Cultural and linguistic barriers in medical health care

Transcription

1 Cultural and linguistic barriers in medical health care Ludwien Meeuwesen Utrecht University Conference Reggio Emilia, March 13, 2008

2 Aim: Overview of communication research in primary health care in the case of immigrant patients: Rotterdam Intercultural Communication in Medical Settings project (RICIM) Initiator: Dr. J.A. M. Harmsen (Harmsen, 2003)

3 Research team Hans Harmsen: general practitioner Ludwien Meeuwesen: psychologist Barbara Schouten: psychologist Sione Twilt: social scientist, linguist

4 RICIM project Validation studies (questionnaires) (Harmsen) Intervention study (training for doctors and patients) (Harmsen) Communication studies based on videos (Meeuwesen, Schouten)

5 Data Questionnaires (n=986): cultural views, language proficiency; mutual understanding Videos of doctor-patient consultations in general practice (n=250) Effect study: intervention (training) Ethnicity: Turkish, Moroccan, Surinamese, Antillean, Cape Verdean, Dutch

6 Barriers in medical communication Institutional barriers (voice of medicine voice of lifeworld) Cultural barriers Linguistic barriers

7 Cultural barriers Cultural: - doctor s and patient s explanatory model (Kleinman) - differences in cultural views - differences in preferred communication style - differences in health care system

8 Linguistic barriers Patients proficiency of host countries language Availability of professional interpreters Informal interpreters in daily medical practice, mostly family members. Language proficiency of informal interpreters (host language and immigrant language)

9 Results based on review Mainly research from U.S. Western doctors communicate less affective with ethnic minority patients compared to western patients (less supporting, less inviting, reflecting, less social talk); also less psychosocial talk Patients of ethnic minority groups are verbally less expressive less assertive and less affective compared to western patients. Communicative interaction may result in a form of non-engagement, leading to more miscommunication. (Schouten & Meeuwesen, 2005)

10 Communication results RICIM project Doctors regard communication with immigrant patients as more difficult and emotionally demanding Immigrant patients are less satisfied Consultations take 2 minutes shorter (or 3, for Turkish/Moroccan) Doctors are less emphatic Doctors are focused on gathering information and trying to understand the patient (paraphrasing, asking for clarification) They are prone to talk louder and to use the p.c. Immigrant patients fall silent more frequently.

11 Mean number of utterances of GP and patient 120 utterances Ethnic minority Dutch Total GP utterances Patient utterances

12 Mutual understanding (MU) between patient and doctor * Knowledge of patient and doctor about each other opinions regarding the complaints and the symptoms. * Mutual understanding is related to ethnicity, age, education, and language proficiency: poorer mutual understanding in ethnic minority patient groups (46% vs 34%)

13 Cultural barriers Cultural: - doctor s and patient s explanatory model (Kleinman) - differences in cultural views - differences in preferred communication style - differences in health care system

14 Ethnicity items and patients views: traditional and modern Your GP always is prejudiced because you are a foreigner : agree 22% vs 5%; Understands that you are accompanied by an interpreter: 96% vs 71%; Has information booklets in your language: 54% vs 24%; Understands that your problems are sometimes different from Dutch patients: 92% vs 47%; Is interested in your culture: 50% vs 46%. (Harmsen et al., in press)

15 Linguistic barriers Patients proficiency of host countries language Availability of professional interpreters Informal interpreters in daily medical practice, mostly family members. Language proficiency of informal interpreters (host language and immigrant language)

16 Communication and patients language proficiency: poor vs good Your GP always - Takes enough time to talk: 82% vs 91% - Talks with you seriously: 85% vs 94% - Is willing to talk about mistakes; 82% vs 92% - Is willing to talk about your problems: 80% vs 93% - Gives opportunity for you to decide about treatment: 64% vs 86% - Refers to a specialist when asked: 67% vs 93% - Clearly explains what is wrong: 74% vs 95%. (Harmsen et al., in press)

17 Linguistic barriers - Over half of immigrant patients have poor language proficiency in Dutch; - About 15% to 20% is accompanied by an informal interpreter (mostly family members) - About half of the informal interpreters take the role of facilitator - The other half takes the role of intermediair or direct source

18 Relation between interpreting and mutual understanding In the case of low mutual understanding between doctor and patient there is: - more side talk - more giving of context information - more examples of miscommunication (with or without recognition) - more changes in the translation (mainly content reductions and omissions) - (Twilt et al., in press)

19 Conclusion Substantial communication gap between immigrant patient and GP; Professional interpreters are seldom used; Knowledge of patients values and norms are useful for a GP; Accent on the instrumental aspects of the communication, instead of both instrumental AND affective; Different opinions: immigrant patients behave cooperatively OR fall silent; Training in intercultural communication for health care providers seems necessary.

20 Future projects? BICOM project Promoting bilingual and intercultural competencies in public health Recognition and valuing of informal interpreting as an aspect of citizenship in a multilingual society Learning partnership: Germany, Italy, Netherlands, UK Grundtvig// Life Long Learning (Harmsen, Meyer, Meeuwesen, Schouten)

21 Future projects Three party talk Doctor patient interpreter Cues and concerns (Verona group) European Association of Communication in Health Care (EACH) European project??

22 Thank you! Further information? Ludwien Meeuwesen: Publications downloadable from: