After encounters: revealing patients’ unseen work through their pathways to care

Mechanisms and attitudes in responsive healthcare for forced migrant communities: a qualitative study of transnational practice

OBJECTIVES

To understand the opportunities and practices that can support responsive healthcare for forced migrant communities.

DESIGN

A qualitative study of five transnational case examples of services actively working to improve access and experiences of care for forced migrant communities, which is one strand of the MORRA Study.

SETTING

Five services (Australia, Belgium, UK) providing a range of care (primary care, health advocacy, education and support, holistic health screening, care planning/coordination, transcultural mental healthcare). Delivered through state and not-for-profit structures in initial and contingency accommodation sites, health clinics and community spaces. Data collection took place between July and October 2022.

PARTICIPANTS

47 participants including forced migrants using or having used one of the five services, service leads, clinical and non-clinical workers (paid and volunteer), interpreters and service partners. Services supported recruitment of a crude representative sample of worker roles and service users/clients. Participants were required to speak one of nine languages for which we had translated study materials.

MAIN OUTCOME MEASURES

Experiences, practices, knowledges, skills and attributes of workers; experiences of forced migrants engaging in services.

RESULTS

Services showed a willingness to innovate and work outside existing practice and organisational structures, including a 'microflexibility' in their interactions with patients, and through the creation of safe spaces that encouraged trust in providers. Other positive behaviours included engaging in intercultural exchange; facilitating the connection of people with their cultural sphere (eg, nationality, language) and a reflexive attitude to the individual and their broader circumstances. Social and political structures can diminish these efforts.

CONCLUSIONS

Environments that enable good health and support forced migrants to live lives of meaning are vital components of responsive care. This requires flexibility and reflexivity in practice, intercultural exchange, humility, and a commitment to communication. A broader range of caring practitioners can, and should, through intentional and interconnected communities of care, contribute to the healthcare of forced migrants. Opening up healthcare systems to include other state actors such as teachers and settlement workers and a range of non-state actors that should include community leaders and peers and private players is a key step in this process. Future work should focus on the health and health service implications of immigration practices; the inclusion of peers in a range of healthcare roles; alliance-building across unlikely collaborators and the embedding of intercultural exchange in practice.

Listening, learning, caring: exploring assemblages of, ethics of and pathways to care for avoidant restrictive food intake disorder (ARFID)

Care has been theorised in relationship to eating disorders as a central consideration across diagnoses. In the context of avoidant restrictive food intake disorder (ARFID) specifically, there is room to further develop the nuances around layers of care involved in working towards well-being. In this paper, we engage with the stories of 14 caregivers of people with ARFID, exploring their pathways to care (or lack thereof) through the healthcare system in Aotearoa New Zealand. We explore the material, affective and relational aspects of care and care-seeking, engaging with the power and politics of care as it flows through care-seeking assemblages. Using postqualitative methods of analysis, we discuss how while participants were seeking care, they received (or, at times, did not receive) treatment, and unpack how care and treatment are not always synonymous. We work up extracts from parents' stories surrounding their caring for their children and how their actions were, at times, interpreted in ways that made them feel blame and shame rather than care. Participants' stories also offer glimmers of care within a resource-strapped healthcare system, which invite us to consider the potentiality of a relational ethics of care as an assemblage-shifting moment.

Getting airtime: Exploring how patients shape the stories they tell health practitioners

INTRODUCTION

Effective communication during health encounters is known to decrease patient complaints, increase patient adherence and optimise health outcomes. While the aim of patient-centred care is to find common ground, health practitioners tend to drive the encounter, often interrupting patients within the first minute of the clinical conversation. Optimal care for people with chronic illnesses requires individuals to interact with health practitioners regarding their health concerns, but given these constraints, we know little about how patients strategise conversations with their care providers. This understanding may further our efforts to educate health practitioners and trainees to learn and practice patient-centred care.

METHODS

A constructivist grounded theory approach with iterative data collection and analysis was used to explore the processes patients use to present and shape their stories for interactions with health practitioners. Twenty-one patients (n = 16 female; 5 male) representing a variety of chronic illnesses participated in semi-structured interviews. Using the constant comparative method of analysis, salient themes were ascertained.

RESULTS

Patients engage in extensive strategic preparations for productive health encounters. From the data, we identified four related elements comprising patients' process of planning, preparing, and strategising for health encounters: deciding to go, organising to get airtime, rehearsing a game plan, and anticipating external forces. By focusing on the extensive preparatory work patients engage in, our study expands the dimensions of how we understand illness-related work. Assembling personal health information, gathering disease information and achieving equanimity represent the dimensions of this 'health interaction work'.

CONCLUSION

The work patients engage in for health encounters is noteworthy yet often invisible. And work that is unseen may also be undervalued. Acknowledging, illuminating and valuing patients' preparatory work for health encounters add to how we understand patient-centred care, and this offers new targets for us to effectively teach and deliver it.