La Méthode Delphi - Bonnes pratiques dans les soins pour migrants (Etude EUGATE: DG Sanco) - Bonnes pratiques en supervision pour intervenantes CAPEDP : VAD périnatales (PHRC/INPES) Tim Greacen Laboratoire de recherche EPS Maison Blanche Paris 1

La Pythie 2

Delphi Process a systematic, interactive forecasting method used to gather expert opinion to predict the future also used regularly in complex policy- making areas Example in health area: OECD’s 2006 Healthcare Quality Indicator Project  a set of quality indicators for assessing the performance of primary care systems. 3

Exemple : utilisation du Delphi dans le projet CAPEDP CAPEDP : évaluer, chez des jeunes mères primipares en situation sociale difficile, l'impact d’une intervention avec des intervenants faisant du soutien à domicile, sur la santé mentale de l’enfant, la qualité de l’environnement à la maison et la dépression postnatale Etude randomisée contrôlée PHRC + INPES 440 femmes enceintes recrutées dans les maternités franciliennes 8 psychologues qui font des visites à domicile jusqu'au 2 ans de l'enfant : intervention manualisée Une équipe de superviseurs Quelles sont les bonnes pratiques en matière de supervision pour les intervenants à domicile ? 4

Sous-projet : Supervision Question de recherche : Quels sont les facteurs constituant les bonnes pratiques en matière de supervision d’intervenantes faisant des visites à domicile type CAPEDP auprès de jeunes mères primipares ? Méthode: Delphi 5

Renvoyez votre liste à Tim Greacen : tgreacen@ch-maison-blanche.fr Etape 1: Demander à chaque membre du groupe de lister des facteurs de bonnes pratiques Essayez d’identifier environ 10 facteurs (mais vous pouvez en ajouter davantage) Pour chaque facteur, donnez une petite explication en quelques lignes : merci d’être précis dans votre explication quant à la signification de ce facteur ! Renvoyez votre liste à Tim Greacen : tgreacen@ch-maison-blanche.fr 6

Exemples de réponse étape 1 Facteur Explication 1. Se mettre d’accord sur les objectifs de la supervision avec l’intervenante Cela permet de proposer un cadre rassurant pour l’intervenante et qu’elle puisse préparer ce qu’elle va présenter 2. Etre présente et disponible si nécessaire Cela lui permet de s’appuyer sur cette possibilité connue pendant les visites surtout en cas de visite compliquée 3. Etre une « base de sécurité » pour l’intervenante Elle peut être ainsi plus sereine en visite, sachant qu’elle pourra toujours faire part de ses difficultés lors de la supervision et entre si cela est nécessaire. 4. Apporter des éléments techniques en terme d’entretiens Permettre à l’intervenante de mieux se positionner vis-à-vis de la famille pendant les entretiens 5. Préciser avec l’intervenante les objectifs et les focus de sa visite Permet de garder des repères et des lignes directrices pendant les visites surtout face aux familles « désorganisées » qui peuvent devenir « désorganisantes » 7

…suite 6. Aider l’intervenante à ne pas « perdre de vue » le nourrisson Toujours avoir à l’esprit l’importance des éléments d’évaluation du nourrisson pendant les visites par rapport à son développement. 7. Aider à repérer, surtout dans les situations difficiles, les éléments positifs qui permettent dans un second temps d’aborder plus facilement les éléments négatifs Permettre à l’intervenante de ne pas être submergée par des affects trop négatifs lors des visites et de pouvoir rester soutenante avec la maman. 8. Analyser avec l’intervenante les éléments de transfert contre-transfert mobilisés pendants les visites Permettre à l’intervenante de comprendre les éléments du fonctionnement familial qui peuvent la parasiter pendant ses interventions et induirent des contre attitudes négatives. 9. Permettre à l’intervenant de repérer les éléments de psychopathologie chez lez parents Permettre à l’intervenante d’adapter ses interventions à des adultes qui présentent des psychopathologies qui ont une influence sur les modes relationnels . 10. Ne pas perdre de vue l’ensemble des dimensions qui peuvent être actives dans les difficultés rencontrées par une famille. Permettre à l’intervenante de soutenir la famille dans des démarches concrètes et des recherches e soutien auprès des professionnels du réseau de leur bassin de vie. 8

Résultat Etape 1 Chacun a listé 10 à 13 facteurs Anonymisation (TG) un petit groupe de travail indépendant du groupe de superviseurs regroupe l’ensemble des facteurs de tous les superviseurs en catégories principales, élimine les doublons et harmonise le format. Il en résultait 37 facteurs différents (c’est-à-dire, exclusifs les uns des autres) 9

Supervision CAPEDP : Etape 2 pour chacun des 37 facteurs proposés ci- dessous, indiquez le degré d'importance que vous lui attribuez, au regard du processus de supervision et dans le cadre d'un projet préventif. Une échelle de 1 (pas du tout pertinent) à 9 (extrêmement pertinent) vous permettra d'exprimer votre jugement. 10

Exemples Reconnaître et valoriser le travail de l'intervenante Pas du tout important Extrêmement important 1 2 3 4 5 6 7 8 9          signifie : "Je trouve le fait d'exprimer de la reconnaissance et de la valorisation à l'intervenante très important dans le cadre d'un projet du type CAPEDP". Exemple 2 Offrir un cadre régulier Pas du tout important Extrêmement important          Signifie : "J'estime que la régularité du cadre n'est pas un critère essentiel à la réussite du processus de supervision, dans le cadre d'un projet du type CAPEDP".  pour cocher les cases, il vous suffit de remplacer la case par un X, comme dans les exemples Merci d'avance ! 11

Ensuite on fait les moyens des scores pour chaque facteur Puis on identifie les facteurs qui ont le plus haut score moyen Et je ne vais pas encore vous dire les résultats car ils ne sont pas encore publiés ! 12

Exemple 2: l’étude EUGATE Financée par la Commission européenne (DG Sanco) “Which factors constitute best practice in health care for immigrants?” Quels facteurs constituent les bonnes pratiques en matière de soins de santé pour les migrants ? 13

Method: Delphi Process 8 experts per country 16 countries 4 steps Each expert proposes factors Each site regroups all experts’ factors into one list Each expert rates factors in list from 1 (not important) to 5 (very important) Each expert reconsiders their ratings in the light of the mean rating for all experts Final 10 highest ratings selected for each site Data collection: July 2008 to November 2009 14

Le Delphi : consensus ou conformisme ? Delphi recherche des consensus Conformisme des opinions majoritaires Utile pour le décisionnel ? Utile pour le prévisionnel ? 15 15

Advantages & difficulties High power: a way of bringing together influential quality opinions Practical: experts don’t have to come to meetings, can be done by email Anonymous: experts can say what they really think Difficulties Experts can be ‘too close to the problem’, they often forget to list the obvious, they take things for granted On complex questions, choice of experts is a problem, i.e. you need a group that brings together expertise in all possible areas related to the issue The method tends to find rapid consensus on the easy issues, the more difficult or controversial issues are lower on the list or excluded 16

The example of France Delphi Process from 27/10/2008 to 26/04/2009 8 experts experts with very different professional backgrounds, 2 are immigrants themselves all working in the Ile-de-France region (capital city, Paris) by far the largest region in terms of population in France (11M) with the highest immigrant population (2M?). experts in other regions, having other sorts of immigration issues, may not have the same views on best practice for migrant populations. e.g. Regions in rural areas with little immigration French Overseas Departments & Territories: Martinique, Guadeloupe, la Guyane, la Réunion, New Caledonia, Mayotte… Regions with common borders with other countries: Pyrenees, Alpes-Maritimes, Hautes-Alpes, Alsace, Nord, Pas de Calais 17

Results in France 41 different factors identified the first 18 were highly consensual: i.e. considered to be important (11) or very important (7) by all experts Factors n° 10 to 16 have the same mean score (4.3). Factors 17 and 18 included because mean score >4.0, i.e. considered to be “important” and, furthermore, unlike the factors with lower mean scores, all of these 18 factors are ‘consensual’ in the EUGATE definition – i.e. all experts have given a mean score of within two (2.0) of the overall rounded mean. For these 18 factors, it also so happens that there is no expert with a rounded score >1 from the rounded overall mean. 18

Migrant healthcare: a political question During the same period (early 2009), healthcare provision for illegal migrants was a subject of considerable political and public debate (public demonstrations, etc.). Of the 23 remaining factors, all with a final mean score of less than 4.0, 14 still had strong differences of opinion (of 3 or more points) even after experts were asked to reconsider their opinion in the light of the mean scores of all 8 experts on the factor in question. They chose to differ, often adding comments to explain their opinion. 19

Problems with presenting Delphi results on delicate issues Certain experts may feel that certain aspects of best practice to these populations may be missing from the list : individual factors might be consensual, but not the list. Experts who feel strongly about these issues might not want their name or the name of their organisation to be associated with the resulting list of “best practice” factors The Policy Delphi solution: the results should also present these differences of opinion. This phenomenon is particularly important for the EUGATE Project, which sets out to identify best practices for migrant care for Europe, by linking together 16 different Delphi Groups in 16 countries 20

Results in France: The first group of 7 ‘very important’ factors (rounded mean score = 5) 1 Easy-to-access and easy-to-use health care system 4,9 Health care for migrants should be dispensed through the standard health care system and provided for in ordinary rules of law Comply with French rules on secular society 4 Guarantee access and continuity of health care to migrants who are temporary legal residents 4,8 Health care professionals who take the time to care for, listen to and verify the understanding of their patients, who establish trust, who obtain truly informed consent 6 Inform migrants upon arrival of health care services available, the costs involved and the health care process 4,6 Adapt the health care offer to the person’s lifestyle, his/her capacity to receive and self-manage care 21

Results in France: the second group of 11 ‘important’ factors (mean score: 4.1 to 4.4) 8 Fight against racism, xenophobia and prejudice 4,4 Ensure cultural adaptation of health education and prevention messages 10 Provide fast access to comprehensive health care 4,3 Avoid focusing on language and cultural issues as if they were a barrier to a therapeutic relationship with patients of different cultural origins Inform migrants with disabilities or chronic health problems of their rights to medical and social assistance available Get to know the medical history and personal background of the person Proactively engage in outreach programmes with migrant populations and if necessary, help them obtain care Offer newcomers a high-quality, initial medical consultation to provide them with information, explanations and orientation on the health care system Guarantee proper living conditions for migrant populations 17 Provide qualified interpreting services 4,1 Train reception and administrative staff on how to best deal with persons of migrant origin 22

Controversy 1 Some public health experts consider it to be important to be able to identify and count the different cultural and ethnic groups in France in order to evaluate their healthcare needs. Others strongly object to this, arguing that this information invariably misrepresents cultural intermingling and social integration from one generation to the next and can fodder racism and intolerance 23

Controversy 2 Some public health experts consider it to be important to put in a large amount of energy into training healthcare professionals to be aware of ethnic and cultural issues and making them take these into account Others consider this to be a trap, arguing that the most important issue is for the health professional to be able to take his/her time and have access to a translator. This latter difference of opinion becomes more pronounced concerning the creation of culture-specific or migrant-specific service provision, with opponents arguing that healthcare professionals are not anthropologists and that these sorts of structures often become under-funded ghettos. 24

Controversies 3 & 4 Some experts considered that certain ideas put forward by other experts appear to be good ideas in theory, but in everyday practice are ineffective: for example, relying on interpreting possibilities within hospital staff. These strategies may even be counter-productive if they give the service or funders the false impression that they are therefore handling issue in an effective manner. Some experts consider that the problem with access to healthcare for migrants is primarily political (i.e. related to controlling population flow) and neither medical nor ethnic. For them, the same rules of best practice apply to all people, not just migrants. 25

INTERPRETING SERVICES INFORMATION ABOUT SYSTEM Factor N° 1 for each country Country Priority Factor Rating    ACCESS TO CARE France 1 Easy-to-access and easy-to- use health care system 4,9 Germany Equal access to the health care system 4,8 Italy Access/Entitlement to NHS services 4,6 Netherlands 4.9 Portugal Legislation on immigrants' access to health services 4.8 Spain Facilitate and guarantee equal access to health system 5,0 UK Easy access and free health care to all immigrant groups INTERPRETING SERVICES Austria Interpreting services 4,4 Denmark Access to interpretation assistance 5.0 Finland Interpretation INFORMATION ABOUT SYSTEM Hungary Information for immigrants about health care system, service rules and treatment methods 3.7 Poland Easily accessible, clear information on healthcare system and services OTHER FACTORS Belgium Presence of intercultural mediators in primary care Greece Medical History 4.5 Lithuania Language skills of immigrants 4.75 Sweden Do not generalise migrants, treat them individually 26

Macro: Fundamental principles of the health care system – migration policy (1) General equal accessibility of the health care system (NHS or health insurance system): 9/15 (AU, BE, ENG, FI, FR, GE, GR, LI, NL) Equal quality: 4/15 (HU, IT, LI, SW) Equity: LI, IT. SW 27

Patient oriented health care (AU) Professional qualification (ENG) Macro: Fundamental principles of the health care system – migration policy (2) Patient oriented health care (AU) Professional qualification (ENG) Legislation (PO) Regularisation (PO) Reporting of UDM (GR) 28

Meso: Organisation of the health care system (1) Interpreting services: 10/15 (AU, BE, DK, ENG, FI, FR, GE, GR, SP, SW) Intersectoral collaboration health care and social work: 7/15 (BE, DK, FI, IT, NL, PO, SP) Follow-up, continuity, compliance, referral 2nd care: 6/15 (BE, DK, FI, GE, GR, IT) [NO SPECIAL SERVICES] Proactive primary care > integrated care: 5/15 (BE, FR, NL, PO) 29

Meso: Organisation of the health care system (2) Cultural mediators: 5/15 (BE, GE, IT, NL, SP) Time during consultations: 6/15 (DK, FI, FR, NL, SP,SW) Timely access:4/15 (FR, LI, PO, SP) Special intake: FR Preventive services: GE Sustainibility: AU 30

Meso: Organisation of the health care system (3) Discordance: No focus on language and cultural dimensions: FR Special services: AU Adaptation to ‘culture’ in delivering services (FR) vs taking account of religious rules (LI) 31

Micro: health care providers (1) Intercultural competences:15! Role of practitioner, attitude:9/15 (DK, FI, ENG, GE, HU, LI, NL, SW) Attention to mental health: 6/15 (FI, ENG, GE, GR, HU, SP) Information about right to health care: 3/15 (ENG, PO, SW) Antidiscrimination: 3/15 (FR, HU, SP) Migrant HC providers: 3 (AU, GR, SP) 32

Micro: health care providers (2) Attention for individual patient: 3/15 (DK,FR, SW) Learning foreign languages: 2/15 (HU, LI) Support of carers: eNG Attention to risk factors: FI Epidemiological knowledge: NL 33

Micro: health care providers (3) Appropriateness: IT Training of administrative staff: FR Motivation to deliver qualitative care: NL Cultural diagnoses: SW Taking account of mobility of population: SP Financial support, resources: HU, DK 34

Micro: patients / populations (1) Information about health care system & prevention & rights: 1O/15 (FI, FR, ENG, GR, HU, IT, LI, NL, PO, SP) Multilingual health information, health education & prevention: 7/15 (AU, BE, ENG, FR, GE, GR, SW) Integrated specific outreach activities: FR, PO, SP Monitoring, collection data: AU, BE, SP 35

Micro: means addressing patients / populations (2) Health history: FI, FR, GR Participation & empowerment: FR, IT, PO NGO involvement: HU, PO 36

Micro: patients / populations (3) Conditions outside health care: Language classes: ENG, GE, LI Information jobs: ENG, GE Social networks: NL Advocacy: PO Attitude community: LI Integration: LI 37

References Devillé W, Greacen T, Bogic M, Dauvrin M, Dias S, Gaddini A, Jensen NK, Karamanidou C, Kluge U, Mertaniemi R, Riera RP, Sárváry A, Soares JJ, Stankunas M, Strassmayr C, Welbel M, Priebe S.Health care for immigrants in Europe: is there still consensus among country experts about principles of good practice? A Delphi study. BMC Public Health. 2011 Sep 13;11:699. Tubach F, Greacen T, Saias T, Dugravier R, Ravaud P, Tereno S, Tremblay R, Falissard B, Guedeney A. A home-visiting intervention targeting determinants of infant mental health: the study protocol for the CAPEDP randomized controlled trial in France BMC Public Health. 2012 Aug 13;12(1):648. 38