The Language Barrier in Primary Care: Perspectives of Refugees and Asylum Seekers Department of General Practice Health Services Research Seminar December.

The Language Barrier in Primary Care: Perspectives of Refugees and Asylum Seekers

Department of General Practice

Health Services Research Seminar

December 13th 2005

Anne MacFarlane, Department of General Practice, NUI, Galway

Unprecedented Patterns of Migration

Anne MacFarlane, Department of General Practice, HSR Seminar December, 13 th 2005

Research about Refugee and Asylum Seeker Health Language differences, communication

difficulties Refugees, asylum seekers, services

providers (primary and secondary care) Use of interpreters

Formal interpreters (telephone/face to face interpreting)

Informal interpreters (Friends and relatives)

Anne MacFarlane, Department of General Practice, HSR Seminar December, 13th 2005

Communication Matters

General Practice and nursing Biopsychosocial model of health Participation of patients

Patient agenda Patient narratives Shared decision making


CARe Communication with Asylum Seekers and Refugees Conduct an in-depth exploration of the impact

of language as a barrier in primary care Document experiences of refugees, asylum

seekers & primary care providers Identify key features of the language barrier

and its impact Explore solutions and strategies for service

development and improvement


Perspectives of Refugees and Asylum Seekers Aim is to document experiences of refugees

and asylum who have experience of accessing and using primary care with little or no English

Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005

Research Approach

Participatory Learning and Action (PLA) More radical form of organisational action

research Derived from Participatory Rural Appraisal

(Chambers, 1994c) “growing family of approaches and methods that enable

local people to share, enhance and analyse their knowledge of life and conditions, to plan and to act.


PLA Key Characteristics

Meaningful participation of community members; acknowledging local expertise

Focus on concrete actions arising out of data collection

Equal relationship between the ‘researcher’ and the ‘researched’

Doing research ‘with people’ rather than ‘on them’


PLA in action

Inter-agency Partners HSE WA Health Promotion, Public Health Community Representation

Galway Refugee Support Group


PLA in action

Core group for the research Croatian woman, Ukrainian man, two Russian women

and Nigerian woman Research planning – project name and logo, project

materials PLA training to facilitate peer researcher model for data

collection and data analysis


Methods: Sampling and Recruitment Purposeful sampling

Ethnicity (Serb-Croat and Russian speaking communities)

Gender (men and women) 26 participants

16 women and 10 men 10 asylum seekers, 6 refugees, 10 with residency on the basis of having Irish born

children


Methods: Data Collection Topic Guide Research question

“Tell me about people’s experiences of language differences and communication difficulties with GPs” Experiences of making appointments Arriving at the surgery, place of consultation Being in the consultation What happens afterwards

Experiences with public health nurses and pharmacists


Methods: Technique

Emic card sort Qualitative data ‘Insider’ perspective

Researcher elicits stories Interviews them Story broken down onto cards Cards ‘sorted’ thematically by participant


Methods: Emic Card Sort

Story about daughter acting as an interpreter ‘daughter interprets’ ‘daughter interpreter absent from school’ ‘daughter interpreter explains everything’

‘Sorted’ with cards about friend acting as interpreter


Methods: Co-analysis of Card Sorts Recording forms translated Sharing of data Manual analysis Framework analysis


Overview of Thematic Framework

GPs & Interpreting

Strategies

GP ‘Attitude’

GP Competency

Competency & Communication

Responses


Strategies for Approaching GPs Three main strategies

Use of informal interpreters Friends or relatives, including children

Preparing with dictionaries, phrasebooks Gestures and body language

Sense of agency among refugees and asylum seekers to manage the language barrier in the absence of an adequate structural supports in general practice


Children as informal interpreters B2, for instance, a woman aged 37 who is an asylum seeker,

married with two children had no English on arrival in Ireland daughter had very good English made appointments for her and interpreted for her during GP

consultations absent from school for up to one or two hours This woman tried to attend GP consultations alone with sentences

learned by heart ….once she had told her GP these few sentences, she couldn’t ask

anything else and the consultation folded.


English language ability of informal interpreters B1 is an asylum seeker from Croatia married two children living in

direct provision. She had no English when she arrived in Ireland No Croatian speaking friends informal interpreters was a friend from Czechoslovakia because there

was some similarity between their languages and they could understand each other a little

inevitable misunderstandings during her GP consultations ….on one occasion her son who had diarrhoea was prescribed

medication for constipation


GPs’ Responses to Interpreters Mixed responses to informal interpreters

sent away by GPs to find someone to interpret friends or relatives turned away by GPs resistance

to informal interpreters


Informal Interpreter as a ‘Complication’ B3 a Croatian woman brought her friend along to interpret.

Her friend did not have very good English but had better English that the woman.

GP felt “friend was just complicating matters” …”understood enough” …B3 emphasised that this view, even if accurate which it was not,

did not take into account that she did not have enough English to ask questions of the GP or discuss her case with the GP in any depth


Formal Interpreting?

Only 4 participants had ever used formal telephone interpreters in general practice

No participant had access to formal interpreter during the data collection period

Formal interpreting highly valued Requests to GPs turned down Limits of formal interpreting

Face to face versus telephone Issues of training and professionalism


Decisions about Interpreters

There is a power differential at play whereby decisions about the use of formal and informal

interpreters lie with general practitioners rather than with refugees and asylum seekers.


GP ‘Attitude’

Z1 described a consultation where her doctor didn’t make any effort to understand what she was trying to say. The GP “switched off”, appeared annoyed and angry and started writing a prescription. Z1 stopped trying to explain herself, took the prescription offered and left.

She emphasised how awful it was feeling that the GP wanted to get rid of her.


Prescriptions and Treatments Being written before participant finished Prescriptions for over the counter

medications (eg calpol) Repeat prescriptions for on-going problems Refused tests and investigations


Attitudes and Language Differences Z6 felt that as soon as she opens her mouth, there is a negative

response because the GP realises that there is a language difference. She does not feel attended to by her GP and feels that her/his GP thinks he doesn’t have to explain anything to people with little English

In her experience, the GP doesn’t like to be asked many questions, pretends to be busy to “get rid of us”, frequently writing a prescription to end the consultation.


Lack of English = less responsibility for GPs?

K2 believed that GPs do not feel responsible for patients who do not speak English because the patient cannot control or cross check the treatments that are being given. In this way, GPs feels free to prescribe whatever they wish, or to send patient away.


Lack of English = Lack of Intelligence? B4 felt strongly that GPs think people are less intelligent and stupid

if they have bad English. GP openly shows that his lack of English irritates him, sneering

when he speaks English. blood test but no result from GP B4 explained that he had no energy for fighting or standing up

for himself; he felt humiliated and degraded.


Relevance of being a ‘foreigner’? D4 describes her GPs manner in their consultations as “superficially

pleasant, polite, well-mannered” but holds a strong perception that he is indifferent.

an absence of true medical interest in her and engagement with her There is no open racist attitude but, she does wonder whether

this underlies his behaviour and manner?

Communication is embedded in social relations…there are significant racial and cultural dimensions at play


Competencies

B1 had a small child with bad cough repeat visits to her GP, asked for analysis and tests but the GP

would not arrange them A&E diagnosis of asthma was made. New medicines were

administered and were effective. B1 thinks that the fundamental problem was that her doctor

didn’t listen to her and didn’t take her consultations seriously.


GP Competency and Communication Z4 asked “If there is no interpreter and you cannot explain the

problem how can you clarify the problem, how can you get quality care from GP?”

Competence of GP depends on quality of interpretation


Responses

Significant lack of faith and trust in Irish GPs Unused prescriptions Change GP Prefer hospital A&E department


Medicine from home

Z4 feels strongly that her GP doesn’t care about her or her family’s health. The GP cannot understand the seriousness of the problems and at the end of their consultations Z4 feels like a second class citizen. She only goes to the doctor if it is really really necessary. She uses alternative medicine, such as herbal medicine and supplements from health food shops as much as possible, particularly for her young son who has a skin condition. She also has contact with a Russian doctor in the city who has a cupboard of

medicine from home.


Health Seeking Behaviour

Health-seeking behaviour of refugees and asylum seekers is characterised by heterogeneity of actions within which utilisation of GP services is carefully negotiated and managed


Key Findings

Three main informal strategies identified the use of informal interpreters, dictionaries and

gestures/body language The inadequacy of these informal strategies has

been highlighted problems include the use of children

friends/family members who may not be trusted friends/family members who may not actually have ‘good’

English examples of errors and misdiagnoses as a result of

language and communication difficulties


Key Findings

Good English does not guarantee ‘problem free’ communication

Decisions about the use of formal and informal interpreters lie primarily with GPs. Refugees and asylum seekers do not feel

listened to by GPs Profound lack of faith in GP care


Solutions

Accessible and Available Formal Interpreters Trained interpreters Training for uptake and use of interpreters Options for different kinds of interpreting for

different kinds of consultations English Classes Exchange of Experiences and Perspectives


Concrete Actions…

Action Research Process and Outcomes Representation, participation, empowerment Impact on health policy and service delivery

Presentation to HSE Primary Care Unit Network of regional projects

Fellow in Refugee and Asylum Seeker Healthcare MARTA Galway Refugee Support Group Community

Health Project Planned national inter-agency conference


Acknowledgements

Peer Researcher Group Galway Refugee Support Group

Triona NicGiolla Choille Celine Geoffret

Steering Group Members Mary Kilraine Hannon, Health Promotion, HSE WA Ena Polenjee, Public Health Nurse, HSE WA Ann O Kelly, Centre for Nursing Studies, NUI, Galway

PLA Trainers Mary O’Rielly de Brun, Centre for Participatory Studies, Co. Galway Tomas de Brun, Centre for Participatory Studies, Co. Galway

Research with Service Providers Pauline Clerkin, NUI, Galway Liam Glynn, NUI, Galway Julie McMahon, NUI, Galway Phillipe Mosinike, NUI, Galway


Perspectives of Primary Care Providers Telephone Survey (GPs and PHNs)

n=91/119; Response rate 76%;

Qualitative Interviews (GPs) n=12


Overview of Results

Use of interpreters 90% Relative or friend 70% Formal interpreter by telephone 19% Formal interpreter face to face 7%

Preference for informal interpreter 36% Preference for formal interpreter 41% Managed without interpretation 63%

Accounts of difficulties or sensitivities with informal and formal interpreters

Language barrier not perceived as a major problem in their work


The Language Barrier in Primary Care: Perspectives of Refugees and Asylum Seekers Department of General Practice Health Services Research Seminar December.

Documents

hsr seminar

relatives anne macfarlane

improvement anne macfarlane

english anne macfarlane

galway slide

data analysis anne macfarlane

action pla

care communication