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

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


1
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

2
Unprecedented Patterns of Migration
Anne MacFarlane, Department of General Practice,
HSR Seminar December, 13th 2005
3
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
4
Communication Matters
  • General Practice and nursing
  • Biopsychosocial model of health
  • Participation of patients
  • Patient agenda
  • Patient narratives
  • Shared decision making

Anne MacFarlane, Department of General Practice,
HSR Seminar December, 13th 2005
5
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

Anne MacFarlane, Department of General Practice,
HSR Seminar December, 13th 2005
6
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
7
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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
8
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
9
PLA in action
  • Inter-agency Partners
  • HSE WA Health Promotion, Public Health
  • Community Representation
  • Galway Refugee Support Group

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
10
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
11
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
12
Methods Data Collection Topic Guide
  • Research question
  • Tell me about peoples 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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
13
Methods Technique
  • Emic card sort
  • Qualitative data
  • Insider perspective
  • Researcher elicits stories
  • Interviews them
  • Story broken down onto cards
  • Cards sorted thematically by participant

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
14
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
15
Methods Co-analysis of Card Sorts
  • Recording forms translated
  • Sharing of data
  • Manual analysis
  • Framework analysis

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
16
Overview of Thematic Framework
GP Attitude
Responses
GPs Interpreting
GP Competency
Strategies
Competency Communication
Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
17
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
18
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 couldnt ask anything else and the
    consultation folded.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
19
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
20
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
21
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
22
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
23
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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
24
GP Attitude
  • Z1 described a consultation where her doctor
    didnt 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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
25
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
26
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 doesnt have to explain
    anything to people with little English
  • In her experience, the GP doesnt like to be
    asked many questions, pretends to be busy to get
    rid of us, frequently writing a prescription to
    end the consultation.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
27
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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
28
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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
29
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
    relationsthere are significant racial and
    cultural dimensions at play

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
30
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
  • AE diagnosis of asthma was made. New medicines
    were administered and were effective.
  • B1 thinks that the fundamental problem was that
    her doctor didnt listen to her and didnt take
    her consultations seriously.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
31
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
32
Responses
  • Significant lack of faith and trust in Irish GPs
  • Unused prescriptions
  • Change GP
  • Prefer hospital AE department

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
33
Medicine from home
  • Z4 feels strongly that her GP doesnt care about
    her or her familys 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.

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
34
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
35
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
36
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
37
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
38
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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
39
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 ORielly 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

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
40
Perspectives of Primary Care Providers
  • Telephone Survey (GPs and PHNs)
  • n91/119 Response rate 76
  • Qualitative Interviews (GPs)
  • n12

Anne MacFarlane, Department of General Practice,
HSR Seminar, December 13th 2005
41
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

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