What strategies to address communication barriers for refugees and migrants in healthcare settings have been implemented and evaluated across the WHO European Region?

The provision of effective health care to linguistically and culturally diverse migrant populations has been identified as a crucial public health issue. Persistent evidence across countries shows that communication barriers can severely impact access to and use of health care services by refugees and migrants and lead to health inequalities. However, many European countries have no clear policy guidance on migrant health as it relates to communication barriers.  

Between 2008-2018 in 14 different countries in the WHO European Region, four main strategies were in use to improve access to health care, support management of specific communicable and non-communicable diseases and promote health across a wide variety of health care settings:

1. cultural mediation
2. interpretation
3. translation of health information, and
4. guidance and training for health care providers.

Implementing these strategies often relied on intersectoral collaborations between those working in statutory health care, community NGOs, and academic settings and resulted in positive changes in health knowledge, health behavior and access and utilization of health care for refugees and migrants. 

“A qualitative analysis of the role of community representatives [doulas] in a local community collaboration to increase the participation of foreign-born women in a cervical cancer screening program in Sweden found it beneficial to engage representatives who shared the cultural background and mother tongue of the target group. In a Swedish case study, after one year of collaboration with doulas, the number of Pap smears in the target community increased by 42%.”

 

Challenges:

The two most commonly discussed strategies were cultural mediation and interpretation. There are different perspectives on whether these are two distinct roles or a dual role. This confusion, as well as problems in the nature and quality of training for cultural mediators and interpreters, can prevent refugees and migrants from fully participating in consultations and reduce the motivation of health care providers to use these formal strategies to support communication with refugees and migrants. 

Other implementation challenges included a lack of training among healthcare providers to work with cultural mediators and interpreters and a lack of availability of trained and accredited cultural mediators and interpreters in healthcare settings. 

Where do we go from here? 

To improve the implementation of formal strategies to address communication barriers experienced by refugees and migrants in health care settings, the main policy and practice considerations are: 

Intersectoral Collaboration:

• Encourage collaboration between statutory health care organizations, nonstatutory organizations such as NGOs with an interest in migrant health, and academic institutions to develop and implement strategies to address communication barriers for refugees and migrants in health care settings. 
• Establish intersectoral dialogues on cultural mediation and interpretation among academic, policy, health care and professional organizations, and NGOs concerned with refugee and migrant health to:
  a) clarify the terminology used to describe the role(s) of mediating and interpreting,
  b) develop and implement consistent systems across countries for training, accreditation and professionalization.

Training:

• Ensure the use of professionals who have been trained and accredited for mediating and interpreting roles in health care settings.
• Provide training for health care staff in working effectively with cultural mediators and interpreters in cross-cultural consultations with refugees and migrants.

Policies & Systems:

• Establish incident reporting systems in health care settings where strategies to address communication barriers are being implemented to provide a system-level mechanism for reporting, monitoring and responding to problems and barriers to implementation.
• Encourage the development of a combination of strategies such as specific clinics and support services within a center to support both health care professionals and refugees and migrants in provision of effective health care.
• Develop a national policy that emphasizes the importance of formal strategies to effectively address communication barriers experienced by refugees and migrants in health care settings.

Most importantly, involve migrants in developing and implementing strategies to address communication barriers.

How can this research apply to maternal health?

 We’ve seen from the Swedish case study (and many other studies) that community-based doulas are able to integrate beneficially into a range of women’s healthcare services – from cervical cancer screening to birth and caring for newborns. However, for community-based doulas or Maternity Peer Supporters to overcome the challenges commonly faced by cultural mediators and interpreters, intersectoral collaboration that heavily involves parents, doulas, and midwives is necessary. With a lot of different perspectives around the profession of a doula, it’s time to come together and clarify the terminology about what a doula is and does and to develop a system for them to work alongside health institutions as a formal strategy for overcoming communication barriers and overall, improving maternal health outcomes for refugee/migrant families. 

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