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Culturally appropriate communication requires adjusting one’s practice and identifying appropriate resources, such as interpreters, to ensure that the patient can communicate needs and have those needs understood. Select interpreters carefully. Do not use casual bystanders, minors or those who have accompanied the trafficked person as interpreters (see action sheets 3, 6 and 10).
RequIRed ACTIonS To provide care that is culturally responsive • Provide access to interpreters if there are language barriers (see action sheet 3). Have a system for identifying a patient’s language needs, including in-person or telephone access to interpreters.
• Assess an individual’s literacy level to ensure that information is conveyed in understandable ways. Some people respond well to information conveyed using visual aids.
• Don’t make rapid or negative assumptions about individuals’ reactions or behaviour. Consider possible cultural, social or personal reasons for individual reactions.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS• Identify current social stressors, including housing, legal and financial constraints, and making appropriate and timely referrals to social services (see action sheet 10).
• Explore the patient’s own understanding of their illness. See section on the explanatory model, below.
• Ensure that the patient’s wishes for a provider of the same sex is respected when possible, as well as the patient’s choices about whom they would permit to examine them.
• Recognize the importance of religious beliefs in a patient’s recovery, as well as their understanding of the trafficking experience in the context of their religion and cultural beliefs.
Explanatory model (EM)
Exploring the patient’s meaning of illness is important, particularly while evaluating the range of symptoms. The ‘explanatory model’ is a practical approach to assessing this that can help providers avoid cultural stereotyping.
Because it is not possible to know everything about every culture, it is important to learn how to ask trafficked persons about their expectations for care. Suggested questions for eliciting the patient’s perspective on their
1. What is the problem? How do you describe what is going on?
2. What do you think has caused your problem? How?
3. Why do you think the problem started when it did?
4. How does it affect you?
5. What worries you most? (Severity? Duration?)
6. What kind of treatment do you think you should receive?
(Expectations?) Provider-patient negotiation Once you have explored the patient’s concerns and elicited the patient’s perspectives on their illness (their explanatory model), utilizing the support of interpreters and visual aids as necessary, work with the patient to develop a treatment plan that is understandable, feasible and sustainable.
Creating a mutually acceptable plan that acknowledges the background and individuality of each patient for next steps requires shifting paradigms from ‘making a patient comply with treatment’ to ‘supporting patients in their healing and recovery’. Planning treatment in cooperation with the trafficked person conveys responsive support and a sense of empowerment: it is a signal to the patient that you have listened and understood the patient’s concerns.
44 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSA mutually acceptable treatment plan is more likely to be embraced by the patient and result in improved outcomes. Such negotiations may be constrained when clinical encounters are brief (e.g., if the patient is in detention or in transit) or by a patient’s lack of health insurance or resources to pay for care.19 While you may be concerned about the additional time involved in communicating and negotiating with patients, particularly those from diverse backgrounds, evidence suggests that using these strategies actually shortens the amount of time ultimately required to diagnose and treat. Patients are more engaged and open to communication when providers offer culturally responsive care. Using these techniques to take medical histories from those who may express their illnesses differently and to plan treatment for individuals familiar with other medical practices is likely to take less time and be more effective than guessing, missing diagnoses and failing to get adherence to care.
Health is a recognized human right and many countries strive to provide universal access to health care for victims of violence, those in need of emergency care and vulnerable groups. However, in reality it can be very complicated to provide the necessary medical and mental health care for a victim of trafficking who cannot pay and may not have the identity documents required to access existing social services. Coordination with other service providers, particularly those with experience in meeting the many non-health needs of trafficked persons, is essential (see action sheet 10).
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Denoba, D. L. et al.
1998 “Reducing health disparities through cultural competence”, American Journal of Health Education, vol. 29 (5 Suppl.), pp.
RATIonAle Accurate communication is essential to providing quality, rightsbased health care to trafficked persons. Due to the nature of trafficking, many trafficked persons are offered care when they are away from their home country by health care providers who do not speak their language.
(Persons trafficked within a country may also face language barriers.) In these situations, care is often facilitated by interpreters. This action sheet focuses on communication via interpreters, while acknowledging that there are also cultural, gender, age-related and other sensitivities (e.g., literacy, disability, culture or capacity) that may affect communication with trafficked persons.
(See action sheets 1, 2, 5, 9, and 10 for more information on other topics related to communication.) Working with interpreters in health care settings can be enjoyable as well as challenging. Such topics as abuse and psychiatric symptoms may be more difficult to discuss through interpreters. Some health care providers report greater detachment from their patients and feel less effective in their work or frustrated because treatments take longer. However, in many cases, care strategies can be enhanced by working with an interpreter who fosters better communication and engagement with the trafficked person, and who helps the provider obtain accurate information within a cultural understanding of the individual (see action sheet 2).
Interpreters in health care settings can have various roles. When working with an interpreter it is worth considering the potential roles that he or she might take. This role will depend on the care setting, the patient’s needs and the professional experience of the interpreter and the clinician. The following
roles have been identified for interpreters:
50 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS• Interpreter who provides a neutral and impartial service.
• Cultural broker who explains and gives cultural and contextual understanding to the health care provider and the client.
• Advocate who represents the patient’s interests.
• Intermediary or conciliator who resolves conflicts between the patient and the health care provider.
• link worker who helps the clinician identify unmet needs of the patients and provides support to the patient.
• Bilingual co-worker who takes on a more involved therapeutic role in addition to providing translation.
RequIRed ACTIonS Before beginning work with an interpreter there are some preparations that you might wish to consider to facilitate your work with the trafficked person and the interpreter.
Selecting an interpreter Selecting an interpreter is an extremely important step that is crucial to the safety and well-being of the trafficked person as well as that of the health
provider. The following basic cautionary notes should be followed:
For the patient encounter • Find out the trafficked person’s first language and dialect and if he or she speaks any other languages.
• Take into account the nationality, religion and gender of the patient (see action sheet 2).
• Book longer sessions that will allow time for interpretation.
• Try to find a way to explain to the trafficked person that you are seeking interpreting services.
• Try to find a way to encourage the trafficked person to let you know if he or she becomes uncomfortable with the selected interpreter for any reason.
For the interpreter
• Notify the interpreter or his or her agency of the subject matter (e.g., confidential medical discussions that may cover violence, rape, etc.). Be aware that if you don’t do that you might find that the interpreter is reluctant or feels uncomfortable with the subject matter.
• Because confidentially is extremely important when working with trafficked persons (see action sheets 7 and 9), you may want to consider establishing a formal mechanism which makes clear the role of the interpreter and their responsibilities to maintain confidentiality. An example of this could be a standard operating procedure agreed to with the agency or individual.
• In order to establish a relationship in which the trafficked person feels safe working with you and the interpreter, it is important to carry out all consultations with the same interpreter if more than one meeting is possible. When arranging for an interpreter it is important to ensure that the agency and the individual interpreter know that you are planning to use the same interpreter in your future sessions.
• Warn the interpreter not to give out personal contact details and against disclosing any information to others about the trafficked person.
52 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSDuring the consultation
• If you have serious doubts about the interpreter's conduct, discuss this with the interpreter. If the individual is employed by a service, provide feedback to the employer.
• Reflect on how to maintain good working alliances with interpreters who have demonstrated that they can be trusted.
RefeRenCeS And ReSouRCeS Raval, H.
2005 “Being heard and understood in the context of seeking asylum and refuge: communicating with the help of bilingual coworkers”, Clinical Child Psychology and Psychiatry, vol. 10, no. 2, 1 April 2005, pp. 197–216.
Tribe, R. and H. Raval (Eds.) 2003 Working with Interpreters in Mental Health, Brunner-Routledge, Hove, United Kingdom and New York, NY, USA, 2003.
Action Sheet 4:
TION Comprehensive health assessment
RATIonAle A comprehensive health assessment is important because many trafficked persons will experience a range of abuses and other health risks that result in co-occurring conditions.20 Although patients may present with specific symptoms that seem to be the focus of the clinical encounter, patients are likely to require a comprehensive medical and mental health assessment because the high likelihood of co-occurring disorders. Knowing the multiple health problems that trafficked persons face may assist you in using a systematic care approach to address patients whose medical problems are often complex. Depending on the trafficking context, trafficked persons may have experienced a range of abuse, violence and other health risks. For example, a child exploited sexually will also likely have experienced physical abuse, poor nutrition and sleep deprivation. Careful ‘head-to-toe’ assessments should be developmentally appropriate. Examination of children should be conducted by providers who are comfortable with the care of abused children and with forensic examination whenever possible (see action sheets 5 and 12). Infectious diseases are discussed in detail in action sheet 15.
Many trafficked persons may have had poor health prior to being trafficked, because factors such as poverty and poor living conditions, which increase susceptibility to being trafficked, also predict baseline poor health.21,22 Many patients may have additional multiple active medical problems (e.g., asthma, diabetes, anaemia and parasitosis) that are likely to have been exacerbated in the context of trafficking. Living in overcrowded This action sheet assumes that health care providers are aware of the basic principles of trauma-informed care (see action sheet 1) and cross-cultural care (see action sheet 2), appropriate identification and safety assessments have been conducted (see action sheet 7), and referral options for legal advocacy and social services have been identified (see action sheet 10).
Beyrer, C., “Is trafficking a health issue?” The Lancet, vol. 363, no. 9408, 14 February 2004, p. 564.
Zimmerman, C. et al. (2003).