**1. Introduction**

Around 37,000 people a day are forced to flee their homes according to the United Nations High Commissioner for Refugees (UNHCR) [1]. The majority of refugees are internally displaced persons or refugees seeking relief close to home in neighboring countries. About one-third of global refugees flee to neighboring, less developed, or least developed countries. In 2019, about 200,000 refugees sought safety in Europe by crossing the Mediterranean Sea [2]. Refugees are a high-risk population for mental health problems as a result of stressful and traumatizing events and circumstances in their country of origin as well as during and after their flight. Prevalence rates of up to 40% for any mental health problems are described in relevant literature [3,4]. Post-traumatic stress disorder (PTSD), depression, anxiety disorder, somatoform disorders, and substance abuse are the most commonly reported mental health issues [3,5]. These facts result in a high need for psychosocial support services among refugees and asylum seekers which are, however, often insufficient and associated with many barriers [6–9].

Newly arrived refugees and refugees living in refugee camps are especially vulnerable to mental health problems [10,11]. Cross-sectional studies in different state registration

**Citation:** Zehetmair, C.; Zeyher, V.; Cranz, A.; Ditzen, B.; Herpertz, S.C.; Kohl, R.M.; Nikendei, C. A Walk-In Clinic for Newly Arrived Mentally Burdened Refugees: The Patient Perspective. *Int. J. Environ. Res. Public Health* **2021**, *18*, 2275. https:// doi.org/10.3390/ijerph18052275

Academic Editors: Lillian Mwanri, Hailay Gesesew, Nelsensius Klau Fauk and William Mude

Received: 26 January 2021 Accepted: 21 February 2021 Published: 25 February 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

and reception centers in Germany have found PTSD prevalence rates between 23.6% and 40% [5,8,12–14]. Still, psychosocial support offers in state registration and reception centers across Germany are sparse, although evidently urgently needed [15,16]. In Germany, clinical care is provided by inpatient and outpatient services. Currently, 26 psychiatric and psychosomatic clinics offer outpatient and inpatient support for migrants and refugees [17]. However, rehabilitation centers for refugees and survivors of torture as well as relief organizations play an important role in mental healthcare for mentally burdened refugees [17]. These rehabilitation centers' primary services for refugees and torture survivors include psychosocial and psychological counseling, psychotherapeutic sessions, crisis intervention, stabilization work, diagnostics and clearing, and social counseling. According to the annual report of the Federal Association of Rehabilitation Centers for Refugees and Survivors of Torture (Bundesweite Arbeitsgemeinschaft Psychosozialer Zentren für Flüchtlinge und Folteropfer e.V, BAfF), 22,746 refugees and torture survivors received psychosocial care in 2018, of which approximately 41% had psychotherapeutic treatments [18]. Furthermore, various clinical care models exist in the literature. Brakemeier et al. [19] described an interpersonal integrative pilot project for refugees with mental disorders with promising effects in reducing symptoms of PTSD, depression, and anxiety disorder. Other models of care, such as the STEP-by-STEP approach in a German registration and reception center [20], or the Baden-Württemberg humanitarian reception program for Yezidi women and children who have fled captivity of the so-called Islamic State [21], have been reported, but data on their effectiveness have not yet been published. According to Bauhoff and Göpffarth [22], asylum seekers in Germany are twice as likely to report psychiatric hospitalization than regularly insured persons. However, this group also has over three times less access to psychotherapists than regularly insured patients. Satinsky et al. [7] examined the utilization of mental health and psychosocial support services in European countries in their systematic review. They concluded that refugees and asylum seekers are more likely to use medical/somatic health services and to be hospitalized for mental health problems [7]. Providing appropriate care shortly after the refugees' arrival in the host country can lead to initial stabilization of symptom burden and, thus, prevent further exacerbation and chronification of mental health problems.

Since 2016, a psychosocial walk-in clinic has supported psychologically burdened refugees within the state reception and registration center "Patrick Henry Village" in Heidelberg, Germany. For this center, a mental health inventory has shown that a sample of 228 patients attending the psychosocial walk-in clinic was burdened by PTSD (41.2%), adjustment disorder (22.4%), depression (25.0%), anxiety disorder (6.1%), substance abuse (10.5%), and somatoform disorders (5.3%) [14]. Next to supportive and stabilizing counseling offers, including group psychotherapy [23,24] as well as a program facilitating the self-practice of stabilizing techniques via audio-files [25], half of the patients received psychopharmacological treatment. Outpatient psychotherapy treatment was recommended to 66% of patients after reallocation to municipal housing [14]. Together, these data underscore the necessity of needs-based psychosocial support services shortly after the refugees' arrival in the host country. So far, the patients' perspective regarding their experiences with the psychosocial walk-in clinic in a German state registration and reception center has received little attention. Considering the perspective of refugee patients, however, can improve the quality of psychiatric care and provide important implications for future treatment. Carey [26] noted that focusing on patient preferences, needs, and values (as is intended by patient-centered approaches) can help reduce time spent in hospital, readmissions, and emergency room visits, as well as improve compliance and engagement. Considering the patient perspective via qualitative research methods allows us to systematically illustrate and animate individual narratives and, thus, helps us avoid reducing patients to mere diagnoses, numbers, or test subjects [27].

Therefore, this study aimed to gain a deeper understanding of the barriers that refugees face in their mental healthcare efforts to develop strategies in addressing them. To this end, we assessed the perspectives of refugees attending the psychosocial walk-in clinic in the state registration and reception center in Heidelberg, with a focus on the following research questions: (1) How do patients experience their mental health burden and how do they deal with it? (2) What are facilitating and impeding factors when seeking help in the psychosocial walk-in clinic? (3) How do the patients experience the consultations in the psychosocial walk-in clinic? (4) What are the patients' future attitudes towards further help-seeking behavior?

### **2. Materials and Methods**

#### *2.1. Data Collection*

From March to May 2019, we conducted a descriptive study using qualitative semistructured interviews in the refugee state registration and reception center 'Patrick Henry Village' (PHV), Heidelberg-Kirchheim, Germany. The PHV are former US military barracks currently accommodating around 1,200 newly arrived refugees and asylum seekers. During their PHV stay, newly arriving refugees and asylum seekers' personal data are registered, their identity is verified, and a medical examination for communicable diseases is carried out as part of the asylum procedure. As a rule, refugees and asylum seekers are redistributed to other accommodations within a short period of time. Since 2016, the Heidelberg University Hospital has been operating a medical and psychosocial walk-in clinic at the PHV in cooperation with physicians in private practice [28,29].

Our target group were refugees who sought help in the psychosocial walk-in clinic [28] and fulfilled our inclusion criteria. Inclusion criteria were an age of 18 or older and the ability to understand one of the following languages: German, English, French, Farsi, Arabic, Turkish, Kurmanji, Urdu, Hausa, Russia, Serbian, Albania, Macedonian, Georgian, Mandinka, or Tigrinya. We asked the refugees to participate in our study while they were waiting for their psychosocial counseling appointment. If a refugee was unable to converse in German or English, a PHV-based interpreter was called or a telephone interpreter was contacted via an interpreter service. If the individual was willing to participate in the study, they were interviewed after their counseling appointment. First, sociodemographic data questions, such as age, nationality, religion, and education level, were answered and then the interview was conducted. The clinical diagnosis information was collected from the participants' medical files after the consultation appointment. The interviews were conducted by one of the two first authors (V.Z.) who has a medical background.

#### *2.2. Participants*

In total, *n* = 49 patients waiting for their counseling appointment at the psychosocial outpatient clinic were asked to take part in the study. We interviewed *n* = 22 of 49 patients (44.9%). *n* = 11 (22.4%) patients did not meet our inclusion criteria. Other reasons for non-participation were cognitive impairment (*n* = 3, 6.1%), unwillingness (*n* = 9, 18.3%), or parallel appointments (*n* = 4, 8.2%). Table 1 shows the sample characteristics of the *n* = 22 study participants. *n* = 2 interviews were held in English, *n* = 1 interview was done with a face-to-face interpreter, and *n* = 19 interviews were conducted using a telephone interpreter.
