Dr Patrick O’Donnell is a Clinical Fellow in Social Inclusion at the Partnership for Health Equity, a pilot project of the the University of Limerick’s Graduate Entry Medical School
The RESTORE conference took place from March 26–27th 2015 in Limerick, Ireland.
This morning, I had a busy clinic in Limerick city, Ireland. I saw about 10 patients who did not speak English well. Three of these consultations were facilitated by the patient bringing a child or friend in to interpret; for two other patients, I had to rely on Google Translate; for the next one, I spoke to a relative in English over the phone about the patient sitting in front of me; for the remainder, a mixture of broken English and miming had to suffice.
This is typical primary health care for migrants in Ireland in 2015. These types of consultation are often unsatisfactory for both parties involved and can be unsafe. Access to trained professional interpreters nationally is a problem; there is lack of clarity on funding these services, in addition to a shortage of qualified interpreters. It is also recognized internationally that, in settings where trained interpreters are recommended and available in primary care, there is not uniform acceptance and uptake of this vital service.
Recently, I attended an international conference showcasing research about communication in cross-cultural consultations with a focus on implementing strategies to improve these interactions. The event marked the culmination of a 4-year European collaboration called the RESTORE project. This work was funded by the European Union and carried out in Austria, Scotland, England, Greece, Ireland and the Netherlands. The project was looking at migrant health care from a practice and policy point of view. Researchers used a novel combination of participatory learning and action (PLA) and normalization process theory (NPT) to identify and implement guidelines and training initiatives designed to improve communication between migrants and their primary care providers.
The conference itself opened with Professor Anne MacFarlane (University of Limerick and Coordinator of RESTORE) reminding us of the complexity of migration in the Irish context. We live in a small country that has seen waves of emigration throughout our history and more recently immigration by those seeking to improve their circumstances. The country is facing challenges in caring for many of the new Irish people who have settled here who now represent 12% of our population and speak more than 180 languages. They have hugely varied cultural practices and influences, particularly in the realm of health. The situation in Ireland reflects what is happening across the EU, with movements of people from within and outside the 27 member states increasing. Improving the standards of primary care for these migrants is one part of the problem that the RESTORE project sought to address. The project also looked at the gap between the availability of evidence-based guidelines and training and their translation into routine clinical practice when caring for migrants.
The first plenary was chaired by Professor Chris Dowrick. It was very different and thought-provoking, in that a panel of three migrants who had participated in the work of the RESTORE project spoke. The beauty of PLA research is that it is carried out with and not on participants (often called co-researchers). Each participant recounted their own journey to their new home country and their experience of being involved in the RESTORE project. The difficulties of accessing and adapting to new systems of primary health care were very real for these migrants, and for the people in their social networks.
Professor David Ingleby then gave a stimulating presentation on problems from a systems viewpoint; where often there is a top-down approach and lip service is paid to involving the recipients of health care in the planning of services, but all real decisions are made by the “experts.” He noted that, at present, most health structures are tailored to suit the middle class and those who work in the service, not to those who are most in need of services or least able to use them properly. He called this an exclusionary method of inclusion. With the advent of a new age in medicine where partnership between the patient and the providers of health care are encouraged and the health literacy is promoted in the population, we should always think of those who are often unable to step up and be involved in their own health care.
Dr. Judith Sim presented an interesting study on biomedical pluralism that looked at how medicine is practiced very differently in countries that are quite similar. The participants were Polish women who had undergone maternity care in Scotland. These women expressed great uncertainty about the hands-off care model employed in Scotland, being more used to the medicalized care at home. The women struggled with this and often ended up using both systems in parallel; sometimes with email, Skype or actual visits to obstetricians in Poland during pregnancy. The staff in Scotland felt frustrated and undermined by these outside opinions, and felt that they had to prove their system was better. It was an interesting example of cultures clashing, showing that if these issues are not addressed early, then everyone can feel unhappy.
David Hunt of Critical Measures described the American context and the continuing resistance to using qualified medical interpreters in consultations, despite the existence of various laws and best-practice guidelines for a number of years. His group has developed e-learning cases to educate health care providers on the legal and health benefits of proper interpreting in health care. Results have shown that health care staff were more confident in caring for migrants and used more interpreters for consulting after this intervention, particularly for complex consultations around issues of consent. There may be potential to adapt this type of e-learning program for use in the EU and beyond.
These and many other presentations from academics and key policy stakeholders from the Council of Europe, the World Health Organization and the International Organization for Migration (Belgium) over the 2 days served to inspire and give hope that the problems faced by migrants navigating health care systems are being researched and solutions are being recommended. As one of the RESTORE migrant presenters said, we mustn’t stop now with this work, we need to continue to help these people — these people who are just like you and me.