Primary Health Care: Open Access

A Reflection on Providing Cultural and Linguistic Responsive Care to Immigrant Families

Jessica Addison, Rose Ashraf and Emily Pluhar

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Introduction

My next patient checked in on my schedule. Slight panic set in as I realized that I would likely fall behind and spend my whole day trying to catch up. I had reviewed my list of patients that morning and I knew the next patient was a 16-year-old, first generation immigrant who moved to the United States 2 weeks ago. He was accompanied by his mother, both were non-English speaking and they arrived slightly early for his 30-minute new patient physical visit. The virtual interpreter was not available because this platform was being used in another office and the interpreter phone in the exam room was not working properly at that time. As the patient and his mother patiently waited in the exam room, I anxiously checked in with them and reassured them I would be with them as soon as I could. The feeling on falling behind and knowing there would be a delay in his appointment was stressful. Twenty-seven long minutes later an in-person interpreter became available and kindly assisted me with this visit. I completed the full physical in addition to a routine adolescent psychosocial screening and offered to connect them to mental health and social work services. I also asked him about how transitioning to the United States has been. At the end of the forty-minute visit that started approximately 30 minutes late, I apologized again for the wait. His mother said it was fine, and that this was not the first time this has happened since moving to the United States which was upsetting for me to hear.

Adolescence is the period of transition between childhood and adulthood; a time where significant physical, emotional, and psychological development occur. If you compound this with immigrating to a new country and interfacing with a new healthcare system, it can add additional challenges to this transition period. When entering the US healthcare system these patients often experience language barriers, differences in social and cultural practices in relation to physical and mental health as they try to assimilate into a new society [1]. Organizations such as the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention outline recommended medical and mental health screening guidelines for immigrant children and adolescents [2,3]. The recommendations include providing care in an efficient, comprehensive, culturally and linguistically competent way.

Cultural Responsivity

As an adolescent medicine provider I currently practice at a large academic medical center and an affiliated community based health centers. Two questions I constantly ask myself when interacting with immigrant adolescents and families are: How can I best deliver efficient and comprehensive care within the allotted appointment time? Do my patients and families feel like I provided them care in a culturally and linguistically responsive way? I have reflected on my experiences and although I feel that I provided cultural and linguistic responsive care that day, how do I know the family felt the same way? How did the patient feel about me asking his mother to leave the room for the confidential portion the visit? Or when I discussed mental health concerns with him? The family was agreeable to everything that occurred during his visit, but were they truly comfortable? It would be reassuring to know that when that patient and his mother left my clinic they understood everything that was discussed and that they felt like they were treated in a culturally competent way; as that is always my goal. Typically, I would not have had that buffer but the subsequent patient did not show for their appointment. To complete a comprehensive new patient appointment with a family that is new to your practice where there are language and cultural barriers is quite challenging. Moreover, there has been an increase in the complexity of psychosocial concerns among adolescents and helping them navigate a new clinical setting for the first time in the scheduled 30 minutes to make sure you are on time for the next patient is not always possible. Having equal time for appointments does not always translate into equal quality of care when patients cannot communicate directly with physicians due to differences in language [4]. This highlights the importance of having adequate resources to readily access interpreter services. While there are barriers to allocating providers with adequate time to complete these visits such as lack of reimbursement for the additional time, scheduling sufficient time for these visits is extremely important. Barriers such as meeting required clinic volume and insurance reimbursement play a role in determining appointment duration. However, in my specific case, the one aspect that significantly affected the efficiency to which I could provide adequate care was the delay in accessing interpreter services. Providing professional, efficient interpreter services is recommended by the AAP can reduce the occurrence of medical errors resulting in better quality of care. Sufficient interpreter services can also lead to increased office visits, improved medication adherence and better health outcomes [5]. There have been studies that have surveyed the needs of immigrant communities and the paucity of multilingual providers and interpreters were noted to be some of the greatest barriers when interfacing with a new healthcare system where you do not speak the native language [6]. Not having efficient access to qualified interpreters in health care settings can often result in utilization of unqualified interpreter services; such as using English-speaking family members. This can result in compromised confidentiality and confuse roles between health care providers and family members. The medical field has inquired about the reliability, capability, and availability of interpreters in healthcare environments. Suggested approaches to mprove interpreter services include: increasing the number of bilingual providers, increasing the fluency of providers, increasing the number of multilingual or minority staff, and increasing the number and variety of modalities of interpreter services [6].

Improving Care

When I think about some of the immigrant patients and families that have been lost to follow up, was it because there was a disconnect between their expectations and their actual experience? How do we measure if we are providing culturally competent care? One way to possibly assess would be to ask for confidential feedback from this population about their experiences interfacing with our healthcare system for the first time. A good starting point would be performing a needs assessment and asking what topics are important to them in addition to the recommended checklists provided by professional organizations. Should there be an automatic follow up phone call made after the initial visit? New patient visits typically include a lot of new information (reviewing health forms and medical history and depression/ mental health screening) and a phone check-in may be a good avenue to address questions that may have arisen since the initial visit. There have been various studies that have implemented interventions in efforts to evaluate health interventions for immigrants but many had limitations such as subjective outcome measures and did not focus on the priorities of immigrant populations [7]. Leadership in my clinical practice has noticed that families requiring interpreter services have longer wait time compared to those who do not require this service. There are times when their visit gets cut short due to technical difficulties which results in frequent follow up. At the end of the visit we do not routinely solicit feedback from these families regarding the care they received. This has brought about changes to our clinic policies. An initiative is starting where all patients who require interpreter services will have anywhere from a 60 to 90 minute initial visit. Allocated time for subsequent visits will be at the discretion of the provider. At the end of each visit there will be surveys provided asking them their experience in the clinic and suggestions for improvement. There will more of an effort to obtain interpreter services ahead of time with the priority being an in-person interpreter and troubleshooting technical difficulties if other modalities need to be used (e.g. Phone, iPad). As providers, we may not be allotted additional time for visits with patients and families who are immigrants and may have cultural and linguistic needs. We strive to provide culturally responsive care and sometimes we may unknowingly fall short which may have unexpected sequelae. There is much room for improvement in all of these arenas but it starts with increased awareness, self-reflection and open discussion with patients, families, and stakeholders as these can be the driving force and motivation to implement change.

Funding Source

HRSA/MCHB through the BCH LEAH training grant #T71MC00009

Financial Disclosures

All authors have indicated they have no financial relationships relevant to this article to disclose.

Conflict of Interest

All authors have indicated they have no potential conflicts of interest to disclose.

Contributor Statement

Dr. Addison drafted the initial manuscript, and approved the final manuscript as submitted.

Dr. Rose Ashraf and Dr. Emily Pluhar critically reviewed and revised the initial manuscript and approved the final manuscript as submitted.

References

1. 1. Schulz, Richard, Jill Eden, and National Academies of Sciences, Engineering, and Medicine. "Family caregiving roles and impacts." Families caring for an aging America. National Academies Press (US), (2016).
2. 2. American Academy of Pediatrics “Mental and Emotional Health.” Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aaphealth-initiatives/Immigrant-Child-Health-Toolkit/Pages/Mental-andEmotional-Health.aspx
3. 3. American Academy of Pediatrics “Clinical Care.” Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-healthinitiatives/Immigrant-Child-Health-Toolkit/Pages/Clinical-Care.aspx
4. 4. Hunter-Adams, J., & Rother, H-A. “A Qualitative study of language barriers between South African health care providers and cross-border migrants.”BMC Health Services Res 17.1(2017):1-9.
5. 5. Jacobs, E.A., et al. “Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services.” Am J Public Health 94.5(2004):866-869.
6. 6. Bowen, S. “Language Barriers in Access to Health Care. Ottawa: Health Canada (2001). Retrieved from https://www.canada.ca/en/healthcanada/services/health-care-system/reports-publications/healthcare-accessibility/language-barriers.html
7. 7. Esperanza, D., et al. “Interventions to improve immigrant health. A scoping review.” Eur J Public Health 27.3(2017):433-439.