Between two worlds: a qualitative exploration of language, cultural and other barriers in diabetes consultations involving Pakistani patients.
The AIMS of this study are to: (1) Explore the perceptions and experiences of diabetes consultations from the perspectives of Pakistani patients, health professionals and interpreters (when one was involved). (2) Identify the processes and mechanisms which hinder or foster effective communication between healthcare professionals and their patients. (3) Provide recommendations for ways in which communication can be improved between healthcare professionals and their Pakistani patients STUDY DESIGN: A prospective qualitative study was developed, comprising three sequential components; namely: In-depth interviews with patients prior to a diabetes consultation; observation of the consultation; and, in-depth interviews with patients, health professionals and interpreters (when one was involved) following the consultation. Data were collected in the form of 10 detailed case studies. Each case study involved a Pakistani patient with type 2 diabetes mellitus (T2DM), their practitioner (s) involved in the consultation and an interpreter (if one was used). SAMPLE: Five male and five female Pakistani with T2DM (aged 41-80 years), 12 practitioners (some patients consulted with two people) and three interpreters (two professional and one lay) were recruited through health services and personal contacts within Edinburgh’s Pakistani community. Individual case studies were thematically analysed before all the case studies were compared/contrasted to identify cross-cutting themes. FINDINGS: Alongside language, a range of barriers and issues were identified which impacted upon communication between patients and health professionals in the consultations observed. Because of previous experiences of attending consultations in the UK and also in Pakistan, patients tended to come to their diabetes consultations with limited expectations; namely, to have their medication reviewed and receive test results. Consequently, patients tended not to raise health concerns and other issues unless they perceived these to be directly relevant to the consultation. In some cases, this resulted in patients not disclosing important information relating to their diabetes management and led to health professionals making inappropriate treatment recommendations. The routine and predictable nature of these diabetes review consultations meant that patients could be passive, offer very little information and ‘get by’ in their consultations; for instance, by offering responses after guessing what the professional was asking. As a result, some health professionals were unaware of patients’ poor English and of how little they had understood during the consultation. Health professionals found it difficult to establish understanding and rapport with patients who adopted a passive role in their consultations. This hindered them from identifying, and appropriately addressing, gaps in patients’ diabetes knowledge and any concerns they may have had. Interpreters did not always address the language barrier and edited and misinterpreted information. This is partly because they struggled to interpret medical terminology. However, this research also revealed how interpreters can experience dilemmas and role conflicts by virtue of being members of the same closely-knit Pakistani community as the patients they interpret for. Some of the barriers identified during this study also arose because patients tended to see different professionals at every visit which discouraged patient-provider relationships from being established. CONCLUSION: Patients would benefit from receiving ‘continuity in care’ and education and training on how to use their consultations more effectively. Providers would also benefit from education and training on more effective ways to communicate with these patients.