To identify processes of discrimination and to develop adequate strategies to combat discrimination in different situations and phases of health care trajectories, four questions were answered:
1. To which aspect of health care is the problem related?
2. In which phase of the health care trajectory does the problem occur? (where)
3. Where does the problem originate from?
4. What are the consequences of discrimination?

1. To which aspects of health care is the problem related?
As discrimination is to a high extent the result of specific interactions between migrants and health care employees (medical as well as non-medical), six factors that influence these interactions can be distinguished:
- Conditions in which the encounters take place
For instance, referral for admission of a Muslim woman to a non-segregated ward or genital research by women performed by male doctors, absence of interpreters or lack of time
- Concepts underlying the health care interactions
For instance the concept of autonomous self and internal locus of control underlying psychotherapeutic practice versus a socio-centric and community oriented world view of the patient;
- Practices, protocols and procedures guiding the encounter
For instance, intake procedures and ward protocols that don't take into account family support;
- Attitude of migrant and health care employees
For instance, the general attitude of the health care employees towards migrants (stereotyping) or a 'demanding' attitude of the migrant;
- Behaviour of migrant and health care employees
For instance, a from the migrant's point of view improper or even insulting way of addressing by the health care employee or from a professional's point of view unfamiliar ways of expressing the suffering by the migrant.
- Knowledge of health care problems and health care provision of migrant and health care employee.
For instance, lack of cultural sensitivity and knowledge as the health care employee concerns or insufficient knowledge of the health care system as the migrant concerns.

There are many other issues that can be studied: A main problem is the time budget (as perceived and told by health professionals and immigrants), which may lead to interaction problems. Furthermore, language problems: the professional who does not ask questions to determine the specific needs of his patient or client (cultural sensitivity/knowledge); attitudes like certain non-verbal behaviours of professionals that sometimes may be an "insult" to the immigrant,. Often such events are not even noticed because they pass so quickly, but yet they will influence perceptions of discrimination or exclusion. In this case a video camera would be of use indeed, although the use of a camera is contestable.

2. In which phase of the health trajectory does the problem occur?
Problems may occur long before the encounter of migrant and health care takes place. Illness trajectories also encompass home care, out-reaching, compliance, care in case of (temporary) disabilities. Starting from the model of Goldberg and Huxley different stages are to be distinguished:
- Health seeking behaviour
For instance, is the migrant population informed about health promoting behaviour and available health care facilities?
- Recognition of health problems
For instance, are health problems in time and in an effective way recognized by the system (lay referral system, employers, teachers, general practitioners)?
- Referral to appropriate health facilities
For instance, are general practitioners aware of the referral possibilities and capable of adequate referral?
- Admission to appropriate health facilities
For instance, do procedures, protocols and practices block admission
- Assistance in an effective way.
For instance, do medical professionals, therapeutic interventions and accommodation of health care adequately take into account of the migrants culture, their needs and intra-ethnic diversity? Also gender differences, age, co-morbidity, multiple health problems are aspects to reckon.

3. Where does the problem originates from?
As to the origin of the problem five issues can be distinguished:
- general system issues related to the specific living conditions of migrants, for instance legality of residence, employment, housing;
- general health care system issues effecting the population in general, for instance lack of cooperation between different health care facilities;
- specific health care issues effecting a specific migrant population, for instance the availability of interpreters, accustomed health care facilities, professional cultural competence;
- target group issues, for instance particular cultural defined habits or life style, knowledge of the native language, degree of openness of the ethnic community, degree of integration;
- health-problem related issues, for instance the migrants health seeking behaviour, specific culture-bound diseases, definition and meanings of health-problems (taboo, stigma).

4. What are the consequences of discrimination?
The consequences for migrants may vary from psychological distress to under-of health care services and drop-out. This may cause deterioration of the health situation and marginalizing of certain parts of the population in a country. Discrimination may also result in seeking alternative health care, medical shopping or being referred wrongly

The members of the working group have hypothesised that the combat against discrimination within the health care system implies operating in the area where health care personnel and migrant communities interact. These actors include: medical and paramedical professionals, mediators, administration, single migrants and migrant communities. The respective behaviours are determined by the cultural context of origin, by practices, bureaucratic procedures and protocols, by different conceptions of health, illness and perception of the body, by former experiences, by the nature of obtained information.

How to map discrimination in health care

The first step to detect and map discrimination could be to pose questions concerning relevant elements or processes which can contribute to exclusion or lead to discrimination. The amount of questions can be unlimited, but once can start with a dozen questions, divided over five domains. In answering these questions there are in every case four sub-questions.

Domain: Society Patient Interaction Professional Health Care
Focus: Rights Knowledge/ Communication Competence Cultural
Information Information diversity
Knowledge

Measuring discrimination

The working group has defined measurement of discrimination as a qualitative practice that brings to the fore indicators of discrimination. Because discrimination is a subjective experience and a sensitive issue, it is problematic to measure discrimination in a quantitative way. The main conclusion is that certain situations that are "prone" to discrimination. There are
- endangering situations: impersonality of professional approaches of immigrants
- bureaucracy: the formalised diagnostic process
- inadequate relationships between professionals: the referral process based on cultural prejudices, and language problems.
The conclusion is that discrimination is not a matter of more or less; every situation in the health care process has its own specific danger of discrimination.
However, feelings of discrimination of immigrants are more frequent and intense in certain situations:
- administration
- registration
- gynaecological treatment.

To measure discrimination, we can ask the following questions:
Society: Is equal access enforced by law? Are patients able to make use of health care facilities?
Patient: Is the patient aware of the existence of all health care facilities? Has the patient adequate information? Is this information provided by health care facilities?
Interaction: What are the communication problems according to patients and professionals? Which measures are taken to improve interaction (interpreters, mediators)?
Professionals: Are they trained in transcultural work? Are there any measure to improve cultural competence?
Health care: Is there a policy aiming at managing cultural diversity within the setting?

A common mechanism of discrimination is also that when a health system is more bureaucratic, it will be more likely that health workers discriminate. Discontinuity in health seeking processes, assumptions on the side of health professionals of worldviews of their immigrant clients will easily lead to exclusive and discriminatory behaviour. Culture plays an important role in the sense that health care professionals interpret attitudes and behaviour of immigrant clients as cultural determinedand stereotypical. The effect is discrimination.