Background
Methods
Study Design and setting
Construct | What it addresses |
---|---|
Sense-making | Can those involved in the implementation make sense of it? |
Cognitive Participation | Do relevant stakeholders ‘buy into’ the implementation work? Can those involved maintain their involvement and get others involved and engaged? |
Enacting | What has to be done to make the intervention being implemented work in routine practice? |
Appraisal work | How can the intervention be monitored and evaluated? Can it be re-designed to sustain its use? |
Sampling and recruitment
Country | |||||
---|---|---|---|---|---|
Austria1
| England | Greece | Ireland | Netherlands | |
Migrants/migrant representatives | 3 | 5 | 2 | 5 | 3 |
General practitioners | 4 | 2 | 4 | 2 | 2 |
Primary care nurses | 0 | 0 | 5 | 0 | 3 |
Primary care administrators | 0 | 1 | 1 | 2 | 2 |
Interpreters/cultural mediators | 0 | 0 | 0 | 3 | 1 |
Health service planners/policy makers/academics | 1 | 2 | 7 | 1 | 1 |
Trainers | 2 | 2 | 0 | 0 | 0 |
TOTAL | 10 | 12 | 19 | 13 | 12 |
Engaging migrant communities: |
• Austria: GPs work in single handed practices without migrant patient representative groups. The research team fostered dialogue between academically-oriented stakeholders from primary care and migrant representatives. |
• Greece & the Netherlands: GPs engaged with migrants at project meetings in general but expressed discomfort about involving migrant representatives directly in discussions about the practice. Research teams addressed this by engaging in parallel dialogues about these issues with migrant representatives and shared the information across the groups. |
Engaging primary care staff: |
• England: Restructuring of primary care made it difficult to involve a GP practice in the early stages of fieldwork. GP members of the stakeholder group offered their perspectives until a primary care team agreed to participate. |
• Greece & the Netherlands: Healthcare staff found it difficult to attend long PLA focus groups. In the Netherlands research teams introduced shorter sessions; in Greece they met individually with practice staff. |
• Ireland: Poor engagement of some GPs and administrators in the participating practice was offset by sustained commitment by the principal GP and practice manager. |
Engaging interpreters: |
• Greece: No formal primary care interpreting service existed. The research team made innovative arrangements with an NGO and a certified interpreter to negotiate telephone-based interpretation services for primary care patients. |
• Ireland: There was no national interpreting service with trained interpreters. This was resolved by exploring and drawing on expertise of trained community interpreters within the stakeholder group. |
Engaging policy makers and health service planners: |
• England: Restructuring of primary care due to policy changes meant that a key policymaker stakeholder was moved to a different job. The stakeholder group brought in new policymakers/health service planners at a later stage of the project. |
Data generation and analysis
Flexible Brainstorming | Fast and creative approach of using materials, such as pictures or objects, to generate information and ideas about the topic. |
Direct Ranking | A transparent and democratic process that enables a group of stakeholders to indicate priorities or preferences. |
Card sort | An interactive method for facilitating and recording brain storming around topics. |
Seasonal calendar | Seasonal Calendar is a grid-based diagram used for co-operative planning and democratic decision-making. A flexible adaptive tool, it can be used as a ‘running record’ of stakeholder’s planning over time. |
Speed evaluation | Speed evaluations are short verbal or written evaluations, often used at the end of a PLA session to indicate (to stakeholders and researchers alike) what key positive, negative and/or neutral experiences have occurred. |
NPT construct | Sense-making | Cognitive Participation | Enacting | Appraisal work |
---|---|---|---|---|
Descriptor | Stakeholders making sense of the G TIs presented to them Which ones do they think have value and benefit for their local setting? What are the positive and negative features of the G/TIs they examined? Were there shared views or not during this phase of thinking about the G/TIs? | Stakeholders’ engagement with the implementation project, process of direct ranking and selecting one G/TI to Process of selecting a G/TI reveals data about their motivation, willingness and perceived capacity to implement the G or TI, plus their feelings that it is right to be involved in the implementation work. Stakeholders thinking about other relevant stakeholders to enrol e.g., migrants, other practice staff members, trainers is part of the work of driving it forward Active enrolment work e.g., meeting someone to recruit them to the project | Stakeholders activities to introduce G Tis into clinical settings Planning imminent activities e.g. discussing divisions of labour about who makes a poster Information on what resources are available in their context to them to support these activities Stakeholders’ skills and participation in training to develop their skills Stakeholders fine tune their selected GTI to improve its quality or relevance for them Stakeholders implement knowledge from their selected G Tis into practice Divisions of labour to progress the implementation project e.g. who does what to enrol other stakeholders, to ensure smooth running of an interpreted consultation Descriptions of trying out new ways of working/communication with migrants and how it felt to apply the new way of working in e.g., consultations – did stakeholders have confidence in it? Data about the length of consultations and whether the new ways of working had positive or negative effects on consultations in practice | Stakeholders’ appraising the impact of the new way of working preferably after a period of use Stakeholders’ discussions about planning formal appraisals e.g. setting up exit interviews or patient questionnaires to monitor impact; collecting data on number of interpreted consultations Stakeholders’ reflections on findings from these appraisals, informal appraisals also relevant Can the new way of working be sustained in practice and what changes do stakeholders think are necessary to the service to ensure this? |
Results
Adapting G/TI to local context
Original G/TI | Adapted G/TI |
---|---|
Austria | |
Training Initiative: New European migrants and the NHS: Learning from each other, Manual for Trainers, First Edition February 2009, NHS Lothian, Dermot Gorman, Scotland | |
• Aimed at community health professionals, GPs and clinical support staff • Content specific to Eastern European migrants in Scotland • Material on a broad range of healthcare issues including pregnancy and midwifery • E-learning module | • Aimed at GPs • Content adapted to Turkish, African and Arabic migrants in Austria • Material focused on healthcare issues relevant to GPs • Lectures, quality circles and e-learning module |
England | |
Training Initiative: Ears of Babel: Culturally sensitive primary healthcare, Pharos, Netherlands | |
• One training session (4 hours) • Aimed at GPs only • Delivered by GP trainer & Migrant trainer • Focus on palliative care • Presentation, role play, group discussion | • Two training sessions (1½ hour, 2½ hours) • Aimed at multidisciplinary practice team • Delivered by professional drama based training company • Focus on mental health • Actor performed scenarios & adapted role play, group discussion |
Greece | |
Guideline: Guidance for communication in cross-cultural general practice consultations: Developed using a participatory research approach, Discipline of General Practice, Centre for Participatory Strategies, Health Services Executive & The Health Research Board, Ireland | |
• Developed in setting with established face-to-face interpretation services | • Introduced in setting without face-to-face interpretation services • Setting up telephone interpretation service |
Ireland | |
Guideline and Training Initiative: Working with an interpreter is easy: Self-directed training package for health professionals, SPIRASI, Ireland | |
• Aimed at health professionals only • Apparent acceptance of the use of informal interpreters in certain circumstances • Lack of detailed information about the dynamics of culture | • Aimed at inter-stakeholder multi-cultural multi-disciplinary group • Agreement on need to use formal interpreters • Additional training session on the dynamics of culture • Complemented by PLA style ‘Walk-Through’ to allow stakeholders to practise the application of knowledge from training into practice |
The Netherlands | |
Training Initiative: “Did I explain it clearly?” How to communicate with migrants with lower education and less command of the Dutch language, Pharos, The Netherlands | |
• One training session (4 hours) • Aimed mainly at medical practice assistants • Use of formal interpreters • Focus on migrants with limited education and command of the Dutch language | • Two training sessions (4 hours, 3 hours) • Aimed at entire practice team (including GPs and practice nurses) • Use of formal and informal interpreters • Focus on migrants and natives with limited education and command of the Dutch language • Developing ‘improvement plans’ with GP practice • Regular evaluations of the impact of the training |
Adapting target group
Adapting content
“I’ve clearly never had it [the services of a professional interpreter], it’s brilliant! [….] The thoughts of doing that [consultation] with someone with broken English, with or without a friend, a non-professional interpreter, would be a nightmare. It would take so long to deal with one problem and so many people in the waiting room! (Ire, GP, SH1)
Adapting mode of delivery
Adapting trainers
Introducing G/TIs in practice
Logistics of delivering training
Resources for interpreted consultations
Advertising and recruiting for interpretation services
Migrant: “I notice that many migrants come in with their boss, primarily the migrants that work in the fields and usually the boss tries to interpret. What will the GP do then? Will the service still be offered?” (Gr, MSU, SH14)
GP: “I think that we should ask the boss (…) to wait in the waiting area and we should use the phone line service only if okay with the patient. Does everyone agree with this? (..)(Gr, GP, SH6)
[All nod and say yes]
Evaluation
COUNTRY➔ Evaluation activity ↓ Number of: | Ireland Implementation of G &TI | England Implementation of TI | Austria Implementation of TI | The Netherlands Implementation of TI |
---|---|---|---|---|
Interviews to appraise impact on practice of the implemented G/TI | 4 MSU 1 GP 1 I | 1 PS | 3 MSU | |
Evaluation Forms to appraise training and impact on practice | 1 (M, GP, PS, I, H, T) | 7 (GP) | 15 (GP, PN, PS) | |
E-mails to appraise impact on practice | 6 (GP, PN, PS) |
“We are more aware of low literacy: we ask patients about it, take more time and arrange more support of social workers (..) we register it now in the patient record, and discuss consequences with the other practice members (The Netherlands, GP, SH4)
“I can transfer the lessons learned in the training into daily practice, especially in addressing mental health problems (Austria, GP, SH5)
“I am now reacting much calmer than I did before, with more patience, when a migrant who doesn’t speak Dutch stands before me at the desk”. (The Netherlands, PN, SH5)
“The receptionists were all talking about the training which was good, because you know from that the other girls [receptionists] were saying positive things.” (England, PN, SH15)
“RESTORE helped me open my eyes to my migrant patients and their needs, where in the past I just scanned over them.” (Greece,/GP/SH6)
“We could also go to a training low literacy together, and then go home, and then you have heard the information and that’s it. But we really have worked with each other, and therefore it is more relevant…” (The Netherlands, PN, SH5)
“So (..) I got a much truer picture of the type of symptoms she was having, and therefore [knew] which treatment to give her (….)[The last day] I gave her a treatment, without an interpreted consultation (..)(…).that wasn’t at all appropriate. So today we revised that, I told her to get rid of that prescription (…). (Ire, GP, SH1)
“I think after the first few sentences she [the patient] actually realised that the communication is flowing and the fact that she’s speaking only Polish means she can focus on what she wanted to say. Not on how to translate it herself. And I think I could see that the difficulty she had was with medical terminology. There was a name of a medical condition that she had and that was interpreted - I think this is where I gained the trust.” (Ireland, interpreter, SH7)
“In my case, it’s easy to trust when the interpreter is present, because I knew that she would be able to convey everything that I meant and that I would be understood. I did not feel any discomfort about it [the presence of the interpreter].” (Ireland MSU, SH2)
“If the services available were clear to us migrants, on what rights we have and this was posted at the health centres, in many cases I wouldn’t bring someone with me. I am lost when I enter the health centre.” (Gr, MSU, SH3)