Do Dutch doctors communicate differently with immigrant patients than with Dutch patients?

An Overview of Dentist-Patient Communication in Quality Dental Care

Dentist-patient communication is at the core of providing quality dental care. This study aims to review the importance, challenges, strategies, and training of dentist-patient communication. The World Dental Federation (FDI) emphasizes the importance of effective communication between oral healthcare providers and patients as a critical component of high-quality care. Effective dentist-patient communication allows dentists to accurately and effectively pass on essential medical information to patients. It improves the dentist's efficiency, boosts self-confidence, reduces occupational stress, and minimizes the risks of complaint or litigation. Moreover, it alleviates dental anxiety and fear, helps build trust between dentists and patients, addresses patients' needs and preferences, increases patients' adherence to improved treatment outcomes, and ultimately leads to enhanced patient satisfaction. Nonetheless, it has been widely acknowledged that dentists universally encounter the repercussions arising from suboptimal communication strategies. Time constraints, difficulties in establishing rapport, the oral-health illiteracy of the patients, the poor communication skills of the dentists, dentists' perceptions, and language barriers often hinder dentist-patient communication. Dentists should take the patient-centered approach as a premise and acquire verbal and non-verbal communication skills to overcome these communication barriers. The patient-centered approach comprises the understanding of patients' illness, shared decision-making, and intervention with mindfulness of the patient's own pace. Simple, succinct, and jargon-free language should be used in verbal communication. Proper body postures and gestures are fundamental for showing positive attitudes towards patients. Communication training for dental students should involve a structured pedagogical approach that includes didactic instruction, role-playing exercises, patient interviewing, and ongoing assessments. Key components of effective communication skills training in dental education include motivational interviewing, open-ended questioning, affirmations, reflective listening, and summaries to enhance patient engagement and adherence to treatment plans.

Improving Patient Experience by Understanding Barriers and Incentives to Telehealth Adoption Among Physicians at a Large Academic Medical Center

Patients benefit from and appreciate the option to use telehealth with their providers. Such patient expectations have therefore led to new questions about the factors that affect providers' willingness to adopt telehealth as part of their clinical practice. We interviewed 19 physicians across four specialties with differential rates of telehealth use (Psychiatry, Anesthesiology, Physical Medicine & Rehabilitation [PM&R], and Ophthalmology) to discern the barriers and incentives to telehealth adoption among physicians. We then conducted a qualitative analysis of interview transcripts, following precepts of Directed Content Analysis. Conclusions drawn from matrix building and thematic analysis were verified with negative evidence searches and if-then tests. Robust investigations for outliers and rival explanations in responses were used to disconfirm findings. The results of this analysis revealed distinct barriers and incentives to telehealth adoption for the four specialties. Physicians in psychiatry and anesthesiology are refining the strengths and applications of telehealth based on the characteristic needs of their specialties. Physicians in PM&R and ophthalmology face additional barriers to acquiring physical exam data, leading them to use telehealth as a supplement to, rather than as a replacement for, core functions of patient care. The insights stemming from these barriers and incentives can be used to build thoughtful telehealth applications for physicians, allowing them to provide effective clinical care while also improving the patient experience.

Exploring discrimination and racism in healthcare: a qualitative phenomenology study of Dutch persons with migration backgrounds

OBJECTIVE

To explore and characterise the discrimination and racism experienced in healthcare from the perspective of Dutch patients with a migration background.

DESIGN

This was a qualitative phenomenological study incorporating an inductive thematic analysis of the answers provided to a free form online survey. Descriptive and differential analyses were conducted for the closed-ended questions.

SETTING

This study used an online survey distributed in Dutch about experiences of discrimination and racism in healthcare to the general population in the Netherlands.

PARTICIPANTS

The survey was completed by 188 participants (Mage=39.89, SDage=10.2). Of whom 80 (Mage=37.92, SDage=10.87) met the eligibility criteria for thematic analysis (ie, has a migration background or a relative with a migration background and experienced discrimination in healthcare based on their background) and were thus included in the analysis.

RESULTS

From the total sample, women, relative to men, were 2.31 times more likely to report experiencing healthcare discrimination (OR=2.31; 95% CI 1.23 to 4.37). The majority of the participants (60.1%) had a Moroccan or Turkish background. Six themes were identified relating to experienced discrimination in healthcare based on one's migration background: (1) explicit discrimination, (2) prejudice, (3) not being taken seriously, (4) discriminatory behaviour, (5) language barriers and (6) pain attribution to cultural background. Some participants reported that their attire or religion was linked to their migration background, thus contributing to their experiences of discrimination.

CONCLUSION

Dutch patients with a migration background may experience discrimination based on their ethnic identity or other factors related to their backgrounds, such as their faith, culture and skin colour. Discrimination manifests as intersectional and may take different forms (eg, discrimination based on the intersection between race and gender). Therefore, healthcare discrimination may increase health inequities and lead to unequal access to healthcare services. Implicitly or explicitly discriminating against patients is immoral, unethical, illegal and hazardous for individual and public health. Further research on the magnitude of discrimination in healthcare and its relation to health is needed.

Towards a better understanding between non-Muslim primary care clinicians and Muslim patients: A literature review intended to reduce health care inequities in Muslim patients

Although Muslims are a growing population within many non-Muslim countries, there are insufficient Muslim clinicians to care for them. Studies have shown that non-Muslim clinicians have limited knowledge and understanding of Islamic practices affecting health, which may lead to disparities in the quality of healthcare delivery and outcomes when caring for Muslim patients. Muslims come from many different cultures and ethnicities and have variations in their beliefs and practices. This literature review provides some insights which may strengthen therapeutic bonds between non-Muslim clinicians and their Muslim patients resulting in improved holistic, patient-centered care in the areas of cancer screening, mental health, nutrition, and pharmacotherapy. Additionally, this review informs clinicians about the Islamic perspective on childbirth, end of life issues, travel for Islamic pilgrimage, and fasting during the month of Ramadan. Literature was sourced by a comprehensive search in PubMed, Scopus, and CINAHL along with hand screening of citations. Title and abstract screening followed by full-text screening excluded studies including less than 30% Muslim participants, protocols, or reporting results deemed irrelevant to primary care. 115 papers were selected for inclusion in the literature review. These were grouped into the themes of general spirituality, which were discussed in the Introduction, and Islam and health, Social etiquette, Cancer screening, Diet, Medications and their alternatives, Ramadan, Hajj, Mental health, Organ donation and transplants, and End of life. Summarizing the findings of the review, we conclude that health inequities affecting Muslim patients can be addressed at least in part by improved cultural competency in non-Muslim clinicians, as well as further research into this area.

Video-based observation research: A systematic review of studies in outpatient health care settings

OBJECTIVE

To examine the use of video-based observation research in outpatient health care encounter research.

METHODS

We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics.

RESULTS

175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies.

CONCLUSION

Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement.

PRACTICE IMPLICATIONS

Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Caring for older culturally and linguistically diverse patients with Cancer: Healthcare Providers' perceived barriers to communication

BACKGROUND

Due to various socio-cultural and language related factors, healthcare providers experience barriers when communicating with older culturally and linguistically diverse (CALD) patients with cancer, which can lower the quality of care received by patients and negatively impact healthcare providers. Studies focusing on communication barriers of older CALD patients with cancer and a systematic comparison of those barriers between different healthcare providers have been largely missing.

OBJECTIVES

In order to lay out the healthcare providers' perceived barriers to communication, the present study identified and compared communication barriers among different healthcare providers when caring for older CALD patients with cancer.

METHODS

An online survey was conducted among healthcare providers in the Netherlands who identified as being involved in the care of CALD patients with cancer (N = 191), specifically; GPs (N_GPs = 54), specialists (N_specialists = 29), oncology nurses (N_nurses = 77), and pharmacists (N_pharmacists = 31). Providers assessed twelve pre-specified factors on (i) importance and (ii) frequency of these factors as barriers to communication. A composite score by employing the QUOTE (Quality Of care Through the patients' Eyes) methodology was used to rank, and classify factors as either potential or influential barriers.

RESULTS AND CONCLUSION

Overall, low Dutch language proficiency of older CALD patients with cancer, family interpreters providing inadequate translations, not knowing the extent of patients' informational needs, cultural differences in views about healthcare (i.e., illnesses and treatments) and family members blocking communication were found to be influential communication barriers. Healthcare providers showed several differences in what they perceived to be a potential or an influential barrier: Cultural differences in views about healthcare and patients getting treatment in their home countries were important barriers for GPs, while not knowing the patient's contact person was for pharmacists. Nurses perceived the highest number of influential barriers, while specialists perceived the least. We conclude that specific interventions that address differences in perceived barriers among providers are needed, and we highlight potential interventions that involve digital communication tools, such as the Conversation Starter.

Barriers to Accessing Primary Care and Appropriateness of Healthcare Among Immigrants in Italy

INTRODUCTION

The health status and health care needs of immigrant populations must be assessed. The aim of this study was to evaluate barriers to accessing primary care and the appropriateness of health care among resident immigrants in Italy, using indicators regarding maternal health, avoidable hospitalization, and emergency care.

METHODS

Cross-sectional study using some indicators of the National Monitoring System of Health Status and Healthcare of the Immigrant Population (MSHIP), coordinated by the National Institute for Health, Migration and Poverty (INMP), calculated on perinatal care, hospital discharge, and emergency department databases for the years 2016-2017 in nine Italian regions (Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Latium, Basilicata, Sicily). The analyses were conducted comparing immigrant and Italian residents.

RESULTS

Compared to Italian women, immigrant women had fewer than five gynecological examinations (8.5 vs. 16.3%), fewer first examinations after the 12th week of gestational age (3.8 vs. 12.5%), and fewer than two ultrasounds (1.0 vs. 3.8%). Compared to Italians, immigrants had higher standardized rates (× 1,000 residents) of avoidable hospitalizations (males: 2.1 vs. 1.4; females: 0.9 vs. 0.7) and of access to emergency departments for non-urgent conditions (males: 62.0 vs. 32.7; females: 52.9 vs. 31.4).

CONCLUSIONS

In Italy, there appear to be major issues regarding accessing services and care for the immigrant population. Policies aimed at improving socioeconomic conditions and promoting integration can promote healthy lifestyles and appropriate access to health care, counteracting the emergence of health inequities in the immigrant population.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

Use of health care services among Syrian refugees migrating to Norway: a prospective longitudinal study

Background

Understanding the differential utilization of healthcare services is essential to address the public health challenges. Through the migration process, refugees move from one set of health risk factors to another and can face multiple healthcare challenges along their journey. Yet how these changing risk factors influence refugees’ use of health care services is poorly understood.

Methods

A longitudinal survey assessing health care utilization of 353 adult Syrian refugees was conducted; first in a transit setting in Lebanon and after one year of resettlement in Norway. The main outcomes are the utilization of general practitioner services, emergency care, outpatient and/or specialist care and hospitalization during the previous 12 months. Associations between use of healthcare services and several sociodemographic, migration-related and health status variables at both time points were found using regression analysis. We also analyzed longitudinal changes in utilization rates using generalized estimating equations.

Results

The use of general practitioner and emergency care increased after resettlement while outpatient/specialist care markedly dropped, and hospitalization rates remained the same. Undocumented status and poor self-rated health (SRH) prior to resettlement were identified as predictors for use of health care after arrival. After resettlement, higher health literacy, higher education, higher social support and poor SRH and quality of life were significantly associated with use of healthcare services.

Conclusions

Utilization of health services changes post migration to the destination country and are associated with migration-related and socio-demographic factors. Poor SRH is associated with use of services, both pre-arrival and post-resettlement. Our findings have implications for future resettlements, health care policies and service provision to newly arrived refugees with regard to both health needs as well as delivery of services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06571-5.

Discussing personalized prognosis in amyotrophic lateral sclerosis: development of a communication guide

BACKGROUND

Personalized ENCALS survival prediction model reliably estimates the personalized prognosis of patients with amyotrophic lateral sclerosis. Concerns were raised on discussing personalized prognosis without causing anxiety and destroying hope. Tailoring communication to patient readiness and patient needs mediates the impact of prognostic disclosure. We developed a communication guide to support physicians in discussing personalized prognosis tailored to individual needs and preferences of people with ALS and their families.

METHODS

A multidisciplinary working group of neurologists, rehabilitation physicians, and healthcare researchers A) identified relevant topics for guidance, B) conducted a systematic review on needs of patients regarding prognostic discussion in life-limiting disease, C) drafted recommendations based on evidence and expert opinion, and refined and finalized these recommendations in consensus rounds, based on feedback of an expert advisory panel (patients, family member, ethicist, and spiritual counsellor).

RESULTS

A) Topics identified for guidance were 1) filling in the ENCALS survival model, and interpreting outcomes and uncertainty, and 2) tailoring discussion to individual needs and preferences of patients (information needs, role and needs of family, severe cognitive impairment or frontotemporal dementia, and non-western patients). B) 17 studies were included in the systematic review. C) Consensus procedures on drafted recommendations focused on selection of outcomes, uncertainty about estimated survival, culturally sensitive communication, and lack of decisional capacity. Recommendations for discussing the prognosis include the following: discuss prognosis based on the prognostic groups and their median survival, or, if more precise information is desired, on the interquartile range of the survival probability. Investigate needs and preferences of the patients and their families for prognostic disclosure, regardless of cultural background. If the patient does not want to know their prognosis, with patient permission discuss the prognosis with their family. If the patient is judged to lack decisional capacity, ask the family if they want to discuss the prognosis. Tailor prognostic disclosure step by step, discuss it in terms of time range, and emphasize uncertainty of individual survival time.

CONCLUSION

This communication guide supports physicians in tailoring discussion of personalized prognosis to the individual needs and preferences of people with ALS and their families.

Critical patient insights from the same-day feedback programme at Stanford Health Care

PATIENT-CENTERED ORGANISATIONS

Healthcare organisations now integrate patient feedback into value-based compensation formulas. This research considered Stanford Healthcare's same-day feedback, a programme designed to evaluate the patient experience. Specifically, how did patients with cancer interviewed in the programme assess their physicians? Furthermore, how did assessments differ across emotional, physical, practical and informational needs when interviewed by volunteer patient and family partners (PAFPs) versus hospital staff?

PATIENT-PHYSICIAN COMMUNICATION BARRIERS

Integral to this research was Communication Accommodation Theory (CAT), which suggests individuals adjust interactions based on conversational roles, needs and understanding. Previous influential research was conducted by Frosch et al (2012) and Di Bartolo et al (2017), who revealed barriers to patient-physician communication, and Baker et al (2011) who associated CAT with these interactions. However, we still did not know if patients alter physician assessments between interviewers.

VOLUNTEERS COLLECT PATIENT NEEDS

This mixed methods study worked with 190 oncology unit patient interviews from 2009 to 2017. Open-ended interview responses underwent thematic analysis. When compared with hospital staff, PAFPs collected more practical and informational needs from patients. PAFPs also collected more verbose responses that resembled detailed narratives of the patients' hospital experiences. This study contributed insightful patient perspectives of physician care in a novel hospital programme.

Pharmacists' experience of asthma management in culturally and linguistically diverse (CALD) patients

BACKGROUND

In Australia, one of the world's significantly multicultural nations, asthma is one of the most common chronic conditions. A significant level of health disparities have been observed in many countries with a culturally and linguistically diverse demography. Previous studies have identified that language and culture affect health care provision, this is why culturally competent care is crucial when managing chronic conditions in diverse populations.

OBJECTIVE

The purpose of this study was to explore Australian community pharmacists' experience and perspective about providing care for CALD people with asthma.

METHODS

Qualitative semi-structured interviews were used as the method of choice to fulfil the study objective. Participants were recruited purposively from suburbs of relative diversity in two Australian cities: Melbourne and Sydney. Interviews with consenting pharmacist were conducted using an interview guide. Verbatim transcripts of interviews were then thematically analysed.

RESULTS

Thirty-two interviews resulted in five emergent themes 1) Pharmacists' attitudes towards CALD patients and Cultural Competence; 2) Barriers and facilitators; 3) Clinical issues; 4) Cultural barriers; 5) Workarounds. It was evident that language and to a smaller extent, cultural barriers were experienced regularly by pharmacists managing CALD patients; pharmacists had mostly adapted with a range of methods to work around these barriers. Although pharmacists had a positive attitude, there seemed to be a need for enhanced cultural competence skills; reflections from pharmacists supported the need for further training and pharmacy specific resources.

CONCLUSIONS

There is a significant gap in cultural awareness among Australian pharmacists. Future direction suggests obligatory training in cultural competence for health professionals in order to be able to provide cultural proficient care.

Consultations with patients for whom English is not their first language

Good communication is essential in neurological consultations, yet this is obviously compromised by the absence of a common language. Interpreters can make valuable contributions to improving consultations, but translation has its shortcomings. The consultation dialogue is not always interpreted correctly or accurately, even (or especially) when friends or family are translating. Clinicians should therefore try to ensure that key information has been communicated and understood, perhaps by repetition or asking the patient to say what they have understood. Cultural factors are also important in the patient–physician interaction. Physicians should try to adopt a culturally sensitive approach during consultations, familiarising themselves with cultural norms within the prevalent ethnic minority groups in their area. They should resist directive approaches to save time and try to involve the patient in decision-making. This requires allocating extra time to consultations with patients for whom English is not their first language.

Perceptions of Barriers to Patient Participation: Are They Due to Language, Culture, or Discrimination?

Previous research has shown that ethnic minority patients participate less during medical encounters than patients from majority populations. Given the positive outcomes of active patient participation, such as higher understanding of information and better treatment adherence, interventions are required to enhance ethnic minority patients' participation levels. However, little is known about what patients perceive as barriers hindering their participation. This study therefore aimed to explore differences in perceptions of barriers to patient participation among ethnic minority and ethnic majority patients in general practice. Eight focus-groups with Turkish-Dutch and indigenous Dutch participants were performed. A semi-structured topic-list concerning patients' enabling and predisposing factors to participate, and physicians' responses guided the interviews. Interviews were recorded, transcribed verbatim, and transcripts were analyzed using the constant comparison method described in Grounded Theory. Regarding Turkish-Dutch patients' enabling factors to participate, two perceptions of barriers were identified: (i) low Dutch language proficiency; (ii) a preference for an indirect communication style. Three perceptions of barriers to Turkish-Dutch patients' predisposition to participate were identified: (i) collectivistic values; (ii) power distance; (iii) uncertainty avoidance. Regarding doctors' responses, discrimination was identified among Turkish-Dutch patients as a perception of barrier to their patients' participation. None of these perceptions of barriers emerged among indigenous Dutch patients. This study contributes to our understanding of which perceptions of barriers might impede ethnic minority patients' level of patient participation. To enhance their participation, a combined intervention is needed, tackling the language barrier, raising awareness about cultural differences in values, and increasing doctors' cultural competencies to communicate adequately with ethnic minority patients.

Universal or Targeted Antenatal Care for Immigrant Women? Mapping and Qualitative Analysis of Practices in Denmark

Inequity in immigrants' health during pregnancy and childbirth has been shown. We studied the Danish regional organization of public midwifery-based antenatal care (ANC) for immigrant women to assess the strengths and weaknesses of organizing ANC as either universal or immigrant-targeted. A telephone survey in 2012 to all the Danish maternity wards (n = 20) was conducted. Semi-structured interviews with midwives providing targeted care (n = 6) were undertaken and characteristics of care were qualitatively analyzed, having the immigrant density of the facilities, the Danish ANC policy, and theories of cultural competence as the frame of reference. Six maternity wards were providing immigrant-targeted ANC. Targeted care implied longer consultations and increased attention to the individual needs of immigrant women. At these facilities, navigation in the health care system, body awareness, and use of interpreter services were key topics. The selection of women for targeted care was based on criteria (including names) that risk stigmatizing immigrant women. The arguments for not providing targeted care included that immigrant-targeted care was considered stigmatizing. Current universal care may overlook the needs of immigrant women and contribute to inequities. A strategy could be to improve dynamic cultural competencies of midwives, interpreter services, and flexibility of the care provision of the universal ANC system.

The Right to Accessible and Acceptable Healthcare Services. Negotiating Rules and Solutions With Members of Ethnocultural Minorities

The right to health implies, among other things, that individuals and communities must be allowed to have a voice in decisions concerning the definition of their well-being. The article argues for a more active participation of ethnocultural minorities in healthcare decisions and highlights the relevance of strategies aimed at creating a bottom-up engagement of people and groups, as well as of measures aimed at a broader organizational flexibility, in order to meet migrants' and minorities' needs. Finally, the article clarifies that these strategies are not simply the outcome of a welcoming attitude of the Western healthcare system but may be interpreted as a specific duty resulting from the notion of "particularly vulnerable groups," as formulated by the ECtHR in its case law: when vulnerable groups are at stake, every decision about state actions and rules regarding healthcare should start from an a consideration of the specific conditions and needs of people belonging to vulnerable minority groups.

Living with Diabetes: Personal Interviews with Pakistani Women in Norway

The prevalence of Type 2 diabetes (T2D) among Pakistani women in Norway is remarkably high. This study aims to assess how they live with the disease and their response to lifestyle and medical information. 120 Pakistani women living in Norway (mean age: 55.7 years) were personally interviewed about their T2D using a structured questionnaire (response rate: 95%). The participants were first-generation immigrants (mean residence time: 28.7 years) of whom 27% were illiterates. Poor health was reported by one-third, and 71% had developed macrovascular comorbidities. A majority reported physical inactivity and an unhealthy diet included religious fasting. One-third was not able to self-measure their blood glucose. There was a great variation in antidiabetic drug regimens and one-fourth had to use insulin in addition to tablets. Pakistani women in Norway showed suboptimal control of their T2D in terms of lifestyle habits, comorbidities and drug use. Low literacy and cultural factors seem to challenge adherence to lifestyle and medical information.

Health related outcomes among people with type 2 diabetes by country of birth: Result from the 45 and Up Study

BACKGROUND

Ethnic variation in the occurrence of type 2 diabetes, complications, mortality, and health behaviours has been reported. The current research examined patterns of health-related outcomes by country of birth in people with diabetes aged 45years and over in New South Wales, Australia.

METHODS

This study was based on the baseline data of 266,848 participants aged 45years and over from "The Sax Institute's 45 and Up Study" (2006-2009), NSW; Australia's most populous state. Health-related factors including self-rated overall health, Quality of Life (QoL), eyesight, subjective memory complaint, hearing loss, psychological distress and functional limitation were examined according to country of birth among 23,112 people with type 2 diabetes. Logistic regression modelling was used to compare the odds of poor outcomes between Australian-born and overseas-born participants, adjusting for potential confounding and mediating variables. Both age-sex and fully adjusted odds ratios (aORs) are reported.

RESULTS

Nearly half of the people with diabetes in the sample reported hearing loss and high levels of functional limitations, a third reported poor overall health. Compared to people with diabetes born in Australia, people born in South East Europe, North Africa, the Middle East had significantly greater odds of poor outcomes across the majority of examined health-related factors, with the largest odds observed in the elevated level of psychological distress outcome (aOR=3.4 in North African and the Middle East group). Higher aORs of poor overall health, QoL, memory problems and poor eyesight, and lower aORs for hearing loss, were also found among those born in the Asian countries.

CONCLUSIONS

The results demonstrated significant ethnic disparity in the prevalence of health-related outcomes. These findings provide important context for the formulation of culturally sensitive secondary prevention strategies.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research

Background

Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period.

Methods

We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background.

Results

From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems’ responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women’s needs. The ‘respect for persons’ domains ‘autonomy’, ‘communication’ and ‘dignity’ and the ‘client orientation’ domain ‘prompt attention’ were judged most negatively.

Conclusions

The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women’s population.

Trust and Perceptions of Physicians' Nonverbal Behavior Among Women with Immigrant Backgrounds

Previous findings suggest immigrant patients have lower trust in their physicians, and perceive nonverbal communication differently compared to non-immigrant patients. We tested discrepancies in trust and the impact of non-verbal behavior between immigrants and non-immigrants in The Netherlands. Nonverbal communication of an oncologist was systematically varied in an experimental video vignettes design. Breast cancer patients (n = 34) and healthy women (n = 34) viewed one of eight video versions and evaluated trust and perceived friendliness of the oncologist. In a matched control design, women with immigrant and non-immigrant backgrounds were paired. Immigrant women reported stronger trust. Nonverbal communication by the oncologist did not influence trust differently for immigrants compared to for non-immigrants. However, smiling strongly enhanced perceived friendliness for non-immigrants, but not for immigrants. Immigrant patients' strong trust levels may be formed a priori, instead of based on physicians' communication. Physicians may need to make extra efforts to optimize their communication.

Culturally Competent Practice: A Mixed Methods Study Among Students, Academics and Alumni of Clinical Psychology Master's Programs in the Netherlands

This is the first research into preparation for multicultural clinical psychology practice in Europe. It applies the theory of multicultural counselling competency (MCC) to a case study in the Netherlands. It was hypothesized that cross-cultural practice experience, identification as a cultural minority, and satisfaction with cultural training was associated with MCC. The Multicultural Awareness Knowledge and Skills Survey was completed by 106 participants (22 students, 10 academics, 74 alumni) from clinical psychology masters’ programs. MANOVA detected a main effect of cross-cultural experience on MCC for all groups and universities. The data were enriched with exploratory qualitative data from 14 interviews (5 students, 5 academics, 4 alumni). Interpretative Phenomenological Analysis revealed three themes: limitations of clinical psychology, strategies for culturally competent practice, and strategies for cultural competency development. These outcomes suggest that cultural competency continues to require attention in master’s programs. The paper makes recommendations for further research enquiry related to training clinical psychologists to practice in Europe’s multicultural societies.

General Practitioners' experiences of asthma management in culturally and linguistically diverse populations

OBJECTIVE

The purpose of this study was to explore General Practitioners' experiences and perspectives about asthma management of culturally and linguistically diverse (CALD) people with asthma, particularly with reference to Arabic-speaking patients with low English proficiency (LEP).

METHODS

Semi-structured interviews guided by an interview protocol were conducted with general practitioners who deal with CALD patients with asthma. Participants were recruited from medical practices in Melbourne, Australia. Interviews were recorded and transcribed verbatim, followed by an inductive thematic analysis.

RESULTS

Data saturation was achieved after 21 interviews. Interviews lasted on average 30 minutes. Thematic analyses of the interview transcripts highlighted five key emergent themes: self-autonomy, language issues, accessibility and engagement, health literacy, and cultural/beliefs issues. Many participants highlighted that CALD patients do not self-manage their asthma. Miscommunication was mentioned by some participants as stemming from language barriers. Patients' difficulty in engagement with the health system, lower accessibility to health care, social isolation, and non-acclimatization were other issues participants highlighted as problems in providing effective asthma care to CALD patients. Participants reported finding it more difficult to treat CALD patients with asthma compared to local patients.

CONCLUSION

General practitioners perceived that treating culturally and linguistically diverse patients with asthma is difficult and many key barriers were observed to affect treatment. Cultural competence training for health professionals, as well as improving asthma and health system awareness in CALD patients with asthma and their carers, are key interventions that may address asthma management gaps in CALD patients.

Prevalence and management of diabetes in immigrants resident in the Lombardy Region: the importance of ethnicity and duration of stay

AIMS

To describe the prevalence and management of diabetes among immigrants according to ethnic group and duration of stay, compared to Italian citizens.

METHODS

Diabetic immigrant and Italian residents aged 20-69 years in the administrative database of the Lombardy Region. Immigrants were classified by region of origin and as long-term residents (LTR) and short-term residents (STR). Age- and sex-adjusted prevalence and indicators of diabetes management were calculated for immigrants by region of origin and by length of stay using Cox proportional models.

RESULTS

In 2010 19,992 immigrants (mean age 49.1 ± 10.8, 53.7% males) and 195,049 Italians (mean age 58.7 ± 9.3, 61.1 males) with diabetes were identified. Immigrants had a higher adjusted diabetes prevalence than Italians (OR 1.48; 95% CI 1.45-1.50). STR received significantly fewer recommended cardiovascular drugs (antiplatelets, statins and ACE-inhibitors/ARBs) than Italians, although prescription was higher among LTR from some ethnic groups. Immigrants were less likely to be seen by a diabetologist and to do at least one HbA1c test per year. Although the recommended tests/visits were more often done for the LTR than the STR, in the majority of ethnic groups these indicators were still far from optimal.

CONCLUSION

The prevalence and management of diabetes differ between immigrants and Italians, although some improvement can be seen among LTR.

How family physicians respond to unpleasant emotions of ethnic minority patients

OBJECTIVE

The diversity in our society makes patient-centered care more difficult. In this study, we aim to describe how family physicians respond to unpleasant emotions of ethnic minority patients.

METHODS

One hundred ninety one consultations of family physicians with ethnic minority patients were video-recorded and analyzed using the Verona Codes for Provider Responses (VR-CoDES-P) to describe physicians' responses to patients' expressed unpleasant emotions or cues (implicit) and concerns (explicit).

RESULTS

42.4% (n=81) of all the consultations contained no cues or concerns, and thus no physician responses. Of the consultations containing at least one cue or concern, a mean of 3.45 cues and a mean of 1.82 concerns per consultation were found. Physicians are significantly (p≤0.001) more frequently stimulating further disclosure of patients' cues and concerns (providing space: n=339/494 or 68.6% versus reducing space: n=155/494 or 31.4%). However, these explorations are more often about the factual, medical content of the cue than about the emotion itself (n=110/494 or 22.3% versus n=79/494 or 16%). The inter-physician variation in response to patients' cues is larger than the variation in response to the patient's concerns.

CONCLUSIONS

Although family physicians are quite often providing room for patients' emotions, there is much room for improvement when it comes to explicitly talking about emotional issues with patients.

PRACTICE IMPLICATIONS

Further research should focus on a more qualitative in-depth analysis of the complex interplay between culture and language of ethnic minority patients in primary care and, consequently, create awareness among these healthcare providers about the importance of ethnic minority patients' emotions and how to respond accordingly.

Safe and ethical living kidney donation in Qatar: A national health system's approach

The increasing incidence of end-stage kidney disease in Qatar has led to growing demand for donor kidneys. The deceased donor kidney program has yet to achieve its full potential; hence, living kidney donation has been widely adopted as an appropriate alternative. The reliance on living kidney donors however, raises a number of social, ethical, and legal concerns surrounding informed consent, voluntarism, psychosocial evaluation, perioperative care, and long-term follow-up of living kidney donors. Many of these concerns become heightened in a multicultural, multilingual society within a Gulf country such as Qatar. This article provides an insight into the challenges that living kidney donation poses in a multiethnic society with significant socioeconomic divides. It also discusses the remedial measures that the Qatari government, healthcare authorities, and transplant community have adopted to address these issues.

Has the quality of health care for the immigrant population changed during the economic crisis in Catalonia (Spain)? Opinions of health professionals and immigrant users

OBJECTIVE

To analyse changes in health professionals' and immigrant users' perceptions of the quality of care provided to the immigrant population during the crisis.

METHODS

A qualitative descriptive-interpretative and exploratory study was conducted in two areas of Catalonia. Semi-structured individual interviews were used with a theoretical sample of medical (n=24) and administrative (n=10) professionals in primary care (PC) and secondary care (SC), and immigrant users (n=20). Thematic analysis was conducted and the results were triangulated.

RESULTS

Problems related to technical and interpersonal quality emerged from the discourse of both professionals and immigrants. These problems were attributed to cutbacks during the economic crisis. Regarding technical quality, respondents reported an increase in erroneous or non-specific diagnoses, inappropriate use of diagnostic tests and non-specific treatments, due to reduction in consultation times as a result of cuts in human resources. With regard to interpersonal quality, professionals reported less empathy, and users also reported worse communication, due to changes in professionals' working conditions and users' attitudes. Finally, a reduction in the resolution capacity of the health services emerged: professionals described unnecessary repeated PC visits and limited responses in SC, while young immigrants reported an insufficient response to their health problems.

CONCLUSION

The results indicate a deterioration in perceived technical and interpersonal quality during the economic crisis, due to cutbacks mainly in human resources. These changes affect the whole population, but especially immigrants.

Knowledge and utilization of sexual and reproductive healthcare services among Thai immigrant women in Sweden

Background

Migration from Thailand to Sweden has increased threefold over the last 10 years. Today Thailand is one of the most common countries of origin among immigrants in Sweden. Since the year 2000, new HIV cases are also more prevalent among Thai immigrants compared to other immigrant nationalities in Sweden. The purpose of this study was to investigate the association between knowledge and utilization of sexual and reproductive healthcare services, contraceptive knowledge and socio-demographic characteristics and social capital among Thai immigrant women in Sweden.

Methods

This is a cross-sectional study using a postal questionnaire to all Thai women (18–64) in two Swedish regions, who immigrated to the country between 2006 and 2011. The questionnaire was answered by 804 women (response rate 62.3 %). Bivariate and multivariate logistic regression analyses were used.

Results

The majority (52.1 %) of Thai women had poor knowledge of where they should turn when they need sexual and reproductive healthcare services. After controlling for potential confounders, living without a partner (OR = 2.02, CI: 1.16–3.54), having low trust in others (OR = 1.61, CI: 1.10–2.35), having predominantly bonding social capital (OR = 1.50, CI: 1.02–2.23) and belonging to the oldest age group (OR = 2.65, CI: 1.32–5.29) were identified as risk factors for having poor knowledge. The majority (56.7 %) had never been in contact with healthcare services to get advice on contraception, and about 75 % had never been HIV/STI tested in Sweden. Low utilization of healthcare was associated with poor knowledge about healthcare services (OR = 6.07, CI: 3.94–9.34) and living without a partner (OR = 2.53, CI: 1.30–4.90). Most Thai women had knowledge of how to prevent an unwanted pregnancy (91.6 %) and infection with HIV/STI (91.1 %).

Conclusions

The findings indicate that social capital factors such as high trust in others and predominantly bridging social capital promote access to knowledge about healthcare services.

However, only one-fourth of the women had been HIV/STI tested, and due to the HIV prevalence among Thai immigrants in Sweden, policy makers and health professionals need to include Thai immigrants in planning health promotion efforts and healthcare interventions.

How do medical specialists value their own intercultural communication behaviour? A reflective practice study

BACKGROUND

Intercultural communication behaviour of doctors with patients requires specific intercultural communication skills, which do not seem structurally implemented in medical education. It is unclear what motivates doctors to apply intercultural communication skills. We investigated how purposefully medical specialists think they practise intercultural communication and how they reflect on their own communication behaviour.

METHODS

Using reflective practice, 17 medical specialists independently watched two fragments of videotapes of their own outpatient consultations: one with a native patient and one with a non-native patient. They were asked to reflect on their own communication and on challenges they experience in intercultural communication. The interviews were open coded and analysed using thematic network analysis.

RESULTS

The participants experienced only little differences in their communication with native and non-native patients. They mainly mentioned generic communication skills, such as listening and checking if the patient understood. Many participants experienced their communication with non-native patients positively. The participants mentioned critical incidences of intercultural communication: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere.

CONCLUSION

Despite extensive experience in intercultural communication, the participants of this study noticed hardly any differences between their own communication behaviour with native and non-native patients. This could mean that they are unaware that consultations with non-native patients might cause them to communicate differently than with native patients. The reason for this could be that medical specialists lack the skills to reflect on the process of the communication. The participants focused on their generic communication skills rather than on specific intercultural communication skills, which could either indicate their lack of awareness, or demonstrate that practicing generic communication is more important than applying specific intercultural communication. They mentioned well-known critical incidences of ICC: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. Nevertheless, they showed a remarkably enthusiastic attitude overall was noteworthy. A strategy to make doctors more aware of their intercultural communication behaviour could be a combination of experiential learning and ICC training, for example a module with reflective practice.

Geographical, Ethnic and Socio-Economic Differences in Utilization of Obstetric Care in the Netherlands

Background

All women in the Netherlands should have equal access to obstetric care. However, utilization of care is shaped by demand and supply factors. Demand is increased in high risk groups (non-Western women, low socio-economic status (SES)), and supply is influenced by availability of hospital facilities (hospital density). To explore the dynamics of obstetric care utilization we investigated the joint association of hospital density and individual characteristics with prototype obstetric interventions.

Methods

A logistic multi-level model was fitted on retrospective data from the Netherlands Perinatal Registry (years 2000–2008, 1.532.441 singleton pregnancies). In this analysis, the first level comprised individual maternal characteristics, the second of neighbourhood SES and hospital density. The four outcome variables were: referral during pregnancy, elective caesarean section (term and post-term breech pregnancies), induction of labour (term and post-term pregnancies), and birth setting in assumed low-risk pregnancies.

Results

Higher hospital density is not associated with more obstetric interventions. Adjusted for maternal characteristics and hospital density, living in low SES neighbourhoods, and non-Western ethnicity were generally associated with a lower probability of interventions. For example, non-Western women had considerably lower odds for induction of labour in all geographical areas, with strongest effects in the more rural areas (non-Western women: OR 0.78, 95% CI 0.77–0.80, p<0.001).

Conclusion

Our results suggest inequalities in obstetric care utilization in the Netherlands, and more specifically a relative underservice to the deprived, independent of level of supply.

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases (NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a PubMed search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Does Media Use Result in More Active Communicators? Differences Between Native Dutch and Turkish-Dutch Patients in Information-Seeking Behavior and Participation During Consultations With General Practitioners

This study investigates differences between native Dutch and Turkish-Dutch patients with respect to media usage before and patient participation during medical consultations with general practitioners. In addition, the authors assessed the relation between patient participation and communication outcomes. The patients were recruited in the waiting rooms of general practitioners, and 191 patients (117 native Dutch, 74 Turkish-Dutch) completed pre- and postconsultation questionnaires. Of this sample, 120 patients (62.8%; 82 native Dutch, 38 Turkish-Dutch) agreed to have their consultations recorded to measure patient participation. Compared with Turkish-Dutch patients of similar educational levels, results showed that native Dutch patients used different media to search for information, participated to a greater extent during their consultations and were more responsive to their general practitioner. With respect to the Turkish-Dutch patients, media usage was related to increased patient participation, which was correlated with having fewer unfulfilled information needs; however, these relations were not found in the native Dutch patient sample. In conclusion, interventions that enhance participation among ethnic minority patients will better fulfill informational needs when such interventions stimulate information-seeking behavior in that group before a medical consultation.

'I still have no idea why this patient was here': An exploration of the difficulties GP trainees experience when gathering information

OBJECTIVE

Collecting information during patient encounters is essential for the delivery of patient-centered care. To obtain insight into areas that require more attention in medical communication training, this study explores what difficulties GP trainees encounter when gathering information.

METHODS

In this phenomenological study, we observed a morning clinic of 15 GP trainees. To explore trainees' experiences with information-gathering, we held brief interviews after every consultation and a lengthier interview directly after the morning clinic. The resulting data were analyzed using template analysis.

RESULTS

From trainees' reflections, we distilled five difficulties that trainees experience when gathering information: (1) Goal conflicts; (2) Ineffectiveness of trained communication skills in specific situations; (3) Trainees' distress hampers open communication; (4) Untrustworthy information; (5) Tunnel vision.

CONCLUSION

Information-gathering is difficult for GP trainees. Current generic communication skills training does not seem to support trainees sufficiently to handle effectively the challenges they encounter during consultations.

PRACTICE IMPLICATIONS

Medical communication training needs to support trainees in handling their goal-conflicts and feelings that hamper information-gathering, while also providing them with communication strategies adapted to handling specific challenging situations.

Factors influencing intercultural doctor-patient communication: a realist review

OBJECTIVE

Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works.

METHODS

A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication.

RESULTS

In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training.

CONCLUSION

The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication.

PRACTICE IMPLICATIONS

Training for improving ICC can be developed as an extension of the existing training for patient-centered communication.

Language barriers and patient safety risks in hospital care. A mixed methods study

INTRODUCTION

A language barrier has been shown to be a threat for quality of hospital care. International studies highlighted a lack of adequate noticing, reporting, and bridging of a language barrier. However, studies on the link between language proficiency and patient safety are scarce, especially in Europe. The present study investigates patient safety risks due to language barriers during hospitalization, and the way language barriers are detected, reported, and bridged in Dutch hospital care.

METHODS

We combined quantitative and qualitative methods in a sample of 576 ethnic minority patients who were hospitalized on 30 wards within four urban hospitals. The nursing and medical records of 17 hospital admissions of patients with language barriers were qualitatively analyzed, and complemented by 12 in-depth interviews with care providers and patients and/or their relatives to identify patient safety risks during hospitalization. The medical records of all 576 patients were screened for language barrier reports. The results were compared to patients' self-reported Dutch language proficiency. The policies of wards regarding bridging language barriers were compared with the reported use of interpreters in the medical records.

RESULTS

Situations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient-physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were hardly used.

DISCUSSION

The present study showed a wide variety of risky situations in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier, which, in the first place, demands adequate detecting and reporting of a language barrier. This is currently not sufficiently done in most Dutch hospitals. Moreover, new solutions to bridge language barriers are needed for situations such as routine safety checks performed by nurses, in which a professional or even informal interpreter is not feasible.

Turkish migrant GP patients' expression of emotional cues and concerns in encounters with and without informal interpreters

OBJECTIVE

The aim of this study was to compare patients' expressions of emotional cues and concerns, and GPs' responses during consultations with and without informal interpreters. Furthermore, informal interpreters' expression of emotional cues and concerns and their responses were examined too.

METHODS

Twenty-two audiotaped medical encounters with Turkish migrant patients, eleven with and eleven without an informal interpreter, were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (VR-CoDES-P).

RESULTS

In encounters with informal interpreters, patients expressed less emotional concerns than in encounters without informal interpreters. Only half of all patients' cues is being translated by the informal interpreter to the GP. Furthermore, 20% of all cues in encounters with informal interpreters is being expressed by the interpreter, independent of patients' expression of emotions.

CONCLUSION

The presence of an informal interpreter decreases the amount of patients' expression of emotional concerns and cues. Furthermore, a substantial amount of cues is being expressed by the informal interpreter, corroborating the often-made observation that they are active participants in triadic medical encounters.

PRACTICE IMPLICATIONS

GPs should be trained in communication strategies that enable elicitation of migrant patients' emotions, in particular in encounters with informal interpreters.

Under-treatment of migrants with diabetes in a universalistic health care system: the ARNO Observatory

AIMS

To assess whereas prevalence, treatment and direct costs of drug-treated diabetes were similar in migrants and in people of Italian citizenship under the universalistic Italian health care system.

METHODS AND RESULTS

Drug-treated diabetic individuals were identified in the population-based multiregional ARNO Observatory on the basis of 2010 prescriptions. Migrants were identified by the country-of-birth code on the fiscal identification code. Diabetes prevalence was calculated for Italians (n = 7,328,383) and migrants (n = 527,965). To assess the odds of migrants of having diabetes compared to Italians, we individually matched all migrants to Italians for major confounders (age, sex and place of residence). Finally, all migrants with diabetes were individually matched for confounders to Italians with diabetes to compare prescriptions, hospitalization rates, services use and direct costs for the National Health System. We identified 368,797 subjects with diabetes among Italians and 10,336 among migrants, giving prevalence of 5.03% and 1.96%, respectively. Migrants with diabetes were younger than Italians (52 ± 13 years vs. 68 ± 14 years, P < 0.001); after matching, their risk of disease was higher (odds ratio, 1.55, 95% confidence interval, 1.50-1.60). The total cost was 27% lower in migrants, due to lower cost of drugs (-29%), hospital admission (-27%) and health services (-22%). The number of packages/treated person-year of all glucose-lowering drugs was also lower in migrants (-15%) (P < 0.001).

CONCLUSIONS

Compared to subjects of Italian ancestry, migrants to Italy show a higher risk of diabetes but less intense treatment. Inequalities in health care use are likely and are maintained also in a universalistic system.

Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices

Background

Patient-provider communication, in particular physicians’ ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care.

Method

We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members).

Results

Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members’ questions or requests for information. Patients’ participation in the consultation was minimal, and limited to brief answers to clinicians’ questions.

Conclusions

Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

Perceived barriers to initiating and maintaining physical activity among South Asian and White British adults in their 60s living in the United Kingdom: a qualitative study

OBJECTIVE

To explore the barriers to initiating and maintaining regular physical activity (PA) among UK Indian, Pakistani and White British adults in their 60s.

DESIGN

An exploratory qualitative approach was utilised using 15 focus groups and 40 in-depth interviews. Purposive sampling was used to recruit participants with different experiences of participation or non-participation in PA.

RESULTS

Misunderstandings about the value of exercise in later life, particularly for those with ongoing healthcare problems, were identified in UK South Asian and White British older adults' accounts of their experience of the barriers to initiating and maintaining regular PA. Both groups and genders said that PA could exacerbate pre-existing health problems and result in physical harm. Although most beliefs were similar to those of the White British, ethnic-specific factors, such as language barriers, religious beliefs and cultural practices could act as additional barriers to undertaking and maintaining PA among UK South Asian older adults.

CONCLUSIONS AND IMPLICATIONS

Understanding the multiple levels of influence on older adults' PA behaviour can provide the basis for developing comprehensive approaches to health promotion initiatives aimed at increasing PA levels. Healthcare providers need to understand the characteristics and specific barriers faced by these groups of older adults; work with older people from these groups to develop culturally appropriate PA programmes and address the misunderstandings and misconceptions about the value of exercise in later-life, particularly in those with ongoing health problems.

Communication in cross-cultural consultations in primary care in Europe: the case for improvement. The rationale for the RESTORE FP 7 project

The purpose of this paper is to substantiate the importance of research about barriers and levers to the implementation of supports for cross-cultural communication in primary care settings in Europe. After an overview of migrant health issues, with the focus on communication in cross-cultural consultations in primary care and the importance of language barriers, we highlight the fact that there are serious problems in routine practice that persist over time and across different European settings. Language and cultural barriers hamper communication in consultations between doctors and migrants, with a range of negative effects including poorer compliance and a greater propensity to access emergency services. It is well established that there is a need for skilled interpreters and for professionals who are culturally competent to address this problem. A range of professional guidelines and training initiatives exist that support the communication in cross-cultural consultations in primary care. However, these are commonly not implemented in daily practice. It is as yet unknown why professionals do not accept or implement these guidelines and interventions, or under what circumstances they would do so. A new study involving six European countries, RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings), aims to address these gaps in knowledge. It uses a unique combination of a contemporary social theory, normalisation process theory (NPT) and participatory learning and action (PLA) research. This should enhance understanding of the levers and barriers to implementation, as well as providing stakeholders, with the opportunity to generate creative solutions to problems experienced with the implementation of such interventions.

A first approach to differences in continuity of care perceived by immigrants and natives in the Catalan public healthcare system

Objective: To compare immigrants’ and natives’ perceptions of relational, managerial and informational continuity of care and to explore the influence of the length of stay on immigrants’ perceptions of continuity. Methods: Cross-sectional study based on a survey of a random sample of 1,500 patients, of which 22% (331) were immigrants. The study area was made up by three healthcare areas of the Catalan healthcare system. To collect data, the CCAENA questionnaire was applied. Multivariate logistic regression models were conducted. Results: Like natives, immigrants perceive high levels of managerial continuity (88.5%) and relational continuity with primary and secondary care physicians (86.7 and 81.8%), and lower levels of informational continuity (59.1%). There were no statistically significant differences in managerial and informational continuity between immigrants and natives. However, immigrants perceive a worse relational continuity with primary care physicians in terms of trust, communication and clinical responsibility. Conversely, immigrants perceive higher relational continuity with secondary care physicians in terms of effective communication and clinical responsibility. Discussion: Similar managerial and informational continuity perceptions seem to point towards a similar treatment of patients, regardless of their immigrant status. However, differences in relational continuity highlight the need for improvements in professionals’ skills in treating immigrants’ patients.

A rasch model to test the cross-cultural validity in the positive and negative syndrome scale (PANSS) across six geo-cultural groups

Background

The objective of this study was to examine the cross-cultural differences of the PANSS across six geo-cultural regions. The specific aims are (1) to examine measurement properties of the PANSS; and (2) to examine how each of the 30 items function across geo-cultural regions.

Methods

Data was obtained for 1,169 raters from 6 different regions: Eastern Asia (n = 202), India (n = 185), Northern Europe (n = 126), Russia & Ukraine (n = 197), Southern Europe (n = 162), United States (n = 297). A principle components analysis assessed unidimensionality of the subscales. Rasch rating scale analysis examined cross-cultural differences among each item of the PANSS.

Results

Lower item values reflects items in which raters often showed less variation in the scores; higher item values reflects items with more variation in the scores. Positive Subscale: Most regions found item P5 (Excitement) to be the most difficult item to score. Items varied in severity from −0.93 [item P6. Suspiciousness/persecution (USA) to 0.69 item P4. Excitement (Eastern Asia)]. Item P3 (Hallucinatory Behavior) was the easiest item to score for all geographical regions. Negative Subscale: The most difficult item to score for all regions is N7 (Stereotyped Thinking) with India showing the most difficulty Δ = 0.69, and Northern Europe and the United States showing the least difficulty Δ = 0.21, each. The second most difficult item for raters to score was N1 (Blunted Affect) for most countries including Southern Europe (Δ = 0.30), Eastern Asia (Δ = 0.28), Russia & Ukraine (Δ = 0.22) and India (Δ = 0.10). General Psychopathology: The most difficult item for raters to score for all regions is G4 (Tension) with difficulty levels ranging from Δ = 1.38 (India) to Δ = 0.72.

Conclusions

There were significant differences in response to a number of items on the PANSS, possibly caused by a lack of equivalence between the original and translated versions, cultural differences among interpretation of items or scoring parameters. Knowing which items are problematic for various cultures can help guide PANSS training and make training specialized for specific geographical regions.