Research Commentary  February 2019
Feb 1, 2019
The focus of this review is on equitable access to primary health care for Asian, refugee and migrant populations. New Zealand studies show that Maori, Asian and Pacific populations show less satisfaction compared to other groups, with the latter two citing language and cultural barriers to appropriate healthcare (Lee & Sibley, 2017). International studies identify the challenges and facilitators for health professionals providing health care for refugee and migrant groups including: cultural competency training; interpreters and the use of patient navigators to support patient access to primary health care (Furneaux et al., 2016; Robertshaw et al., 2017).
Furneaux, S., Duell-Piening, P., Christensen, S., Jaraba, S., Loupetis, M. & Varenica R. (2016). Engaging and supporting general practice in refugee health. Victorian Refugee Health Network, EACH Social and Community Health Service and ISIS Primary Care: Melbourne. http://refugeehealthnetwork.org.au/wp-content/uploads/Report_2016_August_Primary-Care-Report_FINAL-REPORT.pdf
Lee, C. H. J., & Sibley, C. G. (2017). Demographic and psychological correlates of satisfaction with healthcare access in New Zealand. New Zealand Medical Journal, 130 (1459), 11-23. http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459-21-july-2017/7313
Robertshaw, L., Dhesi, S. & Jones, L.L. (2017). Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ Open 2017;7:e015981. doi: 10.1136/bmjopen-2017-015981. https://www.ncbi.nlm.nih.gov/pubmed/28780549
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: Demographic and psychological correlates of satisfaction with healthcare access in New Zealand
The aim of this study was to explore the distribution of New Zealanders’ satisfaction with their healthcare access and to identify various demographic and psychological factors associated with this satisfaction. The New Zealand Attitudes and Values Study (NZAVS) is a longitudinal panel survey that aims to track changes in New Zealanders’ attitudes and life circumstances over time. Using a nationally representative sample of New Zealand adults, this study investigated people’s satisfaction with their access to healthcare when needed.
The results revealed considerable ethnic differences in levels of satisfaction with healthcare access. After controlling for various demographic and psychological factors, Māori, Pacific and Asian peoples were found to express lower satisfaction with their healthcare access than Europeans. This result can be
linked to findings that ethnic minorities are more inclined to experience language, information and cultural barriers to healthcare, and the lack of cultural competence among health professionals.
The findings suggest that perceptions of low healthcare access among ethnic minorities cannot be fully explained by population differences in socio-economic or personality factors. The authors conclude that in order to increase healthcare access for ethnic minorities, it is essential to develop tailored health interventions that target the unique cultural barriers encountered by these groups.
The following articles discuss successful models of intervention including cultural competency training for health professionals, the competent use of professional interpreters, better knowledge of the physical and psychological conditions presented in refugee populations, and the use of health navigators to improve access for CALD patients to primary healthcare.
Authors: Lee, C. H. J., & Sibley, C. G.
Citation: Lee, C. H. J., & Sibley, C. G. (2017). Demographic and psychological correlates of satisfaction with healthcare access in New Zealand. New Zealand Medical Journal, 130 (1459), 11-23.
Article 2: Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research
The aim of this study was to thematically synthesise primary qualitative studies that explore challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries. These health professionals face significant challenges when caring for refugees and asylum seekers. They must address their complex health and social needs, often in cross-cultural interactions, and operate within health systems that may not be structurally configured or politically favourable towards this group. These challenges impact on their ability to provide the same quality of care as the general population, leading to healthcare inequalities.
Challenges and facilitators for healthcare provision to refugees and asylum seekers were experienced within the healthcare encounter. Five inter-related factors influenced health professionals’ practice: trusting relationship, communication, cultural understanding, health and social conditions and time.
Facilitators included continuity of the attending care provider; taking an active interest in the patient’s background, language and culture and assisting them with their wider needs. Having a compassionate and empathetic disposition was also seen as important in relationship building.
The language barrier was widely cited as challenging while caring for refugees and asylum Seekers, presenting difficulties in assessing case histories, gaining consent and ensuring that patients understood treatment. Using interpreters was considered a major facilitator in communication and was maximised when interpreters were well-trained and familiar with medical terminology. Continuity of the interpreter was deemed important in fostering good communication and increased confidence in the integrity of translation.
Gaining knowledge and understanding about the cultures of refugees and asylum seekers was viewed as an important facilitator in cross-cultural care. This included understanding differences in health beliefs, body language, health practices and health presentations. Cultural understanding allowed health professionals to adjust their healthcare practice accordingly.
4.Health and social conditions
Several facilitators were identified that could help deal with complex physical and psychological conditions. Careful history-taking of medical, social and migration background was helpful and could identify possible risk factors. Training in conditions common among refugees and asylum seekers was deemed valuable, increasing confidence in care delivery and resulting in more effective, evidence-based care. Clinical guidelines for refugee healthcare were considered beneficial. Professional support was regarded as a facilitator, provided within services or from external organisations specialising in refugee healthcare. The importance of psychological support for those working with traumatised patients was highlighted, such as counselling or debriefing.
A significant challenge faced by health professionals was the time required to provide healthcare for refugees and asylum seekers. More time was necessary due to the challenges around building relationships, communication, achieving cultural understanding and dealing with complex health conditions. This additional time demand meant that appointments needed to be extended in duration or occur more frequently.
The implications for practice are that health professionals should be sufficiently resourced to meet the complex needs of refugees and asylum seekers. This should include provision of appropriate training on areas of cultural competence, asylum policies and process and health conditions. It is recommended that specific clinical guidelines are developed for provision of care to refugees and asylum seekers, drawing on the best available evidence. Further professional support should be given to those working with patients who present with complex psychological and social difficulties. Relevant, up-to-date information should be made available to inform health professionals about the needs of current waves of refugees and asylum seekers and other available services for referral and collaboration. Health providers should ensure adequate time is allocated for appointments with refugees and asylum seekers allowing space for trust building, communication and cultural understanding. They should develop infrastructure to ensure that trained interpreters are provided in a timely manner for appointments. Where resources permit, trained interpreters should be available with face-to-face and remote options (eg, via phone), depending on patients’ preferences.
Authors: Robertshaw. L., Dhesi, S., Jones, L.L.
Citation: Robertshaw. L., Dhesi, S., Jones, L.L. (2017). Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries: a systematic review and thematic synthesis of qualitative research. BMJ Open 2017; 7:e015981. doi:10.1136/ bmjopen-2017-015981
Article 3: Engaging and supporting general practice in refugee health
The Victorian Refugee Health Network led a two-year Primary Care Project, which was guided by a multi-sectoral project advisory group. General practices partnered with the Network for one year to develop and trial approaches to facilitating practice changes. The project aimed to develop and trial an approach to engaging and collaborating with general practices to promote the delivery of accessible and appropriate health care to people from refugee backgrounds, including those seeking asylum. There are lessons to be learned for PHOs in New Zealand wanting to increase the number of general practices who are able, willing and confident to work in this area.
The Victorian policy context offers an enviable level of care for refugee patients. For example, in addition to the community health services we offer in New Zealand, refugee patients are offered priority of access for dental care and fee waivers for general and specialist dental and other services.
In the study, when communities were asked about challenges accessing a general practice, the most common responses related to language and cultural barriers, and the use of interpreters. This related to the experience with GPs as well as reception and pharmacy staff. The reception experience was particularly important, including the need for people to feel welcome in the practice, and to understand the practicalities associated with making, changing or cancelling appointments.
Bilingual GPs were identified as potentially both a challenge and an enabler for good experiences with general practice. Bilingual GPs were preferred by many people from refugee backgrounds for ease of communication. However, there were some views that the depth of understanding of the Australian health system by bilingual GPs may be more limited. When asked what makes for a good experience when accessing a general practice, common themes included the interaction with the GP, such as cultural sensitivities/appropriateness, using interpreters, and clear explanations of health issues and medications.
The service providers interviewed noted general practices were required to do a lot for refugee patients. The perception of many practice managers, was that refugee health is both time consuming and expensive. Where practices were responsive, having a champion GP, practice nurse or practice manager as a key contact, helped with general practice engagement. In addition, offering tangible, flexible, practical and persistent support acted as an enabler. This included clinical support, data collection item support and support for the upskilling of practice nurses. Having the whole practice on board made general practice engagement work well. Common priorities included engaging practice managers and administration staff to support practice cultural change and capacity building for non-clinical staff; cultural competence/refugee experience training for all practice staff; working with interpreters for all practice staff; business guidelines and support; and localised training and supports.
Authors: Furneaux, S., Duell-Piening, P., Christensen, S., Jaraba, S., Loupetis, M. & Varenica R.
Citation: Furneaux, S., Duell-Piening, P., Christensen, S., Jaraba, S., Loupetis, M. & Varenica, R. (2016). Engaging and supporting general practice in refugee health. Victorian Refugee Health Network, EACH Social and Community Health Service and ISIS Primary Care: Melbourne.
Article 4: Patient navigators facilitating access to primary care: a scoping review
The aim of this scoping review was to examine the use of patient navigators to facilitate access to primary healthcare and how they were defined and described, their components and the extent to which they were patient centred. Primary care is the first level of access to healthcare, delivered in the community most often by general practitioners. However, not all people from CALD backgrounds access primary care that best meets their healthcare needs. Although reforms to primary healthcare in New Zealand and abroad have focused on trialling new processes and models of care to improve access including integrated care models, after-hours telephone consultations, walk-in centres and nurse-led initiatives, disparities in care remain for many, such as people having low literacy and low or no English-language skills.
A new approach to improve access to primary care is patient navigation, a process where a person (navigator) engages with a patient to determine barriers to care and provides information to improve access to components of the health system, not just primary care. A patient navigator can be described as a type of ‘broker’ who uses a biopsychosocial approach to provide a range of instrumental and relational functions and processes to support patients to access primary care. Patient navigators have been shown to: facilitate access to health-related programmes, promote and facilitate continuity of care, identify and remove barriers to care and effective and efficient use of the health system. In this study, the authors also found that added to these activities, a key feature of patient navigation to facilitate access to primary care is a relationship-based approach, informing and involving patients in connecting them to care.
Authors: Peart, A., Lewis, V., Brown, T., et al.
Citation: Peart, A., Lewis, V., Brown, T., et al. (2018). Patient navigators facilitating access to primary care: a scoping review. BMJ Open 2018; 8:e019252. doi:10.1136/bmjopen-2017-019252
Article 5: Ethnic disparities in community antibacterial dispensing in New Zealand, 2015
There are significant ethnic disparities in the incidence of various infectious diseases in New Zealand. The aim of the study was to measure the rates of community antibacterial dispensing for the major ethnic groups during 2015; to inform the development of antimicrobial stewardship interventions in New Zealand. Demographic data on all patients registered with a general practice in New Zealand and on all community pharmacy antibacterial dispensings during 2015 were obtained from national healthcare databases. The rates of dispensing were measured as the number of dispensings per 1,000 population per day and as defined daily doses per 1,000 population per day.
The results of the study show that the rates of community antibacterial dispensing for the total population surveyed was 3.01 dispensings per 1,000 population per day, and was 3.49 for Pacific, 3.23 for Maori, 3.02 for European, 2.70 for Middle Eastern, Latin American and African, and 2.35 for Asian people. In all ethnic groups the rate of community antibacterial dispensing increased with increasing socioeconomic deprivation. Seasonal variation in antibacterial dispensing ranged between 34% in Asian people and 24% in European people.
The authors concluded that the ethnic disparities in the rates of antibacterial dispensing in New Zealand are consistent with, but less marked than, the ethnic disparities in the incidence of infectious diseases in New Zealand. Improved community-wide understanding of both the benefits and the harms of antibacterial medicines is necessary to support improved antibacterial use in New Zealand in the future.
The findings of the study showed that the seasonal variation in antibacterial dispensing ranged from 25% in European people to 35% in Asian people, suggesting that, based on this indicator, the quality of antibacterial prescribing is relatively consistent across ethnic groups in New Zealand. However, the relatively high levels of seasonal variation in antibacterial dispensing in all ethnic groups in New Zealand, when compared with the overall levels in Denmark and the UK, do suggest that there is considerable scope to reduce prescribing in New Zealand for patients with winter coughs and colds. In order to achieve lower levels of antibiotic prescribing patient education messages will need to be tailored and targeted for all ethnic groups, including translation into the main languages represented in non-English speaking populations in New Zealand.
Authors: Whyler, N., Tomlin, A., Tilyard, M. & Thomas, M.
Citation: Whyler, N., Tomlin, A., Tilyard, M. & Thomas, M. (2018). Ethnic disparities in community antibacterial dispensing in New Zealand, 2015. N Z Med J, 131(1480), 50-60.