Background
Conducted in 2017, the latest micro-population census counted 19.3 million individuals who either migrated themselves or had at least one parent who migrated to Germany. This accounts for 23.6% of the entire population in Germany [
1]. The migrant population is heterogeneous in terms of cultural and religious background, socioeconomic status, language proficiency, literacy, and health behavior [
2]. Even though health care services in Germany take migrant health issues into account, people with a migrant background often experience difficulties regarding health care provision [
3]. Migrants have to overcome language barriers and cross-cultural challenges within health care, especially when it comes to noncommunicable diseases such as cancer [
4]. CRC is the second most common cancer type in Europe [
5]; in Germany, one in seven of all diagnosed cancers is located in the colorectum [
6]. In Germany, all those with statutory health insurance (about 90% of the population) have the right to participate in free CRC screening programs starting from the age of 50, but migrants make less use of this service than the autochthonous population does [
7,
8].
Furthermore, migrants attend follow-up consultations, which are offered to all CRC patients, less frequently than non-migrants do [
9]. Migrant patients report language barriers, difficulty in understanding the local health system and a lack of cultural sensitivity and understanding from medical professionals as the reasons for this behavior [
10,
11]. Comprehensible medical information that meets the needs of the individual is essential for every patient, regardless of the migrant background. Studies show [
12] that sharing prognostic information with patients may facilitate a better understanding of their illness and greater patient involvement in medical decision making [
13]. Furthermore, according to Hillen et al., oncologists gain their patients’ trust if they present themselves as competent, honest, and caring. Caring behavior—such as making emotionally supporting statements—has the strongest effect on trust [
14]. Cultural sensitive communication on behalf of health professionals is needed to prevent misunderstandings and medical malpractice [
15]. Although physicians are aware of the importance of cross-cultural care, especially when it comes to aspects of information delivery, there is a gap between physicians’ willingness to deliver cross-cultural care and the willingness in other clinical and technical areas [
16]. To the best of our knowledge, variances in the preferences for exact information regarding prognosis and the level of trust in the treating physician between migrants and non-migrants have not yet been explored. Hence, in the current study, we aimed to explore the differences in migrant and non-migrant CRC patients’ preferences for information about life expectancy and level of trust in the treating physician. According to the German Public Health Institute (Robert Koch Institute), data on migrant health and behavior in Germany are still scarce [
17]. The findings may contribute to establishing equal and appropriate treatment and care plans for both migrant and non-migrant CRC patients and promote cross-cultural knowledge for health professionals which might minimize the gap between willingness of delivering cross-cultural care and performance in other clinical areas.
Discussion
We compared CRC patient characteristics between migrants and non-migrants and examined which parameters influenced how precisely CRC patients wanted to be informed about their further life expectancy. We observed that having a migrant background and gender predicted the extent of clinical information favored regarding life expectancy. To the best of our knowledge, this is the first study on the desired precision of information concerning life expectancy, focusing on migrants.
In general, the fact that there were no differences regarding the demographic factors, UICC stage, and cancer treatment between migrant and non-migrant CRC patients may be understood as CRC patients—regardless of their ethnicity—had a similar cancer stage at the time of diagnosis, were treated equally, and received the same treatment choices, respectively. This might indicate that there are more similarities than discrepancies between CRC patients of different origins than assumed from the results of other migrant-specific studies that determined differences in terms of tumor biology, diagnostics, and treatment in breast cancer patients [
24] or in health transition patterns [
21]. Our results could be explained by the “healthy migrant effect,” which is the phenomenon that the overall health of migrants is often better than those who stay in their country of origin, possibly as a result of selective migration [
22]. However, most of the migrants in our study population were first-generation migrants who, according to their age and language proficiency, migrated to Germany during the guest worker recruitment phase in the 1970s and 1980s. Hence, they may have adapted to the German lifestyle and diet by now, and the “healthy migrant effect” would not apply to them.
The fact that our study did not exactly identify the most important information for CRC patients might be because of the item construction: Patients were asked, “What information about your disease is most important to you?” and were given seven answer categories with more than one answer possible. This might have caused the majority of participants to mark more than one box, which impaired the statistical analysis. Our analysis revealed that there were no differences between migrants and non-migrants regarding the most important information for CRC patients.
Concerning the favored extent of information about life expectancy, the bivariate analysis showed that fewer patients with a migrant background wanted to be informed about their life expectancy compared with native German patients. In some cultures, cancer as a disease means fate, and it is believed that such a diagnosis implies death. One is powerless, and help is delegated to the healer: the medical experts [
25]. Furthermore, a severe disease such as cancer underlies certain taboos in some cultures. Giving “strangers” an insight into family matters or one’s feelings and emotions can be very uncomfortable [
26]. This would explain our findings of the multinomial regression model that migrant background had an influence on how precisely the CRC patient wanted to be informed. Compared with “I don’t want to know my life expectancy” as a reference category, non-migrants wanted to be approximately informed about life expectancy more often than migrants did. Indeed, the migrant study population originated from 34 countries, the majority of which are dominated by an Orthodox or Muslim religion. Tayjeb et al. found that Muslims tend to value spiritual and emotional support and believe that death is closely linked to fate [
27]. Orthodox patients tend to interpret the end-of-life situation as given by God [
28]. Thus, patients from cultures in which religion plays an important role possibly deal with death and estimated life expectancy in a less rational way than native Germans do. Still, our results should not be overemphasized because the majority of the study population wanted to be exactly informed about their life expectancy. Furthermore, the questionnaire did not assess religious affiliation, so we can only assume religious affiliation from the country of origin.
Another point that should be taken into account is the individualism–collectivism construct [
29] that provides a framework for understanding cultural variations in communication. Germany is stated as an individualistic culture, which is more assertive and more direct in their conversation than Africans or Asians, who are collectivist. The latter have rather general situations and paralinguistic signals in mind, whereas individualist cultures turn their attention to the concrete statement and are more likely to omit the paralinguistic signals [
30]. Interactions between individualist and collectivist cultures may have an impact on the extent of information wanted during a medical consultation. However, because the migrant population in our study comprised 34 countries of origin from both collectivist and individualist cultures, it would be problematic to draw strong conclusions according to this construct.
Other studies have shown that health care professionals and patients often report challenges in their interactions because of discrepancies in language [
31,
32]. Our results show that language proficiency has no influence on how accurately patients want to be informed about their life expectancy. One could assume that being fluent in German may facilitate a better understanding of the medical consultation, which also deals with life expectancy. Being confronted with a negative message - which is often the case regarding the life expectancy of cancer patients - may be more easily understood in one’s mother tongue. On the other hand, we do not know whether the treating physician might have had proficiency in the language of the patient. Ilkilic reported that when it comes to end-of-live conversations between medical persons and patients, it is important to be aware of cultural traditions and to call in a professional translator to avoid misunderstandings. Making use of a relative as a translator may lead to misinterpretations [
33]. This underlines the importance of language within the patient–physician relationship. A qualitative study approach, such as semi structured interviews, might be used in future research to clarify this issue. However, the majority of patients, both migrants and non-migrants, believed that their treating physician was honest with them about their treatment plan. Hence, this may be interpreted as equal treatment of all patients, regardless of migrant background.
Some limitations must be considered. Because of the retrospective assessment of migrant background, the migrant sample (16.3%) was quite small, which did not allow for stratification for language and country of origin, hence reducing the scope of interpretation when it came to the multivariate analysis. Nevertheless, the response rate of the patients with a migration background is comparable with other German migrant specific studies [
34,
35]. Further, the term “person with a migrant background” includes many aspects, such as cultural and religious beliefs, language, health literacy, and duration of stay in the host country. What is more, familial culture was not assessed; there might be a difference between migrants living in Germany, those keeping up the traditions of the country of origin, and those cultivating the traditions of their host country. These aspects might influence the extent of information the individual patient desires. Besides language, we could not address these diversity factors in our analysis. In addition, it should be mentioned that the current study not only included those of non-German nationality, but also patients with a migrant background. Because most of the health registers and nationwide surveys in Germany do not assess the migrant background of an individual, migrant-specific health research is hindered and remains scarce. What is more, due to data protection regulations, it was impossible to merge our dataset with health service utilization data of the statutory health insurance system, which would have provided more comprehensive information of health behavior and attitudes.
This study provides some implications for clinicians who might work with migrant patients in their daily practice, e.g. delivering the information about life expectancy in a cultural sensitive way, as migrants tend do not want to know it exactly. However, our study highlights that migrant health research in Germany is hindered due to limited data availability. The assessment of nationality and/or migration background in health registers is not consistently established [
36]. For example, the Cancer Register of Berlin, Brandenburg, Mecklenburg-West Pomerania, Saxony-Anhalt, Saxony and Thuringia decided in 2018 to eliminate the variable “nationality” from their register. Taking migrant health into account, registers in Germany should assess the migrant background according to the definition of the Federal Office for Migration and Refugees [
2] which would facilitate migrant sensitive research.
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