Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: A qualitative analysis using Normalisation Process Theory

Problem

The forced movement of people as refugees around the globe is increasing and reached record highs in recent years. Refugee resettlement has therefore affected increasing numbers of primary care practitioners. There are concerns about health equity in primary care for refugees. This is primarily because of well-documented communication challenges in consultations due to cultural and linguistic diversity. While access to trained interpreters is a priority for primary care practitioners and refugees alike, there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research to guide policy and practice. The purpose of this research is to conduct a comparative analysis of barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory.

Approach

We developed and piloted an online survey with closed and open questions about the use of formal interpreting agencies by primary care practitioners who work with refugees. We recruited via email through primary care networks in four countries: Australia, Canada, Ireland and US (n=314). The survey response rates were average rages for external surveys (10-15%) in all countries except Ireland: Australia 26%, Canada and US (networks overlapped) 12.3%, and Ireland 5.9%. This presentation is based on qualitative analysis of responses to open questions.We completed a two-stage qualitative analysis of responses about barriers to interpreter use (n= 178). We conducted an inductive thematic analysis, following the principles of framework analysis, and then mapped the emergent themes onto Normalisation Process Theory’s (NPT) construct about enactment. We explored whether data fell outside the focus of this NPT construct; there were none that did.

Findings

Most respondents to the open questions were over 40 years of age (n = 122, 68.5%%), female (n = 131, 73.6%) and were not a refugee or an immigrant (n = 139, 78%). The majority were physicians/doctors (n = 146, 82%) and working in a practice using formal interpreters (n = 11; 62.5%).In all four countries, the use of an interpreter presented interactional challenges between providers and patients (e.g. difficult to develop rapport in a triadic consultation). Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters (e.g. breaches in confidentiality). There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources.

Consequences

There are shared and differential barriers to implementation of interpreted consultations in the four countries. It is necessary to identify transferrable interventions to address shared barriers and country specific interventions to address system level issues that are specific to the national context. Taken together, this will help reduce the current health inequities experienced by refugees in primary care.