COMMUNICATIONBibiana Navarro‐Matillas. Andalusian

School of Public Health

• The migration medicine is not a medicine of strange viruses or parasites; it is a medicine of men and women who differ from us in the form of express suffering and problems, in the way of conceiving life, illness, pain and death. They have left in their country a health culture without abandoning it and incorporate another without having understood it; it is the medicine for some patients who expect our wise world with a mythologized technology will save them, but they could not make their physicians and caregivers understand their internal problems.

Migration medicine:

Migration medicine:

• The health care to immigrants, besides their cultural peculiarities, not differs significantly from the provided to autochthonous people.

• The health professional should know how to serve the population, considering the diverse aspects of each one, so he/she can customize the support give in relation with the diversity, the culture and religious differences that influence the way that we understand health and life in general.

Specific aspects about the clinical interview to the immigrant population.

General Objective:

• Provide the participants of basic tools that allow them to have good communication with immigrant patients to achieve greater efficiency in the physician-patient relationship.

Specific objectives:

• Knowing the particular aspects in the clinical interview with immigrant patients.

• Identify what changes are needed to establish effective interpersonal communication in their relationship with immigrant patients.

Video

Communication with the immigrant population

Difficulties in delivering care to the immigrant population.

• Language barriers• Ignorance of their customs / beliefs / values • They come with different expectations, some

of which aren’t always realistic• Distrust of us• Difficulty in understanding their demands

and responding to them. • Some diseases that we do not handle.

Difficulties in the attention to the immigrant population. (1)

•Personal prejudices, negative emotions.•Their social conditions (health, housing, timing at work, lack of monitoring …)

•Difficulty in physical examination. •No previous reports, we do not spend time with them, no good records are available and sometimes we repeat tests.

Difficulties in the attention to the immigrant population. (2)

Difficulties in the attention to the immigrant population. (3)

Esteva M et al. 2006.

Clinic• I have more trouble keeping track of the

pathological process in the immigrant than with the rest of my patients.

•More often immigrant patients do not comply with treatment compared to the rest of my patient.

• There are differences in the disease that immigrant patients have regarding the rest of patients.

• Immigrants come to the consultation due to mental health problems more often than other patients.

Communication is a process whereby an idea or a

message is transferred from a source to a receiver.

Sender Receiver

Channels: Visual, Gestural, Vocal...

Characteristics of the communication

•Linguistic problems

• Cultural interferences

• Emotional interferences

Linguistic problems

•Ignorance of the language.

•Different use.

•Different use of non-verbal language

Linguistic problems

Challenges:a. when defining the complaint. b. present diagnostic and therapeutic plan. c. distrust of the physician regarding the correct

treatment compliance d. understanding and approaching to the

problem. e. and mistrust of the patient with the instructions that he cannot understand and an medium that he does not know.

Cultural Interference

Concept of "culture": Set of theories on the reality that we observe which determine in advance in all the cases the interpretation of the above mentioned observations:a. we understand that the forms of illness, cure and healing are different for each culture. b. beliefs (myths, traditions, taboos) and values, interpretation and expression of symptoms or the social implications are different for each one.

Cultural Interference

Syndromes dependent on the culture:•“Fright"•“Fit of panic" in Latin Americans.•"Evil eye" in certain Mediterranean populations.

Emotional interference

Professionala. Time limited b. Difficulty tracking "job

loss" c. Lack of knowledge of

possible pathologies. d. Misuse of resources e. racial stereotypes

Immigrantf. misunderstood g. incorrectly treatedh. Fear ...

Sender

Receiver

Channels: visual, gestural,vocal…

Sometimes it may happen that they are not understanding what we’ve said

Basic techniques for interviewing

• Choose a suitable environment and situation, ideally a place that is quiet, private and secure. Seek to be alone with the migrant at some point

• It is essential to observe and to be attentive to what the migrant says or what he/she doesn’t say, as well as to his/her verbal and non-verbal expression.

• Try not to let your own anxieties obstruct the intervention

• The time spent on the interview greatly influences its effectiveness. Conducting it in a hurry, or without limits, can reduce efficiency.

• Possess sufficient knowledge and maturity to conduct the interview under these conditions.

Basic techniques for interviewing

Communication Barriers

Interview Skills

• Empathy: ability to understand, tune in and interact with the migrant and the problems that his/she relates

• Warmth: emotional closeness between the migrant and the interviewer - which unlike empathy is expressed primarily in nonverbal ways

Communication barriers

Interview Skills

• Empathy: ability to understand, tune in and interact with the migrant and the problems that his/she relates

• Warmth: emotional closeness between the migrant and the interviewer - which unlike empathy is expressed primarily in nonverbal ways

• Respect: interviewer's ability to convey the migrant that his/her problem concern to him, preserving his way of thinking and its ethical and ideological values

• Concretion: interviewer's ability to define mutual objectives and shared goals during the interview, ensuring that it takes place in a language understandable for both.

Interview Skills

Basic techniques for interviewing

Communication Barriers• Choose a suitable environment and situation. What we

need is a quiet, private and secure. Seek to be alone with the patient at some point

• It is precise to observe and to be attentive to what the patient demonstrates and to what he/she omits, as well as to his/her verbal and not verbal expression.

• Try that own anxieties do not obstruct the clinical intervention

Basic techniques for interviewing

• The time spent on the interview greatly influences its effectiveness. Do it with hurries or without limits can reduce efficiency.

• It is useful to clarify and agree in advance the expected length, being helpful to have 40-60 min at least in the first evaluation

• Possess a level of knowledge and a maturity sufficient to carry it out under the conditions laid

Interview Skills

• Empathy, ability to understand, tune in and interact with the patient and the problems that his/she relates

• Warmth, emotional closeness between the patient and the interviewer, which unlike empathy is expressed primarily nonverbal

• Respect, interviewer's ability to convey the patient that his/her problem concern to him, preserving his way of thinking and its ethical and ideological values

• Concretion, interviewer's ability to define mutual objectives and shared ones in the interview, ensuring that it develops in a language understandable for both directions

Multiculturality Reality

Cross-cultural Dynamics

Interculturality Achieve

Immigrant Cultural Assessment

Approximation to the Cultural Model of the Immigrant

Cultural Assessment. Kleinman methodology• What do you think is causing the problem? • Why do you think that has started in this way? • What do you think this problem is doing to you? • What is your biggest fear about this problem? • How serious is it? • What do you think is going to happen? • What kind of solutions do you believe you should

receive?

Universal Therapeutic Aspects

The therapeutic basic operations: identification and nomination of the problem for which the patient is consulting, prescription of a medicine and control of the treatment.The elements of treatment• Establishment of a therapeutic relationship conveyed by treatment • Construction of a consistent therapeutic framework (including items such as suitable clothing, the institutional environment, the decoration of the place, the rituals of the therapist to identify his as such, etc.).

Universal Therapeutic Aspects

• The act of defining the etiology of the problem (through exploratory dialogue, additional tests, etc.).

• The explanation of the problem to the patient in understandable terms acceptable from his world conception.

• The prescription of treatment (medication, behavior tips, changes in the environment, rituals, ceremonies, etc.).

Tseng WS, McDermott JF. Psychoterapy: historical roots, universal elements and cultural variations. American Journal of Psychiatry. 1975; 132: 378-384.

Why do we need cultural competence?

• The disease varies with cultures. • There are different beliefs about the welfare, health and

healing systems. • Cultural attitudes affect relations with physicians and

other professionals. • Patients seeking health services complementary and

alternatives • There is a shortage of professionals who come from

minority groups to go to. • There are many dropouts and lack of adherence to

treatment, plans and follow up. • Increases customer satisfaction and facilitates continuity of

care.

Principles of care centered on the patient which includes the empathy,

the exploration of beliefs, the valuation of the sensibility of the

patients, his/her needs, values, and preferences

Non-verbal communication

“It is possible to lie with the mouth,but the expression that goes

with the words tells the truth”

Nietzsche

Video

Nonverbal communication

• Non-verbal communication is most suitable for the transmission of emotions and feelings; it regulates and validates verbal messages

Non-verbal Communication

Non-verbal Communication

•65% of the communication

•No sinlge meaning

•Doesn’t exist to communicate but to be felt

•Although it may say “A” what it really means is “B”

When patients can not understand medical terms that we use, they look at the professional's nonverbal behavior as a way of understanding the situation.

• Warmth-Friendliness

• Empathy

• Respect

• Concretion

• Assertiveness

• Low reactivity

Which are the characteristics that an interviewer should have?

The model of communication centered on the patient of Western Ontario

Exploration of the disease and the sickness (the experience of being or to feel sick)• Comprehension of the person.• Person understanding • find common points regard to the plan.• Incorporate prevention and health promotion. • Improve the doctor-patient. Relationship• be realistic.

1. Sickness and Disease

Examination• The patient's ideas about what succeeds to

him/her • The patient's feelings, especially fears. • The patient's expectations about the

professional• The impact of the symptoms or the

experiences of them have in his/her life.

2. Understanding the person.

• Patient• Context:• Family• Social• Labor• Education• Economic

3. Search common points regard to the plan

• Definition of the problem.• Setting goals and treatment goals.

4. Incorporating prevention and health promotion.

• The model incorporates elements such as improving health in its broadest concept, risk reduction, early detection of disease and decrease of its effect.

5. Improving the doctor-patient relationship

• The type of relationship that is proposed in this model is of collaboration between practitioner and patient. An essential aspect in the relationship is to recognize the differences and particularities of each person.

• The practitioner must remain open and alert to the changing needs of the patient.

6. Be realistic

• All this must be done within the framework of the real resources, with the actual professional interview time and the means available to them. Be realistic implies not to address health utopias, known what a patient is willing to, what is his/her commitment and what are the available resources.

In our practice we will use…

Semi structured interview

• Constitutes a protocol of action in the communicative aspects opposite to the ones spontaneously developed.

• Easy to memorize and incorporate into daily routines.

• Ensure a minimum of quality.

Semi structured interview

• Exploratory Phase

• Decisive phase

Exploratory Phase

• Warm Welcome.• Delimit the complaints.• Listen.• Search and complete data.• Summary of information received.• Accompaniment to exploration.

1. Warm Welcome

The first minute is important • Show kindness• Looking at the patient• Mention your name• Modular your voice to give kindness to the

meeting

Question to situate us within the patient reality

• Where is he/she from? • Why he/she has migrated? • In what situation is he/she here?

2. Delimitation of the consultation reason

Some peculiarities

• Asians do not usually talk about abstract things; they are often very direct and concrete about their visit.

• The South Americans are in the habit of digressing more.

• The Muslim woman refuses to talk about their sexual activity even if the practitioner is female will not be easier to broach the subject.

3. Active listening

• Techniques that pursue to emptied the pre- elaborate information

• These techniques are focused on both the interpreter and the patient

3. Active listening

Empathy• Facilitations• Quotes by repetition• Clarifications• Signs• Functional silences

4.Search and complete data

Data that are: • Real• Reliable • Valid

Techniques: • Open questions • Closed questions • Menu of suggestions

A Peculiarity

Sometimes in the immigrant patient interview, due to the language barrier and cultural interference we tend to induced response to questions made. The patient has a tendency to respond what the interviewer wants or expected to respond, we must avoid it , although initially help us to initiate or stimulate conversation, it can lead to false diagnoses.

5. Summary of the received information

Provide a summary and ask•Do you think that this summary accurately reflect what happens?

6 Accompaniment to exploration

Sentence bridge that will accommodate the patient to the exploration.

Decisive phase

This phase starts when the professional takes a decision about the best intervention.

Information is gives to the patient

Decisive phase

Objectives• Improve understanding of the patient. • Improve enforcement • Facilitate changes • Addressing the concerns of patient information.

Decisive phase

Techniques to use•Listing •Exemplifications •Rationality •Observe Changes •Check assimilation.

Decisive phase

• Report on the origin of health problem. • Propose an action plan. • Explain treatment and course. • Check the assimilation by the patient. • Take precautions and finish the interview.

1. Report the origin of the problem. Enunciation

• The statement of the problem of health consists on giving a diagnosis or defining the problem of health. Formal aspects in the emission of informative messages:

• Short phrases. • Vocabulary neutral. • Clear diction and appropriate intonation. • Visual complement - tactile. • Use examples.

2. Propose a plan of action

When we have an idea of the diagnosis (or possible diagnosis) of the patient, we have to propose a plan that can range from taking medication, exercising, eating a diet, through certain tests…

3.Explain the treatment and evolution

Techniques: • Rationality of the therapeutic measure. • Highlight the important • Repeat. What is repeated is better

remembered • Detailing the instructions and behavioral

changes and give writing instructions • Explain the expected evolution.

4. Verify the patient assimilation

• Verify if the patient or his/her accompanist have understood well the treatment

• Encourage the patient to repeat the treatment • Try to identify the explanations for each

patient and make sure they understand you.• Be aware of nonverbal doubts of the patient

or his/her companion and encouraging them to verbalize them.

5. Take precautions and finish the interview

• The practitioner informs the patient of possible adverse evolution and invites him/her to a new consultation if such a situation arises. • A good end: •Provokes reinforcement in the therapeutic alliance.• Minimize risks. •Regulates the health load and the patient follow-up

A Peculiarity

• The clandestine situation of some of them cause that they go to the consultations with fear and only if necessary.

• They ignore our health system and have not information about its services, they do not find the professional interested in their problem, some facts can be interpreted as rejection or neglect.

Systematic LEARN

• Listen• Explain • Acknowledge • Recommend • Negotiate

Berlin EA,Fowkes WC, jr. A teachimg framework for cross-cultural health care- application in family practice, in

cross-cultural medicine. West J Med 1983;12: 93-98.

Abstract

• Communication with the immigrant is based on cultural competence and clinical interview techniques.

• We know that there are cultural, emotional and sometimes linguistic differences. Be aware of it.

• knowledge, skills and attitudes regarding communication with health care can be learned.

Abstract

• The model of patient-centered communication has been shown to be the most useful way to approach communication in the immigrant population.

• Clinical interview techniques that we use in our consultations can be applied to the immigrant population, taking account of their idiosyncrasies.

• Communication with the immigrant population is a communication with the person, as we do every day with all our patients.

Thank For your Attention...