Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study

Saito et al. BMC Health Services Research (2021) 21:921 https://doi.org/10.1186/s12913-021-06884-5 RESEARCH ARTICLE Open Access Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study Shoko Saito1, Mark F Harris1,2*, Katrina M Long3, Virginia Lewis4, Sue Casey5, William Hogg6, I-Hao Cheng3, Jenny Advocat3, Geraldine Marsh4, Nilakshi Gunatillaka3 and Grant Russell3 Abstract Background: Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention. Methods: The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention. Results: Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier. Conclusions: In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP’s opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services. Keywords: Refugees, General Practice, Language barriers, Interpreter use, Practice-wide facilitation * Correspondence: 1 Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, New South Wales, Kensington, Australia 2 UNSW Sydney, NSW 2052 Sydney, Australia Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Saito et al. BMC Health Services Research (2021) 21:921 Background Between 2014 and 2019, 15,000 to 20,000 refugees have resettled annually in Australia [1]. A refugee is defined by the 1951 United Nations Convention relating to the state of Refugees as “someone who is unable or unwilling to return to their country of origin owing to a wellfounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion” [2]. Many arrive with complex physical and mental health and social issues and face challenges to accessing primary health care services [3]. Linguistic and cultural differences between patients from refugee backgrounds and health care providers are major challenges to this population receiving effective primary health care [4–7]. Language barriers may reduce access to quality care from general practice [8], manifesting as missed opportunities for proactive and appropriate care [9, 10]. Language barriers may persist even after resettling for some time in their host country among some people from refugee background with continued need for an interpreter [11]. These barriers may also lead to misdiagnoses or misunderstandings with serious consequences, including the death of a patient or accusations of practitioner negligence [9, 12]. There have been concerted efforts to address language barriers to healthcare access in Australia. These include English language programs [13] and the provision of credentialled interpreter services. The federal government funded the Translating and Interpreting Service (TIS National, hereafter TIS) provides credentialed interpreters via telephone or face-to-face free of charge to medical practices and practitioners for Medicare-funded services [14]. The Royal Australian College of General Practitioners (RACGP) recommends the use of credentialed interpreters in its practice accreditation standards [15, 16]. Yet, the use of TIS was previously reported low at 1 % of Medicare consultations with patients with limited English proficiency in Australia [17], where 33 % of its population was born overseas and 21 % speak language other than English at home. 17 % of the latter group reported not being proficient in English [18]. Instead, family members, friends and relatives or bilingual practice staff continue to be used as interpreters for patients with limited English [9, 19, 20]. This approach affects the quality of health care, posing risks to patient safety due to inaccuracy [19, 21] and raises ethical issues such as confidentiality [21, 22]. Engaging credentialed interpreters has been demonstrated to help improve access and quality of care, uptake of preventive services, compliance to treatment, and satisfaction with care [18, 23, 24] and trust towards the health system [19]. Utilisation of interpreting services may also reduce hospital admissions [19] and lead to Page 2 of 12 long-term cost saving across the health care system [19, 25]. However, to realise these benefits in gene (...truncated)