Tinkering toward departure: The limits of improvisation in rural Ethiopian biomedical practices

'That's how we got around it': a qualitative exploration of healthcare professionals' experiences of care provision for asylum applicants' with limited English proficiency in UK contingency accommodation

OBJECTIVES

The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care.

DESIGN

Qualitative research using semistructured interviews and inductive thematic analysis.

SETTING

An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages.

PARTICIPANTS

Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic.

RESULTS

All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP.

CONCLUSIONS

This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

Wrangling for health: Moving beyond 'tinkering' to struggling against the odds

This article proposes and outlines a new metaphor - 'wrangling for health'- to think about the health seeking efforts occurring within the complex and exhausting everyday realities of resource-poor communities. It draws on fieldwork carried out in a rural community in Sri Lanka (in 2019) with the aim of generating data on the therapeutic practices and health seeking activities of 20 households in the face of everyday ill-health matters. For people in such resource-poor communities, achieving a 'good' health outcome(s) means a constant and ongoing struggle against the challenges of a low-income household, inhospitable healthcare settings and a diverse therapeutic landscape. Based on my findings, I present four key trends in this struggle: a) negotiating the costs and economies of healthcare, b) seeking treatment only as a desperate measure, c) navigating the diverse therapeutic alternatives and d) circumventing the system. These give a glimpse into the ongoing and painstaking efforts by which people creatively mobilise and manipulate whatever resources accessible to them, balance the pros and cons of potential outcome(s) and persevere courageously against adverse circumstances. As such, the struggle for health mirrors their ongoing struggle to 'tie it up together' or wrangle it in everyday life ("jeewithaya gatagaha-gannava"). Wrangling for health - in its sense of struggling against the odds - is therefore proposed as a metaphor for health engagements that challenge the notion of 'tinkering' (Mol, 2008; Mol et al., 2015) so as to depict more accurately the broad range of health seeking efforts that occur within the diverse healthcare landscapes around the world.

Aligning in the dark: Variable and shifting (user-) settings in developing point-of-care diagnostics for tuberculosis and HIV

To be effective, healthcare technologies should be attuned to particular contexts of use. This article examines how such attuning is articulated in global innovation practices for tuberculosis and HIV diagnostics, and to what effect. It examines the development of point-of-care (POC) diagnostics - promised to be designed for users outside laboratories or in resource constrained settings - to study what developers and implementers do to align diagnostic technologies to the POC. Fieldwork among global health actors involved in diagnostic development, including manufacturers, donors, industry consultants, international organizations, policymakers, regulators and researchers, is combined with fieldwork among users of diagnostics in India, including decision-makers, NGOs, program officers, laboratory technicians and nurses. The article adds to STS's theory of alignment and user interaction, where the setting and user to which developers and implementers of global health diagnostics align are multiple, varied, emerging and keep shifting. The characteristics of a local user setting include multiple engaged and imagined user settings, but also the settings of developers, of global intermediaries, competitors and diseases. As such, alignment is happening across multiple dimensions and scales and has an important temporal dimension. The results reveal how alignment happens to some extent in the dark, characterized by uncertainty about the elements that should align. Standardizing elements, politics and scarce resources cause frictions in the temporalities of aligning and over what constitutes a well-aligned diagnostic.