Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices.

BACKGROUND: Patient-provider communication, in particular physicians' ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care. METHOD: We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members). RESULTS: Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members' questions or requests for information. Patients' participation in the consultation was minimal, and limited to brief answers to clinicians' questions. CONCLUSIONS: Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

Self-reported cardiovascular risk factors in immigrants and Swiss nationals.

OBJECTIVE: The purpose of this study was to investigate whether the prevalence of self-reported cardiovascular risk factors differs between immigrants and Swiss nationals. DESIGN AND SAMPLE: This study is a secondary data analysis of the Swiss Health Survey 2002, a cross-sectional survey. In total, 19,249 individuals living in Switzerland were included. MEASURES: The prevalence of hypertension, high cholesterol level, smoking, diabetes, overweight, low fruit and vegetable intake, and physical inactivity were calculated for major immigrant groups and Swiss nationals. Demographic data were used to control for age and socioeconomic status. RESULTS: Major immigrant groups were people from Italy, Germany, former Yugoslavia, Spain, Portugal, France, and Turkey. Compared with Swiss women, women from former Yugoslavia were more likely to have hypertension, and women from Germany were more likely to have high cholesterol levels. Women from Italy, former Yugoslavia, Spain, Portugal, and Turkey were more likely to show physical inactivity and (except Turkish women) to be overweight. Men from these countries (except Spanish men) were more likely to be overweight than Swiss men. CONCLUSIONS: Differences exist in the prevalence of modifiable cardiovascular risk factors between Swiss nationals and many of the immigrant groups. Age and socioeconomic status could only partly explain the differences.

Reproductive health care for asylum-seeking women - a challenge for health professionals.

BACKGROUND: Dealing with pregnancy, childbirth and the care of newborn babies is a challenge for female asylum seekers and their health care providers. The aim of our study was to identify reproductive health issues in a population of women seeking asylum in Switzerland, and to examine the care they received. The women were insured through a special Health Maintenance Organisation (HMO) and were attending the Women's Clinic of the University Hospital in Basel. We also investigated how the health professionals involved perceived the experience of providing health care for these patients. METHODS: A mixed methods approach combined the analysis of quantitative descriptive data and qualitative data obtained from semi-structured interviews with health care providers and from patients' files. We analysed the records of 80 asylum-seeking patients attending the Women's Clinic insured through an HMO. We conducted semi-structured interviews with 10 care providers from different professional groups. Quantitative data were analysed descriptively. Qualitative data analysis was guided by Grounded Theory. RESULTS: The principal health problems among the asylum seekers were a high rate of induced abortions (2.5 times higher than in the local population), due to inadequate contraception, and psychosocial stress due to the experience of forced migration and their current difficult life situation. The language barriers were identified as a major difficulty for health professionals in providing care. Health care providers also faced major emotional challenges when taking care of asylum seekers. Additional problems for physicians were that they were often required to act in an official capacity on behalf of the authorities in charge of the asylum process, and they also had to make decisions about controlling expenditure to fulfil the requirements of the HMO. They felt that these decisions sometimes conflicted with their duty towards the patient. CONCLUSION: Health policies for asylum seekers need to be designed to assure access to adequate contraception, and to provide psychological care for this vulnerable group of patients. Care for asylum seekers may be emotionally very challenging for health professionals.

What do language barriers cost? An exploratory study among asylum seekers in Switzerland.

BACKGROUND: Language barriers have a major impact on both the quality and the costs of health care. While there is a growing body of evidence demonstrating the detrimental effects of language barriers on the quality of health care provision, less is known about their impact on costs. This purpose of this study was to investigate the association between language barriers and the costs of health care. METHODS: The data source was a representative set of asylum seekers whose health care was provided by a Swiss Health Maintenance Organisation (HMO). A cross-sectional survey was conducted: data was collected on all the asylum seekers' health care costs including consultations, diagnostic examinations, medical interventions, stays in the clinic, medication, and interpreter services. The data were analysed using path analysis. RESULTS: Asylum seekers showed higher health care costs if there were language barriers between them and the health professionals. Most of these increased costs were attributable to those patients who received interpreter services: they used more health care services and more material. However, these patients also had a lower number of visits to the HMO than patients who faced language barriers but did not receive interpreter services. CONCLUSION: Language barriers impact health care costs. In line with the limited literature, the results of this study seem to show that interpreter services lead to more targeted health care, concentrating higher health care utilisation into a smaller number of visits. Although the initial costs are higher, it can be posited that the use of interpreter services prevents the escalation of long-term costs. A future study specially designed to examine this presumption is needed.

The evolution of a healthcare interpreting service mapped against the bilingual health communication model: a historical qualitative case study.

BACKGROUND: Twenty-five years ago, the need for health care interpreting in Switzerland increased due to the sharp influx of asylum seekers from war zones and countries of political unrest. Due to complex health needs, there was a need to move away from using volunteers as interpreters towards qualified interpreter services. METHODS: A historical qualitative case study design was used to describe the evolution of the language assistance programmes at Geneva University Hospitals, between 1992 and 2017. The aim was to map the evolution of the interpreter services against the Bilingual Health Communication Model with the constructs-Communicative Goals, Individual Agency, System Norms and Quality and Equality of Care-while identifying key factors to optimise interpreter service and patient care. RESULTS AND DISCUSSION: Five phases were identified during the 25 years of service evolution studied: (1) Service initiation-the interpreter services were first used in a small service that cared for refugees and asylum seekers. (2) Growth and formalisation-due to the arrival of high numbers of Albanian-speaking asylum seekers, Albanian-speaking interpreters were provided to all departments of the Geneva University Hospitals. This helped roll out the use of interpreters among doctors and nurses. (3) Ensuring quality-the care for all patients, whether foreign-language speaking or not, became an issue and led to research into the quality of patient-provider communication. (4) Institutionalisation-this phase dealt with challenges including the lack of interpreter financing regulation and the clarification of interpreter roles. (5) Equity-healthcare interpreter services were put in an overall framework of equity standards. The Bilingual Health Communication Model was applied and showed that some items were not implemented: clear shifts (i) towards a culturally sensitive focus, (ii) towards community interpreting, (iii) towards triadic communication, (iv) towards spelling out the right to have an interpreter and (v) towards the involvement of insurance companies. Finally, the inclusion of healthcare interpreting as an essential ingredient in healthcare provision, including chronic disease management, is incomplete or missing. CONCLUSIONS: Healthcare interpreting at Geneva University Hospitals has evolved from a 'muddling-through' approach towards an institutional approach by addressing quality of care, by focussing on the mental health of asylum seekers, training of both interpreters and users of interpreters and institutional policy based on equity.

Health and ill health of asylum seekers in Switzerland: an epidemiological study.

BACKGROUND: Although the focus of health care for people seeking asylum in Western European countries is usually on communicable diseases, there is little data about the general health care need of this population. In this study, we investigated the actual burden of disease among asylum seekers. METHODS: Data were collected from a Swiss Health Maintenance Organisation (HMO; a type of managed care organization in which physicians act as gate keepers) that was set up specifically to provide health care for asylum seekers. The data included socio-demographic characteristics, international classification of diseases (ICD-10) diagnoses and number of clinic visits. Descriptive statistics were used to assess the types of health problems and the number of clinic visits. Logistic regression analysis was used to determine whether age, gender or country or region of origin was predictive in terms of incidence of disease as diagnosed by using ICD classifications. RESULTS: The total number of asylum seekers (mean age 22 years; 38% women) enrolled in the HMO from 2000 through 2003 was 979. Half of this group came from the former country of Yugoslavia. The remainder came primarily from sub-Saharan Africa, Turkey, Iraq and Sri Lanka. The most common health problems encountered in the population included musculoskeletal diseases, respiratory diseases, depression and post-traumatic stress disorder. The prevalence of all disease clusters was significantly associated with age. One-fifth of the population did not request health care at all during the time they were enrolled in the HMO. It is not known whether those who did not visit the medical clinic did not require health care or just chose not to request clinic services. CONCLUSIONS: The most frequent health problems encountered in the study population were chronic medical conditions, not communicable acute diseases. Although health care services provided to asylum seekers usually focus on episodic acute care, what this group actually needs is continuity of care.

"Migrant-friendly hospitals": a European initiative in an age of increasing mobility.

European cities are characterized by increasing numbers of foreign-born and foreign-language speaking inhabitants. The resulting cultural and linguistic diversity presents a number of challenges to health-care services. This paper describes a European initiative aimed at improving hospitals' responses to the health-care needs of migrants and ethnic minorities. We summarise the current health situation of these groups, describe how the EU initiative began and how it led to the Amsterdam declaration, and conclude by outlining current developments.

Doctor-patient gender concordance and patient satisfaction in interpreter-mediated consultations: an exploratory study.

BACKGROUND: Research suggests that doctor-patient communication patterns and patient satisfaction are influenced by gender. However, little is known about the effect of gender in consultations with foreign language-speaking patients and in interpreter-mediated consultations. METHODS: The objective of the study was to explore the effect of doctor-patient gender concordance on satisfaction of foreign language-speaking patients in consultations with and without a professional interpreter. Its design consists of a cross-sectional analysis of patients' reports. A total of 363 consultations with foreign language-speaking patients were included in the analysis. We measured the mean scores of six items on the quality of communication (answer scale 0-10): the doctor's response to the patient's needs, the doctors' explanations, the doctor's respectfulness toward the patient, the quality of communication in general, the overall consultation process, and information provided regarding follow-up. RESULTS: When interpreters were used, mean scores were similar for doctor-patient concordant and discordant pairs. However, in the absence of interpreters, doctor-patient gender discordance was associated with lower overall ratings of the quality of communication (-0.46, p= 0.01). CONCLUSIONS: Our results suggest that the presence of a professional interpreter may reduce gender-related communication barriers during medical encounters with foreign language-speaking patients.

Uptake of breast cancer screening measures among immigrant and Swiss women in Switzerland.

BACKGROUND: Early detection of breast cancer plays a crucial role in survival, and in most developed countries immigrant women present for treatment at a later stage of the disease. Compared to the indigenous population, immigrant women have a lower uptake of breast cancer prevention services. The situation for immigrant women in Switzerland is compounded by the fact that all women living in Switzerland are at major risk of developing breast cancer during their lifetime. QUESTION UNDER STUDY: Our study aimed to detect disparities in uptake of preventive methods such as mammography, clinical breast examination (CBE) and breast self-examination (BSE) among women from the four major immigrant groups Italy, Spain, former Yugoslavia and Portugal, compared to the native population in Switzerland. METHODS: This study is a secondary analysis of data from the 2002 Swiss Health Survey, a nationwide cross-sectional telephone survey. The self-reported questionnaires addressed immigrant and Swiss women of age 20 and over (n = 9,790). Descriptive statistics were used to describe the demographic characteristics of the sample. The dichotomous variables of interest, mammography, CBE and BSE were adjusted for nationality and further sociodemographic factors using logistic regression, with Swiss women serving as the comparison group. RESULTS: Main predictors for mammography uptake were higher income and older age. For the use of CBE, lower age, higher income and nationality were the strongest predictors. Women from former Yugoslavia (OR = 2.6) and Portugal (OR = 2.8) more frequently stated that they did not receive CBE compared to Swiss females (p = .011). BSE is linked to a higher socioprofessional status and to nationality. Women from Italy (OR = 1.62) and former Yugoslavia (OR = 2.6) perform BSE significantly less often than Swiss women (p = .0001). CONCLUSION: Differences exist in the use of mammography, CBE and BSE among the four major foreign nationality groups living in Switzerland compared to Swiss nationals. Immigrant and low-income women might draw benefit from a systematic and culturally adapted breast cancer screening programme to overcome disparities in access to screening.

[Nursing interpreters? Interpreting nurses?]. / Pflegende Dolmetschende? Dolmetschende Pflegende? Literaturanalyse.

Swiss hospitals are characterized by an increasing diversity, in the sense of personal and social differences such as including origin, gender language, skills, age, lifestyles and social status. Diversity is a challenge for hospitals. It is crucial to language barriers and migration and their clinical consequences. In spite of a trend towards interpreter services "going professional", interpreters are only reluctantly used. This is surprising. In this article we deal with three questions: What are clinical consequences of language barriers? How can language barriers be overcome? Should nurses act as interpreters? The literature available clearly shows that due to insufficient flow of information patients speaking a foreign language tend to receive inadequate care. Also, there is a consensus that patients' relatives acting as ad hoc interpreters are ill-equipped or unsuited to overcome language barriers. Conversely, professional interpreters improve most evidently the quality of care of patients speaking a foreign language. However in clinical everyday life the consistent use of interpreters is not always feasible. Thus, the setting-up of a pool of hospital-based ("internal"), trained bilingual health professionals appears to be an acceptable alternative.

Establishing a faith-based organisation nursing school within a national primary health care programme in rural Tanzania: an auto-ethnographic case study.

BACKGROUND: In 2007, the Tanzanian government called for improvements in its primary health care services. Part of this initiative was to accelerate the training rate for nurses qualified to work in rural areas. The aim of this study was to reflect on the issues experienced whilst establishing and implementing a faith-based organisation (FBO) nursing school and make recommendations for other similar initiatives. DESIGN: This paper describes an auto-ethnographic case study design to identify the key difficulties involved with establishing and implementing a new nursing school, and which factors helped the project achieve its goals. RESULTS: Six themes emerged from the experiences that shaped the course of the project: 1) Motivation can be sustained if the rationale of the project is in line with its aims. Indeed, the project's primary health care focus was to strengthen the nursing workforce and build a public-private partnership with an FBO. All these were strengths, which helped in the midst of all the uncertainties. 2) Communication was an important and often underrated factor for all types of development projects. 3) Managing the unknown and 4) managing expectations characterised the project inception. Almost all themes had to do with 5) handling conflicts. With so many participants having their own agendas, tensions were unavoidable. A final theme was 6) the need to adjust to ever-changing targets. CONCLUSIONS: This retrospective auto-ethnographic manuscript serves as a small-scale case study, to illustrate how issues that can be generalised to other settings can be deconstructed to demonstrate how they influence health development projects in developing countries. From this narrative of experiences, key recommendations include the following: 1) Find the right ratio of stakeholders, participants, and agendas, and do not overload the project; 2) Be alert and communicate as much as possible with staff and do not ignore issues hoping they will solve themselves; 3) Think flexibly and do not stubbornly stick to original plans that might not be working; 4) Be realistic and do not romanticise. Embarking on such a project was a timely response to the Tanzanian's government call for strengthening Primary Health Care and for rapidly accelerating the training of nurses able to work in rural areas.

Structure determination of mycolactone C via total synthesis.

[structure: see text] By total synthesis, mycolactone C has been established as an approximately 1:1 mixture of Z-Delta4'5'- and E-Delta4'5'-geometric isomers of C12'-deoxymycolactones A and B.

Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral.

The objective of this study was to determine whether language barriers during the screening interview affected the reporting of asylum seekers' health problems and their referral to further health care. Seven hundred and twenty-three standard screening questionnaires, administered by nurses to asylum-seekers at the time of entry into Geneva/Switzerland between June and December 1998, were reviewed, as well as information pertaining to language use during the interview. Language concordance between nurses and asylum seekers was assessed by considering the presence/absence of an interpreter, the type of interpreter present (trained, untrained), and the nurse's self-assessed proficiency in the language used during the medical interview. Nurses also recorded their own subjective assessment of the overall quality of communication during the interview. More than half of the asylum seekers came from Europe, mainly the Balkan regions, and a third of them from Africa. Most asylum seekers were men (72%). The median age was 26.5 years, and 50% were younger than 25 years. Severe physical and psychological symptoms were reported by 19% and traumatic events prior to migration were reported by 63%. The nurses referred 36% of all refugees to further medical care and 6% to psychological care. Professional interpreters were used in 8% of the interviews and ad hoc interpreters in 16%. Adequate, partial and inadequate language concordance was reported for 54%, 27% and 18% of the consultations respectively. Adequate language concordance was significantly associated with higher reporting of past experience of traumatic events and of severe psychological symptoms, contrasting with much fewer referrals to psychological care when language concordance was inadequate. These results suggest the importance of addressing language barriers in primary care centres in order to adequately detect and refer traumatised refugees. To address this problem, the use of professional interpreters is recommended.

Improving communication between physicians and patients who speak a foreign language.

BACKGROUND: Communication between physicians and patients is particularly challenging when patients do not speak the local language (in Switzerland, they are known as allophones). AIM: To assess the effectiveness of an intervention to improve communication skills of physicians who deal with allophone patients. DESIGN OF STUDY: 'Before-and-after' intervention study, in which both patients (allophone and francophone) and physicians completed visit-specific questionnaires assessing the quality of communication. SETTING: Two consecutive samples of patients attending the medical outpatient clinic of a teaching hospital in French-speaking Switzerland. METHOD: The intervention consisted of training physicians in communicating with allophone patients and working with interpreters. French-speaking patients served as the control group. The outcomes measured were: patient satisfaction with care received and with communication during consultation; and provider (primary care physician) satisfaction with care provided and communication during consultation. RESULTS: At baseline, mean scores of patients' assessments of communication were lower for allophone than for francophone patients. At follow-up, five out of six of the scores of allophone patients showed small increases (P < 0.05) when compared with French-speaking patients: explanations given by physician; respectfulness of physician; communication; overall process of the consultation; and information about future care. In contrast, physicians' assessments did not change significantly. Finally, after the intervention, the proportion of consultations with allophone patients in which professional interpreters were present increased significantly from 46% to 67%. CONCLUSIONS: The quality of communication as perceived by allophone patients can be improved with specific training aimed at primary care physicians.

Asymmetric Total Synthesis of the Gastroprotective Microbial Agent AI-77-B.

An enantioselective total synthesis of the pseudopeptide microbial agent AI-77-B, which has shown potent antiulcerogenic properties, is described. The synthesis is convergent and involves the assembly of a dihydroisocoumarin fragment and a hydroxy amino acid. The dihydroisocoumarin derivative was synthesised by means of a Diels-Alder reaction between 1-methoxy-1,3-cyclohexadiene and an alkynyl ester derivative as the dienophile. The alkynyl ester was obtained stereo-selectively by two different synthetic routes: (1) A stereoselective allylation of leucinal, and (2) a titanium enolate-mediated anti-aldol reaction with trichlorobutyraldehyde, a novel homopropargylaldehyde equivalent. The stereocentres of the hydroxy amino acid moiety were generated through a titanium enolate-mediated syn-aldol reaction, Curtius rearrangement, and application of Dondoni's aldehyde homo-logation. Condensation of the dihydroisocoumarin and hydroxy amino acid moieties and subsequent removal of the protecting groups furnished optically active AI-77-B.

The cost of war and the cost of health care - an epidemiological study of asylum seekers.

BACKGROUND: The aim of this study was to explore differences in health care costs for asylum seekers from countries experiencing violent conflict and those from countries experiencing no violent conflict. METHDODS: Data were collected from a representative sample of refugees in an urban Swiss canton who were assigned to a Health Maintenance Organisation that covered all their health care costs. Cost differences for individuals coming from countries experiencing violent conflicts and from countries experiencing no violent conflict were tested by using multiple regression techniques and by controlling for confounding demographic, clinical and migration-related variables. RESULTS: Health care costs were higher for patients from countries with violent conflict. The higher costs could be attributed in part to increased frequencies of somatic diseases, however, the higher costs were linked primarily to the duration of the asylum seeker's enrolment in the insurance programme, the number of visits to the medical facility, and the procedural status of the person's application for asylum. CONCLUSIONS: Despite a higher prevalence of illness in patients from countries with violent conflict, the length of time spent in administrative "asylum seeker" status seemed to be the main driver of health care costs. Language barriers may be skewing results, with respect to the importance of specific diagnoses (especially mental health disorders), in driving costs upward. These results indicate a need for more comprehensive screening strategies for asylum seekers in receiving countries, particularly for those from countries in conflict.

Communicating with foreign language-speaking patients: is access to professional interpreters enough?

BACKGROUND: The importance of trained interpreters for ensuring adequate communication with limited English proficiency patients is well-established. However, in many contexts, health professionals continue to rely on ad hoc interpreters, such as bilingual employees or patients' relatives to provide linguistic assistance. This is worrisome because these strategies have been shown to be associated with poor quality health care. OBJECTIVE: Examine attitudes and practices related to healthcare interpreting. DESIGN: Mailed, self-administered questionnaire. SETTING AND PARTICIPANTS: Convenience sample of medical and nursing department and service heads at the Geneva University Hospitals. OUTCOME MEASURES: Adequacy of attitudes and practices related to interpreter use. RESULTS: Ninety-nine questionnaires were completed and returned (66% response rate). Between 43% and 86% of respondents relied mainly on patients' relatives and bilingual employees for linguistic assistance, depending on the language in question. Professional interpreter use varied according to language (from 5% to 39%) and seems to reflect the availability of bilingual staff members for the different languages. Professional interpreters appear to be used only in the absence of other available options, due to cost concerns and scheduling difficulties. This practice is further reinforced by the belief that ad hoc interpreters are "good enough" even while recognizing the quality differential between trained and untrained interpreters (91.2% of respondents rated bilingual staff as satisfactory or good, and 79.5% rated family/friends as satisfactory or good). CONCLUSIONS: Simply making professional interpreter services available to healthcare professionals does not appear to guarantee their use for limited French proficiency (LFP) patients. Future efforts should focus on developing procedures for systematically identifying patients needing linguistic assistance, linguistic assistance strategies that are responsive to provider and institutional contexts and constraints, and institutional directives to ensure use of qualified interpreters for all medically important communication with LFP patients.