ORIGINAL ARTICLE

Role of the intercultural facilitator for international migrants in chilean health centres: perspectives from four groups of key actors

Camila Sepúlveda^1,a, Báltica Cabieses^1,2,b

¹ Programa de Estudios Sociales en Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile.
² Departament of Health Sciences. University of York, York, United Kingdom.
^a Midwife, Master's Degree in Public Management and Policies; ^b Nurse-midwife, PhD Health Sciences (Social Epidemiology).

This study is part of the thesis: Sepúlveda-Astete C. Qualitative study of the role of intercultural facilitators in the health care of international migrants in two communities in the metropolitan region: Quilicura and Santiago [thesis to obtain a Master’s Degree in Public Management and Policies]. Santiago: Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile; 2019.

ABSTRACT

Objective. To research the perception of different key actors regarding the role of intercultural facilitators in health care for Haitian migrants in the communes of Quilicura and Santiago de Chile. Materials and Methods. Qualitative study of exploratory and descriptive type, with case study design, in family health centers and hospitals of two communes of the Metropolitan Region of Chile. The technique of semi-structured interviews with key actors (health authorities, health workers, intercultural facilitators, and international migrants) was used with verbatim transcription and thematic analysis of contents (n=18). Results. The perception of the role of intercultural facilitators for the health care of international migrants is related to activities like translation, interpretation, health system education in Chile, intercultural mediation, and administrative tasks. In addition, it collaborates in educational activities for migrants who require support in addressing cultural differences. This vision is shared by several key actors considered for the study and according to the current health policy. Conclusions. The intercultural facilitators make a contribution to the intercultural health encounter in Chile, and they are witnesses of how our institutions face different realities in linguistic and socio-cultural matters. Recognizing the importance of the intercultural facilitator in health care with intercultural relevance towards international migrant population is a social advance and one of the Chilean health system, which can be replicated in countries that face similar challenges and do not wish to ignore the growing social and cultural diversity in Latin America and the Caribbean, as a consequence of the dynamic transformations stemming from international migration processes.

Keywords: Transients and Migrants; Public Health; Professional Role; Cultural Competency (source: MeSH NLM).

INTRODUCTION

Approximately 2.9% of the world's population is international migrant (IM) ⁽¹⁾. The diversity of the countries of origin represents a challenge for adequate health care in the host society, where, for example, administrative, language and cultural barriers ⁽²⁾ can be observed, which negatively affect these people’s health ⁽³⁾.

At the international level, one of the main health barriers for IMs is the linguistic gap, with family members and/or volunteers ^(5.6) being incorporated—usually informally—as medical translators and interpreters ^(3.4). In other cases, there is formal incorporation of people who carry out this work in the health system ^(7-9). On its effectiveness, a study in Germany indicates that, although initially the cost is higher due to the assistance from linguistic interpreters, in the long term these costs decrease, since it allows a treatment oriented to therapeutic objectives, avoiding chronicity and misdiagnoses ⁽¹⁰⁾. Other studies mention that the interpreter transmits culturally specific aspects, such as understanding the disease, which increases the effectiveness of health teams in responding to the user’s particular needs ^(11,12). Facilitating the conditions for inclusion of IMs in health systems is therefore beneficial, as a healthy population generates higher productivity and income for host countries ⁽²⁾.

On the other hand, Chile has evidenced a significant increase of IM population, currently representing 6.6% of the national population ⁽¹³⁾. Sixty-six point seven percent (66.7%) of this population entered between 2010 and 2017 ⁽¹⁴⁾ with an upward trend of people from Central American countries, changing the scenario of the main colonies from border countries such as Argentina, Peru, and Bolivia ⁽¹⁵⁾. There has been a marked increase for countries such as Venezuela, with 23% of the total IMs, followed by Peru with 17.9% and Haiti with 14.3% ⁽¹³⁾.

Attending the Haitian population is one of the main challenges within the health sector, given the language and cultural barriers existing in intercultural encounter ⁽¹⁶⁾. Health teams report not having enough tools, with limitations ranging from language, significance of health, and disease processes to everyday aspects such as eating habits ⁽¹⁷⁾. To face this, health teams have undertaken actions to improve access and health coverage for IMs, such as intercultural health trainings, educational materials in Creole (Haitian Creole language), and educational workshops for IMs on how the health system works and available services ⁽¹⁸⁾. In addition, they have incorporated intercultural facilitators (IF), people also known as translators, linguistic facilitators, and/or cultural mediators, dedicated to facilitating communication between the health team and the Haitian migrant population.

In Chile, the term IF is described for the first time in the Special Program for Health and Indigenous Peoples (Programa Especial de Salud y Pueblos Indígenas, PESPI) ⁽¹⁹⁾, referring to a person who articulates the needs of users with the health network and focuses on ending inequity in the health system that affects people from these communities ^(19,20). With the new migration scenario in Chile, it became necessary to rethink the figure of the mediator or facilitator for people with a different culture and language, beyond PESPI’s proposal for indigenous peoples. For this reason, in 2014, the first efforts were made to incorporate IFs for IMs in some communes with high migratory density, mainly in the Metropolitan region ^(2,21). Considering this background and the progressive increase of IMs, the Health Policy for International Migrants in Chile

⁽¹⁸⁾ formally included the figure of the intercultural mediators and linguistic facilitators. Despite the relevance of this figure in the new social scenario, to date, very little is known about its role. Therefore, the objective of this research was to delve into the perception of different key actors regarding the role of intercultural facilitators in providing health care to Haitian migrants in two communes of Chile.

MATERIALS AND METHODS

This is an exploratory, descriptive, qualitative study. It was designed as a case study, which is considered appropriate for topics that are considered practically new, as it studies a contemporary phenomenon in its real environment ⁽²²⁾. This is the first study of its kind in Chile and its qualitative nature is justified when the research problem has not been studied much or has not been addressed before, contributing to the baseline diagnosis for later studies ⁽²³⁾.

The study was conducted in 2018 using semi-structured interviews at the primary and secondary care levels. It was carried out in the commune of Quilicura and Santiago (communes are the most basic unit of administration in Chile), in the Metropolitan region, which hold the first and third place in number of Haitian IM ⁽¹⁴⁾. Regarding the primary level, Quilicura has 9627 Haitians registered in its health centers and has five IFs. Santiago has 2562 Haitians registered in its health centers and one IF, who is installed in the Family Health Center (Centro de Salud Familiar, CESFAM).

In secondary care, work was conducted at the Complejo Hospitalario San Jose, where a quarter of the births were from Haitian women ⁽¹⁵⁾. Here, the first IF was hired in 2014 and currently there are six IFs, which makes it the only hospital with IFs working 24 hours a day. We also worked with Hospital Clinico San Borja Arriaran, which attends a large number of Haitian women, many of whom are not Spanish speakers. The first IF started in 2016 and there are currently two IFs in the daytime.

SAMPLE SELECTION

The sample was intended to interview people directly or indirectly involved in the process of construction and constitution of the IF figure for IMs. Four groups of key actors were considered for this study: 1) Migration Authority/Referent (AS), 2) Health Worker (ST), 3) Intercultural Facilitator (IF), and 4) International Migrant (IM), and a total of 18 interviews were conducted, four of them in creole for the IM group, achieving information saturation.

INFORMATION GATHERING

The main researcher went to each health center after carrying out the interviews in order to inspect the functioning of each center. However, the researcher—who speaks Spanish and Creole—and the study participants met on the day the interviews were conducted. These were carried out in an office in each health center and lasted between 21 and 44 minutes, with audio recording. The audios were literally transcribed, and unique codes were assigned to ensure confidentiality. The material was analyzed using the thematic analysis strategy in an integrated manner for the total number of interviews ⁽²⁴⁾.

ETHICAL CONSIDERATIONS

The project was approved by the Scientific Ethics Committee from the School of Medicine Clinica Alemana -Universidad del Desarrollo, the Scientific Ethics Committee of the Central Metropolitan Health Service, and the Research Ethics Committee of the Northern Metropolitan Health Service. All participants were informed about the study in Spanish or creole, signed an informed consent form before starting their participation in the study, and received a summary of the main results of the study. For the key group of international migrants who did not speak Spanish, it was ensured that the grammar used in the study information, informed consent, interviews, and results was understandable by translating it, editing it according to the corrections of two native speakers, and doing a subsequent final revision with another native speaker.

RESULTS

Table 1 describes the study participants. As for the academic areas of each group of key actors, the health area AS (psychologists, social workers, nutritionists, and midwives) and social area (sociologist) stand out. The TS group included health clinicians such as midwives, nurses, and social workers. The IFs had degrees in Nursing, Human Resources, and Management. IMs had degrees in Economics and Computer Science, and two had secondary education.

The findings were grouped into five thematic axes: 1) Context for incorporation, 2) Functions, 3) Advantages and disadvantages of the IF, 4) Barriers and facilitators for the incorporation of the IF, and 5) Recommendations. Within the latter, recommendations are made both for the formal incorporation of IFs in health centers and about the importance of training health teams in interculturality and migration. The following is a synthesis of the findings grouped into categories (Table 2).

CONTEXT FOR INCORPORATION

The increase of Haitian population challenged health care teams at all levels with cultural and language barriers that hindered effective communication between Haitian users and the health team.

«The stress that it put on the providers was high, the anguish of not being able to communicate (...) of not being able to explain what was needed, that put great stress on the providers. That is why the decision was made» (AS, hospital).

Thus, the role of the IF for IMs without a specific profile was incorporated. For the selection of the IF it was not required, for example, to have a health-related academic background and soft skills were valued more. This is a concept that refers to the qualities, characteristics, or personal competences of people, which are related to the emotional and social perspective needed for interacting and that are currently highly valued in the labor market, such as effective communication, teamwork, positive interpersonal relations, and ability to adapt to the environment and the health team prevail over other types of cognitive competences when giving a welcome, orientation and support to the IM at all times throughout their experience in the health center.

"The intention was for people to be able to provide information that, at the same time, had an emotional support component, for people to be prepared with the basic tools to resolve situations involving bad news» (HA, hospital).

Both HWs and IFs recognized having an academic background in health as a comparative advantage, as they had a more thorough knowledge of health programs in Chile and could guide users using medical terminology. However, the IFs with no training in health state that they overcame these training deficiencies by consulting the health team in a timely manner.

«The fact that he has this knowledge makes it easier for us to explain how they [IMs] have access to care» (HW, CESFAM). «They used medical terms (...) when I didn't understand something, I asked (...) they try to say it in a simpler way so that I can understand» (IF, hospital).

In all the health centers where the study was conducted, the IFs for IMs had a direct relationship with the employer and a contractual relation for payment of fees. In context, in Chile, direct hiring is established with the company in the form of permanent employment, fixed-term, and payment of fees; and for indirect contractual relation, there is payment for services, in which the personnel who should perform functions in the health center is outsourced through an external company.

FUNCTIONS

Reception, translation, orientation, and education about the Chilean health system were identified as functions by the four groups of key actors. The reception is related to welcoming the IM both to the health center and to a health system other than the country of origin; the translation is associated with translating instructions and questions by both parts (HW and IM) from Spanish to Creole and vice versa; the orientation is to guide the IM through the physical location of different services and how to "navigate" within the Chilean health system, being directly involved. Finally, the education about the health system that they provide to the migrant upon arrival to the health center, especially in primary care.

«When I have check-ups with the doctor, it is him [IF] who explains to me, accompanies me; if I need medicines, he goes downstairs with me and then comes back up and accompanies me again everywhere I must go, he is always next to me» (IM, hospital).

The IM, unlike other key actors, does not mention interpretation, health promotion, and cultural and administrative mediation as IF functions. This group mainly lists functions related to translation and guidance on what to do and how the health network works. The function of interpretation, highly valued by the other three groups, is adding to the translation the cultural factor inherent to the language in order to understand in a given context what we want to communicate.

«The facilitator not only has to interpret, but also make communication as empathetic and assertive as possible (...) and on the other hand, delivers information as it is requested by the health team» (HA, hospital).

Cultural mediation refers to the IF’s help with cultural differences between Haitian users and HW, emphasizing, for example, their contribution to understanding actions and/or forms of care of Haitian mothers with their children. Associated with this function is the health promotion, in which the participation of the IF in preventive and health promotion activities such as workshops for prenatal care and insulin dependent people is highlighted.

«Professionals ask me: Is this normal? Because in Haiti, once the baby is born, he or she is not breastfed, but eats regular food, and I said yes (...) Here in Chile we must work with the community, with the mothers to be able to teach them how to change this behavior, what the consequences are, why they should do as told» (IF, CESFAM).

The HW and HA emphasize the role of liaison with the community, seeing it as an opportunity to get closer and learn more about the Haitian migrant population they see, to achieve greater adherence to both the treatment and the health network that hosts them. Finally, there is the administrative function, recognized by HA and IFs, which has entailed continuous learning to respond to the demands of all people, regardless of their nationality.

«They have learned to take complaints, the laws, the rights, the duties (...) they have learned so much about the process of hospital care, diagnoses, confidentiality of diagnoses, how they have to report some things» (HA, hospital).

ADVANTAGES AND DISADVANTAGES OF THE IF

The advantages mentioned by all the key actors are, on the one hand, trust in effective communication and, on the other, the efficient use of the health network, which is directly addressed by the functions of translation, orientation, and reception.

Also, HAs and HWs mention a perception of lower public expenditure by avoiding chronicity and new admissions of IMs that might happen without IFs and, as a consequence, medical instructions would not be understood and followed correctly. In addition, the reduction of stress on the health team by being able to communicate effectively with users, confident that health care is being provided with an intercultural approach and with respect for each user's right to confidentiality of diagnosis. Finally, they highlight the contribution made by the IF, together with the migrant population in general, to establish the need for training in intercultural health issues.

«A person who does not understand what is happening to him and therefore, when given a prescription, does not know that this prescription has certain instructions, if they don’t follow this treatment, their problem most likely will worsen and not only affect them, but their whole family, everyone around them, the State—that will have to take other measures and also invest more in health because of something that could have been treated in an initial stage» (HA, hospital).

«If there is no facilitator, she cannot say what she feels, even if she wants to say what she feels in her language, the doctor will not understand because the doctor does not speak Creole (...). That is why it is important to have an assistant who speaks the language when a person does not yet speak Spanish " (IM, CESFAM).

When asking about disadvantages, none of those interviewed states any, they only mention administrative and economic barriers for their insertion as a limiting factor to be considered and improved in the future.

BARRIERS AND FACILITATORS FOR THE INCORPORATION OF THE IF

HWs and HAs mention administrative and economic barriers to the formal incorporation of this figure into the health teams, since there are no previous experiences at the national level and the current financial focus has been on primary care. At the hospital level, it is stated that there have been no regulatory advances in public policy.

«They never understood that the people who also needed care were those who came to this hospital to be informed that they had to undergo surgery, that their illness was irreversible» (HA, hospital).

Two major components stand out as facilitators: the first relates to the will of the local authority to incorporate IFs, overcoming administrative-economic barriers, and the second relates to the fact that, in all the centers, identification credentials have been provided, and one of them has added institutional uniform.

«The director wanted this hospital to be a hospital without walls, where everyone was welcome" (HA, hospital).

«They have institutional uniform, credential, the hospital knows it is present" (HW, hospital).

RECOMMENDATIONS

Their functions and high demand make IFs a necessary and scarce resource. However, the need to evaluate this figure is mentioned in order to incorporate it according to the local reality of the health centers that do not yet have this human resource. It is also recommended to raise more awareness among health teams about intercultural issues in the health sector and to include IFs in sector meetings and family studies in cases of special care, so they contribute to the analysis of how to deal with certain more complex cases with an intercultural focus.

«It doesn't have to be just for translation, they have to join the team and be helpful as a link between the migrant community and the health center» (HA, CESFAM).

«Get more training as health professionals(...) because cultural barriers are removed only through education» (HW, hospital).

Finally, an emerging issue is the need for mental health care for IFs, as they are exposed to complex situations communicating diagnoses such as fetal deaths, cancer, sexually transmitted diseases, and HIV/AIDS, among others. While IFs value the support, they receive from HWs, they need to receive formal and continuous psycho-emotional support and self-care tools throughout their role. Only one health center in the research took action, holding a weekly meeting moderated by a social worker to support IFs, but other health centers recognize that this is a weakness that requires urgent attention from the teams and the health system as a whole.

«I don't know what the other facilitators do when dealing with something complex, the only thing I know is that sometimes I have a headache that doesn't go away» (IF, hospital).

DISCUSSION

This research suggests that the IF is essential to overcome language (main reason for hiring) and cultural barriers encountered when attending IM Haitian population in health centers, a situation previously described by Cabrera et al ⁽²⁵⁾. However, this study documents that the IF not only "translates," but that his functions are broad, standing out, according to the account of key actors: cultural mediation, education about the health system, interpretation of health and disease processes, and available therapeutic alternatives. In addition, the existence of the IF is considered a good practice in Chile ⁽¹⁸⁾ and internationally ^(11,12,26). The evidence suggests that having professional services rather than family members or volunteers as IFs has significant advantages, since those who perform this role informally do not often have developed intercultural skills, in some cases hide information, and do not use medical terminology, resulting in unsatisfactory medical attention ^(5,6).

The key actors pointed out that academic training in health was not a mandatory requirement for IFs, but they do see as beneficial that a person knows the health programs available in the country and medical terminology used in health care. According to international evidence, facilitators should have, at a minimum, training in intercultural mediation ^(7,8), since the interpretation of medical instructions is a sensitive job where health professionals may be exposed to greater medico-legal risk ⁽²⁷⁾. The decrease in public expenditure is internationally recognized as an advantage of having IFs, since assigning interpreters allows for more effective and specific treatment, avoiding chronicity, improving adherence, and boosting user satisfaction ^(10,28,29).

The recognition of the value and comparative advantages of providing attention with an IF was widely detailed in this study, and it was also described by the literature as a relevant public health strategy ^(7,28). The mental health of the IF stands out as an emerging topic of this research, since it is recognized that this role can represent an occupational risk without adequate definition, training and support, reinforcing the importance of early training in this topic ⁽³⁰⁾.

These results can be used to review the opportunity for health systems to secure government funding for professional translation and interpretation services in health care, with updated, evidence-based regulations covering all levels of health care, which was demanded in this study to formalize secondary level funding. This remains a challenge for Chile, for countries in the Latin American region, and for all countries in the world ^(4,11,28).

The main strength of this research was to have conducted interviews with four groups of key actors involved in linguistic and intercultural facilitation for the IM population. This resulted in a valuable approach to the perception of the role of IFs in IM health care, which considered the voice of Haitian users. A limitation of the study is that, being based on interviews and not on direct observations, it only obtained information about the perceptions of key actors and not from the clinical role in direct attention to the IM population. Therefore, new studies are needed to allow direct observation of intercultural practices of IFs and health teams.

It is concluded that the perception of the role of facilitators is related to specific functions in translation, interpretation, health system education, intercultural mediation, and collaboration with administrative tasks. In addition, they collaborate in educational activities for migrants which require support to address cultural differences. There are important advantages in providing health care with cultural relevance and respecting privacy in health care, so administrativefinancial regulations for their formal incorporation into health centers are urgent. Acknowledging the importance of IFs in health care with intercultural relevance for the IM population in the Health Policy for International Migrants in Chile is a social and health system advance, which can be replicated to other countries facing similar challenges.

Authors’ Contributions: CS participated in the conception and design of the article, collection of results, analysis and interpretation of data, writing of the article, critical review of the article, and approval of the final version. BC participated in the conception and design of the article, provision of technical advice, writing of the article, critical review of the article, and approval of the final version.

Funding: Partial funding from the National Commission for Scientific and Technological Research of Chile (Comision Nacional de Investigacion Cientifica y Tecnologica de Chile), through a National Master Scholarship/2018-22180042.

Conflicts of Interest: The authors declare that they have no conflicts of interest.

REFERENCES