Translation is not enough. Interpreting in a medical setting.

Unique obstacles must be overcome when providing medical care to patients who have an incomplete command of the English language. Serious barriers to effective communication may arise at the exact point where our health care system must succeed or fail. Miscommunication, differences in attitudes about health care, and various other misunderstandings interfere with or frustrate good health care for these patients and their families. Such difficulties are best overcome by the use of a professional interpreter who can ensure good communication between patients and health care professionals. My daily experiences as a professional medical interpreter and translator in Spanish provide insights into the complexities of bilingual and bicultural communication in the hospital setting. Although the examples given relate to Hispanic patients, the lessons learned can be extended to other foreign language patients as well.     

Homeopathic Medicine in the City of Oaxaca, Mexico: Patients'' Perspectives and Observations

This article looks at the growth and use of homeopathic medicine in the city of Oaxaca, Mexico. Based on interviews with 174 male and female patients from half of the homeopathic clinics in the city, this research examined attitudes toward disease causation and how one stays healthy. Findings suggest that women are better at monitoring and trying to improve their health than are their male counterparts. Although homeopathy enjoys a strong and almost devoted following, women seem to be more convinced of the overall efficacy of homeopathic medicine than do men.     

Patients’ Knowledge,Attitudes, Behaviour and Health Care Experiences on the Prevention,Detection, Management and Control of Hypertension in Colombia: A Qualitative Study

Hypertension is a leading cause of premature death worldwide and the most important modifiable risk factor for cardiovascular disease. Effective screening programs, communication with patients, regular monitoring, and adherence to treatment are essential to successful management but may be challenging in health systems facing resource constraints. This qualitative study explored patients’ knowledge, attitudes, behaviour and health care seeking experiences in relation to detection, treatment and control of hypertension in Colombia. We conducted in-depth interviews and focus group discussions with 26 individuals with hypertension and 4 family members in two regions. Few participants were aware of ways to prevent high blood pressure. Once diagnosed, most reported taking medication but had little information about their condition and had a poor understanding of their treatment regime. The desire for good communication and a trusting relationship with the doctor emerged as key themes in promoting adherence to medication and regular attendance at medical appointments. Barriers to accessing treatment included co-payments for medication; costs of transport to health care facilities; unavailability of drugs; and poor access to specialist care. Some patients overcame these barriers with support from social networks, family members and neighbours. However, those who lacked such support, experienced loneliness and struggled to access health care services. The health insurance scheme was frequently described as administratively confusing and those accessing the state subsidized system believed that the treatment was inferior to that provided under the compulsory contributory system. Measures that should be addressed to improve hypertension management in Colombia include better communication between health care professionals and patients, measures to improve understanding of the importance of adherence to treatment, reduction of co-payments and transport costs, and easier access to care, especially in rural areas.     

Characteristics of patients aged over 75 not seen during one year in general practice.

A study was carried out in two large urban practices to determine the number of patients aged over 75 years who had had no contact with the primary care team during one year and to examine their medical and social characteristics. Although their general health was considered to be good, over half needed treatment or other action and half had no identifiable career.     

A Systematic Review of Patients’ Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity

Communication difficulties persist between patients and physicians. In order to improve care, patients’ experiences of this communication must be understood. The main objective of this study is to synthesize qualitative studies exploring patients’ experiences in communicating with a primary care physician. A secondary objective is to explore specific factors pertaining to ethnic minority or majority patients and their influence on patients’ experiences of communication. Pertinent health and social sciences electronic databases were searched systematically (PubMed, Cinahl, PsychNet, and IBSS). Fifty-seven articles were included in the review on the basis of being qualitative studies targeting patients’ experiences of communication with a primary care physician. The meta-ethnography method for qualitative studies was used to interpret data and the COREQ checklist was used to evaluate the quality of included studies. Three concepts emerged from analyses: negative experiences, positive experiences, and outcomes of communication. Negative experiences related to being treated with disrespect, experiencing pressure due to time constraints, and feeling helpless due to the dominance of biomedical culture in the medical encounter. Positive experiences are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician. Outcomes of communication depend on patients’ evaluation of the consultation. Four categories of specific factors exerted mainly a negative influence on consultations for ethnic minorities: language barriers, discrimination, differing values, and acculturation. Ethnic majorities also raised specific factors influencing their experience: differing values and discrimination. Findings of this review are limited by the fact that more than half of the studies did not explore cultural aspects relating to this experience. Future research should address these aspects in more detail. In conclusion, all patients seemed to face additional cultural challenges. Findings provide a foundation for the development of tailored interventions to patients’ preferences, thus ensuring more satisfactory experiences. Health care providers should be sensitive to specific factors (cultural and micro-cultural) during all medical encounters.     

Family perceptions of post-deployment healthcare needs of Iraq/Afghanistan military personnel

Nearly 40 000 service members returning from Iraq and Afghanistan have suffered traumatic injuries, with over 300 000 at risk for post-traumatic stress disorder (PTSD) or other psychiatric problems. These veterans face numerous post-deployment health concerns, sharing substantial burdens with their families. Although many rely upon community-based health care, little is known about how these individuals present at family medicine clinics for perceived medical and psychological issues. We surveyed 347 patients during visits at six clinics, and respondents reported whether they,a family member or a close acquaintance had been deployed since 2001. Patients identified traumatic military experiences, plus any attributable health or social problems. The mean patient age was 47.5 years, with 71% women and 55% Hispanic individuals. Nearly one-quarter reported family members serving overseas while 52% knew someone deployed. Significant events included nearby explosion (21%) or combat injury (9%), along with a variety of other incidents. Among the half of individuals perceiving significant health or social ramifications, the most prevalent consequences were PTSD, depression and alcohol abuse. Divorce or marital problems were noted by13%, while many reported employment, legal or other difficulties. This study offers insights into post-deployment needs of military personnel and subsequent problems reported by family members. A high prevalence of traumatic combat events translated into serious health needs, plus social disruptions for veterans and their loved ones. As the long-term problems disclosed by returning service personnel continue to ripple across community clinics and other health systems, effective treatment planning mandates coordinated attention from multiple providers and service organisations.     

Behind the screens: care staff observations on delivery of oral health care in nursing homes

Objective: To identify qualitatively carer staff attitudes, practices and clinical comments related to oral health care of functionally dependent nursing home clients. Design: Open-ended questions included in a longer quantitative questionnaire. Setting: 22 randomly selected nursing homes in the Bristol area. Subjects: 416 carers employed in these homes. Results: The majority of carers thought that clients had a right to good oral health, accepted the carers' role in helping clients with oral and denture hygiene, but recognised that oral health care provision was deficient. However, some carers believed oral health care to be solely the clients' responsibility despite high disability levels. Main barriers to providing oral health care were low prioritisation of oral health by nursing management, lack of co-operation from cognitively impaired clients, and lack of training. Carers were critical of homes' lack of arrangements for routine professional dental cheeks, lack of commitment to staff training, low standards of oral health care by colleagues, and lack of provision of oral hygiene aids and cleansing materials for clients. Many responses indicated ways in which nursing home oral health care could be improved. Carers reported contrasting experiences of dental treatment, and deplored recent decreased availability of subsidised dental care. Conclusions: Carers' generally positive attitudes towards clients' oral health care should encourage health educators. Insights gained from qualitative data can help to identify the less obvious causes for poor oral care delivery, which can then be addressed in education and training initiatives in nursing home settings.     

The British Columbia Positive Women's Survey: a detailed profile of 110 HIV-infected women

OBJECTIVE: To describe the health, social environment, medical care received and satisfaction with medical care of HIV-infected women in British Columbia. DESIGN: Self-administered 75-item questionnaire distributed by mail or in person between March 1994 and February 1996 through community AIDS organizations and physicians'' offices. SETTING: British Columbia. PARTICIPANTS: A total of 110 HIV-positive women. OUTCOME MEASURES: Sociodemographic data, risk factors for HIV infection, details about HIV testing, health status and medical treatment, use of health care services, degree of satisfaction with medical care and psychosocial stressors. RESULTS: Most of the women surveyed were aged 25 to 39 years (70.0%), were Canadian born (76.4%) and were white (80.9%). Over one-third did not complete high school, and half had an annual household income of less than $20,000. Of the 110 women 51.8% had children, who were HIV-positive in 12.3% of cases. The most frequently reported risk factor for HIV infection was sex with a man (49.1%); 19.1% reported both sex with a man and injection drug use, and 12.7% reported injection drug use only. Seventy-five women indicated that they had become infected through sex with a man, with or without injection drug use. Of these, 65 indicated whether or not this was the result of sexual assault or rape; 8 (12.3%) answered affirmatively. Of the 81 women who responded to the question regarding prior sexual assault or abuse, 43 (53.1%) reported being sexually assaulted as an adult, 35 (43.2%) reported being sexually abused as a child, and 22 (27.2%) reported being sexually abused or assaulted both as a child and as an adult. Women who were sexually abused as a child were more likely than those who were not abused as a child to have injection drug use as a risk factor (54.3% v. 7.5%). Menstrual cycle changes were reported by 70.1% of the respondents. Most women stated that they had not received adequate pre- or post-test counselling, and 47.0% were not satisfied with their doctor''s care. Psychosocial concerns identified to be of greatest importance were financial problems, lack of intimacy or satisfying sexual relationship, and fear of rejection or discrimination. CONCLUSION: Several important concerns for HIV-positive women were identified, including dissatisfaction with medical care, fear of discrimination, violence and abuse, and poverty.     

Patient-Reported Experiences with First-Time Naturopathic Care for Type 2 Diabetes

Differences in the effectiveness of diverse healthcare providers to promote health behavior change and successful diabetes self-care have received little attention. Because training in naturopathic medicine (NM) emphasizes a patient-centered approach, health promotion, and routine use of clinical counseling on wellness and prevention, naturopathic physicians (NDs) may be particularly well-prepared for promoting behavior change. However, patients’ experiences with NM have not been well studied. This study provides the first report of the perceptions of persons with type 2 diabetes of their first experiences with naturopathic care for their diabetes. Following their participation in a one-year prospective cohort study of adjunctive naturopathic care for diabetes, twenty-two patients were interviewed about their experiences working with a naturopathic physician. Using a content analysis approach, nine dominant themes were identified. Three themes characterized the nature of the ND-patient interaction: 1) patient-centered, 2) holistic health rather than diabetes focused, and 3) collaborative. Five themes characterized the content of the clinical encounter: 1) individualized and detailed health promotion, 2) counseling that promoted self-efficacy, 3) pragmatic and practical self-care recommendations, 4) novel treatment options that fostered hopefulness, and 5) patient education that addressed both diabetes self-care and general health. A ninth theme was cross-cutting: the contrast between ND care and conventional medical care. Results indicate that the routine clinical approach used by NDs is consistent with behavior change theory and clinical strategies found most effective in promoting self-efficacy and improving clinical outcomes.     

Refugees' perspectives on barriers to communication about trauma histories in primary care

Objective This study explores refugees'' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries. Qualitative data analysis was guided by grounded theory. Peer debriefings of refugee healthcare professionals were incorporated into the analysis.Results Two-thirds of refugee patients reported that they never shared how they were affected by political conflict with their doctors and that their doctors never asked them about it. Most refugees stated that they would like to learn more about the impact of trauma on their health and to discuss their experiences with their doctors.Conclusion Refugees are hesitant to initiate conversations with physicians due to cultural norms requiring deference to the doctor''s authority. They also lack knowledge about how trauma affects health. Physicians should be educated to inquire directly about trauma histories with refugee patients. Refugees can benefit from education about the effects of trauma on health and about the collaborative nature of the doctor–patient relationship.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists'' services.     

Patient and Healthcare Provider Barriers to Hypertension Awareness,Treatment and Follow Up: A Systematic Review and Meta-Analysis of Qualitative and Quantitative Studies

Background

Although the importance of detecting, treating, and controlling hypertension has been recognized for decades, the majority of patients with hypertension remain uncontrolled. The path from evidence to practice contains many potential barriers, but their role has not been reviewed systematically. This review aimed to synthesize and identify important barriers to hypertension control as reported by patients and healthcare providers.

Methods

Electronic databases MEDLINE, EMBASE and Global Health were searched systematically up to February 2013. Two reviewers independently selected eligible studies. Two reviewers categorized barriers based on a theoretical framework of behavior change. The theoretical framework suggests that a change in behavior requires a strong commitment to change [intention], the necessary skills and abilities to adopt the behavior [capability], and an absence of health system and support constraints.

Findings

Twenty-five qualitative studies and 44 quantitative studies met the inclusion criteria. In qualitative studies, health system barriers were most commonly discussed in studies of patients and health care providers. Quantitative studies identified disagreement with clinical recommendations as the most common barrier among health care providers. Quantitative studies of patients yielded different results: lack of knowledge was the most common barrier to hypertension awareness. Stress, anxiety and depression were most commonly reported as barriers that hindered or delayed adoption of a healthier lifestyle. In terms of hypertension treatment adherence, patients mostly reported forgetting to take their medication. Finally, priority setting barriers were most commonly reported by patients in terms of following up with their health care providers.

Conclusions

This review identified a wide range of barriers facing patients and health care providers pursuing hypertension control, indicating the need for targeted multi-faceted interventions. More methodologically rigorous studies that encompass the range of barriers and that include low- and middle-income countries are required in order to inform policies to improve hypertension control.     

Malign Neglect: Assessing Older Women’s Health Care Experiences in Prison

The problem of providing mandated medical care has become commonplace as correctional systems in the United States struggle to manage unprecedented increases in its aging prison population. This study explores older incarcerated women’s perceptions of prison health care policies and their day-to-day survival experiences. Aggregate data obtained from a sample of 327 older women (mean age?=?56) residing in prison facilities in five Southern states were used to identify a baseline of health conditions and needs for this vulnerable group. With an average of 4.2 chronic health conditions, frequently histories of victimization, and high rates of mental health issues, the women’s experiences of negotiating health care was particularly challenging. By incorporating the voices of older women, we expose the contradictions, dilemmas, and obstacles they experience in their attempts to obtain health care. It is clear from the personal accounts shared that, despite court mandates, penal harm practices such as delaying or denying medical treatment as well as occasional staff indifferences are common in women’s prisons. With older women having the greatest need for health care, an age- and gender-sensitive approach is recommended.     

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou,China

Objectives

China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China.

Methods

The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores.

Results

After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001).

Conclusions

This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care.     

Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study

Objective To describe the experiences of patients with type 2 diabetes in a web based disease management programme based on an interactive electronic medical record.Design Qualitative analysis of semistructured interviews with patients enrolled in a diabetes care module that included access to their electronic medical record, secure email, ability to upload blood glucose readings, an education site with endorsed content, and an interactive online diary for entering exercise, diet, and medication.Setting Patients'' homes in Washington state, United States.Participants Nine participants aged 45-65 completed interviews before and after they used the programme.Results Six themes emerged: feeling that non-acute concerns are uniquely valued; enhanced sense of security about health and health care; frustration with unmet expectations; feeling more able to manage; valuing feedback; and difficulty fitting the programme into activities of daily life. Three themes—valuing non-acute concerns, feeling secure, and unmet expectations—have particular relevance to the design and use of web based tools for care of patients with diabetes and chronic medical conditions.Conclusion Participants'' experiences support further study of open access to the electronic medical record and online communication between patients and their care providers. The development of web based disease management programmes should take into account the specific needs and expectations of patients, and patients and providers should have candid discussions about what web based care can and cannot provide.     

Survey of distressing symptoms in dying patients and their families in hospital and the response to a symptom control team

The care given to 26 dying patients, and their families, being nursed in a hospital where there was no specific terminal care facility was studied. These patients were dying from both malignant and non-malignant disease. Anorexia, sleeplessness, coated or infected mouths, pain, and pressure sores were seen in half of the patients. Fear about caring for the patient at home and lack of information were the problems most frequently identified by the relatives.As a result of this study a multidisciplinary team specialising in symptom control and supportive care has been established. On average half of the total number of patients dying from cancer in the hospital are supported by the team. The number of complaints from relatives of dying patients has been drastically reduced since the team was formed.     

A Pill for the Ill? Patients’ Reports of Their Experience of the Medical Encounter in the Treatment of Depression

Background

Starting in the 1960s, a broad-based patients’ rights movement began to question doctors’ paternalism and to demand disclosure of medical information, informed consent, and active participation by the individual in personal health care. According to scholars, these changes contributed to downplay the biomedical approach in favor of a more patient-oriented perspective. The Swedish non-profit organization Consumer Association for Medicines and Health (KILEN) has offered the possibility for consumers to report their perceptions and experiences from their use of medicines in order to strengthen consumer rights within the health care sector.

Methodology

In this paper, qualitative content analysis was used to analyze 181 KILEN consumer reports of adverse events from antidepressant medications in order to explore patients’ views of mental ill health symptoms and the doctor-patient interaction.

Principal Findings

Overall, the KILEN stories contained negative experiences of the patients’ medical encounters. Some reports indicated intense emotional outrage and strong feelings of abuse by the health care system. Many reports suggested that doctors and patients had very different accounts of the nature of the problems for which the patient was seeking help. Although patients sought help for problems like tiredness and sleeplessness (often with a personal crisis of some sort as a described cause), the treating doctor in most cases was exceptionally quick in both diagnosing depression and prescribing antidepressant treatment. When patients felt they were not being listened to, trust in the doctor was compromised. This was evident in the cases when the doctor tried to convince them to take part in medical treatment, sometimes by threatening to withdraw their sick-listing.

Conclusions

Overall, this study suggests that the dynamics happening in the medical encounter may still be highly affected by a medical dominance, instead of a patient-oriented perspective. This may contribute to a questionable medicalization and/or pharmaceuticalization of depression.     

Medical simulation: the new tool for training and skill assessment

Medical simulation is a new method to facilitate skill training and assessment. Simulation has achieved a high degree of sophistication in aviation and other fields. However, the complexity of health care, the numerous stakeholders, and the lack of central control of medical education have been barriers to the development and broad implementation of medical simulation. Acceptance by the medical community is growing, with the publication of scientific validation studies, the development of economic models and funding, and the integration of simulation into existing curricula and training programs. The major forces for implementing simulation will most likely come from the medical device industry and from institutions with mandates to improve the quality of health care and enhance patient safety. Certification boards are expected to increase their utilization of simulation technology to objectively assess proficiency of skills relevant to physicians and the health care system. Medical simulation has made the transition from an experimental technology to the clinical world, and the next five to 10 years may be viewed as the golden age of medical simulation.     

Clinician experiences of managed mental health care: a rereading of the threat

The threat mental health professionals perceive in managed care, as indicated by their writings on the subject, is re-examined in light of evidence from an ethnographic study. Fieldwork focusing on clinician experiences of managed care was carried out at an urban community mental health center. Existing explanations of "the threat"—the possibility of deprofessionalization and the potential for deterioration in the quality of care—proved inadequate to account for the power it wielded at this site, perhaps because its full impact had yet to be felt at the time of data collection. A "rereading " suggests the meaning of managed care for this group of clinicians lies in the prospect of being gradually, unknowingly, and unwillingly reprofessionalized from critics into proponents simply by virtue of continuing to practice in a managed care context, and in losing a moral vision of good mental health treatment in the process, [clinician experience, mental health, managed care, medical anthropology]     

Poverty and Health Ethics in Developing Countries

Developing countries face difficulties of exploitation, dehumanisation and lack of ethical professionalism, to an extent that developed countries do not encounter. Poverty-related difficulties include lack of infrastructure, unreasonable dominance of defence-related expenses in the budget, lack of a sufficient number of health care providers, absence of accountability for serious medical malpractice, as well as exploitation of patients in pharmaceutical trials. This country report presents the case of Bangladesh, one of the poorest countries in the world and therefore a good example for the deplorable condition of the health sector in developing countries.