Not every patient is the same
How diversity affects the quality of healthcare
21st-century medicine is facing new challenges. Healthcare systems must adapt to increasing social diversity, including LGBT+ patients, refugees, and seniors living alone, among others. Are doctors, nurses, and other healthcare professionals ready for this? This question is addressed in research led by Prof. Michał Czapla from the Department of Emergency Medical Service at Wroclaw Medical University, conducted together with his team in collaboration with experts from Spain and the United States, and published in the journal BMC Medical Education. The work of researchers focused on the HORIZON-HLTH, SP-EU-RCT project, which aims to make healthcare more accessible to vulnerable groups through the implementation and adaptation of Social Prescribing (SP).
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LGBT+ patients - inequalities in the health care system
One of the challenges of medicine is to ensure equal access to health care for all patients, regardless of their gender identity, sexual orientation, background, or age. However, reality shows that people with special needs often face barriers to receiving medical services. A study by Prof. Michal Czapla's team published in BMC Medical Education in the article “Lesbian, gay, bisexual, and transgender clinical competence of health professionals in Poland and Spain: results of the health exclusion research in Europe (HERE) study” points to one of these issues - the competence of medical professionals in caring for LGBT+ (Lesbian, Gay, Bisexual and Transgender and other) patients in Poland and Spain.
Prof. Michał Czapla from the Department of Emergency Medical Service at Wroclaw Medical University
Prof. Michał Czapla from the Department of Emergency Medical Service at Wroclaw Medical University
The survey included 673 medical professionals - 400 from Poland and 273 from Spain. The results of the HERE survey indicate differences in the clinical competence of doctors and nurses in Poland and Spain in caring for LGBT+ patients. Spanish professionals scored higher in clinical preparation, attitudes, and knowledge regarding this patient group. In Poland, on the other hand, scores were lower, suggesting inadequate preparation of medical personnel to work with LGBT+ patients.
The most significant differences were noted in the level of training - in Spain, 35 percent of survey participants said they had taken courses on LGBT+ health in the past five years, while in Poland, the figure was only 17 percent. This suggests that a lack of training may be one of the key reasons for the lower level of competence of Polish doctors and nurses.
"Currently, the training standards for the health professions lack content on the health issues of these groups, which leads to insufficient preparation of professionals to work in conditions of cultural and identity diversity", points out Prof. Michal Czapla.
One of the main problems is the lack of unambiguous standards of medical treatment that take into account the needs of LGBT+ patients. In Poland, transgender people face difficulties in, among other things, accessing gender-affirming care by receiving incomplete information about preventive examinations such as cytology and mammography. It should also be added that LGBT+ patients are more likely to keep silent about important health issues because they fear that revealing them could lead to stigmatization and even hatred.
The study also found that social and cultural attitudes affect healthcare quality. In Spain, the rights of LGBT+ people are more widely protected, which translates into higher acceptance among medical personnel. In Poland, by contrast, doctors and nurses are less likely to be exposed to LGBT+ topics in a professional context, which can hinder the development of cross-cultural competence and contribute to the perpetuation of stereotypes.
The survey also showed that in Poland, LGBT+ patients are more likely to experience prejudice from medical personnel, which negatively affects their contact with the healthcare system.
"The most common problems affecting LGBT+ patients are discrimination and lack of understanding on the part of medical staff. LGBT+ patients often experience stigma, which can lead them to avoid contact with healthcare facilities, resulting in delays in proper diagnosis and treatment", explains Prof. Czapla.
The data shows that up to 40 percent of LGBT+ people avoid going to the doctor for fear of negative experiences, which can lead to later diagnoses and more advanced stages of diseases.
The study's authors emphasize the need to implement systemic changes in medical education and develop standards of care for LGBT+ patients. Countries that have implemented extensive training programs achieve better results regarding inclusivity in health care.
"An important part of improving medical education is introducing comprehensive pre- and post-graduate training for medical personnel. These trainings should include, among other things, aspects of intercultural communication, the specific health needs of LGBT+ patients, health barriers resulting from migration and refugee experiences, or issues of aging, including the isolation of seniors", Professor Michal Czapla concludes.
Refugees and immigrants - language as a barrier to accessing a doctor
Although the study by Prof. Czapla's team focused on LGBT+ patients, the mechanisms of exclusion described are also applicable primarily to other groups exposed to inequalities in health care - including refugees and first-generation immigrants. Their situation, however, is even more complex, as restrictions on access to medical care stem not only from prejudice or staff ignorance but also from administrative, legal, and language barriers.
"The most significant difficulties for refugees relate to language, cultural, and legal barriers. Limited knowledge of the host country's language is a huge problem, as most healthcare facilities do not provide interpreters. In addition, competence in cultural diversity is lacking among medical personnel. This means that doctors often don't understand the patient's context - his or her history, experiences, or even different models of understanding health and illness, which are different in other cultures", explains Prof. Michal Czapla.
The lack of medical interpreters in health facilities leads to a situation where immigrant patients have to rely on family members or bystanders to explain their symptoms and medical history. This can lead to misdiagnoses, inappropriate treatment, and reduced effectiveness of therapy. In extreme cases, patients abandon medical appointments altogether and cannot find someone to help them communicate.
Another challenge is a lack of familiarity with the healthcare system in the host country. Refugees often don't know what services they are entitled to, where they can go for help, or what procedures they must undergoundergo to receive medical benefits. Sometimes,, they end up in the Hospital Emergency Department with problems that could be handled by a family doctor, further overloading the healthcare system.
The trauma faced by many refugees should not be forgotten either. Those fleeing war, persecution, or humanitarian disasters often suffer from PTSD (Post-Traumatic Stress Disorder), depression, or other mental disorders. This context is particularly relevant for immigrant children and adolescents. However, lacking professionals who speak their language means they do not receive adequate support.
Dedicated training programs for medical personnel, integration of medical interpreters in health care facilities, and simplification of administrative procedures for refugees and immigrants could help solve these problems. Many countries, such as Germany and Sweden, have already introduced memorable phone lines with medical interpreters and assistance programs for people with difficulty navigating the healthcare system.
Seniors - the invisible patients of the system
The elderly, especially those living alone, are one of the most vulnerable patient groups in the health care system. The problem is not only their lower mobility but also the lack of systemic support, which makes seniors less likely to use available medical services. As a result, their health problems often go undiagnosed or are treated too late.
"Older adults often face social isolation, mobility problems, and lack of family support. It is worth noting that LGBT+ seniors and elderly refugees face double marginalization. On the one hand, the health care system is not adapted to their needs, and on the other hand, the community in which they live is often not supportive of them", Prof. Michal Czapla stresses.
For many seniors, getting to the doctor is a huge challenge. Problems with transportation, difficulty getting around, or a lack of caregivers to help make appointments and get to medical facilities lead to a situation in which seniors can remain without health care for long periods of time. Healthcare facilities are recording an increasing number of cases in which patients only see a doctor when their condition is already serious. This could be prevented if they had constant access to preventive care.
Loneliness and its impact on seniors' mental health should also not be overlooked. Social isolation is one of the main risk factors for depression and cognitive aging in older adults. Unfortunately, many seniors do not have access to support groups or social activities that could improve their mental well-being.
Greater telemedicine, assistive technology, and initiatives based on the Social Prescribing model - a model that connects seniors with organizations offering social support - could help address these issues. If we don't start treating loneliness as a real threat to seniors' health, in the future, we will have to face a growing number of elderly patients whose health problems have gone unnoticed for years.
Social Prescribing as a solution?
The same mechanisms of exclusion that Prof. Czapla's team's study revealed are being investigated in the SP-EU project, which is part of the HORIZON-HLTH program at the Wroclaw Medical University. This is one of the first such large-scale projects in Europe to analyze the effectiveness of the Social Prescribing model in improving access to health care for LGBT+ people, refugees, and seniors living alone.
What is Social Prescribing? It's an approach that goes beyond traditional drug treatments and medical procedures. It involves connecting patients with community resources, such as NGOs, support groups, and activation programs. In practice, this means that the doctor not only diagnoses and treats the patient but may also refer the patient to an exceptional coordinator, a so-called Link Worker. His job is to talk to the patient individually and help him find appropriate social initiatives tailored to his needs.
"The Social Prescribing (SP) model is currently being studied as part of the SP-EU project involving eight European countries. The study looks at how SP can improve access to health and social care for vulnerable groups, including LGBT++ people, refugees and first-generation immigrants, and older adults living alone. Research is currently underway to adapt the model to different cultural and social contexts in Europe, and the first results will help determine directions for its further development," explains Prof. Czapla
Social Prescribing allows us to look at the patient holistically. Often, health problems stem not only from biological factors but also from the social context - loneliness, discrimination, poverty, or trauma. Traditional medicine is not always able to respond to these challenges. SP-EU explores whether we can effectively integrate elements of social support into the health care system, thereby improving patient outcomes.
"We see great potential for expanding the program to other groups, such as people with disabilities or youth in mental health crises. Social Prescribing has the potential to become a scalable and effective tool for integrating health and social care across Europe, following the example of efforts already underway in the UK", Prof. Czapla adds.
How does Social Prescribing work in practice?
Under SP-EU, patients receive support from so-called "link workers," or specialists who help them find appropriate organizations and services to support their physical and mental health. Link workers act as intermediaries between patients and social institutions, which is especially important for people who have not previously been exposed to the social welfare system or don't know where to seek help.
Here are some scenarios:
An LGBT+ person experiencing discrimination → is referred to an LGBT+ support group, as well as to a doctor trained to work with LGBT+ patients who can provide inclusive care.
A refugee struggling with PTSD → instead of just pharmacotherapy, he is allowed to participate in therapy conducted in his native language, as well as a referral to an organization that helps with social and legal integration.
A lone senior suffering from depression → In addition to drug treatment, he is included in a social activation program that provides for social gatherings, exercise classes, and volunteer support.
Why can this approach be practical?
A growing body of research indicates that Social Prescribing can realistically improve patients' quality of life, reduce feelings of isolation, and increase their motivation to care for their health. In the UK, where the model is already being used, there has been a reduction in visits to primary care physicians and a decrease in hospitalizations related to health problems resulting from social factors.
If SP-EU proves positive results, this model could be implemented more widely across Europe. We want to show that treating a patient is not just about writing a prescription but also about helping them find their way in society and providing them with real support.
The SP-EU project has the potential to become a landmark step in integrating the health and social care system. In the long run, this could reduce inequalities in access to treatment and improve the quality of life for thousands of people from vulnerable groups.
A lesson for Europe. What are the findings of the study?
The HERE study showed that the medical education system is crucial to improving care for patients with special healthcare needs. The results clearly show that where doctors and nurses are better prepared to work with LGBT+ patients, the quality of health care increases.
However, there are still significant gaps in medical education. Currently, the education standards for the medical profession lack content on the health issues of these groups, leading to inadequate preparation of professionals to work in conditions of cultural and identity diversity.
In many countries, including Poland, medical education focuses mainly on biological aspects of health, ignoring the impact of social and cultural factors. There is a lack of training modules on the specific needs of LGBT+ patients, refugees, and older adults living alone. As a result, doctors often do not know how to talk to patients from vulnerable groups, how to diagnose health problems resulting from trauma or social isolation, or how to refer patients to appropriate forms of support.
Even if doctors have good intentions, a lack of knowledge can lead to unconscious discrimination or errors in diagnosis. An LGBT+ patient may fail to disclose their orientation or gender identity if they feel the doctor is not ready to do so, with direct consequences for their health - such as a lack of appropriate preventive testing. Similarly, a refugee who doesn't understand the system may fail to report essential symptoms if the doctor doesn't ask the right questions.
Systemic changes in medical education
One of the study's key findings is the need to implement comprehensive training for medical students and personnel. Countries such as Spain and the UK have already introduced special courses on the health of sexual minorities and migrants, which have improved the quality of care for these groups.
Training should include, among other things:
· The specific health needs of LGBT+ patients - including access to hormone therapy, mental health diagnosis, and HIV/STI prevention.
· Health problems of refugees and migrants - especially those resulting from trauma, migration stress, and different models of understanding health.
· Social isolation and health of seniors - including strategies for connecting with lonely patients and recognizing symptoms of depression, among others.
· Cross-cultural communication: Medical personnel must be able to talk in a way that takes into account patients' different life experiences.
Integrating the health and social support system
In addition, the SP-EU project assumes that engaging communities and eliminating systemic barriers are key to improving the health of marginalized groups.
We cannot rely solely on doctors and nurses. We need to create a system where patients receive comprehensive support - not only in the doctor's office but also in local organizations, support groups, and activation programs. Social Prescribing is the future of healthcare because health is more than just treating diseases - it's also about quality of life and social support.
Implementing such solutions, however, requires a shift in thinking about health care. Instead of treating it as a system focused solely on clinical medicine, it is necessary to integrate it with social support and health education.
Health for all
The study by Prof. Czapla's team and the SP-EU project shows that equality in access to health care requires concrete action. Implementing SP, educating medical personnel, and eliminating biases can contribute to a more equitable health system.
Health should not be a privilege - it should be a right.
Donata Kurpas - Professor at the Department of Family Medicine, Faculty of Medicine, Wroclaw Medical University
Donata Kurpas - Professor at the Department of Family Medicine, Faculty of Medicine, Wroclaw Medical University
Medical University of Wroclaw, one of the partners of the international SP-EU project
The Medical University of Piastów Śląskich in Wrocław is participating in the prestigious SP-EU (Social Prescribing to promote and improve access to health and care services for people in vulnerable situations in Europe) project, funded under the HORIZON-HLTH program. The project aims to improve access to health care for vulnerable groups - LGBT+ people, refugees, and single seniors - by implementing and adapting the Social Prescribing (SP) model. The project is being implemented by the team of Prof. Donata Kupras
Social Prescribing is an innovative approach that combines health care with community resources to support patients' physical and mental health holistically. The SP-EU project is implemented by a consortium of 23 institutions across Europe and coordinated by Charité - Universitätsmedizin Berlin. The Wroclaw Medical University, as one of the partners, contributes to the project knowledge and experience in adapting healthcare to local conditions and patients' needs.
The project involves conducting randomized controlled trials (RCTs) in eight countries and analyzing the effectiveness of SP interventions in improving access to health services. The SP-EU effort also aims to create sustainable systemic solutions to integrate the Social Prescribing model into European health systems.
D. Sikora
FAQ
What are the key inequalities in health care access and quality for vulnerable groups, such as LGBT+ people, refugees, and seniors?
Vulnerable groups face numerous barriers to accessing equal health care. LGBT+ people often experience discrimination and lack of understanding from medical personnel, leading to delayed diagnosis and treatment. Refugees and immigrants struggle with language barriers, unfamiliarity with the health care system, and trauma, making it difficult for them to access necessary care. Seniors, especially those living alone, face isolation, mobility issues, and a lack of systemic support, resulting in undiagnosed or late-treated health problems.
How does the Social Prescribing (SP) model aim to reduce healthcare inequities for vulnerable groups?
The Social Prescribing (SP) model reduces healthcare inequities by connecting patients with community resources, such as community organizations, support groups, and activation programs, to address social and psychological issues affecting health. By connecting patients with "liaison workers" who help them navigate these resources, SP aims to provide holistic care beyond traditional medical treatment. The SP-EU project is studying the effectiveness of this model with LGBT+, refugee, and single seniors in eight European countries.
What role do education and training play in improving the competence of healthcare workers in caring for vulnerable populations?
Education and training play a key role in improving the competence of healthcare workers. Targeted training programs that cover cross-cultural communication, the specific health needs of vulnerable populations (LGBT+ people, refugees, seniors), and the impact of trauma and social isolation are essential. Studies show that healthcare professionals participating in LGBT+ training demonstrate higher clinical preparation and overall competence.
What are the main goals and activities of the SP-EU project?
The SP-EU project aims to evaluate the effectiveness of Social Prescribing in improving access to health care and the social well-being of vulnerable groups, including LGBT+ people, first-generation refugees and immigrants, and single seniors. The project involves conducting randomized controlled trials (RCTs) in eight European countries, developing standardized research protocols, training nurses and liaison staff, and recruiting study sites and participants. The ultimate goal is to provide evidence for the broader implementation of Social Prescribing as an effective tool for reducing health inequities.
What does the HERE study reveal about the clinical competence of healthcare professionals in Poland and Spain in caring for LGBT+ patients?
The HERE study, comparing healthcare professionals in Poland and Spain, reveals significant differences in clinical competencies for caring for LGBT+ patients. Spanish professionals demonstrated a higher level of clinical preparation, more positive attitudes, and more excellent knowledge thanthan their Polish counterparts. A key factor in this difference was that Spanish healthcare professionals frequently participated in training on LGBT+ care. The study also highlighted the impact of social and cultural norms on this group's health care quality.
What are some specific examples of how Social Prescribing has been used to improve care for LGBT+ people, refugees, and single seniors?
Social Prescribing can be tailored to specific needs. An LGBT+ person experiencing discrimination can be referred to an LGBT+ support group and an affirmative action physician for the community. A refugee who has PTSD can be paired with therapy provided in their native language and an organization to help with social and legal integration. A lone senior suffering from depression can be enrolled in a social activation program that includes social gatherings, exercise classes, and volunteer support.
What systemic changes are needed to improve health care access and equity for vulnerable populations in addition to education and training?
In addition to education and training, systemic changes are needed, including integrating health care with social support systems, simplifying administrative procedures for refugees and immigrants, increasing the availability of medical interpreters, and developing clear medical guidelines that consider the needs of vulnerable populations. Integrating health and social care through models such as Social Prescribing is a key step toward a more equitable and comprehensive healthcare system.
This material is based on the article:
Lesbian, gay, bisexual, and transgender clinical competence of health professionals in Poland and Spain: results of the health exclusion research in Europe (HERE) study
Piotr Karniej, Anthony Dissen, Łukasz Pietrzykowski, Raúl Juárez-Vela, Antonio Martinez Sabater, Janina Kulińska, Jakub Zieliński & Michał Czapla
BMC Medical Education
doi: 10.1186/s12909-025-06744-4
Web. A. Hasiak
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