Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study

Abstract

BackgroundCross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice.MethodsWe undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers’ fieldwork reports, were coded and thematically analysed by each team using NPT.ResultsIn all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants’ needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP’s diagnoses and GPs reported a clearer understanding of migrants’ symptoms.ConclusionsMigrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time

“…19,[21][22][23] The EU-funded project RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings; summarized in Table 3) combined NPT and PLA to investigate and support implementation of guidelines and training initiatives to improve communication in primary care with migrants who are not fluent in the language of their host country. 7,11,12,24,25 There was evidence of positive changes to attitudes, knowledge and behaviour in practice settings 12 (see Table 3).…”

“…The use of PLA in RESTORE emerged as a key facilitator for the NPT implementation process. 7,11,12 PLA enabled participants with different levels of knowledge and power-doctors, practice assistants and migrants-to work together in a democratic manner. 7,11,12 This led to a shared feeling that the guidelines and training initiatives made sense (NPT construct 1), a shared sense of responsibility and engagement (NPT construct 2) to implement guidelines and training initiatives and shared work to enact them in daily practice (NPT con- These matters have not yet been explored in relation to RESTORE and warrant investigation.…”

“…This is an interactive method for facilitating and recording brainstorming around topics, which draws on relevant knowledge from previous research. 26 For this study, 23 cards (see Table 5) were created, based on the impact of the RESTORE project on clinical practice 12 Data analysis took place in pairs (RESTORE PI and student) in each country, in the language of the country, following the principles of deductive framework analysis. 27 Specifically, the a priori TA B L E 3 Information on RESTORE project (2011-2015)…”

“…24 Throughout this process, the PLA approach facilitated health-care providers to work collaboratively with migrants; to select and adapt a guideline or training initiative for their local setting; and to introduce it into their practice setting. 11,12 There were multiple impacts across settings. These included changes in knowledge (eg new knowledge and skills from completed training), attitudes (eg more tolerant and positive attitude towards migrant service users among receptionist staff) and behaviour (eg more effective communication in consultations between general practitioners and practice nurses and migrants with low literacy; increased flexibility in accommodating migrants' appointments among all staff).…”

“…Participatory health research and specific approaches such as participatory learning and action (PLA) can enhance public and patient involvement (PPI) and support implementation processes in primary care. 7,[9][10][11][12] There is also increasing recognition of the importance of the role patients/public may play in the broader, macro-level context that shapes organizational capacity and willingness to take action to support implementation of changes in health-care settings. 1,6,13 In this paper, we provide results of a follow-up study of an earlier investigation that combined NPT with PLA in primary care implementation research.…”