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With regard to content, the pilot assessment revealed
weaknesses in the explanation of questions and instructions for
interviewers. We were able to improve this for the assessment
of the community mental health care system in Mitte district.
Overall the assessment tool could not be shortened by the
pilot survey. Instead, in the end, it comprised 16.5 pages/157
items. But the length of the documented interviews appeared feasible
with an average number of 1.5 hours duration. Interviewees
did not complain about it and seemed to be motivated. As a fi nal
product, an assessment tool for the current status of “intercultural
opening” in the community mental health care system 3 was
developed using a three- stage procedure (Fig. 3).
4. Discussion
Based on pre- existing questionnaires and checklists [15,5,29]
aiming to assess interculturally opened institutions but either
developed for self- examination, focusing only on specifi c aspects
of “intercultural opening” and missing validation we constructed
a tool for broad assessment via an expert- based Delphi process
and pilot study. The resulting assessment tool is the fi rst
one to give an all- around assessment of the current status of
“intercultural opening” in mental health care sector in Germany.
It could be used in further studies as well as an instrument for
self- evaluation and quality management. With little changes
concerning response categories the tool could also be used in
other care facilities, which should be piloted fi rst.
To a very large extent, the experts of the Delphi process felt
that all the items in the preliminary assessment tool composing
“intercultural opening” were essential. But as an assessment
tool should not be too long, we had to apply a strict defi nition of
consensus of the Delphi process. We could not take into account
at least one dissenter (xmod=10). The defi nition of xmod=10
would have identifi ed further 54 items reaching consensus
which therefore should have been kept in the assessment tool.
Nevertheless each main topic of the developed preliminary
instrument was confi rmed by the experts of the Delphi process.
Only subordinated items were dropped out. Contrary to
the result of the Delphi process we decided to keep questions
in the assessment tool concerning issues being important
for the structure of the tool or for one goal of the upcoming
assessment.
Because of the defi nition of consensus used in the Delphi
process, we did not take into account the exact distribution of
expert opinions with regard to the judgment of “very important”
or “important”. Therefore we decided to use these distributions
for building up a scale judging the current status of “intercultural
opening” of each assessed institution in detail when analyzing
the data. That means the implementation of aspects which have
mostly been judged as very important by experts in the Delphi
process have to be weighted higher than others which have
mainly been validated as “important”.
The pilot study represented another important part, as it
combined theoretical with practical expertise. Further revision
and optimization of the preliminary assessment tool was
3 See: http://www.segemi.de/delphiprozess/download/IKOE_P_1_English.pdf
S. Penka et al. / European Psychiatry 27 (2012) / supplement n°2 / S63-S69 S67
possible, as it gave important insight into the actual practice of
each type of institution. One item, taken out of the assessment
tool as a result of the Delphi process, had to be added again as
its importance in actual practice became apparent in the pilot
survey data. This example highli ghts the importance of our
three- stage procedure, as Linstone pointed out that a panel of
experts does not constitute expertise on human behavior, group
dynamics and the whole system [21].
In the pilot survey we did not ask interviewees for missing
aspects with regard to improved accessibility and the quality
of treatment of migrants as the goal of the study project is to
check the concepts’ implementation, which has been discussed
in Germany for many years, and its actual effect on the actual
practice. Through additional fi eldwork and qualitative interviews
in selected institutions we will gain some more details about
experiences and opinions of staff which will be important for
the later evaluation of the concept of “intercultural opening”.
As the assessment of the current status of “intercultural
opening” is at risk of being infl uenced by answers given for
reasons of “social desirability”, we can also compensate this
with these additional methods and complete the results.
Our tool is directed to assess institutional level policies, however
individual cultural competencies are a crucial part of the
institutional level concept of “intercultural opening” [2,13,14,25].
Therefore, we decided to assess the cultural competency of the
staff in some selected institutions in parallel independently from
our survey applying one pre- existing checklist [e.g. 10].
In Germany and other European countries a new approach is
increasingly needed for dealing with barriers to social or health
care systems and improving quality of treatment for migrants,
based on “responsiveness to diversity” [8,7]. Contrary to “intercultural
health strategies”, diversity concepts focus on all aspects
of the variety of pluralistic societies, e.g. gender, disabilities,
marginalized population, socio- economic status [27]. One of
the multiple benefi ts is that the focus is no longer placed on
migrants and therefore the reproduction of difference in terms
of migrants is softened. However in Germany, the adoption
of this approach is only reluctantly accepted [27], while the
concept of “intercultural opening” has achieved political and
practical support and gained a central status. The developed tool
represents the German concept of “intercultural opening” and
does not aim at Diversity Strategies being increasingly important
in Europe [7,8]. We decided to pick Germany up where the actual
political and practical discussion is right now. With the help of
the investigation of the concept of “intercultural opening”, on
which our study project is focusing, the discussion in Germany
will perhaps be pushed forward.
No comparisons exist about European “intercultural health
strategies” [23] and the “Cultural Competence” approach of the
United States [1,3], which at fi rst glance appear very similar. Even
within Europe, there is little known about the actual procedure of
each country in detail. A future goal might be an analysis about
these different approaches for improving global transparency in
dealing challenges of migration.
In addition to the detailed presentation of the development
process of our assessment tool for demonstrating the benefi ts of
our approach and being a model for future studies, this paper has
intended to increase transparency in relation to the current German
approach of health care structures in dealing with migrants.
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