The Language Barrier in Primary Care:
Perspectives of Refugees and Asylum
Seekers
Department of General Practice
Health Services Research Seminar
December 13th 2005
Anne MacFarlane, Department of General Practice, NUI, Galway
Unprecedented Patterns of Migration
Anne MacFarlane, Department of General Practice, HSR Seminar December, 13 th 2005
Research about Refugee and Asylum
Seeker Health
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Language differences, communication
difficulties
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Refugees, asylum seekers, services
providers (primary and secondary care)
Use of interpreters
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Formal interpreters (telephone/face to face
interpreting)
Informal interpreters (Friends and relatives)
Anne MacFarlane, Department of General Practice, HSR Seminar December, 13th 2005
Communication Matters
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General Practice and nursing
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Biopsychosocial model of health
Participation of patients
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Patient agenda
Patient narratives
Shared decision making
Anne MacFarlane, Department of General Practice, HSR Seminar December, 13th 2005
CARe Communication with Asylum
Seekers and Refugees

Conduct an in-depth exploration of the impact
of language as a barrier in primary care
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Document experiences of refugees, asylum
seekers & primary care providers
Identify key features of the language barrier
and its impact
Explore solutions and strategies for service
development and improvement
Anne MacFarlane, Department of General Practice, HSR Seminar December, 13th 2005
Perspectives of Refugees and Asylum
Seekers

Aim is to document experiences of refugees
and asylum who have experience of
accessing and using primary care with little or
no English
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Research Approach
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Participatory Learning and Action (PLA)
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More radical form of organisational action
research
Derived from Participatory Rural Appraisal
(Chambers, 1994c)

“growing family of approaches and methods that enable
local people to share, enhance and analyse their
knowledge of life and conditions, to plan and to act.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
PLA Key Characteristics
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Meaningful participation of community members;
acknowledging local expertise
Focus on concrete actions arising out of data
collection
Equal relationship between the ‘researcher’ and
the ‘researched’
Doing research ‘with people’ rather than ‘on them’
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
PLA in action
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Inter-agency Partners
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HSE WA Health Promotion, Public Health
Community Representation
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Galway Refugee Support Group
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
PLA in action
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Core group for the research
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Croatian woman, Ukrainian man, two Russian women
and Nigerian woman

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Research planning – project name and logo, project
materials
PLA training to facilitate peer researcher model for data
collection and data analysis
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Methods: Sampling and Recruitment
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Purposeful sampling
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Ethnicity (Serb-Croat and Russian speaking
communities)
Gender (men and women)
26 participants
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16 women and 10 men
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10 asylum seekers,
6 refugees,
10 with residency on the basis of having Irish born
children
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Methods: Data Collection Topic Guide
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Research question
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“Tell me about people’s experiences of language
differences and communication difficulties with
GPs”
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Experiences of making appointments
Arriving at the surgery, place of consultation
Being in the consultation
What happens afterwards

Experiences with public health nurses and pharmacists
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Methods: Technique
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Emic card sort
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Qualitative data
‘Insider’ perspective
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Researcher elicits stories
Interviews them
Story broken down onto cards
Cards ‘sorted’ thematically by participant
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Methods: Emic Card Sort
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Story about daughter acting as an interpreter
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‘daughter interprets’
‘daughter interpreter absent from school’
‘daughter interpreter explains everything’
‘Sorted’ with cards about friend acting as
interpreter
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Methods: Co-analysis of Card Sorts
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Recording forms translated
Sharing of data
Manual analysis
Framework analysis
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Overview of Thematic Framework
GP ‘Attitude’
GPs & Interpreting
Responses
GP Competency
Strategies
Competency &
Communication
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Strategies for Approaching GPs
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Three main strategies
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Use of informal interpreters
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Friends or relatives, including children
Preparing with dictionaries, phrasebooks
Gestures and body language
Sense of agency among refugees and asylum
seekers to manage the language barrier in the
absence of an adequate structural supports in
general practice
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Children as informal interpreters
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B2, for instance, a woman aged 37 who is an asylum seeker,
married with two children had no English on arrival in Ireland
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daughter had very good English
made appointments for her and interpreted for her during GP
consultations
absent from school for up to one or two hours
This woman tried to attend GP consultations alone with sentences
learned by heart
….once she had told her GP these few sentences, she couldn’t ask
anything else and the consultation folded.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
English language ability of informal
interpreters
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B1 is an asylum seeker from Croatia married two children living in
direct provision. She had no English when she arrived in Ireland
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No Croatian speaking friends
informal interpreters was a friend from Czechoslovakia because there
was some similarity between their languages and they could understand
each other a little
inevitable misunderstandings during her GP consultations
….on one occasion her son who had diarrhoea was prescribed
medication for constipation
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
GPs’ Responses to Interpreters
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Mixed responses to informal interpreters
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sent away by GPs to find someone to interpret
friends or relatives turned away by GPs resistance
to informal interpreters
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Informal Interpreter as a ‘Complication’
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B3 a Croatian woman brought her friend along to interpret.
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Her friend did not have very good English but had better English that the
woman.
GP felt “friend was just complicating matters” …”understood enough”
…B3 emphasised that this view, even if accurate which it was not,
did not take into account that she did not have enough English to
ask questions of the GP or discuss her case with the GP in any
depth
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Formal Interpreting?
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Only 4 participants had ever used formal
telephone interpreters in general practice
No participant had access to formal
interpreter during the data collection period
Formal interpreting highly valued
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Requests to GPs turned down
Limits of formal interpreting
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Face to face versus telephone
Issues of training and professionalism
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Decisions about Interpreters
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There is a power differential at play whereby
decisions about the use of formal and informal
interpreters lie with general practitioners rather than
with refugees and asylum seekers.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
GP ‘Attitude’
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Z1 described a consultation where her doctor didn’t make any effort
to understand what she was trying to say. The GP “switched off”,
appeared annoyed and angry and started writing a prescription. Z1
stopped trying to explain herself, took the prescription offered and
left.
She emphasised how awful it was feeling that the GP wanted to
get rid of her.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Prescriptions and Treatments
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Being written before participant finished
Prescriptions for over the counter
medications (eg calpol)
Repeat prescriptions for on-going problems
Refused tests and investigations
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Attitudes and Language Differences
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Z6 felt that as soon as she opens her mouth, there is a negative
response because the GP realises that there is a language
difference. She does not feel attended to by her GP and feels that
her/his GP thinks he doesn’t have to explain anything to people with
little English
In her experience, the GP doesn’t like to be asked many
questions, pretends to be busy to “get rid of us”, frequently
writing a prescription to end the consultation.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Lack of English = less responsibility for
GPs?
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K2 believed that GPs do not feel responsible for patients
who do not speak English because the patient cannot
control or cross check the treatments that are being
given. In this way, GPs feels free to prescribe whatever they
wish, or to send patient away.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Lack of English = Lack of Intelligence?
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B4 felt strongly that GPs think people are less intelligent and stupid
if they have bad English.
GP openly shows that his lack of English irritates him, sneering
when he speaks English.
blood test but no result from GP
B4 explained that he had no energy for fighting or standing up
for himself; he felt humiliated and degraded.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Relevance of being a ‘foreigner’?
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D4 describes her GPs manner in their consultations as “superficially
pleasant, polite, well-mannered” but holds a strong perception that
he is indifferent.
an absence of true medical interest in her and engagement with her
There is no open racist attitude but, she does wonder whether
this underlies his behaviour and manner?
Communication is embedded in social relations…there are
significant racial and cultural dimensions at play
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Competencies
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B1 had a small child with bad cough
repeat visits to her GP, asked for analysis and tests but the GP
would not arrange them
A&E diagnosis of asthma was made. New medicines were
administered and were effective.
B1 thinks that the fundamental problem was that her doctor
didn’t listen to her and didn’t take her consultations seriously.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
GP Competency and Communication
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Z4 asked “If there is no interpreter and you cannot explain the
problem how can you clarify the problem, how can you get
quality care from GP?”
Competence of GP depends on quality of interpretation
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Responses
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Significant lack of faith and trust in Irish
GPs
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Unused prescriptions
Change GP
Prefer hospital A&E department
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Medicine from home
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Z4 feels strongly that her GP doesn’t care about her or her family’s
health. The GP cannot understand the seriousness of the problems
and at the end of their consultations Z4 feels like a second class
citizen. She only goes to the doctor if it is really really necessary.
She uses alternative medicine, such as herbal medicine and
supplements from health food shops as much as possible,
particularly for her young son who has a skin condition. She also
has contact with a Russian doctor in the city who has a cupboard of
medicine from home.
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Health Seeking Behaviour
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Health-seeking behaviour of refugees and asylum
seekers is characterised by heterogeneity of actions
within which utilisation of GP services is carefully
negotiated and managed
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Key Findings
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Three main informal strategies identified
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the use of informal
gestures/body language
interpreters,
dictionaries
and
The inadequacy of these informal strategies has
been highlighted problems include
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the use of children
friends/family members who may not be trusted
friends/family members who may not actually have ‘good’
English
examples of errors and misdiagnoses as a result of
language and communication difficulties
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Key Findings
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Good English does not guarantee ‘problem
free’ communication
Decisions about the use of formal and
informal interpreters lie primarily with GPs.
Refugees and asylum seekers do not feel
listened to by GPs
Profound lack of faith in GP care
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Solutions
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Accessible and Available Formal Interpreters
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Trained interpreters
Training for uptake and use of interpreters
Options for different kinds of interpreting for
different kinds of consultations
English Classes
Exchange of Experiences and Perspectives
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Concrete Actions…
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Action Research Process and Outcomes
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Representation, participation, empowerment
Impact on health policy and service delivery
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Presentation to HSE Primary Care Unit
Network of regional projects
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Fellow in Refugee and Asylum Seeker Healthcare
MARTA Galway Refugee Support Group Community Health
Project
Planned national inter-agency conference
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Acknowledgements
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Peer Researcher Group
Galway Refugee Support Group
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Steering Group Members
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Mary Kilraine Hannon, Health Promotion, HSE WA
Ena Polenjee, Public Health Nurse, HSE WA
Ann O Kelly, Centre for Nursing Studies, NUI, Galway
PLA Trainers
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Triona NicGiolla Choille
Celine Geoffret
Mary O’Rielly de Brun, Centre for Participatory Studies, Co. Galway
Tomas de Brun, Centre for Participatory Studies, Co. Galway
Research with Service Providers
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Pauline Clerkin, NUI, Galway
Liam Glynn, NUI, Galway
Julie McMahon, NUI, Galway
Phillipe Mosinike, NUI, Galway
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Perspectives of Primary Care Providers
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Telephone Survey (GPs and PHNs)
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n=91/119; Response rate 76%;
Qualitative Interviews (GPs)
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n=12
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005
Overview of Results
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Use of interpreters
Relative or friend
Formal interpreter by telephone
Formal interpreter face to face
90%
70%
19%
7%
Preference for informal interpreter
Preference for formal interpreter
Managed without interpretation
36%
41%
63%
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Accounts of difficulties or sensitivities with informal and formal
interpreters
Language barrier not perceived as a major problem in their work
Anne MacFarlane, Department of General Practice, HSR Seminar, December 13th 2005