simply arriving was another point of contention, causing some patients to disengage from healthcare services entirely. This highlighted the critical role of peer mentors in helping patients navigate these cultural differences and avoid misunderstandings that could hinder their care.
“Many of our patients are lonely and cannot just go out for 5 min to get some fresh air. They spend the whole day in their apartments. So that is one thing I am thinking about. Someone who could initiate getting a patient out, moving and getting some light and fresh air” (F1c).
All participants expressed their hopes that the peer mentors would be able to make a positive change in the patient’s daily lives. Feeling powerless as professionals to provide patients with meaningful and appropriate support was a source of pain for most participants, who mainly wanted to support and help patients in the best way possible.
4. Discussion and Conclusions
4.1. Discussion
Our findings reveal the vulnerability experienced by professionals working with migrants, who often find themselves in socially isolated situations, grappling with language barriers and cultural differences. This aligns with other studies, which highlight that PTSD can cause difficulties in learning a new language and participating in social contexts [21, 22]. These factors can significantly inhibit the ability of patients to navigate the healthcare and social sectors. Thus, our findings provide support for the potential necessity of implementing a peer mentor program that operates in both hospitals and the social sector.
Although our study highlights the potential benefits of peer mentoring programs for migrants, it is essential to approach their implementation thoughtfully, taking into account the unique needs and circumstances of the migrant population being supported. For example, ensuring a suitable match between the peer mentor and the patient becomes crucial, as they may or may not share common cultural and linguistic backgrounds, maximizing the effectiveness of the mentoring relationship [23]. Mentoring has been emphasized by Greenwood and Habibi as a means to provide emotional support, information provision, problem-solving, facilitation, and new perspectives, resulting in positive outcomes [24].
In our study, all participants expressed high expectations for peer mentors in an upcoming program. They expected peer mentors to act as bridge builders, good friends, and interpreters, highlighting that all tasks must be grounded in trust and a strong relationship. An example of a peer mentor project, targeting older vulnerable myocardial infarct patients, illustrated the potential emotional challenges faced by peer mentors, leading to offering training, support, and guidance to their mentors [15]. Participants in our study viewed the peer mentor program as a form of social support, in which peer mentors were expected to provide practical and emotional assistance to patients with migrant backgrounds. Previous studies have demonstrated the positive impacts of this support, including stress reduction [25], anxiety alleviation, enhanced self-esteem and self-efficacy [26], and the promotion of a sense of belonging.
Although our findings did not specify whether a peer mentor program should be tailored to specific stages of the migration process, participants stressed that people coming from war-torn regions and suffering from PTSD often showed increased vulnerability and would benefit from contact with a peer mentor. Van Voorhees et al. examined homeless veterans and demonstrated that self-reported PTSD diagnosis was associated with a sense of disconnectedness and lack of benefit from a peer mentor program. Thus, the authors suggest that the capacity to develop and maintain social bonds in individuals with PTSD may interfere with their ability to benefit from peer mentorship [25].
It is worth noting that most of the participants in our study were women, which may limit the broader gender perspective on expectations of how peer mentors work and support migrants in their daily lives. Consequently, important issues may have been overlooked in the current paper. A review investigating a peer mentor program targeting migrant women emphasized the different challenges faced by women and men with migrant backgrounds. For instance, resettlement policies often fail to recognize the unique challenges faced by female refugees, with interventions primarily focusing on male access to employment and financial independence. Studies on refugee employment in various countries have documented administrative barriers and social discrimination experienced by refugee women in their pursuit of employment [27].
4.2. Limitations
This study employed both focus groups and individual interviews to capture diverse perspectives. However, the small sample size may affect the transferability of the findings to other contexts. Additionally, scheduling challenges led to the use of individual interviews for some participants, which may not provide the same depth of interaction as focus groups. Furthermore, the lack of follow-up interviews limited the ability to further explore participants’ evolving views after the initial data collection.
4.3. Conclusions and Implications for Practice and Research
The results of our study, as well as the findings of the existing literature, highlight the need to develop a peer mentor program specifically targeting patients from refugee backgrounds who are undergoing treatment in hospitals and require extensive support from the municipality. Additionally, the study emphasizes the importance of providing ongoing education and supervision within the context of the peer mentor program. This is crucial considering the emotional nature of the relationships and tasks involved in caring for patients with vulnerable backgrounds and daily lives.
Future research should aim to include diverse gender perspectives related to the development of a peer mentor program. Furthermore, various aspects could be explored, such as identifying the most effective content for peer mentor training programs, as well as the effects of mentoring programs on participants’ well-being, self-efficacy, and social connectedness within a healthcare setting. Future research should prioritize the identification of best practices for peer mentoring programs tailored to patients with challenging and vulnerable backgrounds. Furthermore, it is necessary to investigate the long-term effects of such programs.
Consent
We confirm all patient/personal identifiers have been removed or disguised so the patients/persons described are not identifiable and cannot be identified through the details of the story.
Disclosure
The current paper adheres to the COREQ guidelines.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Conceptualization: D.S.N. and L.D.
Data curation: L.D. and L.T.
Formal analysis: L.D., L.T., and D.S.N.
Funding acquisition: D.S.N. and L.D.
Investigation: L.D., L.T., and D.S.N.
Methodology: L.D., L.T., and D.S.N.
Project administration: D.S.N.
Roles/writing: L.D., L.T., and D.S.N.
Funding
This project was funded by Sundhedskartellet and Danske Regioner.
Acknowledgments
The authors thank Sundhedskartellet and Danske Regioner for financial support—and to all participants for their time and trustfulness. During the preparation of this work, the authors used ChatGPT 3.5 in order to proofread some paragraphs of the paper. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Open Research
Data Availability Statement
The qualitative data used to support the findings of this study have not been made available because of confidentiality and ethical issues related to participants.
