Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers

Contested and nervous spaces: exploring the environment of healthcare provision for international migrants in the Gauteng province of South Africa

BACKGROUND

Notwithstanding the global goal of inclusive universal health coverage, and the notion of migrant-sensitive health systems, limited healthcare access or the exclusion of migrants from national health systems persists. South Africa has a rights-based constitution, but there is an inability or a failure of the health system to recognise and address the health needs of migrants.

OBJECTIVE

To explore the intersection of the environment of healthcare provision for migrants and the everyday practices and behaviours of health workers and patients in the Gauteng province of South Africa.

METHODS

The conceptual frameworks of health system responsiveness and social exclusion informed this institutional ethnographic study at 13 healthcare facilities in Gauteng province. We developed an observation guide to explore the intersection of culture and environment and its influence on healthcare provision to patients, especially migrants. Following ethics approval, we observed the facilities for 234 person-days. We used thematic analysis to analyse the data.

RESULTS

Busy, frantic or nervous spaces, and contestations between patients and health workers, and among health workers formed part of the social and cultural environment of healthcare provision. The presence of migrant patients during busy periods served as a detonator for rude or discriminatory remarks, exacerbated by staff shortages and language barriers. Simultaneously, migrants exercised their agency by rebutting or confronting rude health workers. We also observed encouraging examples of kindness, caring and professionalism of health workers.

CONCLUSION

The study has implications for achieving a migrant-sensitive health system in South Africa.

The cultural adaptation and psychometric evaluation of the Mothers on Respect Index for Native Hawaiians and Pacific Islanders

BACKGROUND

Native Hawaiian and Pacific Islanders (NHPI) are disproportionately burdened by pregnancy-related deaths in the United States and have the lowest engagement in prenatal care compared to all other US racial groups. Aside from access barriers, studies suggest that NHPI face challenges with patient-clinician communication, perceived discrimination, and cultural conflicts within healthcare settings. This paper describes the cultural adaptation of the 14-item Mothers On Respect index for NHPI, originally developed by Vedam et al. (2017) for diverse communities in British Columbia, Canada, and reports the findings of the preliminary psychometric assessment of the adapted measure.

METHODS

Data from 26 interviews with NHPI women, expert, and cognitive interviews were conducted to inform the adaptation. An online survey was administered to a sample of 90 NHPI women to assess construct validity, convergent validity, and internal reliability of the adapted measure using exploratory and confirmatory factor analyses.

RESULTS

The adaptation resulted in substantial changes to the original measure, mainly by the addition of items related to 'feeling cared for by and connected to the provider' and 'perceived threats hindering communication.' The psychometric analyses identified a three-factor structure for the culturally adapted index and confirmatory factor analyses were employed to refine the measure. The result was a 25-item index with acceptable goodness of fit indices, high internal reliability (Cronbach's alpha of 0.96, 95% CI = .94-.97) and convergent validity with a related scale. Overall, participants in this sample indicated high levels of respectful care; however, people who received < 8 prenatal care visits had significantly lower ratings on average.

CONCLUSIONS

Our findings suggest that the elements valued by NHPI are not fully captured in existing measures of respectful maternity care. Efforts to assess more discrete aspects of the patient-provider relationship for culturally distinct and racialized groups could help improve the quality of care and advance equity in maternal and perinatal health marginalized communities.

Communicating effectively with inclusion health populations: 2022 ICCH symposium

OBJECTIVE

To describe communication strategies for clinical practice that allow practitioners to work more effectively with marginalised population groups and to discuss how to incorporate these into medical practice.

METHODS

Active practitioners working in inclusion health and people with lived experience of homelessness and the asylum-seeking process shared their perspectives in the symposium at the 2022 International Conference on Communication in Healthcare (ICCH) and a subsequent conference on empathy in healthcare. The views of attendees were sought.

SYMPOSIUM DISCUSSION

We describe the perspectives shared at the symposia under two main themes: communication needs in people experiencing homelessness and migrant populations, and trauma-informed practice.

CONCLUSIONS

People experiencing homelessness have more communication challenges compared to the general adult population. Migrant, refugee, and asylum-seeking populations also face the complexity of negotiating unfamiliar healthcare, legal and social systems with the added burden of language barriers. Trauma-informed practice provides a useful framework that can improve communication with these groups.

Opportunities for improving patient experiences among medical travellers from Canada's far north: a mixed-methods study

OBJECTIVES

This paper explores patient experiences and identifies barriers and opportunities for improving access to healthcare for patients from the Canadian north who travel to receive medical care in a Southern province.

DESIGN

A mixed-methods, cross-sectional study involved one-on-one interviews, focus group discussions and key informant interviews.

PARTICIPANTS

52 one-on-one interviews with Northwest Territories (NWT) patients and patient escorts and two focus group discussions (n=10). Fourteen key informant interviews were conducted with health workers, programme managers and staff of community organisations providing services for out-of-province patients. A Community Advisory Board guided the development of the questionnaires and interpretation of results.

RESULTS

Respondents were satisfied with the care received overall, but described unnecessary burdens and bureaucratic challenges throughout the travel process. Themes relating to access to healthcare included: plans and logistics for travel; level of communication between services; clarity around jurisdiction and responsibility for care; indirect costs of travel and direct costs of uninsured services; and having a patient escort or advocate available to assist with appointments and navigate the system. Three themes related to healthcare experiences included: cultural awareness, respect and caring, and medical translation. Respondents provided suggestions to improve access to care.

CONCLUSIONS

Patients from NWT need more information and support before and during travel. Ensuring that medical travellers and escorts are prepared before departing, that healthcare providers engage in culturally appropriate communication and connecting travellers to support services on arrival have the potential to improve medical travel experiences.

Embracing the Obstetric Imaginary: Chuukese Women, Migration, and Stratified Reproduction

When a new biomedical hospital was built in Chuuk, women were encouraged to forgo home births and seek obstetric care. Chuuk's infrastructure deteriorated over time, however, and the hospital became known as the place of death. Women maintained faith in obstetric technology despite these conditions; they simply sought better technology in Guam or a US state. Yet, even upon migrating, women continued to suffer disproportionately poor birth outcomes. In this article, I explore how Chuukese women maintained faith in obstetric technology, elucidating the power of the "obstetric imaginary" in the context of neocolonial development, migration, and stratified reproduction.

Diabetes affects everything: Type 2 diabetes self-management among Spanish-speaking hispanic immigrants

This article is a report of qualitative findings of a mixed-methods study of the relationships among knowledge, self-efficacy, health promoting behaviors, and type 2 diabetes mellitus (T2DM) self-management among limited-english-proficient recent Hispanic immigrants, a population with increased incidence of T2DM and barriers to successful T2DM management. Semi-structured interviews were conducted with 30 participants, and physiological and demographic data also were collected. The participants generally attributed developing the disease to strong emotions and viewed T2DM as a serious disease. Although a majority understood the importance of exercise and diet in T2DM self-management, other aspects such as medication adherence were not well-understood. Obstacles to effective T2DM self-management were negative interactions and communications with health care providers and other personnel, cultural stigma related to the disease, financial constraints, immigration status, and the complexity of the disease. Suggested interventions to improve the care and self-management of this at-risk population are discussed.

Keeping out and getting in: reframing emergency department gatekeeping as structural competence

Sociologists have tended to frame medical gatekeeping as an exclusionary social practice, delineating how practitioners and clerical staff police the moral boundaries of medicine by keeping out patients who are categorised as 'bad', 'deviant', or otherwise problematic. Yet medical gatekeeping, understood more broadly, can include not only keeping patients out of particular clinical settings, but also redirecting them to alternative sources of care. In this article, I draw on qualitative analysis of audio-recorded patient-provider interactions in a United States emergency department (ED) to illustrate medical gatekeeping as a two-step process of, first, categorising certain patient complaints as unsuitable for treatment within a particular setting, and second, diverting patients to alternative sites for care. I refer to these as the restrictive and facilitative components of medical gatekeeping to denote how each relates to patients' access to care, recognising that both components of medical gatekeeping are part of a coordinated organisational strategy for managing resource scarcity. By illustrating how ED providers reveal intimate knowledge of structural vulnerabilities in diverting socioeconomically disadvantaged patients with chronic back pain to clinical sites that are better equipped to provide care, I suggest that we rethink the emphasis on restrictive practices in sociological accounts of medical gatekeeping.