transcultural skills for health and care - T

Transcription

Skills
for Health
and Care
Transcultural
Standards and Guidelines for Practice and Training
Collective Work by T-SHaRE team
April 2012
Transcultural Skills for Healht and Care
This handbook is the final outcome of the Project “T-SHaRE - Transcultural Skills for Health and
CaRE” n°504666-LLP-1-2009-1-IT-LMP, within the LLP - Leonardo da Vinci - Multilateral Projects
for Development of Innovation, ended in April 2012, webzone: www.tshare.eu.
This project has been mostly funded by the European Commission. This publication expresses
exclusively the point of view of the author, and the Commission cannot be held responsible for
any use which may be made of the information contained here in.
The present contents are published under the terms of the Creative Commons licence by-nc-nd.
Attribution-NonCommercial-NoDerivs 3.0 Unported (http://creativecommons.org/licenses/bync-nd/3.0): it allows others to copy, distribute and transmit this work and share it with others
as long as they mention the authors and link back to them, but they can’t change it in any way
or use it commercially.
English edition:
TRANSCULTURAL SKILLS FOR HEALTH AND CARE.
Standards and Guidelines for Practice and Training
2012 Edizioni di ARACNE Associazione di Promozione Sociale, Napoli.
Editing: CRIA. Printed in Lisbon.
ISBN 978-88-907245-0-3
Italian edition:
COMPETENZE TRANSCULTURALI PER LA SALUTE E LA CURA.
Linee guida per la formazione e per la qualità nei servizi socio-sanitari
2012 Edizioni di Aracne - Associazione di Promozione Sociale, Napoli.
ISBN 978-88-907245-2-7
Digital versions are available for free download in English, Italian, French, Portuguese on
www.tshare.eu
2
Standards and Guidelines for Practice and training
Table of Contents
ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
T-SHaRE Guidelines proposals and intentions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
T-SHaRE Guidelines potentials uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
To whom T-SHaRE Guidelines are adressed to? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
How to use T-SHaRE Standards and Guidelines of practice? . . . . . . . . . . . . . . . . . . . . . . . . . . 11
T-SHaRE project presentation and innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
General Legislation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
GUIDELINES FOR A TRANSCULTURAL MODEL OF MENTAL HEALTH
AND WOMEN HEALTH SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
A self-reflexive positioning and methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
The role of social and political factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Clinical process and clinical setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Guidelines for quality standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Ethical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
General principals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Specific Guidelines for social and health professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Professional profiles and skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
General competences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Special competences according the health service concerned . . . . . . . . . . . . . . . . . . . . . 27
Specific competences regarding professionals’ identity . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Cultural mediation in the health care sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
A question of professional identity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
The role of cultural mediation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Health cultural mediatior skills and profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Methodology for recognition of prior learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
How to assess and validate skills learned in non formal or informal settings . . . . . . . . . . . 33
3
GUIDELINES APPLICATION AND PRACTICAL CONCERNS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Developing a common and shared theorectical and methodological core . . . . . . . . . . . . . . 40
Analisys of local contexts and the health care sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Analysis of migrants’ and ethnic minorities knowledge on health care. . . . . . . . . . . . . . . . . 41
Analysis of competences and training needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Costs and benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
GUIDELINES FOR TRAINING METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
T-SHaRE training goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
T-SHaRE training protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Local constraints and contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Training health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Methodology of training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Using T-SHaRE pilot training protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
What a protocol is? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
T-SHaRE protocol as tools for programming and assessing services . . . . . . . . . . . . . . . 52
How to transfer the T-SHaRE pilot protocols in further contexts . . . . . . . . . . . . . . . . . . 53
Training assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4
ANNEXES
Section 1 – T-SHaRE Project rationale and consortium introduction . . . . . . . . . . . . . . . . . . . . . 57
Annex 1, by Aracne Associazione di Promozione Sociale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Section 2 – Theorectical Contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Annex 2, by Associazione Frantz Fanon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Section 3 – Methodological instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Annex 3 - Assessment of health care systems and health services for immigrants
by CRIA - Centro em Rede de Investigacao em Antropologia . . . . . . . . . . . . . . . . 82
Annex 4 - Analysis of cultural representations of migrant communities
and ethnic minorities relating to the field of health and care
by Associazione culturale Centro Shen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Annex 5 - Analysis of the cultural mediation skills that the health practitioners
should have/acquire/improve, from the immigrant’s point of view
by Kulturno Drustvo Gmajna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Annex 6 - Analysis of the cultural mediation skills that the health practitioners . . . . . . . . .
should have/acquire/improve, from the health cultural mediators’
and the health care practitioners’ point of view, by Nasjonal
Kompetanseenhet for minoritetshelse and Folkeuniversitetet . . . . . . . . . . . . . . 115
Annex 7 - Training tested protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
by Centre médico-psycho-social Françoise MINKOWSKA . . . . . . . . . . . . . . . . . . . 120
Annex 8 - General Evaluation Questionnaire – T-SHaRE training pilot experience
by CRIA - Centro em Rede de Investigacao em Antropologia . . . . . . . . . . . . . . . 123
Annex 9 - Pre-Training and post-training evaluation questionnaire
– T-SHaRE training pilot experience
by Centre Médico-Psycho-Social Françoise Minkowska . . . . . . . . . . . . . . . . . . . . 124
Annex 10 - Assessment of health care systems and health services for immigrants
by Kulturno Drustvo Gmajna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Section 4 – T-SHaRE Training Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Annex 11 - T-SHaRE protocol Turin (IT) byAssociazione Frantz Fanon. . . . . . . . . . . . . . . . . 000
Annex 12 - T-SHaRE protocol naples (IT) by ASL Napoli 2 Nord . . . . . . . . . . . . . . . . . . . . . . 000
Annex 13 - T-SHaRE protocol paris (fr)
by Centre Médico-psycho-social Françoise MINKOWSKA . . . . . . . . . . . . . . . . . 000
Annex 14 - T-SHaRE protocol lisbon (pt)
by Centro em Rede de Investigacao em Antropologia CRIA . . . . . . . . . . . . . . . 000
Annex 15 - T-SHaRE protocol ljubjana (si) by Kulturno Drustvo Gmajna GMAJNA . . . . . . . 000
Annex 16 - T-SHaRE protocol oslo (no)
by Nasjonal kompetanseenhet for minoritetshelse NAKMI . . . . . . . . . . . . . . . 000
5
Acknowledgements
T-SHARE TEAM
Associazione Frantz Fanon (Turin - IT)
Roberto Beneduce
Roberto Bertolino
Simona Gioia
Irene Morra
Simona Taliani
Eleonora Voli
ASL NA 2 Nord (Pozzuoli– IT)
Paola Amodeo
Giuseppina Carannante
Rosa dell’Aversana
Laura Del Pezzo
Christina Harrison
Anna Manzo
Silvana Petri
Francesca Romagnuolo
ARACNE (Naples – IT)
Roberta Moscarelli
Enza Somella
Maria Fernanda Spina
GMAJNA (Ljubljana – SI)
Barbara Beznec
Aigul Hakimova
Polona Mozeti
Sara Pistotnik
MINKOWSKA (Paris – FR)
Ursula Acklin-Kalil
Rachid Bennegadi
Marie Jo-Bourdin
Stéphanie Larchanché
Christophe Paris
Daria Rostirolla
NAKMI and Folkeuniversitetet (Oslo – NO)
Karin H. Hjelde
Ragnhild Spilker
Ida Marie Bregård
Vera Minja Ingebjørg Gram
Synnøve F. Graneng
Kjersti Kanck
T-SHARE SCIENTIFIC COMMITTE
Centro SHEN (Naples – IT)
Lidia Azzarita
Francesca Carrera
Laura Intrito
Maria Rosaria Marini
Maria Toledo
CRIA (Lisbon – PT)
Elizabeth Challinor
Joaquim Jorge
Carla Moleiro
Silvia Olivença
Chiara Pussetti
Manuela Raminhos
Cristina Santinho
Joana Santos
Francesco Vacchiano
6
Simona Taliani (Associazione Frantz Fanon)
Roberto Beneduce (Associazione Frantz Fanon)
Teresa Capacchione (Aracne)
Roberta Moscarelli (Aracne)
Maria Fernanda Spina (Aracne)
Silvana Petri (ASL NA 2 Nord)
Rosanna Blasi (ASL NA 2 Nord)
Gemma Zontini (Centro Shen)
Alfredo Pisacane (Centro Shen)
Carla Moleiro (CRIA)
Sara Pistotnik (Gmaina)
Barabara Beznec (Gmajna)
Polona Mozetic – (Gmajna)
Karin H. Hjelde (NAKMI)
Rachid Bennegadi (Minkowska)
Stephanie Larchanché (Minkowska)
With thanks to
This research would not have been possible without the contribution of all the individuals,
groups, organizations and communities that contributed to the production of knowledge during
the project. We especially acknowledge all the participants in the action research, both migrants
and their communities, health care workers, mediators and advocates. We sincerely hope that
this document builds to a large extent on the expression of their voices from below.
ASSOCIAZIONE FRANTZ FANON
Thanks to the Public Health Services “Dipartimento di Salute Mentale” and “Dipartimento
Materno Infantile” - ASL TO1 to let us develop the T-Share training project for health care
operators and mediators. Dott.ssa Vilma Xocco, Dott.ssa Luisella Cesari, Dott.ssa Antonella Arras
had an important role for the dissemination of the Project in their own Services and Centres.
Thanks to Lahcen Aalla, Grace Aigbeghian, Luz Cardenas, Simona Maria Nastasa, Berthin Nzonza
and all the involved healthcare operators, cultural mediators and migrants for their contributions.
ASL NA 2 Nord
Thanks to ASL NA2 Nord Mental Health Department, Gennaro Perrino, Manlio Converti;
Dipartimento Materno Infantile ASL NA2 Nord, Maria Teresa Pini, Rosanna Blasi, Giuseppina
Gallicchio; Department of Gynecology and Obstetrics Giugliano Hospital of ASL NA 2 Nord, Salvatore Sciorio; Resp.le UOC Integrazione Socio Sanitaria ASL NA2 Nord, Maria Femiano;
Lifelong Learning Center, University of Naples “L’Orientale”, Luigia Melillo; University of Palermo,
Antonio d’Angiò; Dedalus Cooperative - Naples, Elena De Filippo; Ass. Pari Opportunità Comune
di Napoli, Giuseppina Tommassielli; association al Lavoro, formazione e Immigrazione Regione
Campania, Severino Nappi; Presidente V Commissione Sanità Regione Campania, Michele
Schiano di Visconti and all the involved healthcare operators, cultural mediators and migrants
for their contribution
ARACNE – Associazione di Promozione Sociale
Thanks to A3-I – Napoli; Associazione Cantiere dell’immaginario - Napoli; Associazione Garibaldi
101, Napoli; Coop. Casba; Napoli; CIDIS Onlus; CISS O.N.G.; Coop. Dedalus; Napoli; Forum Anti
razzista Campania; Gruppo Lavoro Rifugiati Bari; Macchia di Colori Onlus; Associazione Jolibà –
Napoli; Rete antirazzista Napoli; Rivista di Filosofia Porta di Massa; Stranieriincampania.it; Caffè
dell’Epoca - Piazza Bellini (NA); CEICC- Comune di Napoli. And also to: Sergio Piro, Alfonso De
Vito, Erminia Sabrina Rizzi, Teresa Capacchione: they have inspired, helped, supported us in
ideational stage of T-SHaRE project; Abdel Fattah Zaami, Chandrasiri Nanayakkara Appuge, Louis
Benjamin Ndong, Ndiaye El Hadji Omar, Wioletta Sardyko, Yacoubou Ibrahim: they have shared
with us reflections about their precious esperience in the field of migrants right promotion and
of healthcare cultural mediation (during a Sunday afternoon of spring!); Sara Cotugno e Raffaele
Romano: they have done shooting and editing of the video “Percorsi Salutari - narrazione di una
valutazione qualitativa partecipata” and also, thank you for the friendship; the whole InsùTV
collective: they have shared, promoted and hosted in their place, our workshop “ Healthcare
paths: the experience of migrants within Campanian healthcare services as starting point of
their improvement”.
7
Centro SHEN
Thanks to: Tatiana Perezvera, Nimal Pereira, Paolo Fierro, Luciano Gualdieri, Gemma Zontini,
Olha Lyubymova, Cissè Hassan, Sampath Pereira, Sean Scott, Alfredo Pisacane, Leonie Sowole
Tchwimba, Katia Filonetes, Adriana Villa, Asad Mahmood Raja, Xiao Ming, Galjia Gali, Chandrasiri
Nanayakkara Appuge, Stella Savino, Paola Costa, Malinie Alahakoon, Chiara Leone and Francesca
Riccio.
CRIA
Thanks to ACIDI (Dr. Rosário Farmhouse and Dr. Filomena Cassis and the cultural mediator group);
focus group participants: Médicos do Mundo (MdM); Associação de Melhoramentos e Recriativa
do Talude (AMRT); PROSAUDESC; Associação de Jovens Promotores da Amadora Saudável
(AJPAS); Associação de Refugiados em Portugal (ARP); Santa Casa da Misericórdia de Lisboa:
Direcção da Acção Social (Dr. Samuel Esteves) e Direcção do Serviço de Saúde de proximidade
(Dr.José Castro Ferreira); ARS-LVT: Unidade de Saúde da Amadora: Drª Helena Cargaleiro e Dr.
António Carlos; Associação GIS (Grupo Imigração e Saúde) and Vítor Barros.
GMAJNA
Thanks to IWW – Invisible workers of the World (Slovenia); African Center of Slovenia; Nigerian
association in Slovenia; Movement of sans-papier and asylum seekers World for everyone; Social
center Rog; Department of Ethnology and Cultural Anthropology of University of Ljubljana; Students of the Department of Ethnology and Cultural Anthropology; Movement 15O; CIIA - Civil
Initiative of Erased Activists; Kings of the Street, association of homeless in Ljubljana; Pro Bono
Clinic in Ljubljana; IZ-HOD, initiative for deinstitutionalization of mental and care health institutions; Union of Crane Operators in port of Koper; Union of Subcontracting Workers in port of
Koper
MINKOWSKA
Thanks to Tiphaine Dequesne, Fatou Dia and Inter Service Migrants, Association AFAVO, Bintou
Boiguillé (Afrique Partenaire Service), Jimmy Makete and Vikamuya Ndontoni (ATCK-France),
Monief Labidi (Café Social), Nafissatou Fall (AHAM Le Havre), Néné Sow-Camara (FIA-Normandie), Fatou N’Dir Niang (La Passerelle), Jackie Botimela Loteteka (LAJP).
NAKMI and Folkeuniversitetet
Thanks to all migrants and health workers that participated in the focus groups, Oslo University Hospital, Section of Equality, The Norwegian Directorate of Health
8
Introduction
T-SHaRE Guidelines proposals and intentions
Human flows of immigrants, refugees, exiles, guest workers and other migrant groups are in
constant growth, although with significant differences in the individual Member States. The removal of customs barriers and the admission of new countries in Europe have increased this
mobility. Migrants, asylum seekers and illegal immigrants are at high risk of poverty and social
exclusion and there is evidence that they sometimes do not receive the care that best responds
to their needs. The testing of a transcultural approach responds to the need of adapting health
care models to migrant and ethnic minority members: promoting skills that enable professionals
to meet the cultural and personal background of users in their care activities is essential, in order
to remove forms of exclusion, rejection or misunderstanding that frequently occur in these services, when the users have a hard time orienting themselves in a system of signs, interpretations
and interventions that are too distant or disrespectful of their condition and culture.
In the EU there have been many experiments of specific cultural mediation in the health field,
however this is not enough. Some pilot projects were developed to strengthen the role of hospitals in strategies for promotion, information and health education for immigrants and ethnic
minorities also combining the cultural patterns of ethnic minorities with the resources of the
host society (see for example, “Migrant Friendly” 2002 EU Public Health Program)1. Yet, as today
the functions and responsibilities of the cultural mediator who operates in the area of care are
not clearly defined or shared in the Member State and at the European level. This often creates
misunderstandings with health care providers and physicians, which affect the intervention. The
acquisition of appropriate competences to face the difficulties that arise in daily practice is in
fact a need strongly felt by all health professionals. This emerges with particular urgency in the
complex and delicate area of women’s health and mental health, where the health dimension is
closely related with the social, cultural, relational, legal and economic dimension.
Within the present T-SHaRE Standards and Guidelines, we consider as final users of the healthcare
services concerned: documented and undocumented immigrants, asylum seekers, refugees,
victims of torture, trafficked persons, unaccompanied minors, and also second-generation
immigrants, ethnic and/or cultural minority members. For practical reasons, in our text, we will
gather them in a more global ‘category’ as “migrants and ethnic minority members” (except in
cases where there’s the need to be more specific).
T-SHARE Standards and Guidelines for Practice and Training intends to help overcome these
gaps in training, laying the foundations for mutual recognition of competences learned in formal
and non-formal settings and at the same time, to help addressing the limits of reception and
inclusion policies at a local and European level. The acquisition of forecasted competences and
the quality of services intend to facilitate mobility, employability and professional development
of health care practitioners and cultural mediators.
1
The European project “Migrant-friendly hospitals” (MFH), ended in 2004, sponsored by the European Commission, DG Health and Consumer
Protection (SANCO) brought together hospitals from 12 member states of the European Union, a scientific institution as co-ordinator, experts,
international organisations and networks. See http://www.mfh-eu.net
9
T-SHaRE Guidelines Potential Uses
T-SHaRE Transcultural Standards and Guidelines for Practice and Training can be used for several
purposes:
1. Guideposts in the designing, planning and/or improving health care services addressed to
migrant and ethnic minority members and/or users with diverse cultural backgrounds.
2. Guideposts in the development of educational and training programs to practitioners working
within healthcare services addressed to migrant and ethnic minority members and/or users with
diverse cultural backgrounds;
3. Guideposts in the definition, recognition and implementation of expertise in cultural mediation
in the health sector;
4. Guideposts to organize the validation and certification of professional skills learned on the
job in the field of cultural mediation within the healthcare services
5. Guideposts and instruments to the creation of an evaluation tool which can serve as pre-selected criteria against which the performance trainees or practitioners in the field can be evaluated. As an outcome measure, these standards can also be used to determine whether or not a
trainee/professional has achieved mastery of the required skills. At the workplace, they can be
used both to assess the level of competency at the point of entry and as a supervisory tool to
provide ongoing feedback. Health cultural mediators and health professionals (doctors, nurses,
social assistances, psychologists, etc.) can also use these standards to continue to monitor and
assess their own performance individually.
To whom T-SHaRE Standards and Guidelines are addressed?
Following these propositions, T-SHaRE Standards and Guidelines are addressed to:
•
•
Stakeholders that intend to design and/or plan and/or organise and/or improve healthcare
services addressed to migrant individuals and ethnic minority members;
Stakeholders that intend to design and/or plan and/or organise and/or improve training
paths addressed to professional teams working within healthcare services addressed to
immigrant population or within services receiving an important percentage of migrant
individuals and ethnic minority members.
Regarding T-SHaRE contents and aims, stakeholders are considered:
•
•
•
•
10
Health care authorities (national or regional), NGO, institutions
Professionals and practitioners from the public health sector: doctors, psychiatrists,
midwives, psychologists, nurses
Cultural Mediators
Immigrants and ethnic minority members experts in the field of health and care
•
•
•
•
•
•
Immigrant and ethnic minority members users of health services and social services, public
and private
Professors, researchers and university students
Key players of social and social-health systems and services
Key players of health policy
Key players of policies for social inclusion, immigration, equal opportunities
Key players of Vocational and Education Training systems
How to use T-SHaRE Standards and Guidelines of Practice?
T-SHaRE standards and guidelines propose guidance paths and related tools/instruments to
promoters who intend to implement one (or several) of the health care interventions described
above , in an adapted way to local national policies, needs and potential of the country where
the intervention intends to be implemented.
In developing these standards of practice, one of the major challenge was to set standards that
uphold excellence in the accuracy and completeness of interpretation while responding to the
need to adapt the intervention to the local context, by providing tools, instruments and methodologies to assess the local needs and potentialities. To offer methodological instruments for
agencies and promoters that have basic necessities to adapt their field work activities to the
‘reality’ of local context and situation.
T-SHaRE standards and guidelines is structured in three main parts:
Part 1 – Main standards, guidelines, theoretical and epistemological proposals to promote a
transcultural anthropological approach.
Part 2 – Methodological tools and strategies to assess local needs, potentials and contexts. Aim:
actively involve, from the initial planning phase, public and private organizations of the health
care system, research and training centres, associations.
Part 3 – T-SHaRE training path on the basis of needs analysis and suggestions of users, mediators,
health professionals and medical experts of immigrant and ethnic minority cultures. It is based
on a constructivist and decentralized approach.
Innovative aspects of the T-SHaRE project
The T-SHaRE Standards and Guidelines are the main outcome of the cooperation of nine partners
from five European countries (Italy, Portugal, France, Slovenia and Norway), within the project
“T-Share - Transcultural Skills for Health and CaRe”, a LLP - Leonardo da Vinci - Multilateral
Projects for Development of Innovation, started in November 2009 and ended in April 2012.2
2
To a more detailed description of the T-SHaRE Project rationale and of the involved partners, see Annex 1
11
The T-Share project has defined several objectives aimed at developing transcultural skills for
health and care with particular attention to women’s health and mental health. In general,
T-SHaRE project aimed to improve models of healthcare that make them more friendly to users
from immigrant communities and ethnic minorities, by improving relations among healthcare
professionals, health cultural mediators immigrant communities and ethnic minorities, and
finally, by valuing different cultural approaches to health and care.
Additionally, T-SHaRE intended to develop methodologies and tools for the continuous learning
and the recognition of competences learned in a non-formal and informal settings both for
practitioners and for cultural mediators, which are part of T-SHaRE Guidelines.
To effectively address the complex issues related to health field and migration, it is necessary
to make cross-cultural competence at all levels - both relational-communication and medical
treatment ones – of the European health services, considered as “learning communities”. To
determine how, T-SHaRE actively engages users, researchers, privileged witnesses and other
professionals working in the field in an action-research activity, both in the analysis of training
needs of health services, and in the realization of pilot experiences of on-the-job orientation and
management of services in a cross-cultural approach addressed to women’s health and mental
health.
Another important aspect of this research was the attention concerning health care systems
and the diverse linkages and intersections that exist between legislative, economic, political and
social dimensions related to health and migration in each country. Indeed, clinical settings are
realms where one can observe different layers of subjects that are involved in the provision of
health care, reflecting not only formal dimensions and policies intrinsic to bureaucratic and state
domains, but also social mechanisms and relations that are constituted within these formal
frameworks.
To attain the mentioned aims and proposals, various stages of action-research were identified,
particularly in the domains of women’s health and mental health:
12
•
Stage one: Description and analysis of the national and local contexts and health care systems.
•
Stage two: Analysis of the state of art in the field of cultural mediation in the healthcare
sector and description of official skills required for cultural mediators to work in the healthcare context.
•
Stage three: Analysis of different visions, approaches, knowledge, competences, needs belonging to local immigrants’ and ethnic minorities cultures in the area of health and care.
•
Stage four: Analysis of local skills in the field of cultural mediation that health care professionals should have/acquire/improve from the immigrants’ and ethnic minority members’
points of view.
•
Stage five: Analysis of local training needs in the field of cultural mediation within health
and care services from the cultural mediators’ and the health care practitioners’ points of
view.
•
Stage six: Design six innovative and context-specific protocols proposals aimed at building
and/or improving healthcare services for migrant users and at training inter-professional
and intercultural team working in these healthcare services.
•
Stage seven: On the bases of the previous experiences, design of approaches, methodologies
and tools addressed to building and/or improving healthcare services for migrant and ethnic
minority members users and at training inter-professional and intercultural team working
in these healthcare services. In particular this stage provides an approach (and related
methodologies and tools) aimed at recognizing skills from formal and/or non-formal learning;
validating skills learnt on the job.
•
Stage eight: Testing and validation on the job of innovative protocols for building and guiding
inter-professional and intercultural team working in the healthcare services for migrant and
ethnic minority members users.
13
Legislation
There is extensive international and national legislation that advocates for equality of access
to health and legal services, although in many instances the use of health cultural mediators is
not always clearly articulated. Legal frameworks that advocate for equality of access to health
services include:
•
•
•
•
•
14
European Convention for the Protection of Human Rights and Fundamental Freedoms (1950)
The United Nations Convention of the Rights of the Child (1989)
Human Rights Act (1998)
Race Relations Amendment Act (2000)
The Disability Discrimination Act (1995) and the Disability Discrimination Act (2005)
Guidelines for a
transcultural model
of mental health
and women health
services
15
16
Guidelines for a transcultural model of mental health
and women health services
Introduction
The T-SHaRE Standards and Guidelines of Practice are founded on the assumption that a
culturally competent health service acknowledges that users are diverse in terms of gender, age,
ability, sexual orientation, beliefs, and that this difference is constructed in a complex field of
social forces and political constrains.
T-SHaRE Standards and Guidelines of Practice also recognizes the importance of achieving a
critical, and above all, reflexive approach, capable of considering the role that social and political
factors have as compelling aspects in the production of illness and in the construction of
therapeutic initiatives.
But what does it mean to work with/in a culturally competent health approach? Which problems
led to the use of health cultural mediation?
Over the last few years, the ethnoclinical and linguistic cultural mediation has represented the
real challenge for all those who were interested in working with ethnopsychiatry and transcultural
psychiatry and, more generally, in health services for immigrant and ethnic minority members
users. In Europe, as well as in the USA, in Canada or in Australia, many experiments in linguistic
and cultural mediation have been carried out within ethnopsychiatry or transcultural psychiatry
services to try and respond to health care problems of immigrant people or of members of
minority groups and, more generally, to confront the issue of their accessibility to the services.
Since the problems of cultural accessibility have to be added to the economical, juridical and
institutional ones, these are responsible for (1) the decrease of the accessibility, (2) the creation
of weaker therapeutic relationships and (3) the increase of the risk of drop out.
The social workers and the researchers have put forward a number of questions about these
issues, which can be summarized as follows:
• What happens when a foreign citizen or a migrant family meets the health services?
• Are their symptoms and experiences listened to appropriately?
• Can we reduce the risk of misunderstanding in the diagnostic and therapeutic process?
• What kind of specific difficulties do professionals come upon in the clinical encounter with
foreign patients?
• Which kind of “cultural competence” is required in order to properly construct an intercultural
psychotherapy?
It is clear that the presence of the Other, the foreigner, can expose the difficulties of the host
countries and reveal the contradictions and the grey areas behind many assumed truths. The
presence of the Other is a real “epistemological marker”, revealing weaknesses of various kinds3.
3
Expression by Garrigues (2003, “Les villages noires en France et en Europe”, L’Ethnographie, 2, pp. 13-51).
17
Operators and experts often fail to respond to this situation because they are unable to recognize
the weakness of their practices and interpretative models in relation with new or different
questions and conflicts.
A certain psychiatry or medicine prefers to talk about “drop out”, “low compliance” of the patient,
“poor collaboration” of the family: but all these concepts can be turned around to indicate, in many
cases, the “low quality of both the welcoming process and the relationship”, the “non sustainability
of the pharmacological therapy” (economical, linked with collateral effects often not communicated
to the patient), the inability to manage complex relational dynamics. The meeting between
alienists and foreigners4 has increased these problems and the abuse of similar pseudo- concepts.
In this complex scenery we have to consider at least two factors, often linked with each other:
a) The first one can be defined “the cultural matter”. The lack of knowledge about categories,
representations, and interpretative models, characteristic of a certain system of care, the weak
familiarity with other aetiological and therapeutic approaches, the lack of knowledge in relation
with different points of view about suffering and illness, are at the basis of most of the difficulties normally reported. These difficulties concern both the users and the operators: both have
sometimes a limited knowledge of the healing practices in the host country and, respectively, in
the countries from which migrants and ethnic minority members originate.
b) The second one concerns the “language/translation matter”. The difficulty in translating in
a proper and well-structured way their own concerns, uneasiness, fears and experiences, put the
patient in an uncomfortable position, especially in those areas of diagnosis and healing where, as
in the case of mental health, a great deal of the problem lies in the “speech area”. In the same way,
the therapist’s analyses and prescriptions aren’t met with an adequate response when expressed
in a language that the patient does not master, and are devoid of all relevance if given in a language
suggesting epistemological, psychological, moral or religious assumptions which are potentially far
from (or even contradictory with) those of the patient and his family. These assumptions contribute
to the production of misunderstandings; they interfere with the process of building a successful
healing strategy and are an obstacle to the required cooperation. On the other side, the latter often
represents the most important resource when it comes to overcoming the distrust of patients and
families who perceive the care subjects and the social control actors as indistinguishable.
What are the consequences of these factors in Mental Health Services or Services for Women
Health, today? Even though the patients’ stories, their clinical biographies (anamnesis), and the
social, economic and political conditions of their countries are often unknown, a diagnosis is expressed after few meetings: a diagnosis that claims to be legitimate on the basis of a presumed
methodological objectivity. Expressions are coined such as “reactive psychosis”, “bouffée delirante”,
“religious” delirium are very recurrent and often veritable pseudo-diagnoses, that reveal the
operators’ uncertainty.
4
18
This wording used in reference the work of Lipsedge and Littlewood (1989, Aliens and alienist. Ethnic minorities and psychiatry, London,
Unwin Hyman), in which, in the title, the authors used the double sense of the term “alien”, to underline how many problems crossed, in the
past, the meeting between psychiatry and patients from other cultures.
Facing the unintelligibility of the Other, doubly alien (mad and foreigner), facing unknown
languages, usually people adopt two strategies: the denial of the cultural-linguistic difference,
reducing the psychic/physical suffering to the only supposed valuable model of our categories
and our strategies; or imagining that the cultural difference is the hidden code of the observed
behaviour, the secret that once revealed will make the pathological symptom vanish as if by
magic. From this to a bad use of cultural mediation and a “cultural approach”, the way is short,
hence we underline the importance of achieving a critical, and above all, reflexive approach.
A self-reflexive positioning and methodology
Through the various possible paths, one central aspect emerges in the self-reflexive positioning
on behalf of health practitioners, resulting in questioning and interrogating diagnostic procedures
and tools. This consists in an invitation to explore semantic domains and linguistic uses of concepts and categories applied in the clinical context. It also implies rethinking notions, interpretative and therapeutic frameworks, situating them as products of historic, economic and political
dimensions.
1. A self-reflexive positioning implies, on the one hand, the questioning of disciplinary knowledge
and paradigms and, on the other hand, the reformulation of their institution foundations and
sites of application. This reveals the political and cultural character even of those aspects we
tend to consider factual and natural – body, sensations and emotions, suffering and so forth.
Through questioning such matters, we are to understand how definitions such as ‘normal’,
‘pathological’, ‘reasonable’, ‘foolish’, ‘healthy’, and ‘morbid’ are products of a specific historical,
political and social-cultural context. In this sense, medical categories emerge not as discursive
fragments of what is ‘real’ but as part of a framework with analytical devices that construct reality. A peculiar attention has to be paid to the evaluation of the position of the interlocutors
and to the ideology conveyed by diagnostic categories.
2. An analogous criticism is necessary regarding the social and administrative categories that
frame immigration, namely the ones of “irregular”, “clandestine”, “alien” and so forth. A quality
and competent health service may not reinforce the classification tools of citizenship according
to origins and papers. In reverse, competent social and health professionals are aware that these
same categories and its agents do actively contribute to produce and reinforce the conditions
producing and worsening illness.
The role of social and political factors
Developing a competent intervention implies also the acknowledgement of the role that social
and political factors have as compelling aspects in the production of illness and in the construction
of therapeutic initiatives.
The framework we embrace claims the necessity of rethinking clinical settings as places of
conflict and change, where social actors with different positions and belongings interact. This
19
is a process that conveys the recognition of the patients’ (and their groups’) voice, listening to
histories and narratives and integrating local interpretations and explanations in the process.
To do this is to acknowledge the dignity of the patient and the effectiveness of his/her “local”
knowledge in representing the personal positioning through contexts.
The T-SHaRE proposal considers ill bodies not only as physical organisms but as subjective projections of personal itineraries, historical processes, forms of categorization and processes of
bodily signification.
This coalescence is made particularly visible in the stories of migrants and ethnic minorities. In
this way, healing is made possible by the location of personal experience into the fractured space
of interaction between the body and outside world. Combining the interest for migrants’ narratives
with the analysis of the socio-political and economic contexts of life represents the possibility
to track down the personal process of construction of symptoms as a form of bargain between
adaptation and resistance. Inevitably, interpretations of illness inevitably carry historic discursive
accounts and their contexts are always influenced by local relations of power.
Clinical process and clinical intervention
The quality of the first contact should be particularly heightened, in the sense that users should
feel at ease through finding a nice, calm and reassuring atmosphere, which accesses their diverse
needs (elders, disabled, families with children, etc.)
The team should allow the user to explain his/her problems and be able to interpret the underlying issues that led to the health seeking process. The team will mobilize diverse approaches
in order to identify not only the problem but also, and more importantly, the tacit dimensions
involved in the presentation of the problem. This is a flexible and open process in the sense that
the intervention and program emerges through a discussion involving the team and the user at
any stage.
The interpretation of the problem acknowledges various relations: personal and health biography
and the present social conditions, previous health seeking behaviours, community and kinship
relations, and the users own interpretations of the problem.
During the intervention, diligences concerning the quality of the relationship between the user
and the team will be undertaken at diverse levels. Interventions will take place according to the
methodology and deontology of each disciplinary field (general practice, psychology, psychiatry,
genecology, paediatrics, etc.) and will act according to the more up-to-date and effective techniques and methods.
The intervention will come to a closure through an agreement with the user regarding the
effectiveness of the process or the necessity of seeking further interventions in other services.
For users sent from other institutions, closure of the intervention is obtained through sharing
information and communicating the user’s situation or further necessities.
20
To practice cultural competence in health services is a complex, multi-level process
involving not only interactions within the system, but also exchanges with the community
and other agencies. Within the health care system, important areas related to cultural
competence are represented by policy-making. A high qualitative standard of intervention in health and care can only be achieved if “cultural competence” is systematically
considered a “goal” for professionals, agencies and policy makers.
Cultural sensibility is overall a political issue. The health and psychological condition of
the immigrants, as well their access to health care facilities, are deeply influenced by
their overall social status in the host societies. Furthermore, social and health services
often risk to reproduce the effects of exclusion through reductionism and assimilation.
In this way, cultural mediation corresponds to an opportunity to foster an attitude open
to complexity and interrogation regarding new meanings.
Implementing this model implies a therapeutic device that must be necessarily
interdisciplinary and transcultural, where different actors – cultural mediators, clinical
psychologists, psychiatrists, social scientists, as well as patients, families and network
of relations – may confront and discuss organization models, theories, interpretations,
practices and strategies of healing.
Guidelines for Quality Standards
Following these assumptions T-SHare Guidelines for Quality Standards propose a core Quality
Standards for an European Transcultural Model of Mental Health and Women Health:
1. Develop a shared ethical code of conduct
Ethical awareness is a fundamental part of the professional practice of all health professionals.
T-SHaRE Guidelines and Standard for Practice and Training proposes an Ethical Code of Conduct to
be used and adapted by the promoters in the work with multidisciplinary and multilingual teams.
The above mentioned document proposes a set of Ethical Guidelines on culturally-sensitive
health care provision. It refers to social and health care professionals as those practitioners and
professional staff who work in the provision of social and health care to diverse individuals,
including (but not limited to) physicians, nurses, psychologists, clinical social workers, clinical
anthropologists, cultural health mediators, interpreters, other social scientists such as sociologists,
and medical assistants.
2. Create a multilingual and multidisciplinary therapeutic team
Create a multilingual and multi-disciplinary therapeutic team integrating their competences in
a complex intervention (for mental health: psychotherapists and psychiatrists, anthropologists,
21
cultural mediators, social workers, community and clinical psychologists; women health and family
matters: general practice medical practitioners and pediatricians, breast specialists, gynaecologists,
cultural mediators, psychologists, social workers, nurses, anthropologists).
The multidisciplinary and professional team is able to receive users from different nationalities or
communities that have specific linguistic, religious and cultural characteristics through using their
first or preferential language and with consideration for their cultural representations of healthcare,
of the body, and of suffering. It is up to the professionals to answer to specific care-seeking concerns:
diagnostic and therapeutic view, mediation, collaboration with other teams (particularly in the
perspective of joint therapies), raising awareness in the approach of concerned populations.
Favouring pluridisciplinarity can also be achieved by including social services which will ensure/assist
with healthcare access.
3. Health Cultural Mediator is part of the team
The unit of cultural mediation is part of the therapeutic team and composed by professionals
who preferably share language and origins of the main migrant and ethnic minorities populations,
providing the possibility of activating intervention “on demand” for specific needs.
As a general standard, family and friends are not used to provide interpretation services. In case
of specific patients’ request in this sense, the new guest will be considered an interlocutor in
the therapeutic process and not a surrogate of the cultural mediator.
Service providers should have written guidelines and a contract that mediators are asked to adhere
to and ideally sign – covering aspects such as confidentiality, roles, responsibilities, and ethics.
4. Training professionals within the “cultural competence” framework
Train health care professionals and operators within the “cultural competence” framework, and
cultural mediation in the context of healthcare (the training should also be extended, when possible,
to community health workers)
5. Work with the network
The team works in a continuous relationship with the network of services available in the community and community health workers, offering interventions addressing clinical and social
needs. Moreover, the team should represent a resource available to other institutions for activities
of consultation on patients, supervision or institutional advisement.
Cases in which users are sent by other institutions that expressed difficulties with the users
(particularly social services or educative organizations), will be paid particular attention in the
sense that the team’s approach will include the relation between the user and the institution.
6. Assure health care access to all
The access to the service is guaranteed for all patients independently of their administrative
status: papers regularity will not represent a discriminating feature and in no case patients’ data
will be reported to the authorities for immigration.
22
7. Informative documents and data availability
Documents should be tailored to patients’ needs/ literacy and language. Data on performance
should be available to users.
8. Partnering with communities
Partnering with communities should be promoted as a vehicle to facilitate access for mental
health care and women health
9. Promote relations with teaching and research institutions
The team should maintain close relations with teaching and research institutions as a means to
produce and renew knowledge, stimulate further research, supervision and consultation.
10. Promote regular meetings and seminars
Meetings, seminars and other open events should be organized with the aim of promoting a debate within the community about issues of migration, health and institutions.
11. Provide functional and adapted work conditions
Working and reception spaces should be accessible and comfortable, enabling the privacy of clinical consultation and the organization of public events.
Ethical Guidelines – Code of Conduct
It is recognized that all individuals exist in cultural, social, political, historical, and economic contexts, and that professionals are increasingly called upon to understand the influence of these
contexts on individuals’ health and behaviour.
In increasingly diverse societies, it is especially important to acknowledge the role of culture,
ethnicity, migration, language, spirituality and religion, age, gender, sexual orientation, and
(dis)ability on health and well-being, and on health care provision.
These guidelines defend that ethical awareness is a fundamental part of the professional practice of all health professionals. It refers to social and health care professionals as those practitioners and professional staff who work in the provision of social and health care to diverse
individuals, including (but not limited to) physicians, nurses, psychologists, clinical social workers,
clinical anthropologists, cultural health mediators, interpreters, other social scientists such as
sociologists, and medical assistants.
General Principals
Ethical Awareness - Formal codes of ethics and other practice guidelines are helpful, but not
sufficient to ensure that professionals are sensitive to diversity issues in their practice and research. Professional ethical awareness is a continuous, active process that involves constant
questioning and personal responsibility.
23
Respect for People’s Rights and Dignity - Different cultures, ethnicities, religions, languages,
ages, genders, sexual orientations, and other such characteristics are integral to one’s identity
and give meaning to one’s lives. Genuine respect among social and health professionals and
those with whom they interact is key to ethical relationships and to the respect of people’s autonomy and dignity.
Beneficence - The role of social and health professionals is the promotion of health and wellbeing, as a facilitator in clarifying, understanding, encouraging, and helping others gain more
power and satisfaction in their lives.
Nonmaleficence – Social and health professionals should not allow their professional relationships with clients to be prejudiced by any personal views they may hold about lifestyle, gender,
age, disability, race, sexual orientation, beliefs or culture. As such, they are responsible for not
bringing or promoting harm to their clients.
Responsibility – Social and health professionals uphold elevated professional standards of conduct, clarify their professional roles and obligations, and accept appropriate responsibility for
their professional behavior. Furthermore, they are aware of their professional and scientific responsibilities to society and to the specific communities in which they work.
Justice – Justice refers to the recognition that fairness entitles all persons to access to and benefit
from the contributions of one’s work and to equal quality in the processes, procedures, and services being conducted by social and health professionals. Thus, social and health professionals
actively seek to understand the diverse cultural background of the clients with whom they work,
and do not condone or engage in discrimination based on age, culture, ethnicity, disability, gender,
religion, sexual orientation, marital, or socio-economic status.
Competence - Competency consists of attitude (awareness), knowledge (what), skills (how),
judgment (when), and diligence (commitment) in serving the well-being of diverse others, within
the realm of a specific scientific domain in which one has training. Continuous updating of the
evolving research and theory in the scientific and professional literature is an important aspect
of ethical competence.
Context–centered practices - In context–centered practices, social and health professionals recognize that all individuals (including themselves) are influenced by different backgrounds, appreciating the variety of human experiences and belongings. As such, they strive to understand
and respect the diversity of their clients, including differences related to age, ethnicity, culture,
gender, disability, religion, sexual orientation and socioeconomic status, while also taking account
of individual, family, group and community differences.
Consciousness of the complex dimensions of difference – Social and health professionals are
aware that “difference” is not a natural attribute of individuals or groups, but a specific social
and political construction. In their approach they recognize their responsibility in influencing the
common representations of these differences and the consequences over their practice.
24
Specific Guidelines for Social and Health Professionals
Self-Awareness: Social and health professionals are encouraged to recognize that, as cultural
beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions
of and interactions with individuals who are different from themselves in terms of age, ethnicity,
culture, religion, gender, sexual orientation, disability, and socioeconomic status.
Cultural Sensitivity to the Other: Social and health professionals are encouraged to recognize
the importance of cultural sensitivity and responsiveness, knowledge, and understanding about
all individuals as they work with their users.
Self-Knowledge: Culturally competent social and health professionals have specific knowledge
about their own background and how it personally and professionally affects their definitions
and biases of normality-abnormality and the process of healing.
Knowledge: Culturally competent social and health professionals possess knowledge and understanding about how immigration issues, poverty, oppression, powerlessness, racism, sexism,
discrimination, and stereotyping influenced and influence the lives of the people with whom
they work with.
Knowledge of the Other: Culturally competent social and health professionals possess specific
knowledge and information about the particular group(s) that they are working with. They are
aware of the life experiences, cultural heritage, and historical background of their clients, and
how these impact the manifestation of psychological distress, help-seeking behavior, and the
appropriateness or inappropriateness of intervention approaches.
Helping Relationship: Social and health professionals address the ‘comfort needs’ of the patient
in relation to the interpreter with regard to factors such as age, gender, ethnic background, and
other potential areas of discomfort. When the issue arises, these potential areas of discomfort
for the patient are discussed with the patient and addressed appropriately.
Confidentiality: Social and health professionals explain the boundaries and the meaning of confidentiality, and its implications and consequences to their patients, and respect their physical
and personal/emotional privacy, as necessary.
Visions of Health/Illness: Culturally competent social and health professionals respect clients’
religious and/ or spiritual beliefs and values about physical and mental functioning. Hence, they
respect local helping practices and community intrinsic help-giving networks.
Mediation: Culturally competent social and health professionals are able to collaborate with cultural health mediators, and to seek consultation with other healers or religious and spiritual
leaders and practitioners in the treatment when appropriate.
Language: Culturally competent social and health professionals value multilingualism and do
not view another language as an impediment to the intervention. They take responsibility for
25
interacting in the language requested by the client and, thus, may need to (a) seek an interpreter
with cultural knowledge and appropriate professional background or (b) refer to a knowledgeable
and competent bilingual professional.
Limits of Competence: Culturally competent social and health professionals seek out educational,
consultative, and training experiences to enrich their understanding and effectiveness in working
with different social groups. Being able to recognize the limits of their competencies, they (a)
seek consultation, (b) seek further training or education, (c) refer out to more qualified individuals
or resources, or (d) engage in a combination of these.
Supervision: Culturally-sensitive supervision is sought as an indispensable tool to develop an
on-going and active process of questioning and self-awareness, as well as relational awareness
in working with the other.
Organizations: Social and health professionals are encouraged to support culturally-informed
organizational and policy development and practices.
Education: As educators, social and health professionals are encouraged to employ the constructs
elaborated in critical reflections and up-to-date researches approaching diversity in education
and training of other social and health professionals.
Research: Culturally sensitive researchers are encouraged to recognize the importance of conducting context–centered and ethical research, concerned with the environments where persons,
and their relations, are (trans)formed, namely by cultural, social, political and other contextual
factors.
Professional profiles and skills
T-SHaRE Guidelines propose that professionals engaging in an interdisciplinary and inter-professional team that works with immigrants or citizens with different linguistic, religious or cultural characteristic must possess relational competencies in addition to knowledge skills and
clinical competences.
These skills and competences will be subdivided in general competences and specific competences according to the (1) characteristics of the health service concerned and (2) with the professionals involved (health care professionals, as doctors, nurses, psychologists, anthropologists
and health care mediators)
I. General competences
All the members of the intercultural work team (health care mediators, doctors, nurses, psychologists, anthropologists, etc.) should possess and develop the following skills at different
levels in any kind of health care service:
26
1. Relational competencies
Operators should be able to build up a strong therapeutic relationship with the user; the latter
should feel “safe” and welcomed for sharing the reasons for his suffering with the health operators. Each health professional has to question his/her own personal attitude toward migrants
and ethnic minoritiy members, and to reflect upon the care process as a part of an interpersonal
and on-going process, not a simple act.
2. Knowledge skills
Knowledge of core anthropological concepts and in medical anthropological issues (culture, body,
identity, illness/disease/sickness, explanatory models of health, disease, and suffering): critical
attitude towards their own theoretical and methodological premises; knowledge about categories, representations and interpretative models operating in other societies and in other healing systems; knowledge of other aetiological, diagnostic and therapeutic registers, and of other
aspects of suffering and illness; reflection on the relation of power implied in the healing practices; ability to stay and to move inside/outside the dialectic between the concept of equality
and the one of difference.
According to the health service were the professional is working there will be the need to acquire
some specific anthropological/medical knowledge (as proposed in point III)
Knowledge of the service network and its functioning: ability to identify local institutions providing social services and social assistance to immigrants and ethnic minority members. This includes immigrant associations who perform as links or bridges between local institutions, the
individual and his/her community (beyond social services, this includes socialization activities).
Knowledge of the legislation on immigration: knowledge of the legislation on immigration in
France, particularly as it pertains to healthcare issues (ie. visa for medical reasons, conditions of
access to State Medical Assistance) as well as ability to map local institutions providing legal
aid to immigrants and and ethnic minority members.
3. Clinical competences
Decentering, or the ability to see the confrontation of explanatory models at play: With a background training in the clinical medical anthropology approach, the healthcare professional should
learn to identify the various explanatory models which are at play in the clinical interaction (the
clinician’s, the patients’, and the system’s – disease, illness, and sickness) and which are necessary to grasp in order to enhance mutual comprehension and respect on the one hand, and enable
to construction of a reliable diagnosis on the other.
Neutrality and confidentiality
II. Special competences according health service concerned
Professionals working in the field of women’s health have then to deepen their knowledge
around the notion of female bodies, sexuality, pregnancy, social construction of the new born,
27
childrearing practices. In mental health services they will work on the concepts of aetiology, the
issue of the efficacy of the acts of healing and more generally around ethnopsychiatric and medical anthropological notions”.
III. Specific competences regarding professionals’ identity
Health care professionals (doctors, nurses, anthropologists, etc.)
The team has to recognize the central role of the health cultural mediator to benefit and to highlight his/her competences.
Health care professionals should competently manage the often observed process of triangulation that consists in a continuous involvement of the cultural mediator into the dialogue between
health workers and users; they should be able to tolerate the frustration of not immediately understanding the patient’s discourse, for both linguistic and semantic reasons; additionally, they
have to learn to work in the presence of another health worker in the clinical setting (this issue
is particularly important in psychotherapy), accepting to be a third party in a in a process of
clinical co-construction.
Health cultural mediator
Regarding the health care mediator T-SHaRE Guidelines propose a detailed and critical discussion
about this professional figure, his/her role in the health care service and his/her competences
and profile.
Cultural mediation in health care services
A question of professional identity
Cultural mediation is one of the most representative interventions and practices in a transcultural
health model and yet, the less clearly defined professional identity in the health care sector.
Because of non-uniform practices, unequal training requirements, and the absence of a regulatory professional body or committee, cultural mediators often lack legitimacy and recognition
in terms of their professional identity. Although definitions of cultural mediations have evolved,
in some places, cultural mediators are still perceived as “interpreters of traditions” and “representatives of the culture of origin”5.
Likewise, there are no particular formal definitions of cultural mediation in the context of healthcare specifically. In fact, definitions of cultural mediation are embedded in broader definitions
of social mediation as a relational approach seeking to enhance, maintain or re-establish communication between two parties in one given social environment.
5
28
Despite formal definitions of cultural mediations, there does not exist any legal chart framing the practice of cultural mediation in any T-SHaRE
partner country. In France, a legal chart exists that frames the practice of mediation as a profession, along with a code of ethics and deontology.
However, this chart does not make any reference to cultural mediation specifically.
While T-SHaRE principles recognize the importance of constructing a flexible definition of mediation, in dialogue with the contexts and the expected objectives, the non-existence of a coordinated function results in (1) the neglect of already existing practices of mediation (either by
confrontation or by identification) - and (2) the absence of reflection, learning and systematic
dissemination of “good” and “bad” practices (or successes and failures).
These contexts have led to difficult legitimacy and recognition of the mediator as a professional
identity which by consequence erase several obstacles and the ones outlined by cultural mediators during T-SHaRE fieldwork:
•
•
•
•
•
•
•
•
non-professionalization of practice
great heterogeneity of mediation practices/interventions/techniques
lack of a common training and specific intervention methodologies
low technical quality of mediators
no space for reflection or/and supervision on practices, dissemination of good practices
and supervision
difficult dialogue among mediators and institutions
fragile professional identity
precarious work contracts for mediators, leading to job abandonment
Confined to the informal level, to the sole responsibility of non-professional volunteers on the one
hand and informal, sporadic information exchange and advice between health and care professionals
on the other, it definitively lacks the minimum professional standards necessary for an appropriate,
efficient, holistic and just treatment of a patient. Information exchange between professionals and
users, which is crucial in achieving this aim, is in most cases partly or generally incorrect (due to language problems), imperfect (due to lack of understanding of specific terminology) or insufficient
(due to increased time-consumption). These insufficiencies are especially evident and dangerous in
the field of mental health, where a professional mediator with both language and cultural competence skills would be of highest importance, since very small details and nuances in patient’s expression and health professionals perception and understanding of the patient’s cultural background
can lead to very distinct diagnosis and consequently very distinct drug and therapeutic treatment.
And finally, due to the fact, that formal mediation is not perceived and exercised as a systemic basic
right but is actually a kind of an individualized informal favor or sacrifice of another person, it can
produce feelings of gratitude and obligation, that in the final instance, can produce or reproduce
some formal or informal relations of power: between doctor and patient, husband and wife, parents
and children, citizens and migrants, associations and individuals.
In accordance with previous experiences and opinions of migrant users of health services, an institution of cultural mediation should be recognized and formalized as an expert professional service.
The role of cultural mediation in the health care sector
Cultural mediation involves more than linguistic translation. The use of mediation only for translation needs must be discouraged in a context such as a Mental Health Services and during a
Psychiatric or Psychotherapeutic Intervention. The risk to reduce the cultural mediator interven29
tion to a mere technicality and translation activity is high. That is detrimental to the quality of
care and it doesn’t consider all relational dimensions, nonverbal communication included, feeling
of ashamedness, confusion, suspiciousness, trust and mistrust, etc.
As most reports pointed out, its function is to bridge between two worlds, two sets of representations. Culture is understood to be located on both ends of the communication, not simply
on the immigrants’ or the ethnic minority members’ side. Also, the concept of cultural mediation
must give full significance to cultural aspects in an anthropological way, giving value to cultural
identity including religion, tradition and experience. Language aspects are of primary importance
including all forms of communication including body language. The concept of identity is defined
as a factor of significance. Dialogue between diversities is to be considered an added value to culture
resulting from the capacity to develop new cultural relationships in a universal citizenship model.
A major stake in cultural mediation practice is immigrants’ and ethnic minority members’ integration to the host society, rather than their assimilation. That is, cultural mediators enable the
confrontation of cultural “explanatory models” on both ends of the communication, by explaining
and relating the values and norms associated with such models. The ultimate goal is for interlocutors to be able to identify with one another’s model by way of understanding it. Part of the
mediator’s role is therefore to enable a transition.
The cultural mediator, preferably a person sharing the origins and/or the migration experience
of the patient, is neither only a translator nor a sort of (fictitious) “cultural expert”: with her or
his active and critical presence, the cultural mediator introduces a “difference” in the setting,
representing the possibility to reformulate the meaning of stories, experiences and symptoms
in a new productive form. Identity is not a fixed and stereotyped attribute of the person, but a
representation of oneself and the other constantly enacted and reformulated according to the
situation. Cultural mediation is thus properly “productive” of a new “possible common identity”,
allowing communication, mutual reformulation and efficacy.
In no case should the presence of a cultural mediator be imposed in health settings, but always
negotiated as a specific moment of the therapeutic process. At the same time, social and health
professionals are aware that cultural mediation is not simply a strategic tool to obtain compliance
and acquiescence, but a critical device introduced into the therapeutic system for questioning
its premises, its organization and its practice.
Cultural mediation is a commitment for building models of intervention and efficacy that
seriously take into account, the transformation of identities and the pluralism of health
seeking behaviors of the migrants and ethnic minority members patients in search of
health care. If “cultural competence” (Maurice Eisenbruch) represents the best way of
achieving this project, then we must consider at the same time the issue posed by the
transitional position of the migrants or, to put it in different words, we must conceive of
flexible intervention strategies able to cope with their shifting (sometimes erratic) needs
and to negotiate the therapeutic process. Within this field, cultural mediation perhaps
reveals its deeper meaning.
30
Health Cultural mediator profile and skills
To acquire and strengthen the following skills, the involved health cultural mediators should
recognize and respect the code of conduct that will act as a professional regulation.
Interpretation
The general characteristic concerning the ‘cultural mediator’ is that s/he should speak the client’s
first language, and when necessary also speak the same dialect as the client (as a means to be able
to refer and be aware of ethnic and country related issues). A strong theoretical base in translation
theory is required. Nevertheless, it is not certain that a mediator from the same country/ethnic
group may be the best choice. In some cases a match in gender, age and religion among mediators
and users can be considered useful (Nijad, 2003), especially in specific cases (domestic violence,
discussion of taboo areas, etc.). However, it is important to assess the individual requirements,
through the capacity of using the user/patient/clients maternal language.
Cultural mediators are required to be fluent in two languages and to have an understanding of the
different cultural and symbolic contexts, which means, being aware of the diverse linguistic representations and capable of promoting interplay between them6. S/he should manage the flow of
communication in order to preserve accuracy and completeness, and in order to build a good relationship between provider and patient. Furthermore, a specific task is related to ensure that concerns
raised during or after an interview are addressed and referred to the appropriate resources.
The cultural mediator’s role also requires an ability to manage non-verbal interactions which,
without good mediation skills, could quickly generate misunderstandings. Non-verbal elements
may be linked to the flow of the clinical exchange, but also to the social positioning of its
participants (especially with regards to gender and age).
Triangulation
Beyond the basic relational skills mentioned earlier, the health cultural mediator should have
the ability to position him/herself as the third person in the interaction, and maintain the dialogue between the clinician and the patient. This may require preparing the interaction prior to
the clinical interview, especially if the clinician or the patient have never worked with a mediator:
the role of the mediator has to be explained, as well as the dynamics of mediation.
Cultural interface
As indicated earlier, cultural mediators are not mere translators. Their role is to bridge between
explanatory models. That requires an ability to move from one symbolic and semantic system
to another (as underlined in the “decentering” definition), to work on an hypothetical level and
to act as a bridge between different symbolic and semantic worlds, moving across different representations of illness and healing models of the patients and their social and cultural context.
The cultural mediator will be introduced in order to maximize mutual comprehension in the
clinical setting. Nevertheless, it is important to bear in mind that by no means is the contact
6
Guide to languages by country : http://www.ethnologue.com/country_index.asp
31
with the user the exclusive responsibility of the mediator, whose function is to accompany and
facilitate the process. Therefore the mediator’s presence should not be imposed.
Methodology for recognition of prior learning
Today, many individuals consider themselves – and practice as – cultural mediators in the healthcare context. If our goal is to homogenise practices at the national level – on the basis of the
transcultural model provided by the T-Share project – and to make cultural mediation standards
uniform, we need to assess standards for cultural mediation skills which some professionals
may already have acquired along their career.
In order to do so, we must 1) identify the formal institutional process providing acknowledgment
for “experience learning”, and 2) indentify the particular skills expected to be assessed in the
prior learning certification process for cultural mediation professional credits, and for specialization credits in mental health and women’s health.
The recognition of skills learned on the job: the French good practice
The identification of the formal institutional process providing acknowledgment for “experience
learning” will vary according to local national contexts. In France, for example, a national process
exists which enables one to get all or a part of a certification (diploma, certificate with a professional end or professional qualification certificate) based on his/her professional experience, i.e.
a certification of the skills he/she acquired through experience. This process is called VAE, the
French acronym for the Validation of Learning from Experience (Validation des Acquis de l’Expérience).
The objective in obtaining this certification is to acquire the equivalent of school credits necessary
to access a university-level training program. If we anticipate the creation of an “intercultural
clinical mediator” vocation, we would imagine it to be under the tutorship of the local Ministry
of Health and Social Affairs.
How to assess and validate skills learned in non formal or informal settings
The skills and competences identified above can be measured as follows:
Relational competencies can be measured through observation of practice. An evaluation of the
employer/supervisor, together with in situ observation should help evaluate how the professional
performs in practice, specifically how he/she performs with users and other health operators/mediators.
Knowledge and skills: On the basis of skills and competences identified above and developed in
the training program, a written evaluation will be administered for general knowledge, followed
by an oral examination for application of general knowledge in the specific fields of mental health
and women’s health (theoretical questions + clinical case exercise). This examination must be
precise as it will determine how many school credits can be awarded to the professional, and
which skills or competences still need to be acquired in the context of the learning program.
32
The examination team must be composed of at least one clinician and one expert on the subject
of cultural mediation in the context of healthcare.
Units of measurement and school credits must be defined by the institution in charge of the
training program.
Following the results of the evaluation of skills for prior learning:
•
•
•
The health operator/mediator participates in the framework organized as a formal further
education program
Or he/she obtains total recognition of skills for prior learning (formal exams may still be
required, but class attendance may be waved)
Or he/she gets part recognition, and depending on how much school credits are obtained,
and on which skills they correspond, he/she follows part of the further education program
Knowledge
Skills
1. Juridical + network competence
Visa types and administrative
steps to obtaining them
Institutions assisting with
administrative steps
Institutions providing social
and healthcare support
Institutions providing general
support for immigrants and
ethnic minority members
Better assessment of social
situation and its impact on
mental health
Better clinical assessment
Proper referrals for users
2. Fundamental anthropological
concepts
Knowledge of general
anthropological concepts
(culture, body, identity) and of
the medical anthropology
framework
(illness/disease/sickness)
Tease out explanatory models
of health and healthcare
3. Mental health aetiology
Main diagnostic categories
Sociogenesis
Psychogenesis
Genetic/Epigenetic aspects
Explanatory clarity
Ability to “break down the
jargon”
4. Communicative and relational
skills
Variations in communication
registers, attitudes
Establish respect and trust
Figure 1 : mapping of skills related to each typology of practitioner foreseen in the interprofessional,
intercultural work teams in the field of mental health
33
Knowledge
Skills
support for maternal and
infant healths
mental health
concepts
(culture, body, identity) and of
the medical anthropology
framework
3. Women’s health concepts
Variations in understandings
of female bodies, sexuality,
pregnancy, social constructions
of the new born, childrearing
practices, etc.
Explanatory clarity
Ability to “break down
the jargon”
skills
registers, attitudes, especially as
they relate to gender positions
Figure 2: mapping of skills related to each typology of practitioner foreseen in the interprofessional,
intercultural work teams in the field of women’s health
34
1. Juridical
+ network
competence
Knowledge
Skills
Evaluation & Credits
Visa types and
administrative steps to
obtaining them
Better assessment
of social situation
and its impact on
mental health
Written exam
(20% of total credits)
Institutions assisting
with administrative steps
Better clinical
assessment
Proper referrals
for users
Institutions providing
general support for
immigrants and and ethnic
minority members
2. Fundamental
anthropological
concepts
(culture, body, identity)
and of the medical
anthropology framework
Tease out
explanatory models
of health and
healthcare
Written exam
3. Mental health
aetiology
Sociogenesis
Psychogenesis
Explanatory clarity
Ability to “break
down the jargon”
Oral exam
4. Women’s health
concepts
pregnancy, social
constructions of the new
born, childrearing practices,
etc.
Explanatory clarity
Ability to “break down
the jargon”
Oral exam
5. Communicative
and relational
skills
Establish respect
and trust
In situ evaluation
and report
35
36
Guidelines
Application
and Practical
Concerns
37
38
Guidelines Application and Practical Concerns
Introduction
To assure the effectiveness, accuracy and pertinence of the intervention(s), modes of application
of these guidelines will vary according to local national contexts. For effective implementation
and evaluation of a program or project, it is necessary to gather baseline data and maintain an
on-going process of investigation and continuous fieldwork.
Each country is characterized by a singular history in relation to welcoming and managing
immigration flows. Nations’ attitudes towards immigrants have fluctuated across time, but in
the context of economic hardships and resulting uncertainties, immigration politics have become
increasingly restrictive across countries. Meanwhile, each country’s state ideology and politics
shape its healthcare system, and conditions of healthcare access and coverage thus vary from
one national context to another. Even though healthcare access is considered a right in most
European countries, the conditions of access are unequal. With respect to immigrants, healthcare
access and provision may be hindered by such obstacles as legal status, language fluency,
socioeconomic precariousness, or fear and stigmatization, although it is often legal status which
determines an individual’s access to healthcare coverage (Huma Network 2009, Médecins du
Monde 2009, Sargent and Larchanché 2011). In some settings, initiatives were developed to
accommodate the needs of immigrant patients with regards to language and culture, such as
transcultural clinics or resort to interpreter services and intercultural mediation. However, such
initiatives are also dependent on and shaped by local ideological, legal and political contexts. For
example, some systems may be culture-sensitive, while others are culture-blind (Cattacin et al.
2006). As a result, both the quality and availability of such services have evolved with time, and
vary from one context to another.
To be able to develop an effective and efficient training and/or implementation/development
of a transcultural health service, promoters should assess the context and the system specific
dynamics, needs and potentials using/adapting T-SHaRE instruments and tools or building new
ones as a complement.
T-SHaRE proposes that promoters actively engage users, researchers, privileged witnesses and
other professionals working in the field in an action-research activity, both in the analysis of
training needs of health services, and in the realization of pilot experiences of on-the-job orientation and management of services in a cross-cultural approach addressed to women’s health
and mental health.
In order to design innovative and transcultural protocols and/or training adapted to the national
policies, to the field of interventions and in relationship with the network of services available
in the community, T-SHaRE encourages promoters to follow four general goals or stages, as
presented below.
39
Developing a common and shared theoretical and methodological core
Following the need to share core definitions and a common paradigms/vocabulary, T-SHaRE teams
undertook, a scientific and bibliographic critical discussion of several core concepts and discussed
the epistemological position for a transcultural model for health care practitioners (Annex 2).
Analisys of local contexts and the health care sector
One of important steps is to analyse, identify and map out issues concerning migrants’ and
ethnic minorities’ access to health care, to develop a broad characterization of the host country’s
health care system and, in the process, to outline some of the implications that are at stake
concerning migrants’ and ethnic minorities’ rights and access to health care.
To a large extent, there are significant differences between countries and migrant groups,
creating the need for tailored policy responses that take into account the specific barriers to
access to health care in each case.
For migrants, barriers to accessing health care represent a complex issue. Special health risks
and access problems affect different groups, including newly arriving migrants, people living in
40
temporary reception/detention centres and undocumented immigrants in general. Moreover,
there are many challenges for providing health care within a multicultural setting, some of which
can be persistent for migrants who have stayed in the host country for some time. Some of
these challenges are similar to those faced by long-established ethnic minorities and may include: lack of knowledge about available services; language differences and varying cultural attitudes to health and health care.
T-SHare Guidelines developed a questionnaire aimed at producing a state of the
art of the local health care system and national policies with special attention to
immigrant issues (Annex 3).
Analysis of migrants’ and ethnic minorities’ knowledge on health and care
Another important stage consists in analysing cultural representations, skills and needs of migrant communities relating to the field of health and care. Identifying and describing, from a
transcultural point of view, compatibilities, analogies, possible complementarities existing in
different therapeutic cultures in order to use it as a ground for:
•
Identifying and drawing up the shared objectives to innovate health care services.
•
A relevant description of: cultural representations, medical theories, cure approaches, skills,
needs coming from immigrants communities in particular in the field of women health and
mental health.
•
Comparative analyses about visions, needs and different cultural practices in the key sectors
of health and care from immigrants’ points of view.
•
Only considering approaches that are compatible with our scientific epistemological
paradigms.
•
Avoiding ‘western’/ethnocentric interpretations.
The objective is to identify immigrant communities and their key-actors in order to carry out
focus groups and, from those discussions, elaborate a list of practices and current immigrant
community needs in the context of healthcare.
From this perspective, T-SHare Guidelines developed a methodology that includes
an outline to guide focus group discussions (Annex 4)
41
From the focus groups carried out during this stage with immigrants and ethnic minority
group members, there is a widespread belief that Western medicine is “more advanced”
, but that it could be enriched by the encounter with other medical systems, like ‘traditional’ medicines. Frequently, users consult the National Health System of the hosting
country parallel to the use of a dietary trend, healing practices and small remedies of
their country of origin. In such ‘traditional’ health systems, there are characteristic features of a therapeutic system, which are difficultly interchangeable, and which relate to
the systemic consideration of the individual, to the philosophy underlying the criteria
that guide the diagnosis, up to frequently used therapeutic techniques or specific diets.
By acknowledging these factors, health care operators and mediators could promote and
make the process of mediation easier in several stages (giving a meaning to the experience, diagnosis, therapeutic proposal, etc.).
Based on the vast literature questioning and deconstructing the traditional medicine/biomedicine dichotomy (parallel to the opposition tradition/modernity), in this project, we
also caution against risk of running into the classic pitfall of ethnocentrism vs. cultural
relativism. As a result, we wish to highlight that we approach “traditional medicine” as
an abstract category referring to heterogeneous practices. Similarly, we question both
the monolithic view of “biomedicine” as well as its healing models. Our ultimate objective
is for migrant patients to be able to negotiate among different interpretations and healing strategies.
Analysis of (1) competences and (2) training needs for the services
and mediators according to migrant and ethnic minority users
On the basis of the same principals aforementioned promoters should become familiar with and
aware of the weaknesses and potentialities of the existent cultural mediation practices, legal
frames and related skills officially requested, actually used in the local health care services.
After identifying typologies of immigrant users, country promoters should identify and discuss
mediation skills. In this respect, the mediator should have/acquire/improve. This process involves
working with professionals to elicit their point of view on cultural and therapeutic mediation
skills perceived as necessary and/or useful to improve health services in their country/region/institution, but also with immigrant users’ points of view.
It must be underlined that this evaluation stage can be challenging when carried out within
health services, mental health services in particular. Some partners in this project have found it
problematic, and ethically questionable, to interview or carry out focus group discussions with
immigrant patients. Therefore, this stage must be adapted following the institutional context
it takes place in, and results must be analysed.
42
T-Share has developed a methodology to collect and analyze data regarding skills
and competences. The involved professionals should have/acquire/improve from
the immigrants’ point of view (Annex 5) and from the intercultural health mediators’ and the health care operators’ points of view (Annex 6).
It should be noticed that an interesting aspect emerged in the interviews carried out
with healthcare operators: talking about critical aspects in their daily work with migrant
users, they didn't refer to any technical or practical ones. This suggests that here may
be a degree of resistance to the idea that a reflexive and critical attitude may lead to an
exploration of their own interpretative categories and methodological premises. This is
the only suitable path to approach the Other's categories and representations.
Time
The scheduling of “culturally competent” services will depend on the organization and management proper to each institution and on its objectives. In each national setting, the offer will vary
according to the demand. Some institutions will be specifically dedicated to servicing immigrant
populations and will be trained to do it, while others will only resort to cultural mediators on a
case-by-case basis.
Acceptance
The organization of training for cultural mediation in the healthcare context, together with the
implementation of quality standards as outlined above, will generate improvements in several
aspects of healthcare delivery to immigrant populations. In particular, the formal recognition of
the relevance of cultural mediation in the healthcare context will lead social actors to reach
acceptance at various levels:
•
local health and educational authorities will acknowledge the difficulties raised for immigrant
populations in accessing healthcare and negotiating treatment;
•
healthcare and social services professionals will take into account the varying representations
of the illness experience as well as the broader social and structural determinants of health
and healthcare access;
•
these forms of acceptance will improve the relationship between practitioners and patients,
which in turn will optimize treatment.
43
Costs and benefits
In the healthcare context, obstacles related to language and cultural representations may have
concrete financial and organizational consequences: longer consultation times, unjustified
hospitalization, maladapted prescriptions and endless medical leaves. In countries where
national healthcare coverage exists, the costs generated by these obstacles and its consequences
are heavy enough, but in countries where individuals receive coverage from private insurances,
such costs can rapidly become unmanageable.
The inability to properly address linguistic or cultural obstacles through cultural mediation may
result in healthcare referrals to be redirected to emergency care services, overflowing emergency
rooms and dramatically increasing healthcare expenses.
Compared with the cost of one consultation with a cultural mediator, the benefits of calling
for a professional interpreter or of training professionals in cultural mediation in the healthcare
context are evident.
Beyond financial costs, there are ethical costs as well: on the one hand, the lack of access to
cultural mediation may impede professionals from doing their job properly, which in turn may
lead to situations of aggressiveness with patients and to professional burnout; on the other
hand, it may be extremely detrimental, not only for patients’ well-being but also for their human
integrity: not to be cared for properly.
Institutionalizing the presence of professional interpreters and mediators in healthcare
structures may also lead to increasing cultural sensitivity for all healthcare professionals in the
long-term. Working with an interpreter may assist with learning about different views of
psychological well-being, forms of client presentation, idioms of distress, explanatory health
beliefs and world views. Becoming skilled at working with an interpreter will also enhance service
delivery through ensuring that access to psychological services is not limited to those fluent in
the English language, irrespective of need.
Accessibility
In the context of public health, the implementation of cultural mediation in healthcare services
and the training of healthcare professionals in cultural mediation leads to increased accessibility
of services for local migrant populations.
44
Guidelines
for Training
Methodology
45
46
Guidelines for Training Methodology
Introduction
Within the context of a multidisciplinary and multilingual team it is argued that the provision
of appropriate training for both health care professionals (doctors, nurses, psychologists, etc.)
and cultural mediator, as well as the use of effective guidelines, can produce improvements in
service provision (Tribe, 1999). More experienced cultural mediators tend to recognise this need,
and are more likely to advocate training both for themselves and for the professionals for whom
they perform mediation (Granger & Baker 2003). Further, many of the difficulties described when
working with cultural mediators in the health care services seem to arise as a result of inadequate
training for both parties.
T-SHaRE Guidelines for Training Methodology should be used on the basis of needs analysis
and suggestions of users, mediators, health professionals and medical experts of immigrant
cultures of the countries of origin, and it is based on a constructivist and decentralized approach.
Learning is perceived as a process based on experience, in which the acquisition of practices is
parallel to that of identification, belonging of the community and mastery of organizational and
interpersonal characteristics of this community. In this sense, it is a social practice in which we
should highlight the character of relational and situational nature of knowledge and the negotiated character of meaning. The focus is therefore on the size of access, power relations, conflict
management and legitimacy, as well as cross-cutting knowledge and expertise. It is necessary
that people-who-learn legitimately participate in the community of practice for the process of
learning to be effective.
The on the job orientation and training path of T-SHaRE is designed on the basis of needs analysis and suggestions of users, mediators, health professionals and medical experts of immigrant
interpersonal characteristics of this community. In this sense it is a social practice in which we
management and legitimacy, as well as cross-cutting knowledge and expertise. The team of
T-SHaRE seeks to facilitate this process by enabling “environments” of collaborative and blended
learning in offering courses in health services involved in each country.
The training courses are divided into different phases. The first phase of orientation and on site
training is jointly addressed to mediators, doctors, nurses, psychiatrists, psychologists, obstetricians
and pediatricians. The second phase, with the activation of a helpdesk, faq and remote monitoring,
will be carried out during the activities of delivery of services dedicated to immigrants in the field of
mental health and women. The third and final stage, will involve teams in a process of self-assessment of service and path, and a confrontation with the original training proposal regarding the
achievements, difficulties, constrains and innovation resulting from the training process.
47
T-SHaRE training goals
Running appropriate training and information sessions ensures that the health cultural mediator
and health professionals involved are conversant with the organisation’s aims, objectives and
culture and may also provide an integrating function.
In general, T-SHaRE training methodology aimed to:
•
provide health workers (doctors, nurses, psychologists, social assistants, etc.) and cultural
health mediators with the skills to work in multidisciplinary teams, to increase trans-cultural
skills, to promote respect and understanding of demands by users from immigrant communities and ethnic minorities;
•
increase the general competence of trainees in “taking care of individuals with a person
centred approach”;
•
support the learning of techniques aimed at realizing interventions of assistance and support
in foreign patients;
•
promote the establishment of multidisciplinary work groups aimed at reducing the risk of
drop out and diagnostic error, to help the patient’s therapeutic continuity, and to mediate
the conflict in the social and familiar context;
•
train health operators in order to cooperate with new professional profiles, namely health
cultural mediators;
•
to acquire and enhance knowledge on inter-cultural and trans-cultural approaches in health
care and to outline visions, ideas and possibilities for a proposal to implement official intercultural health mediation in the health care system;
•
test innovative protocols for building and guiding inter-professional and intercultural team work
in the healthcare services for migrant users (with a focus on mental health and women’s health).
T-SHaRE training protocol
Following the needs, skills and competences previously identified, a general plan of training
activities was organized around four parts:
Part 1 – A common part of 20 hours to share a common vocabulary and language with the selected team, such as an introduction for analyzing the notion of culture; the work of translation;
the emic representations of disease and illness, etc.;
Part 2 – divided into two different levels concerning the different interventions in Mental Health
Services and Services for Women and Child Care:
48
Mental Health Unit (10 hours), analyzing: mental health issues (more concentrated on ethnopsychiatric and medical anthropological concepts such as the problems of aetiology, the issue of
the efficacy of the acts of healing, the dimension of transference and counter-transference, etc.).
Women Care Unit (10 hours), analyzing: women and children health, the notion of female bodies,
sexuality, pregnancy, the social construction of the newborn, ethno-pedagogies in the first years, etc.).
Part 3 – 20 hours are dedicated to the training on the job of the inter-professional team, including
the cultural mediator. The aim was to constitute and interact as an intercultural team working
with users from immigrant communities and ethnic minorities.
Part 4 – 10 hours dedicated to the intercultural team to assess the results of the intercultural
team training and the feedback of migrant users.
Annex 7 present the details of the training pilot activities implemented and
tested by T-SHaRE (core modules and themes of training).
Local constraints and contexts
Planned variations on the training course occurred for most partners. The methodology was
adapted to the different contexts according to health service organization and general context
in each partner country.
The choice of the audience, target groups and the working methods was discussed and approved
at the meetings of co-ordination with the local organizations/institutions.
Following the T-SHaRE training pilots experience it has been carried out also in countries
where State Institutions look to migration with a very controversial approach (as partially
Italy) or where they lack sensibility to trans-cultural issues and where there is no experience with cultural mediation in health care services (as in Slovenia). The general aim
was to acquire and enhance knowledge on inter-cultural and trans-cultural approaches
in health care and to outline visions, ideas and possibilities for a proposal to implement
official inter-cultural health mediation in the health care system.
Training health professionals: an essential issue
T-SHaRE training beneficiaries were interpreters, cultural mediators and several categories of
health care professionals, mental health and women’s health professionals, as well as social and
medical services staff . In some countries (where there is no official cultural mediation and prac49
tices of advocacy and mediation are not acknowledged in the health care systems) the majority
of trainees were informal advocates for migrants’ access to health care, informal interpreters
and informal cultural mediators.
One of the first and the most necessary steps in cultural competence training, identified
by users from immigrant communities and ethnic minorities and health care mediators
during T-SHaRE fieldwork, is the sensibility of professionals: the sharpening of their
awareness about prevailing stereotypes, language barriers, implicit and explicit racism,
xenophobia and discrimination. A special focus, effort and training on the phenomenon
of migration, migrant rights and cultural competence should be provided in the areas
where there is a large concentration of migrants, asylum seekers and refugees (as was
the case of Ljubljana Vic, which is in charge of health and care for asylum seekers).
Methodology of training
Training was conducted by different trainers (health or university system professionals with
cultural competences and practical experience) reflecting the interdisciplinary nature of the
programme and addressing the diversity of the professionals` needs.
Health care professionals and cultural mediators are trained together, in joint sessions, allowing
for a better understanding of each person’s role as well as the development of a genuine sense
of co-working, improving relations and teamwork between trainees.
The training the program had a participatory nature, allowing trainees to express their ideas and
professional experiences, through different didactic means as “role playing”, clinical case discussions,
brainstorming on critical issues. We believe that this was one of the most important aspects of
this training, in which a major aim was to give theoretical and practical skills on the role of cultural
mediation in health settings.
The instrument of “role playing” was based on an intercultural situation where participants were
confronted with different explanatory models of illness and disease: this instrument initiated a
reflection about the different stereotypes that can arise in the therapeutic relationship and how
to cope with them. Group sharing of experiences enabled participants to stay focused on critical
aspects of work with migrants, to understand the difficulties of all professionals involved (health
professionals, and cultural mediators) and, during the “training on the job”, to explore and
improve integrated work strategies.
Several clinical cases were discussed to allow trainees to engage directly in an intercultural
relationship and to compare different points of view. In some cases, after role playing a clinical
case, the trainer stimulated a short analysis of concepts and key words used in role play by every
role player: in the three dimensions of patient, doctor and cultural mediator. An approach to roleplay and the aspects of non-verbal communication was another theme recurring in training.
50
In most cases, alternating from theoretical presentations to practical workshops during the training has permitted a participatory training whereby participants were invited to exchange with
other participants about their own experiences. The result was a training program enriched by
reciprocal exchange between different professionals who are confronted with these kind of issues all the time in intercultural care settings.
Moreover multimedia technologies were used as teaching materials (power-point, ethnographical and other relevant documentaries): they have the value of immediately showing the audience
what the trainer is speaking about, also involving the trainees at an emotional level. This material
also provides a safe learning environment in which to initiate critical debates, allowing participants to articulate and exchange different points of view, to compare experiences and to formalize new ideas about their professional practice.
Video or professional work experience in the field of women’s health, were the pretext to share
discussion about different childrearing models, different motherhood and parenthood roles, and
different health care practices.
The aim of the “training on the job” section of the project is to put in practice methodologies
and tools of the training, to assess results and to improve the network between all levels of
services offered to migrants.
All trainees were encouraged to access the T-SHaRE website (http://www.tshare.eu/) where
free reports and articles were available.
Supervision is a useful method to help to sustain knowledge acquired during training. It can be
carried out on worksite in-group setting with health worker participants presenting cases with
migrant patients. The presence of health cultural mediators should be encouraged in-group supervision. Supervision should preferably be offered at least twice a month for six months. It can
be a useful method for promoting institutional knowledge, memory building and for improving
multidisciplinary team building.
Using T-SHaRE pilot training protocols
What a protocol is?
A T-SHaRE Protocol for the team building and training of inter-professional and intercultural
work teams operating within the women health and mental health services is an agreement,
signed by each partner in charge for the piloting of the service and the related training of the
practitioners involved, and by at least one authority for the health professional competences
recognition (local/national government, university, etc).
Six innovative and context-specific protocols aimed at building and/or improving healthcare
services for migrant users and at training inter-professional and intercultural team working in
these healthcare services have been developed within the project process, according to the
T-SHaRE transcultural model of mental health and women health services: 2 in Italy (1 in Turin
51
by ASSOCIAZIONE FRANTZ FANON , 1 in Naples by ASL Napoli 2 Nord) and 1 in each partner country.
They are public documents, where there are:
1. A description of the context where the healthcare service has to be settled. The description
might include the following points of view:
• socio-economic context at the local level
• political context and legal and administrative framework on health and immigrants’ and
ethnic minorities’ rights at a local and national level
• description of typologies of immigrants and ethnic minorities settled on the territory
• administrative rules for workers within the health service(s)
• the typologies of practitioners able and allowed to work in the healthcare system
and the skills, competences and certification required to them – including the cultural
mediator
2. A description of the services that the organisation promoting the protocol intends to provide,
in accordance with the T-SHaRE transcultural model:
• Services provided, quality standards and ethical code of conduct considered as references
• List of target users (and related description)
• Epistemological approach used for the organisation of the service
• List of the practitioners required for the services that the organisation intend to provide
– including the cultural mediator
3. Description of the training needed by practitioners – including the cultural mediator, in order
to work within the new services:
• Approach, methodology and tool used
• Objectives of the training
• Topics of training path
• Duration
• Training beneficiaries
• Standards quality related to trainers
4. Description of the methodology, processes and procedures for the recognition of professional
competences within the transcultural health services concerned, for the whole inter-professional team including the cultural mediator:
• skills that are possible to recognize from informal and not formal learning, for example
from past work experiences on the field
• methodology, processes and procedures to be pursued for validating and recognizing
them in accordance with national/regional laws related to the issue.
T-SHaRE protocols as tools for programming and assessing services
A protocol is a public document where everyone may read how a healthcare service has been
organized, on what premises it is based, what are the administrative rules and the laws it has
to respect in order to be legally recognized, why it has chosen to be organised and managed in
the way it is, etc.
52
It constitutes a fundamental tool for programming, managing and assessing the services
provided.
It offers four different perspectives of quality control:
•
Institutional control: it is easy to demonstrate the conformity to institutional rules if this is
the aim of the organisation that is founding the service.
•
Internal workers’ control: it is easy also for people working in the service to check if the work
and the work conditions fit what has been declared in the protocol
•
Final beneficiaries’ and citizens’ control: the protocol allows them to check if the services
provided fit what has been declared in the protocol, why they are provided that way, what is
possible to ask tochange and what depends upon administrative rules and national/regional
laws that cannot be changed in the short run..
•
Internal managers’ control: The protocol provides quality standards that have to be respected.
The managers in charge for quality have an easy to use track in order to adapt T-Share qualitative and quantitative tools to their specific conditions in order to assess the quality of
services provided.
Thanks to the institutional agreements stipulated, the protocol allows to:
•
provide pilot transcultural services within the framework of healthcare local/national
system
•
build and train interprofessional and intercultural work teams operating in women’s health
and mental health services
•
obtain the recognition of the innovative healthcare services concerned by National/local
authorities
•
obtain the validation and recognition of the professional roles and skills in the field of
the transcultural approach to cure and of the intercultural management and the cultural
mediation within the health services by National/local authority
•
be used as public proposal for the beginning of public debates, where there isn’t any service
addressed to immigrants and ethnic minority members
How to transfer the T-SHaRE pilot protocols in further contexts
Thanks to the self-assessment tools for the identification of needs, delivered by the T-SHaRE
team, any policy maker or health services manager interested in establishing a new transcultural
health service or in improving an existing service may be able to identify which T-SHaRE protocol
is more adaptable, usable and useful as track in his/her case. Of course it is also possible to
reuse different parts and tools of more protocols, in order to conceive a new one, if necessary.
53
The six pilot protocols defined by T-SHaRE partners are all based on the T-SHaRE
transcultural model but are quite different, in order to address the specific needs
of each real context concerned. They could be used as practical examples for
delivering further pilot services and protocols, even in those contexts where there
isn’t any service addressed to immigrants and ethnic minority members.
T-SHaRE local protocols are available in Section 4 – Annexes 11-16
Training assessment
The T-SHaRE Training Protocol considers that evaluation provides the only effective way to learn
about (1) the impact of a specific intervention (in this case the training pilot experience), but also
(2) intended and unintended outcomes and innovations allowing, at the same time, for feedback
into the organization/institution and community.
This final stage, involved teams in a process of self-assessment of the service and path through
an evaluation of the training pilot experience which was carried out.
Evaluation form, a pre-test and a post-test were delivered to participants at the
beginning and end of training (Annex 9 and 10).
Innovation was obtained by all professionals mainly through the acquisition of cultural competences in daily practice and in team work introducing the use of supervision.
T-SHaRE major findings/innovations concerning training pilot experience were:
54
•
Trainees stressed that one important conclusion and innovation of this training protocol was
the importance of mediation as a tool to question healthcare practices not only on the side
of the patient, but on the side of professionals and medical institutions as well;
•
Trainees growth of awareness and understanding of different explanatory models and illness
representations, of social determinants and of their impact on health; culture is not a static
concept but a process and can be approached in terms of professional competence, which
requires training compliance; cultural mediation is no longer only a personal skill, but is part
of a professional profile of someone who can promote a cultural approach with his professional competences;
•
Training pilot experience allowed some partners, the introduction of the cultural mediators
in second level health care services, such as Mother and Child Health Consultancy Services
and Mental Health Units, thus representing an local innovation;
•
One of the partners received an external funding from the national Ministry of Health and
Care Settings to continue the training, specifically on mental health and women health care.
An important function for quality assessment of health care is feedback by migrant users of
health care services. This may be obtained using various methodological tools such as interviews,
questionnaires, focus groups. Feedback can be obtained by migrants in an anonymous way with
respect of confidentiality. However it is helpful to collect general information of the respondents,
such as gender, age, status of migration, nationality, time of stay in country, previous use
of services. Other relevant question should concern satisfaction with health care services. The
assessment should be administered by a neutral person.
Results should be fed-back to the health-care team so as to obtain a qualitative assessment
of what patients experience as helpful or important and to allow the team to change or modify
approaches in accordance to relevant observations. This is also an important step of learning on
the job and migrant users participation.
T-SHaRE designed a questionnaire to receive feedback from migrant users who
have experienced health care treatment (Annex 11)
During the training, participants were involved in the construction of a document defining the
role of mediation in the health care context, with the intention to (1) identify and summarize
the most important aspects of the training (2) draft professional guidelines that can be used by
any professional in any healthcare context in the local context where the training was given. This
circular and on-going process of action-research is one of the methodologies allowing for feedback/adaptation/co-construction to/with local organization/institution and community.
55
AnnExES
56
Section 1
The T-SHaRE
Project Rationale
and Consosrtium
Introduction
57
58
Annex 1
By Aracne Associazione di promozione sociale*
1.a) The T-SHaRE Project: Rationale and aims
Motivation and background
T-SHARE seeks to promote and develop transcultural approach to cure in health care services in
Europe, with particular attention to women’s health and mental health. The goal is to help respond to emerging training needs in the sector, linked to the increase of users immigrants living
in Europe and their demand for health care, prevention, but also of inclusion, participation and
shared planning of health services. The testing of a transcultural approach to care responds to
the need to adapt health care models to immigrant users: promoting skills that allow to meet
the cultural and personal background of users in the care activity is essential to remove forms
of exclusion, rejection or misunderstanding that often occur in these services, when the users
have a hard time orienting themselves in a system of signs, interpretations and interventions
that are too distant or disrespectful of their condition and culture.
In the EU there have been many experiments of specific cultural mediation in the health field,
however this is not enough. Some pilot projects were developed to strengthen the role of hospitals in strategies for promotion, information and health education for immigrants and ethnic
minorities also combining the cultural patterns of ethnic minorities with the resources of the
host society (see for example, “Migrant Friendly” 2002 EU Public Health Programme1). Yet, as
today the functions and responsibilities of the cultural mediator that operates in the area of
care are not clearly defined or shared in the Member State and at the European level. This often
creates misunderstandings with health care providers and physicians, which affect the intervention. The acquisition of appropriate competences to face the difficulties that arise in daily
practice is in fact a need strongly felt by all health professionals. This emerges with particularly
urgency in the complex and delicate area of women’s health and mental health, where the health
dimension is closely related with the social, cultural, relational, legal and economic dimension.
T-SHARE intends to help overcome these gaps in training, laying the foundations for mutual
recognition of competences learned in formal and non-formal settings and at the same time, to
help address the limits of reception and inclusion policies at a local and European level. The acquisition of forecasted competences and the quality of services intend to facilitate mobility, employability and professional development of health care practitioners and cultural mediators.
We are in debt to many people for having inspired, advised, guided and helped us in drafting the project T-SHaRE and the present text. Here
we want to mention at least Maria Rosaria Marini of Centro Shen, since this project would not have been conceived without her precious insight,
and Roberto Beneduce of Associazione F. Fanon, for the fundamental political references, theoretical and methodological.
1
The European project “Migrant-friendly hospitals” (MFH), ended in 2004, sponsored by the European Commission, DG Health and Consumer
Protection (SANCO) brought together hospitals from 12 member states of the European Union, a scientific institution as co-ordinator, experts,
international organisations and networks. See http://www.mfh-eu.net
*
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General Aims
T-SHARE intends:
•
•
•
•
•
to improve European health services models to make them more accessible to migrant users
through the promotion of cross-cultural competences in social and health care services, essential to get in touch with the user paying attention to his cultural and personal background,
and therefore remove forms of exclusion, rejection or misunderstanding that occur when the
users have a hard time orienting themselves in a system of signs, interpretations and interventions that are too distant or disrespectful of their condition and their culture;
to make health services places for professional lifelong learning, considering the services
and business units, the interprofessional teams which provide support to users arriving from
different social and cultural contexts as a “community of practice”, privileged places for action
research, continuous education and recognition of competences acquired on the job, in the
field of cross-cultural approach to treatment;
to improve the relationship between doctors, health professionals, mediators, immigrant
communities, through the development of methodologies and tools for managing the personal implications, interacting constructively in the group and enhancing the soft and hard
skills of both individual players/teams and cross-cultural ones;
to define, enhance and recognize the expertise in cultural mediation in the health sector, and
to identify the role and profile of (inter)cultural mediator as a key professional in the process
of interaction with the patient, to improve their employability, professional growth and social
inclusion of immigrants in the health sector;
to valorize the other visions, approaches, knowledge, expertise in the health care field and
of the care that migrants carry, through the active involvement of privileged witnesses both
in the activity of the needs analysis and participatory evaluation of models and services, and
in the perspective of integrating complementary medicines and different medical cultures
in the European health care systems, with the intention to improve and innovate services
for all.
Assumptions and Fields of Intervention
The analysis of the emerging needs of health services and migrant users is indeed the starting
point to understand if the answer is to train cultural mediators in a more appropriate way, in
order to recognize their role of interpreters of complex meanings or to enable them to take care
of users through complementary practices for health promotion, whether there is sufficient ongoing training of health personnel, or, as hypothesized by T-SHaRE, a systemic action is necessary
which includes both interventions.
At the transnational level, flexible and integrated pathways have not yet been made for lifelong
learning of interprofessional and intercultural teams in health services: it is what T-SHaRE
intends to design and test, to make services “culturally competent” and ready to respond to
complex, diverse and constantly changing needs; to prepare mediators to manage counter-transference conditions and work with other health professionals with the awareness of roles, hierarchies and competences; to facilitate the positive interaction of health professionals (including
60
doctors) with atypical professional profiles such as linguistic-cultural mediators, often being the
only one with the privilege of being able to have an effective communication with the user.
It needs to be remarked that immigrants in the EU territory are not only users of health services,
but sometimes they bring their own knowledge, practices, cultural representations of illness,
health, medical practices, relationships help. Such figures are often informally but, in facts,
points of reference for the purposes of prevention and treatment of immigrant communities
present on the territory, as well as public health facilities in host countries. This data cannot be
ignored when it comes to health rights and immigrants integration. This phenomenon can cause
problems, but could also represent an opportunity for innovation and improvement of European
healthcare models, not only for immigrants but for all citizens. T-SHaRE will then bring out diverse visions and practices in the field of health and care, with a view (when this does not collide
with the health of the individual and the community) to make them talk and eventually integrate
them with the medical culture and health services of host countries.
Methodological Approach
To effectively address the complex issues related to health field and migration, it is necessary
to make cross-cultural competence at all levels - both relational-communication and medical
treatment ones – of the European health services, considered as “learning communities”. To
determine how, T-SHaRE actively engages users, researchers, privileged witnesses and other
professionals working in the field in an action-research activity, both in the analysis of training
needs of health services, and in the realization of pilot experiences of on-the-job orientation and
management of services in a cross-cultural approach addressed to women’s health and mental
health.
Action research
T-SHaRE brings out the point of view of all the key players by involving them through action
research to design innovative protocols for health and social services including and welcoming
immigrants, and strengthen cross-cultural competences of services at all levels. T-SHaRE reveals
needs and suggestions of users, enhancing knowledge and medical practices from other cultures,
identifying the necessary competences for the dedicated teams and to individual operators;
promotes the recognition of competences learned in a non-formal and informal settings; designs,
tests and evaluate blended learning paths for training on the job.
T-SHaRE actively involves, from the initial planning phase, public and private organizations of
the health care system, research and training centres, associations for the promotion of rights
and inclusion of immigrants, cultural mediators, privileged witnesses with expertise in complementary medicine coming from immigrant communities and immigrant users of health services.
The position of researcher is appointed by each party: each one elaborates his/her own knowledge and participates in the elaboration of others’ knowledge, developing a common knowledge.
The expert, the operator is not the owner of the knowledge, but is a resource available to the
community. This allows initiating shared processes of change, producing empowerment giving
space and legitimacy to the views of the weakest, and designing open processes of transformation, without rigidly predetermined locations, results and outcomes.
61
T-SHaRE combines quantitative and qualitative methods of data collection: analysis of policy
documents and evaluation studies; questionnaires, focus groups and/or semi-structured interviews with key informants, practitioners, cultural mediators and patients; participant observation
and self-assessment during the testing stage. Strategies for data analysis will include thematic
and narrative analysis.
Anthropological and transcultural approach to treatment
T-SHaRE promotes a transcultural anthropological approach to offer physicians, psychiatrists,
psychologists, midwives, nurses and healthcare professionals innovative tools - still not sufficiently present in the academic and training curricula of different partners countries - how to
relate to diverse modalities of understanding of the body, health and illness, gender identity,
motherhood, mental suffering. This approach is not just about the encounter between cultures
but, more generally, the relationship between doctors and patients, and allows one to renew the
relationship between the “cure” and “caring”. Furthermore, the awareness of “non-natural” categories of “health” and “disease” stimulates critical reflection on some paradigms of biomedicine
and the importance of attention to socio-cultural and not just organic in the diagnostic process
and treatment. This is why the term ‘culture’ refers not only to patients’ ethnocultural background, but also to the knowledge and practices of health care providers, and to the implicit values and ideologies that structure the health care system. There are fundamental links between
the structure of mental and women health services and the broader socioeconomic, cultural and
political contexts in which they are embedded. An adequate response to cultural diversity will
have to encompass attention to language, racism, and inequalities of power as well as the positive meanings of cultural tradition and ethnic identity.
T-SHaRE is far from those paradigms based on the classification of ethnic groups and cultures
as closed and autonomous systems. These readings leadindeed to a simplistic dichotomy: traditional medicine vs. western biological medicine, and do not take into account the adaptability
and the non-predetermination of strategies and behaviours adopted by people (whether patients
or doctors themselves), who are inclined to opt for different approaches from time to time, connecting them in syncretistic results. The transcultural approach to the care offered by T-SHaRE
allows, instead, to take the perspective of the other (practitioner, health professional, mediator,
user), and to respond effectively to the dilemma: “either be anthropologists of all cultures or
speaking in universal terms” forecasting on the one hand the strengthening of expertise for
members of the team, on the other hand, preparing the team to work in groups and with users
through an “open method”.
Learning on the job and communities of practice
The on the job orientation and training path of T-SHaRE is designed on the basis of needs analysis and suggestions of users, mediators, health professionals and medical experts of immigrant
interpersonal characteristics of this community. In this sense it is a social practice in which we
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management and legitimacy, as well as cross-cutting knowledge and expertise. It is necessary
that people-who-learn legitimately participate in the community of practice for the process of
learning to be effective.2
The team of T-SHaRE seeks to facilitate this process by enabling “environments” of collaborative
and blended learning in offering courses in health services involved in each country. The courses
are divided into different phases. The first phase of orientation and on site training is addressed
separately on one hand to mediators and the other to doctors, nurses, psychiatrists, psychologists, obstetricians, paediatricians; the second phase involves the entire team (professionals
and intermediates) in each partner country. The third phase, with the activation of a helpdesk,
faq and remote monitoring will be carried out during the activities of delivery of services dedicated to immigrants in the field of mental health and women. The fourth and final stage, will
involve teams in a process of self-assessment of service and path, and of comparison and exchange with colleagues in other countries.
Results
The main findings of the research are:
•
Innovative Protocols for the establishment and training of interprofessional intercultural
teams in health services in each country.
•
Guidance pilot paths on the job addressed to cultural mediators and practitioners working
in women’s health and mental health sector:
- field experience “on the job” under supervision in blended elearning.
- self-assessment of the pathways with the active involvement of participants
•
Dossier on the necessary competences for intercultural and interprofessional teams in health
services (focus: mental health, women’s health): a descriptive competence map related to
the functions, roles, tasks to be performed and to the contexts of intervention. The Dossier
is a tool that goes in the direction of recognizing the competences learned on the field and
a better definition of the professionals involved at the local, national and European level.
•
Guidelines for transcultural approach to health and care, that is guidelines for the organization and management of culturally competent health services, based on innovative protocols.
They are based on innovative protocols implemented in each partner country, and provide
details for the organization and management of culturally competent health services. They
should realize: the definition of tasks, responsibilities and code of ethics for mediators and
the team as a whole, the quality standards of services for users in key fields.
•
Training Guidelines for health professionals and mediators, for the acquisition and/or enhancement of competences identified in the dossier.
2
See Lave J., Wenger E., (1991) Situated Learning: Legitimate Peripheral Participation Cambridge University Press; and Wenger E., (1998),
Communities of Practice. Learning, Meaning and Identity, Oxford University Press, Oxford.
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The interim and final results of T-SHaRE are available on the project website www.tshare.eu for
free download by registered users, in the web pages Report of Research and Methodological
tools. According to the project requirements and general approach, these contents are published
under the terms of the Creative Commons licence by-nc-nd. Attribution-NonCommercialNoDerivs 3.0 Unported (http://creativecommons.org/licenses/by-nc-nd/3.0). We truly believe
that public access to contents and free sharing of knowledge are the basis for comparison among
and informing of research teams, and to aware and involve all the stakeholders.
1.b) The European Consortium
Azienda sanitaria Locale Napoli 2 Nord
The ASL Napoli 2 Nord is a structure of the Regional Health System of Campania, a South Italian
Region. The ASL has approximately one million residents and the territory includes 32 municipalities, with 2 islands, 13 Health districts, 5 Hospitals, 5 local departments, 4.000 workers, a
total area of 41.143 Sq. Km; The A.S.L. (before ASL Napoli 2) since 2004 has set up the cultural
mediation in health services, that permitted to have foreign operators, with their cultures, building a bridge between migrants and Health Services. In the year 2010, regular migrants present
in the town areas of the ASL amounted to 22.194 persons. On average, as far as irregular migrants are concerned, the ASL Naples 2 North has 1.500 new accesses a year. Over 12.000 irregular immigrants have passed through specialised services up till now (since year 2003)There is
a dedicated space of medical practice for irregular immigrants with no health coverage and unable to pay treatment. This allows a first contact that filters access to more complex health services and gives information and orientation to access to care services also to immigrants
otherwise invisible to the “State” for their condition of illegality. Doctors are engaged specifically
to treat immigrants in this condition, allowing a relation of trust to grow between doctor and
patient. A service of cultural mediators facilitates team building and develop “know how” in the
care givers. On averageover 8.000 general practice medical visits a year are carried out only for
irregular immigrants in dedicated services.. Since 1997, ASL Napoli 2 Nord organizes training of
staff on Assessment and Quality, Emergency-Urgency, Teamwork and management skills, Computer Science and New Technologies, Communication and Public Relations, Monitoring of vaccination activities, Medical Care, in agreement with the National Programme of Continuing Medical
Education. The “Equal Opportunities Committee” promotes positive action in accordance with
EU directives.
http://www.napoli2nord.it/
Role within T-SHaRE project: The body has been engaged in the project management, in the
management of the stage addressed to testing and validation on the job of innovative protocols
for building and guiding inter-professional and intercultural team working in the healthcare services for migrant and ethnic minority members users (focus: mental health and women health),
in the management of mainstreaming activities, as well as to be engaged in all research stages
foreseen by the project
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Associazione Frantz Fanon
Associazione Frantz Fanon (AFF) is an interdisciplinary group (psychologists, psychiatrists, cultural mediators, social workers, cultural anthropologists) involved in the fields of health, migration and culture. The Association is engaged in the improvement of clinical activities related to
migrants’ mental health and was founded in Turin in 1997.
AFF’s main activities are:
1. Interventions of psychological and psychotherapeutic support, ethnoclinical and cultural mediation, diagnostic orientation and counseling addressed to migrants, not accompanied minors, trafficking and torture victims, refugees and asylum seekers, in cooperation with the
national healthcare service, the municipality of Turin Foreign Office, private associations and
cooperatives;
2. the promotion of the use of cultural mediation among social and healthcare services;
3. training for social and healthcare operators on the themes of mental health and migration;
4. research in the fields of ethnopsychiatry and medical anthropology.
URL: www.associazionefanon.org
Role within T-SHaRE project: The body has been engaged in management of the stage addressed
to designing six innovative and context-specific protocols proposals aimed at building and/or
improving healthcare services for migrant users and at training inter-professional and intercultural team working in these healthcare services, as well as to be engaged in all research stages
foreseen by the project
Centro em Rede de Investigacao em Antropologia
CRIA - Centro em Rede de Investigacao em Antropologia is a non-profit inter-institutional centre
for social and cultural anthropology. This national platform in anthropology provides scientific
research leadership and is organized to optimize intellectual and material resources, while
promoting new research opportunities at both national and international levels. Within The CRIA
there is the NAS -Núcleo de Antropologia da Saúde/ Medical Anthropology Network. It explores
the connections between health and culture in the experiences of different social groups and examines the ways in which issues of risk and pathology interlock with social factors such as poverty,
racism, gender, migration, colonial history, health policies and social exclusion. The network
focuses, in particular, on developing research activities, as well as promoting the scientific results
for practical purposes, in the field of health and migration in colonial, metropolitan and contemporary contexts. The main aim is to develop a comprehensive theory of the therapeutic process
that connects therapeutic and political power to an exploration of mind-body interactions, tracing
the mediation of moral and physiological domains of experience. NAS focuses not only on medical
65
anthropology, but also on the anthropology of public health. Furthermore, CRIA strictly cooperates
with GIS, an interdisciplinary group founded in 2006 dealing with the immigrants’ health.
URL: http://www.cria.org.pt/
to compare healthcare systems in the partners’ countries, in drawing up the definition of the
ethical code of conduct of healthcare operators working in intercultural services, in editing the
Guidelines, as well as to be engaged in all research stages foreseen by the project
Centre médico-psycho-social Françoise MINKOWSKA
The Françoise Minkowska Centre is a medico–psycho-social centre offering person-centered
transcultural psychiatry, and providing mental healthcare services to migrant and refugee patients from in and around the areas of Paris.
The clinic relies on a multidisciplinary and multilingual team - psychiatrists, psychologists, social
workers, medical anthropologist - working from a clinical medical anthropology approach (taking
into account linguistic and cultural representations of mental disorders).
The Center also offers a mediation and orientation unit which objective is to clarify the demand
and make referrals adequate.
The Center also has a training and a research department which organizes seminars, and coordinates a university diploma with University Paris Descartes entitled “Health, Disease, Care and
Culture”.
It publishes a journal entitled “TranSfaire & Cultures”.
URL: www.minkowska.com
to analyse the state of the art in the field of cultural mediation in the healthcare sector and description of official skills required for cultural mediators to work in the healthcare context, in
drawing up definition of quality standards for intercultural healthcare services, in drawing up
the first draft of the Guidelines, as well as to be engaged in all research stages foreseen by the
project
Kulturno Drustvo Gmajna
Kulturno Drustvo Gmajna (KD Gmajna) is a non profit public association found in 2002 in order
to implement cultural, educational and art activities. Some key activities represent elaborating
tools on knowledge sharing by means of reciprocal knowledge production; advisory activity and
66
support to self-organized migrant communities to have an access to legal and social services,
organization of trainings using methodology of militant investigation. Association is also engaged in research and practices around the issues of social rights, citizenship, migration and integration. KD Gmajna is active in alternative multimedia production as a part of Social Centre
Rog and other initiatives concerning current topics on migration, social inclusion and many other
(www.njetwork.org).
During the last 6 years we have made almost 15 short documentaries on different subjects such
migration, no border camps, detention centre, issue on Erased of Slovenia, Euromayday activities
of precarious workers, and etc. In 2007 and 2009 we widely covered migrant workers’ living conditions in so called “samski domovi” i.e. dormitories for workers coming mostly from the former
republics of Yugoslavia. KD Gmajna is the part of self-organized initiatives of migrants as IWW
(Invisible Workers of the World), refugee and sans-papier initiative World for everyone.
Web sites: www.tovarna.org and www.njetwork.org available at this moment in Slovenian and
partly in Serbo-Croatian.
to analyse local skills in the field of therapeutic mediation that health care professionals should
have/acquire/improve from the immigrants’ and ethnic minority members’ points of view,
in drawing up Methodologies and tools for the assessment, with the participation of users,
of innovative protocols tested, as well as to be engaged in all research stages foreseen by the
project
Associazione culturale Centro Shen
The Association was established in 2001 by nathuropaty operators, physicians and therapists
with the task to promote a pattern of intercultural health and care accessible and reasonable
for everyone.
Through the years Shen developed pilot experiences based on a synergy between both scientific
and holistic approach, and between knowledge coming from different therapeutic traditions;
such sinergy is considered by Shen operators necessary for both research, diagnosis and prevention work, together with the need to integrate different medical systems, which must not be in
opposition but mutually integrated.
Shen has been constantly involving representatives of the different immigrant communities
with skills and academic titles/qualifications in the field of health care and specialized in traditional medicine in their own countries existing (Sri Lanka, Senegal, China, Costa d’Avorio and
women from Eastern Europe countries); the final users and the collaborators of the Centre come
mostly from these countries.
Shen Activities: Therapy (nonconventional/complementary practices); Operators training, Sensitization campaigns; Meetings and tutorials (foot reflexology, ayurvedic medicine, traditional
67
Chinese medicine, herbal medicine, massage techniques from traditional Chinese medicine, russian and Indian tradition); Educational activities carried out in the schools and related to: Prevention; Plants and therapeutical effects (in cooperation with Naples Botanical Garden); ADHD
Hyperactivity Disorder – Laboratories with parents and children carried out in schools; Nutrition
and alimenatry diseases: educational paths with students and parents; Relaxing techniques:
yoga, massage and foot massage; Eyes health: the “Bates method”; Health and prevention during childhood and adolescence.
The centre takes part to local projects and programs, in cooperation with universities, institutions
and schools. One of the current projects is “Sportello Salute senza Frontiere” in cooperation
with Naples Provincial Government - Immigration Councillorship.
Today Shen works in constant cooperation with health centres and physicians within the National Health System; Specifically, in last years Shen has been cooperating with the health centre
for immigrants of Ascalesi Hospital in Naples, such cooperation includes two aspects:
Role within T-SHaRE project: The body has elaborated the initial core of the T-SHaRE project; it
has been engaged in management of the stage addressed to analyse different visions, approaches, knowledge, competences, needs belonging to local immigrants’ and ethnic minorities
cultures in the area of health and care, in particular in relation to mental and women health, as
well as to be engaged in some research stages foreseen by the project
ARACNE – Associazione di Promozione Sociale
ARACNE is a non-profit organisation founded in Naples - Italy in 2005 by a group of women after
a pluri-annual experience of collaboration, still in progress, with the Department of Philosophy
“A. Aliotta” of the University of Naples “Federico II”.
ARACNE is an open and collaborative network of project designers, researchers, interactive and
multimedia communication experts, trainers and social workers.
It aims at promoting active citizenship, rights and people empowerment through a shared construction of knowledge, lifelong learning, communication and ICT.
ARACNE produces methodologies and tools for the shared management of knowledge
processes.
It develops research, training and consulting in the field of education, VET and orientation; of
social interventions and equal opportunities policies; of gender differences of migration and interculturalism; of learning communities and territorial virtual networks.
It develops and implements projects, initiatives and interventions at both local and transnational
level, in collaboration with universities, research centers, associations, social cooperatives, SMEs,
training centers, local institutions, public services, school.
68
URL: www.aracne.eu and http://aracneassociazione.wordpress.com
Role within T-SHaRE project: The body has been engaged in designing the approved project
proposal, in choosing the approach to research and designing the project process, in management
an monitoring of project quality (process and results), in management of dissemination and
in the elaboration of sustainability plan, in designing and management of project web site and
related contents.
Folkeuniversitetet
Folkeuniversitetet is Norway’s largest organiser of adult education. Every year, approximately
70 000 people sign up for one or more of our 6 500 courses. Has over 50 years’ experience and
offer practical and theoretical trade-related education, language instruction and courses in cultural and leisure activities.
His activities are deeply rooted in Norwegian tradition and his aim is to make leisure courses and
further education accessible to all adults, regardless of social background.
In addition to university courses, language and IT courses, specialist and craftsman’s training,
the nationwide network of Folkeuniversitetet departments provides occupational training in accounting, health, interior design, administration, marketing, graphic design, travel, caretaking,
fashion, security guard work, and other subjects.
URL: http://www.folkeuniversitetet.no/
Role within T-SHaRE project: The body has supported the other Norwegian partner (NAKMI) in
each activity in which it has been engaged.
Nasjonal kompetanseenhet for minoritetshelse
NAKMI is a governmental unit initiated by the Ministry of Health.
The aim of NAKMI is to become a meeting point for minority health issues in Norway, especially
for competence concerning somatic and mental health care of immigrants and refugees. The
existing knowledge of minority health is scattered among several small groups, specialities and
interested parties.
NAKMI seeks to map and coordinate this knowledge. The centre will also do research and networking as well as information activities. Main target groups are health personnel, scientists
and other groups engaged in health care for minorities.
The objective of establishing a national unit is to ultimately offer equal medical treatment to all
citizens of Norway. NAKMI’s focus will be on issues of interdisciplinary and cross-cultural nature.
69
Through all his activities wishs to contribute to increased knowledge of minority health and over
time to ensure vulnerable minorities and their kin a culture-sensitive and appropriate treatment.
URL: www.nakmi.no
to analyse local training needs in the field of therapeutic mediation from the cultural mediators’
and the health care givers’ points of view, as well as to be engaged in all research stages foreseen
by the project
70
Section 2
Theoretical
Contributions
71
72
Annex 2
By Associazione Frantz Fanon, Torino3
Introduction
In the development of a transcultural model of mental health and women health services,
our aim was to find the answers to these questions: what happens when a foreign citizen or
a migrant family meets the health services? Are their symptoms and experience listened in a
appropriate way? Can we reduce the risk of misunderstanding in the diagnostic and therapeutic
process? What kind of specific difficulties come upon in the clinical encounter with foreign
patients? And which kind of “cultural competence” (Eisenbruch, 2007)4 is required in order to
properly construct an intercultural psychotherapy?
Michele Risso and Wolfang Böker had already shown – in the ‘60s, in Europe – the limits of Western psychiatry and its diagnostic categories facing unease and suffering in migrant patients,
though in that case the patients were “Western” citizens (migrants met in Switzerland were
from Southern Italy: see Risso and Böker, 1968)5. In the same period there were in Africa two
teams that were working on the same issues (the therapeutic efficacies of non-western medicine
and the “conundrum”6 of healing relationships between Western doctors and Non-Western
patients): the team headed by Lambo, in Nigeria, and the Dakar school, directed by Collomb in
Senegal. Thomas Adeoye Lambo (a Nigerian psychiatrist who had studied in England where he
was strongly influenced by the so-called “community psychiatry”) realized at the end of ’50 an
original experience as Director of the Aro Hospital for Nervous Diseases, at Abeokuta, in the
Ogun State (South Nigeria), collaborating with traditional healers in the treatment of in and out
patients for twelve years (see also Collignon, 1985). Henry Collomb (a French psychiatrist) was
professor of Psychiatry at the University of Medicine of Dakar (1958). He founded an interdisciplinary team for the treatment of mental health patients in Dakar-Fann Hospital, working with
native doctors as well as and the social group of the patient (his/her family, etc.). For this
author:
Ethnopsychiatry is not the comparative study of mental disease in the different societies
and cultures. It’s in a more general sense the way in which society and culture defense themselves against mental disorder, and the way in which they are able to reduce the distance
between ills and not-ills (normal and abnormal). Ethnopsychiatry is both a strategy of knowl-
This paper has been developed by Roberto Beneduce and Simona Taliani, members of the Scientific Committee of the T-Share Project.
The contribution is an elaboration of the project results with the scientific literature produced in recent years in Europe and America. Please refer
to Beneduce, 2007, Etnopsichiatria. Sofferenza mentale e alterità fra Storia, dominio e cultura, Roma, Carocci; Simona Taliani e Francesco
Vacchiano, 2006, Altri corpi. Antropologia ed etnopsicologia della migrazione, Milano, Unicopli. We thank Irene Morra and Eleonora Voli for their
contribution in the early stages of research (interviews with mediators, immigrant patients, focus groups, etc..).
4
Eisenbruch, M. (2007) The uses and abuses of culture: Cultural competence in post-mass-crime peace-building in Cambodia. In: (Pouligny,
B., Schnabel, A., Chesterman. S, eds.). Mass Crime and Post-Conflict Peacebuilding, (Center for International Studies and Research, Paris,
International Peace Academy, New York, and United Nations University/Peace and Governance Programme (Tokyo). Tokyo and New York: United
Nations University Press. Pp.71-96
5
Risso M. and Böker W., 1968, Delusions of Witchcraft: A Cross Cultural Study, The British Journal of Psychiatry, 114: 963-972.
6
This was an expression used by Risso and Böker. It’s recently been reused by Stefania Pandolfo (2008) in her field-research on Moroccan mental
health system. See Pandolfo S., “The Knut of the Soul: Postcolonial Conundrums, Madness, and the Imagination”, in Mary-Jo Good, Sandra Hyde,
Sarah Pinto, Byron Good, Postcolonial Disorders, 2008, Berkeley, University of California Press.
3
73
edge of mental disorders and a practice, a treatment to take care of these ill patients, the
knowledge and the practice belonging to each society or culture (Collomb cit. in Boussat,
Boussat, 2002, p. 415)7.
Clearly the presence of the Other (of the foreign) has always been the trigger that revealed
the faults in host societies and showed the contradictions and shadow zones in knowledge
and practice supposed to be sure or taken to be granted. The presence of the Other is a sort of
“epistemological revealer”, showing different kinds of weakness in our systems and Institutions.
Against all this, a sort of resistance in the operators prevents them from recognizing the inadequacy and the limits of their practices and interpretative models in relation to new or different
questions and conflicts. A branch of psychiatry prefers to talk about “drop out”, “low compliance”
of the patient, “poor collaboration” of his or her family: but all these concepts may be often
reversed to indicate: i) “poor strategies of welcome and insufficient quality of relationship”; ii)
“unsustainable therapy”; iii) “inability about handling complex relational dynamics”.
What are the consequences of these factors in mental health services, today? While the patient’s
stories, their clinical biographies (anamnesis), and the social, economic and political conditions
of their own country are fairly known, a diagnosis is though proposed even after few meetings:
a diagnosis that claims for a legitimacy based on presumed methodological objectivity.
These topics are also the most mentioned in the interviews and focus groups of operators and
key-migrants conducted in countries partners and so they should be considered in the planning
of the training.
Concerning the description and the development of a transcultural model of mental health and
women health services, we think it’s important to underline some irremissible keywords to be
used as a reference for a transcultural training of health care practitioners:
- The notion of “culture” and the “work of culture”;
- The Work of Translation and The Risks of a “vulgarization” of Otherness;
- The Emic representations of illness and the “body techniques” involved in the therapeutic
process (and, more generally, the concepts of “illness/disease/sickness” – according with
WHO);
- The Ethno-psychotherapies for migrants: models and practices.
7
8
74
Boussat S., Boussat M., 2002, « A propos de Henry Collomb (1913-1979). De la psychiatrie coloniale à une psychiatrie sans frontières », L’Autre.
Cliniques, Culture et sociétés, 3, 3, pp. 411-424.
Kroeber, A. L. and C. Kluckhohn, 1952. Culture: A Critical Review of Concepts and Definitions. Cambridge, MA: Peabody Museum.
The notion of culture and the work of culture
From an anthropological point of view, “culture” is – so to say – a really complicated word, difficult
to define. It’s quite impossible to find an accordance, between authors, around few meanings
(more than 250 definitions were collected by Kroeber and Kluckhohn, more than fifty years ago)8.
Especially now – after the gender studies, the cultural studies and, moreover, the postcolonial
studies – culture, identity and belongings are continually rethought: these are notions discussed
and deeply elaborated within the anthropological sciences (see, among the American anthropological studies, Clifford Geertz, James Clifford, Lila Abu-Loghod, Marshal Sahlins, Homi Bhabha;
see in Europe e.g.: Jean Loup Amselle and Elikia M’Bokolo, Tim Ingold, Unni Wikan etc.; see in
Italy: e.g.: Francesco Remotti, Ugo Fabietti, Roberto Beneduce).
It’s important to propose some notions of culture useful for health context, that can help health
workers and patients to share meanings and representations so to improve the efficacy of healing strategies (therapeutic, social and symbolic efficacy). Each team will find authors (and related
anthropological perspectives) useful for their own context of intervention. The notion of culture
often become a contested and controversial territory, and we need flexible definitions to share
with health workers and cultural mediators the difficulties concerning this kind of intervention
in health care systems for migrants and minorities.
We propose to start from a definition proposed by Jean Comaroff and John Comaroff (1992, pp.
27-30)9. They wrote:
“We take culture to be the semantic space, the field of signs and practices, in which human
beings construct and represent themselves and others, and hence their societies and
histories. It is not merely an abstract order of signs, or relations among signs. Nor is it just
the sum of habitual practices. Neither pure langue nor pure parole, it never constitutes a
closed entirely coherent system. Quite the contrary: Culture always contains within it polyvalent, potentially contestable messages, images, and actions. It is, in short, a historically
situated, historically unfolding ensemble of signifiers-in-action, signifiers at once material
and symbolic, social and aesthetic”.
[...]
“We treat culture as a shifting semantic field, a field of symbolic production and material
practice empowered in complex ways”.
[...]
“In sum, far from being reducible to a closed system of signs and relations, the meaningful
world is always fluid and ambiguous, a partially integrated mosaic of narratives, images and
signifying practices”.
9
Comaroff, John, and Jean Comaroff. Ethnography and the Historical Imagination. Boulder Colo.: Westview Press, 1992.
75
The work of translation and the risks of a “vulgarization” of otherness
From these premises, what it could be useful to underline – both with health care practitioners
and cultural mediators – is that the risk of a wholesale use of this term, “culture”, can lead to a
crisis: we think to the onward “politicization of culture” (Susan Wright, 1998)10 and to what Merry
said about culture as a “challenged process of meanings’ building”. In the everyday meeting –
and together with a recourse to this term as a passepartout concept (a pass-key), easy to define
any attitude, behaviour, opinion or choice hard to agree with – another risk is to fall into a “vulgarization of culture” and of the suffering of the Other, as Abdelmalek Sayad wrote in his “La
Double Absence. Desillusions de l’émigré aux souffrances de l’immigré”11. These risks may be
perpetuated both by physicians, psychologists and researchers and informants, interpreters,
nurses, cultural and linguistic mediators (as Sayad has well underlined in the chapter on medicine
and migrants). In the Anglo-Saxon context, some anthropologists had spoken about “boxification
of culture” (Praticia Kaufert, 1990)12 to point out the increasingly reification of this concept and
the naive idea that they can rely on “experts” to find a solution to multiple problems raised by
immigrants in health services.
Similarly, Stein used the expression “ethnic cookbook” to mock the equation ‘person/culture’
that such a model will produce. For instance, in front of a Sri Lankan woman or a Berber child, it
could be sufficient to look into an imaginary “book of ethnic recipes” to understand how his/her
culture cooked that child, that woman, and so finding the “correct” answers to his questions,
his needs, as well the oddities of his/her behaviour and his/her symptoms.
The continuous reference to cultural differences would have the paradoxical effect of reproduce
form of racism (racism without race, according to Michael Taussig). If there does not exist a counterpart of the term “culture” (and Clifford Geertz showed us how the dichotomies nature/culture,
biological/cultural are misleading) the culturalization of differences could be, according to some
authors, as threatening as the concept of a universal man without differences, and not far, in
his effects, from traditional forms of racism.
Facing the unintelligibility of the Other, doubly alien (mad and foreigner), facing unknown languages, usually people adopt two strategies: the denial of the cultural-linguistic difference, taking back the psychic/physical suffering to the only supposed valuable model of our categories
and our strategies; or to imagine that the cultural difference is the hidden code of the observed
magic. From this to a bad use of cultural mediation, the way is short.
Given that frequently, in our experience, what health care practitioners ask for is exactly a sort
of the previously quoted “ethnic cookbook”, this trap could be avoided by making them work and
reflect on the consequences of those ways of thinking about culture and on the nature of their
questions, through reformulation of their requests as well as the acquirement of some theoretical skills (anthropological theory, ethnopsychiatry theory etc.) on those subjects.
Wright, S. (1998). Politicization of ‘culture’. Anthropology Today, 14 (1), pp. 7-15.
Abdelmalek Sayad, La Double Absence. Des illusions de l’émigré aux souffrances de l’immigré, préface de Pïerre Bourdieu, Seuil, Paris, 1999
(Italian translation : 2002 ; English translation : 2004).
12
Patricia L. Kaufert, “The box-ification of Culture: The Role of the social scientist”, Santé, Culture, Health, VII, 2/3: pp. 139-148.
10
11
76
The emic representations of illness
Talking about the work of the health workers dealing with foreign users, we have to consider
two sides.
1 . Problems
a) “Cultural matter”. Lack of familiarity with categories, representations and interpretational
patterns belonging to a specific healing system, poor knowledge of other aetiological and
therapeutic registers, lack of knowledge of other aspects of suffering and illness are at
the origin of many issues frequently reported.
b) “Language matter”. The difficulty in translating in a proper and well-structured way the
worker’s concerns, uneasiness, fears and experiences, put the patient in an uncomfortable
position, especially in those areas of diagnosis and healing where, as for mental health, a
great deal of the problem lays in the “speech area”.
c) Mutually, the therapist’s interpretations and prescriptions don’t resound properly when
put in a language not mastered by the patient, and are not relevant if given in a language
based on epistemological, psychological, moral or religious assumptions potentially far
from the patient. Those assumptions contribute to develop misunderstandings and to
disturb the process of building a successful healing strategy and the required cooperation.
2 . Possible solutions
a) Critically explore explanatory and interpretative categories, their theoretical end methodological premises and put them in question;
b) Identify the dull and obstinate layout of the psychic pain in these patients, whose symptoms often reveal an implicit criticism to the social hierarchies they live in a more or less
permanent way.
c) Analyse all the transactional, symbolic, social, psychic and legal patterns laying into these
migrant lives.
Shortly, we should not lead back everything always to cultural matters. Nevertheless, a perspective that investigates and discovers the sense and the power of traditional therapeutic techniques is precious and useful to re-establish the trouble’s meaning and its treatment possibility
(Tobie Nathan, and Marie Rose Moro, spoke about therapeutic level, echoing the Devereux cultural level concept). Because of these techniques, this knowledge and the peculiarity of suffering
idioms, psychotherapy and the ethno-clinical mediation reveal their efficacy when, after passing
through this field of knowledge and representations (psychologies and epistemologies that our
patients, their biographies and their vicissitudes embody), after having evaluated their relevance,
succeed in situating the patient’s conflicts and dilemmas in this horizon of essential ties. Naming
and evoking these fields, these bonds, acting on them, we heal giving meaning to what was
meaningless, and in the meantime we create a time in which it is allowed to fluctuate in worlds
of thoughts, relationships and lived experiences.
We think that contributing to build this is the main task of the “ethno-clinical mediation”: an
area with strategic ambivalence, meeting point of thoughts split between peculiarity and universality. The ethno-clinical mediation becomes a passeur, a true ferryman that allow to pass
77
form a kind of tie to another. Its activity contribute to heal because it promotes new power and
meaning relations.
The ethno-psychotherapies for migrants: models and practices
There are several different Ethno-psychotherapy Schools in Europe today. Anyway, among this
kaleidoscopic and sometimes confused, fragmented landscape, we can share some points
common to every models, or to the majority of them.
The construction of protocol for health workers and cultural health mediators implies to mind
that the work of “translation” and of “mediation” consists in different levels, that we may
summaries in this way13:
1. So called “elementary level: language and use of the mother-tongue of the patient”. The
cultural mediator can give some linguistic translations that help the patient to remember
and elaborate old situations, emotions, traumatic experiences in his/her mother-tongue.
But work on language means to know the impact of this in the psychic and social words of
the patient. This is way we have to trainer the operators to understand the multi-levels of
implications of the mother-tongue during the clinical activity: e.g.: “In some cases patients
prefer to talk in the therapist’s language. To talk a different language reduces the inhibition
that the mother language can generate when we talk about some experiences or conflicts.
The foreign language tone downs anxieties that it’s more difficult to control with the
mother language. So, on one side, changing languages gives the possibility to increase the
metaphorical horizon of the communication, and, in the other side, offers bigger possibility
to enter in patient’s problems”.
2. “Second level: cultural mediation as a place where ‘a living group’ emerges, as multiple
bonds”. Give to the patient a group that can represents a way to construct bonds, ties,
symbolic and material nets. e.g.: “Therapists and mediators, together, function as interpreters, facilitators, experts. What they do is to create the possibility to remember, when
this action seems impossible. The target of the communication net, created about the
clinic problem, is to rebuild meanings, and for this reason this kind of therapy can be called
‘pragmatic of affections’. But this therapy is operable only if we decentralize our models
and our automatic diagnostic interpretations. We have to use a logic that isn’t an explication of the disease but that is the possibility to use different metaphors”.
3. Third level: mediation as strategy able to evoke a “meta-empirical dimension”. The mediator may help the health workers to evoke and use the representations of illness and healing models of the patients and their social and cultural context. e.g.: “The cultural mediator
works often inside the area of “sacred”. In this situation the translation is really a work of
transmission : the transmission of theories works to renovate restless relationships and
renew attachments that seemed threatening.
13
78
For this classification and the reported examples, see Beneduce, R. 2004, Frontiere dell’identità e della memoria, Franco Angeli, Milano.
If these steps can help the patient to understand better the meaning of his illness, they can also
help us to understand where we can start with the care. Cultural mediators work every day in a
field full of sacred, invisible entities”.
For these reasons it’s useful to underline that:
a) the Psychotherapist (or the health worker involved) has to give up the typical quietness
of the dual relationship and the power that it normally has.
b) the cultural health mediator has to acquire, with therapists, a strong theoretical base in
the translation theory.
c) the mediator has to be supported in recognizing, exploring, and managing transfer and
counter-transfer dynamics, as well as his/her own conflicts.
d) the therapist has to tolerate the challenge of a “not understanding time”, when he can’t
understand the conversation between patient and mediator in languages he/she doesn’t
know. He/she must become the silent witness of an interaction that he can’t understand
or interpret; nevertheless, this interaction gives him/her the possibility to think about
what happens, observe emotional profiles of the communication, evaluate reactions of
the patient and so on.
e) the professionals become the actors of a scene that progressively involves the patient
and transforms him/her in a witness, and then in an expert of different cultural worlds
with whom he/she is constantly in interaction.
f) the aspect that we evocated up can be defined as the dimension of a “third pole” (“terzietà” in Italian)14.
14
See Beneduce, Roberto, Etnopsichiatria, 2007, Carocci Editore, Roma.
79
80
Section 3
Methodological
Instruments
81
82
Annex 3
By CRIA - Centro em Rede de Investigacao em Antropologia
Questionnaire – Assessment of health care systems and health services for immigrants
I – IMMIGRANT POPULATION CHARACTERIZATION
1M Indicate which segments of the population are considered by the State as immigrants in
your country.
A
B
C
D
E
F
G
2M Describe briefly the characteristics of the immigrant population in your country.
3M According to recent data, what is the proportion of the immigrant population in your country?
1
2
3
4
5
6
0-5%
5 - 10 %
10 - 15 %
15 - 20 %
20 - 25 %
25 - 30 %
7
8
9
10
11
30 - 35 %
35 - 40 %
40 - 45 %
45 - 50 %
+ 50 %
4M What are the percentage estimates of the following population groups? (fill in the table):
%
A
B
C
D
83
5M What nationalities are numerically expressive in your Country? (enumerate by level of
representation in the national territory). Please, indicate their percentage on the general
population of immigrants.
Countries
%
1
2
3
4
5
6
7
8
9
10
Total
6M How many immigrants are minors? (percentage)
1
2
3
4
5
6
0-5%
5 - 10 %
10 - 15 %
15 - 20 %
20 - 25 %
25 - 30 %
7
8
9
10
11
30 - 35 %
35 - 40 %
40 - 45 %
45 - 50 %
+ 50 %
7M How many of these minors are unaccompanied (percentage)?
1
2
3
4
5
6
0-5%
5 - 10 %
10 - 15 %
15 - 20 %
20 - 25 %
25 - 30 %
7
8
9
10
11
30 - 35 %
35 - 40 %
40 - 45 %
45 - 50 %
+ 50 %
8M Officially, the generic immigrant population is composed by (percentage)?
1
2
Homens
Mulheres
9M What countries of origin have the same official language as the host country?
- Brasil; Angola; Moçambique; Cabo-Verde, Guiné-Bissau; São-Tomé e Príncipe.
84
10M What is the estimate percentage of the immigrants speaking the host country’s language?
1
2
3
4
5
6
0-5%
5 - 10 %
10 - 15 %
15 - 20 %
20 - 25 %
25 - 30 %
7
8
9
10
11
30 - 35 %
35 - 40 %
40 - 45 %
45 - 50 %
+ 50 %
11M What is the general educational level of immigrants (indicate a approximate % for each level)
A
B
C
D
E
12M Indicate the main Professional activities immigrants conduct in your country, according to
origin (ex: Indians – trade; Brazilians – restoration)
13M What are the main religious affiliations?
II – LEGISLATION AND SERVICES OPERATIONALITY
14M Describe briefly the health system structure (public services, private, conjoint system, other
– local institutions, NGO) in your country.
15M If possible, draw an organization chart that represents graphically the health system
85
16M Do any territory based (outreaching) health units exist?
A
B
Yes
No
Proceed to question 18
17M If you answered yes, in which specific fields do they operate?
A
B
C
D
E
F
G
H
I
General Practice
Nursing
Infectious diseases
Vaccination
Maternal and Child Health
Psychology
Psychiatry
Addictions
Other (specify)
18M What is the current legislation regarding immigrant health in your country? Explain briefly.
19M What is the current legislation regarding asylum seekers in your country? Explain.
20M Is the access to public health services available to the following groups?
1
Yes
A
B
C
D
2
No
Undocumented adult immigrants
Undocumented children
Asylum seekers
Refugees
21M In case, specify the other groups excluded, formally or actually, from the access.
86
22M Describe the main type of medical coverage in your country:
A
B
C
D
Completely free access to all basic services
Limited cost participation by a small fee
Costs are paid by private health insurance
Costs are paid by professional health insurance
E
Other
23M Indicate the legal procedures to have access to medical coverage:
24M Specify which services are provided with a fee and their amount in euros:
Amount
A
B
C
D
E
F
G
H
General Practice
Nursing
Infectious diseases
Vaccination
Psychology
Psychiatry
Addictions
I
Other (specify)
Taxes on the Health Centers (which are different from the Hospitals)
25M Specify for which groups are medical expenses completely covered:
A
B
C
D
E
F
G
Pregnant women
People with chronic illnesses
Children
Elders
People with economic difficulties
Asylum seekers and/or refugees
Others*, specify (situation A):
H
Others*, specify (situation B
87
* Regarding exams, medication and continuous expansive treatments, does any kind of coverage
or cost-sharing exist for those unable to afford costs?
A
B
Yes
No
26M Give a generic evaluation of the quality of the health care system
1
2
3
4
5
Very Bad
Weak
Reasonable
Good
Very Good
27M Describe briefly the legislation, structure and functioning of the mental health service.
28M Draw a chart that represents graphically the mental health system
29M What professionals work within the mental health services?
A
B
C
D
E
F
G
H
88
x
x
x
x
x
x
Psychologists
Psychiatrists
Social workers
Anthropologists
Nurses
Cultural Mediators
Therapists, specify:
Others, specify:
30M
What kind of interventions do they offer?
A
B
C
D
E
F
G
Pharmacology and Drug Therapy
Psychotherapy
Social working
Home care service
Day occupational activities
Emergency treatments
Other, specify:
31M Give a generic evaluation of the quality of the mental health system
1
2
3
4
5
Very Bad
Weak
Reasonable
Good
Very Good
III – ACESSIBILITY FOR IMMIGRANTS
III.1 – Specific needs
32M Are there some services specifically dedicated to immigrants?
A
B
Yes
No
33M Which institution provides them?
A
B
C
D
C
34M Which are the services provided?
A
B
C
Scheduling of appointments and information
General Practice
Nursing
89
D
E
F
G
H
I
L
Infectious diseases
Vaccination
Mental Health
Addictions
Other specialist consultation (specify)
Other services (specify)
35M Are treatments continuous and structured?
Yes No
A
B
C
D
E
F
G
H
I
General Practice
Nursing
Infectious diseases
Vaccination
Mental Health
Addictions
36M Are there any specific services for the health of refugees and asylum seekers?
A
B
Yes
No
37M Are treatments for refugees and asylum seekers continuous and structured?
1
2
Yes
No
38M Classify the general quality of health services specific for immigrants:
1
2
3
4
5
90
Very Bad
Weak
Reasonable
Good
Very Good
III.2 – Visibility and Information
39M Is there a pro-active policy of communication, dissemination and information on health
services for immigrants?
A
B
Yes
No
40M Describe briefly, those actions:
41M Is there a pro-active policy of communication, dissemination and information on immigrants rights, conditions and health needs of immigrants addressed to health technicians?
A
B
Yes
No
42M Describe briefly, those actions:
43M Estimate the level of knowledge on immigrant’s rights, conditions and needs in the public
health system:
A
B
C
D
E
Nothing
Little
Medium
Good
Very good
44M Estimate the general level of immigrant’s knowledge on how the public health service /
private health service work:
A
B
C
D
E
Nothing
Little
Medium
Good
Very good
91
45M Are there any sorts of (information) campaigns regarding mental health services?
A
B
Yes
No
46M In case, specify forms, media, messages, etc.
47M Are there any sorts of campaigns regarding maternal and child health?
A
B
Yes
No
48M
In case, specify forms (media, messages, etc.)
49M How would you globally evaluate the immigrant access to information about public health
services?
A
B
C
D
E
Nonexistent
Weak
Reasonable
Good
Very Good
III.3 – Linguistic Accessibility
50M Is general information about health services (location, functioning, access, etc.) available
in translation?
A
B
92
Yes
No
51M In case of availability, specify the languages in which translation is provided
52M On what kind of support? (ex.: leaflets, flyers, posters, internet, etc.)
53M Is there a translation available in the following units (through any means)?
Languages
A
B
C
D
E
F
G
H
Scheduling of appointments and information
General Practice
Nursing
Infectious diseases
Vaccination
Mental Health
Addictions
I
L
54M Are there specific activities of translation in clinical settings?
A
B
Yes
No
55M In which units?
Languages
A
B
C
D
General Practice
Nursing
Infectious diseases
Vaccination
93
E
F
H
Mental Health
Addictions
I
L
56M In case of specific translation activities attending immigrants’ necessities, people providing
this service are:
A
B
C
D
Volunteers
Professionals
Both
Others:
57M Are they officially recognized by the health care system?
A
B
Yes
No
58M Globally how do you evaluate accessibility on the linguistic level?
A
B
C
D
E
Nonexistent
Weak
Reasonable
Good
Very Good
III.4 - Procedural Accessibility
59M Are there official documents required to benefit from health services?
A
B
94
Yes
No
60M What documents and how are they obtained?
61M Are procedures done through forms?
A
B
Yes
No
62M Estimate their level of complexity.
1
2
3
4
5
Not complex – easy
Slightly complex
Nor easy, nor complex
Reasonably complex
Very complex
63M Globally how do you evaluate procedural accessibility?
1
2
3
4
5
Not complex – easy
Slightly complex
Nor easy, nor complex
Reasonably complex
Very complex
III.5 – Economic Accessibility
64M Are there segments or groups of immigrants exempted of payment of fees?
A
B
Yes
No
65M Which groups have medical expenses covered?
A
B
C
D
E
Unemployed immigrants
Pregnant women
Minors
People with infectious diseases (TB, HIV-AIDS)
People with chronic illnesses
F
Others, specify
95
66M In case of necessity of continuous treatment (e.g. chronic illnesses), are there subsidies for
medicines?
A
B
Yes
No
67M Are there free services in Mental Health (ex. medication, consultations, counseling and
psychotherapies, other)?
A
B
Yes
No
68M Specify (with x) the free services.
A
B
C
D
E
F
Pharmacology and Drug Therapy
Psychotherapy
Social working
Home care service
Day occupational activities
Emergency treatments
G
Others, specify:
69M In services of maternal and child health, is there any economic support to purchase care
goods for the newborn?
A
B
Yes
No
70M Existing economic support, specify:
71M In Pediatric health care, is vaccination exempt of costs?
A
B
Yes
No
72M What is the age limit?
96
73M What kind of action is taken, in your area, to overcome problems concerning economic
accessibility for immigrants to health services?
74M Globally how do you evaluate economic accessibility?
1
2
3
4
5
Very heavy
Heavy
Reasonable
Light
Very Light
III.6 - Cultural accessibility
75M Are efforts made, on behalf of health services, to comprehend the social context of immigrant patients?
A
B
Yes
No
76M Being the case, describe the initiatives:
77M How common is the presence of professionals of foreign origins in health service teams?
1
2
3
4
5
Very common – almost always
Common – usually
Slightly common – sometimes
Uncommon – sporadic
Never
78M Foreign professionals usually are:
A
B
C
D
Physicians
Psychologists
Nurses
Social Scientists
97
E
F
Social Workers
Cultural Mediators
G
Others, specify
79M Are there activities of “cultural” mediation?
A
B
Yes
No
80M Who generally conducts mediation?
A
B
H
A country national professional, with specific training and formal qualification as such
A professional issued from the immigrant community, with specific training
and formal qualification as such
A country national with linguistic skills but without specific training
and formal qualification
A figure issued from the immigrant community, without specific training
and formal qualification
A professional of the service (physician, nurse, etc.) with linguistic skills
A professional of the service (physician, nurse, etc.) issued from the immigrant
community
A family member of the patient
I
Others (specify)
C
D
E
F
81M If yes, in which units?
98
A
B
C
D
E
F
H
General Practice
Nursing
Infectious diseases
Vaccination
Mental Health
Addictions
I
L
82M In what regime of collaboration does the mediator usually operate:
A
B
C
D
E
I
Member of the service staff
External individual consultant
Member of a specific subcontracted staff (companies, cooperatives, etc.)
Member of external institutions (university, city council, etc.)
Volunteer of associations, social groups, etc.
Others (specify)
83M What kind of training is required to be a cultural mediator?
A
B
C
D
University postgraduate course (MA, other…)
Specific professional training
Experience in health services
No specific training required
G
Other (specify)
84M What professional qualifications and training are required to be a mediator in the clinical
setting?
85M Is it possible for a patient to choose a religious figure to accompany him/her?
A
B
Yes
No
86M Is it possible for a patient to be accompanied by family members during consultation or
hospitalization?
A
B
Yes
No
87M Is it possible for a patient to choose his/her diet during hospitalization?
A
B
Yes
No
99
88M Are there diversified religious ecumenical worship settings in hospitals?
A
B
Yes
No
89M Is it possible to formally combine other traditional/culture-specific therapeutic practices
with the institutional service?
A
B
Yes
No
90M If yes, what kind of practices:
91M Globally how do you evaluate accessibility on the cultural competency level?
1
2
3
4
5
Nonexistent
Weak
Reasonable
Good
Very Good
IV – IMMIGRANT NEEDS
92M Has research been done about immigrants’ health care necessities?
A
B
100
Yes
No
93M Place the most relevant bibliographical references (max. 5) per group / segment:
1
Groups/Segments
First Generation Immigrants
2
Immigrant Descendents
3
Gender and heath care needs
4
Youth and Children
5
Undocumented immigrants
6
Refugees and asylum seekers
Bibliographical References (max. 5)
94M What are the main references on mental health and migration?
(max. 5 references).
95M What are the main references concerning maternal and child health for immigrants?
(max. 5 references)
96M Summarize the results that enable the identification of the main strengths and weaknesses
regarding health services, from the patient’s point of view.
101
97M Classify the quality of the interventions with immigrants in the mental health sector
1
2
3
4
5
Very Bad
Weak
Reasonable
Good
Very Good
98M Classify the quality of the interventions with immigrants in services for maternal and child
health
1
2
3
4
5
Very Bad
Weak
Reasonable
Good
Very Good
99M Classify, in general, the quality of the relationship between immigrant patients and the
following health professionals (leave blank if not present):
A
B
C
D
E
F
G
Physicians
Psychologists
Nurses
Social Scientists
Social workers
Cultural Mediators
Medical assistants
H
Others, who?
I
Others, who?
1
2
3
4
5
Very Bad
Weak
Reasonable
Good
Very Good
V – PROFESSIONAL NEEDS
100M Based on work done until the present, what are the necessities that emerge for the health
team of professionals, regarding immigrant’s health care?
102
101M What are the training needs generally expressed by the following professionals?
1
No special
training
requested
A
B
C
D
E
F
G
Physicians
Psychologists
Nurses
Social Scientists
Social workers
Cultural Mediators
Administrative assistants
H
Others, who?
I
Others, who?
2
3
4
Just general Information Reformulation
information on “cultural” of practices,
about
practices
structure and
migration and tradition organization
of services
5
Other
102M Are there culturally competent training courses for health?
1
2
Yes
No
103M Which institutions organize training?
A
B
C
D
E
Universities
Hospitals
Professional associations
NGO’s
Municipalities
F
Others, specify?
104M Courses are:
A
B
Structured and continuous
Sporadic
C
Other, specify?
103
105M Globally, how do you consider the health services from the point of view of discrimination?
1
2
3
4
5
Non-discriminatory
Slightly Discriminatory
Neutral
Discriminatory
Highly discriminatory
106M Exemplify by referring a specific case in this context.
107M Is there any sort of professional training on issues such as institutional discrimination or
racism, aimed at health professionals?
1
2
Yes
No
108M Are there innovative projects, practices, models about public health and immigration that
is worth citing?
VI – SYSTEM EVALUATION
109M Do any sorts of evaluation regarding health services and immigration exist?
1
2
Yes
No
110M In case they do, specify who is responsible and how the evaluation is conducted
104
111M It is possible for immigrant patients to evaluate the quality and/or the satisfaction for the
service obtained?
1
2
Yes
No
112M Are there specific initiatives deriving from the evaluation process?
THANK YOU FOR YOUR COLLABORATION!
105
106
Annex 4
By Associazione Culturale Centro Shen
Analysis of cultural representations of migrant communities and ethnic minorities
relating to the field of health and care, in the key sectors.
1. SHORT DESCRIPTION OF GENERAL METHODOLOGY
What is a focus group
“Focus group is a technique of survey for social research, it is based on debate/discussion between a small group of persons, at the presence of one or more moderators, and it is focused on
a subject that needs to be deeply investigated” (Corrao 2002, p.2515).
Focus group has been used for a long time together with other survey tools also to formulate
questions of an interview; this made it a tool of poor/weak effectiveness, because it was not
generally applicable. Today the problem of the general applicability has been overcome, thank
to the fact that the purpose of several researches is to deeply understand and describe a phenomenon, and not to produce generalisations. Therefore, the focus group becomes a valid tool,
even if used alone, able to produce valid information itself, rising questions and issues and providing answers.
How to form a group for a focus group
The members of the group, which are here defined “Privileged witnesses”, choose to take part
to the focus because they are persuaded by the sense of satisfaction derived by the fact of simply
being part of it, and also because they are glad to give a contribution to the scientific research
and to live a new experience, too.
Participants are chosen according to the following criteria:
•
•
•
•
Because they have skills in medical/health care field
Because they are physicians, health operators, or work in health care centres in their own
countries
Because they can be cultural mediators
They might be simply consumers/users of health care practices deriving from the cultural
and anthropological tradition of their own countries.
The number of participants can go from 4 and 12 people.
In order to achieve a good result of the focus the “ideal” number should be 8.
15
Corrao S.(2002), Il focus group, Francoangeli
107
The difference lays in the fact that the in a smaller group there will be probably a deeper investigation of the subjects. Instead, in the larger group there will be described a larger number of
different opinions and points of view.
The duration of the focus group should be between 2,30 and 3 hours.
Benefits
•
•
•
•
•
•
It creates a relational dimension in the creation of one’s own opinion;
It gives birth to a debate, and one participant’s opinion can stimulate the opinion of
another participant, and help the others to find a motivation of that opinion and new
details;
It creates a synergy between the participants;
The participants will feel at ease because they can express their own emotions, feelings
and memories, too;
The presence of a participant who shows more flexibility in expressing his opinions
can stimulate the shyer participants; there is also the risk that it can cause a conformity
between their opinions, though;
The equality condition prevails within the group (one person will express him/herself
more easily within a group than during an individual interview).
Economic benefits
Zero cost. in some cases, in order to encourage people to take part to the focus group there have
been also a reward.
Disadvantages
It is often not easy to find all the persons needed for the creation o a group and to fix a day and
a time suitable for everyone.
There are different kinds of focus, but we can identify a standard/pattern which is better
known and more widespread, which must have some characteristics: homogeneity within
the group (immigrants, health operators in the field of health and care and so on); the
participants DO NOT know each other; there will be a moderator/conductor of the discussion
who must have prepared a guideline of the interview, with questions that have already been
decided and prepared.
Main Features of the focus group
HOMOGENEITY: this is a indispensable and necessary condition for the success of the focus,
since people, when act in a situation of equality feel at ease and can express more easily their
own experiences, background and share them with other participants;
Homogeneity with respect to the genre: some authors prefer a separation of the group with
respect to the genre, while others prefer a situation of equality if the interest in the subject is
for both males and females.
108
Homogeneity with respect to the age: generational distance is not here recommended, because
of the difference both in life experience and analysis; some believe that different age group
might contrast a conformity.
Homogeneity as a feature, it allows a deeper investigation; a differentiation within the group
allows to help the different points of view of the participants come out; all depends on the
purpose of the research.
MODERATOR
There are no fixed rules in the leading of a focus, this is often influenced by the nature and
temperament of the moderator. In a structured focus the moderator will have a stronger control
of both the debate and the group dynamics.
NON PARTICIPATING OBSERVERS
There are usually two observers, and they are supposed to write down the whole debate of the
group.
FOCUS GROUP STRUCTURE
The focus is made of a series of guide-questions prepared and structured before.
The order of the questions can be flexible; sometimes it happens that many aspects to be
discussed come out in a very spontaneous way during the debate, in such case the moderator
must let the discussion flow and intervene at the right moment.
As to the structured focus groups, the guide should be made of a number of 10-12 questions
(it also depends on the purpose of the research an on the subject to be discussed).
BASE OF THE ANALYSIS
The analysis and the data processing will occur through the integral registration and transcription
of the group interview, which will be made easier by the audio (or video) recording and by the
notes wrote down by the observers.
The audio recording will complete the notes.
The integral transcription seem to be very useful/functional in case the researcher is interested
in (Corrao 2002, p.70):
•
•
•
A detailed comparison between the different population categories;
In Using the group debate to create research tools;
In using it in case of an intervention on the population.
The data analysis process must begin within 24 hours, or at least before the following focus;
this first data processing is useful in order not to loose any important information, to control
whether the information that have been gathered correspond to the information actually needed,
to prepare the following interview and to find new subjects to be discussed, too.
109
During this phase is strictly necessary a deep exchange and discussion between the non participating observers and the moderator.
METHOD OF ANALYSIS
• Carefully read the transcriptions and listen to the records;
• Understand the different positions of the participants to the focus;
• To create a reading grid (guide) to be applied to the whole material;
• The reading grid is considered a reference and is built on the base of the research aims.
During the structured focus, the creation of a grid is easier since the questions of the investigation already contains the contents of the reading grid.
If some new aspects within the debate not related to the questions come out, they can be
underlined too, and they can be used in a future debate.
The next step is the description of the event and the transcription of the quotations, or a systematic codification, i.e. a statistical analysis (do not forget that in case of a statistical analysis
the data have only a descriptive value since they can only refer to the groups that generated
them and therefore cannot be generalized)
The number of focus to carry out is generally 3; according to the results achieved it is possible
to carry out more focus groups. In case the saturation criterion related to the grounded theory
is followed, the focus groups will stop when the last one will not produce anything new but it
will confirm the previous focus information.
2. T-SHARE INTERCULTURAL FOCUS GROUPS:
HEALTH AND CARE FROM THE POINT OF VIEW OF PRIVILEGED WITNESSES
Aims and methodology
The general purpose of focus groups is to identify and describe, in a trans-cultural way, elements
of compatibility, analogies and potential complementarities existing in different medical cultures.
The specific purpose is to carry out a qualitative comparative analysis of different views, cultural
representations, needs and therapeutic practices in the key-sectors of mental health and
women’s health.
It is necessary to make the point of view of the privileged witnesses coming from different cultures and living in our countries to come out, and to give them value: with the term “privileged
witnesses”, we mean persons aware of and expert in the field of our research and intervention
of the project.
In this sense the key persons must be considered not only simple informants, but researchers
according to the action-research and “spokesmen/women” of their communities and home countries.
110
Such approach, that must be clarified to all participants, will help to share the purposes and the
results of T-SHAre project with the final users in the following work plans.
The project team researchers will take part to the focus groups and will act as observers and/or
moderators.
In each partner country 3 focus groups will be carried out, each focus group will have the same
participants. Each focus group will last about three hours, according the guidelines shown in the
following part of this document. (in Italy 6 focus groups will be carried out, 3 in Turin and
3 Naples).
At least 10 key persons will be involved in the focus groups, they must come from different
countries and the presence of both males and females will be guaranteed. Each partner will
decide whether to carry out each focus with a smaller number of participants, if he will consider
it more effective. In such case, they will have to carry out 2 focus using the same issues, in order
to involve at least 10 participants.
On the base of the results of the focus groups, each partner will write down a report.
The report will consist of a description, from the point of view of of the key persons, of: cultural
representations, medical theories and patterns, approaches to health and care, skills, practices,
needs, with particular reference to mental health and women’s health.
We need to gather elements for a value comparison with the patterns of western medicine, from
the point of view of the key persons. Therefore, the key persons will be considered “spokesmen/women” of immigrants communities living in our countries.
Finally, Shen will write down the WP4 final report making a comparison between the different
reports made by the partners.
3. OPERATIONAL GUIDELINES FOR THE FOCUS GROUPS
Identify the immigrants’ communities useful to our research
The project teams will identify the most relevant communities living in their countries, considering the following issues:
•
•
The general situation described in WP2, emerged from the national reports and from the
questionnaire related to the immigrants working in the health services in their own countries;
The data related to the immigrants communities of first/second/third generation and
of irregular/illegal immigrants in their own specific territories (province, metropolitan
district) which we believe to be more relevant form a point of view of medical-therapeutic
traditions
111
Identifying and involving of key persons/privileged witnesses
The project team will identify the key persons considering the following points:
•
•
•
•
•
•
Their representativeness with respect to the key-communities identified on the territory/area;
They will be the reference persons who are influential in the field of health and care
within their own community;
Their competence and skills in the health/medical field, they can be doctors/physicians
or medical attendants/nurses in their own countries;
They can have practical skills and/or knowledge in the field of medical-therapeutic
cultures of their countries and with respect to western medicine, too;
They can be cultural mediators in social and health field in the European countries;
They can carry out any activities in medical and complementary therapies field in the
European country they live in.
The members of the “Key-persons” group will be motivated in taking part to the focus group
because:
•
•
•
•
•
•
•
they wish to share the knowledge and the practice they are expert in;
they want to take part to the research and give their contribution to it;
they can be interested in experiencing something new;
they want to compare themselves with key-persons coming from different cultures, with
knowledge and experiences;
they want to give their own contribution to the mutual understanding between European
health operators and persons coming from others countries, removing any doubt, prejudice, and misunderstanding still existing in this field;
they are interested in becoming “spokesmen/women” of cultural representations, approaches to health and care different from the western ones;
they can be really interested to the focus group contents because they can be a way to
learn something useful, taking part to it by asking and answering questions.
Once involved in this process, once the general aims of T-Share project and the specific aim of
the focus group will have been clarified and shared; we will figure out whether the participants
will remain anonymous or they can be interested in be named in the reports that will be shared
on T-share website.
If we believe this is possible and convenient, persons interested in it will receive a certificate for
taking part in the three focus groups and to T-share WP4 as voluntary researchers.
At the end of WP4 it is important to share the results with the participants and to inform them
about all the following steps of T-SHare project, as well as involve them in the dissemination
activities and in the exploitation of the in-between and final results.
112
Guidelines to stimulate the discussion/debate during the focus groups
The methodology we will use will be the semi-structured focus group method, with the key
issues used as main outlines to follow for all the partners of T-SHare, but threw is also the
possibility to add other issues that could come out from the debate. This is in order to make
the results comparable on one side, and to emphasize the specificity of each situation on
another.
The key issues we propose to carry out the debate have been identified by the project team of
Centro Shen, since they have been deeply working in the field of health, care and complementary
medicine from other countries for a very long time, together with the more representative
immigrants communities in Naples metropolitan district.
Of course the issues we are here proposing can be integrated by other issues proposed by the
researchers of each team.
The focus carried out must be fully transcribed by the observers. Besides, it can be useful to use
audio (or video) recording together with the notes taken by the observers.
Key-Issues For Focus Group n.1
1. The CARE. encourage a discussion on:
a. Is it the person who must be cured or the disease?
b. Is the care necessary only when a person is ill?
2. PAIN. How much and why is it bearable?
3. ENERGY AND EMOTION (how the body reacts to the emotions?)
4. IN ORDER TO CURE A PERSON WE MUST NECESSARILY BE DOCTORS OR NOT?
5. HOW USEFUL ARE THE WESTERN SPECIALISTIC MEDICINE AND THE INVESTIGATION
DIAGNOSTICS AND ANALYSIS?
6. FOOD - CAN THE FOOD CURE A PERSON?
7. CAN THE MASSAGE CURE? Encourage a debate on:
a. the contact between two persons caused by the massage
b. the relationship without words between two peoples
c. the use of massage within immigrants’ related communities
8. WHAT IS MADNESS? WHAT IS BALANCE?
9. DO YOU THINK WOMEN ARE MORE TALENTED IN CARE PRACTICES? (if, so, in which
sense? Are they more talented in taking care or in taking care of themselves?)
10. IS THE CHILDBIRTH SACRED?
11. IS THE WOMAN STRONGER OR WEAKER?
12. WHAT IS BASED ON A GOOD HEALTH CARE RELATIONSHIP?
Some questions seem to be philosophical or abstract, for example the questions number, 1, 3, 7.
113
We intend to deeply understand, through the debate:
•
•
•
•
The different points of view, the different meanings, for example: the concept of
Madness according to a cultural mediator form Sri Lanka or a foot reflexology operator
from Russia and so on;
The satisfaction or the preference for one practice compared to another one (see the
question about massage used in the immigrant’s community, or the question about the
usefulness or not of the western health investigation methods)
The different practices used by persons coming from a different culture;
The efficacy and the efficiency oh health care.
The key persons will answer and confront their opinions on the concepts of illness, energy, health
care relationship on the base of their cultural, philosophical, medical, methodological and
practical references.
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Annex 5
By Kulturno Drustvo Gmajna
Analysis of therapeutic mediation skills the involved professionals should
have/acquire/improve from the immigrant’s point of view
I. Access to health care for migrants in each country
•
Identify and describe institutions of the health system that provide health care services
to migrants that don’t have access to regular health system. Are there any health care
institutions specialized in work with migrants that don’t have access to regular health
system?
•
Identify and describe self-organized migrant groups or migrants with practice and/or expertise regarding migrant health in your country.
•
Describe the minimum level of medical aid i.e. urgent care, financed and provided by the
state to a person regardless of his or her official status. Is cultural mediation, translation,
included?
II. Experiences with health professionals from the migrants’ point of view
•
Brief description of migrants experiences with health professionals.
•
Perceived challenges in contact with health professionals.
•
What kind of tools could help migrants when experiencing challenges.
III. Mediation skills for intercultural health mediators from the migrants’ point of view
•
Describe mediation skills mediators should have /require
•
Describe the mediation skills mediators should improve.
IV. Training needs for intercultural health mediators from the migrants’ point of view
•
Describe the training needs for intercultural health mediators
•
Describe the training needs for health professionals
V. Migrants’ need for additional tools
•
Describe migrants’ need for own training/ additional information regarding the health
system
115
•
Describe migrants’ need for interpreter
•
Describe migrants’ need for other tools
VI. Requirements for an intercultural health mediator
•
Describe what should be the requirements for an intercultural health mediator according
to migrants.
VII. Proposals of measures concerning intercultural health mediation
•
Proposals concerning formal or informal requirements
•
Proposals concerning training of mediators
•
Proposals concerning training of health operators
•
Proposals concerning information to migrants
•
Proposals concerning organisation of clinical mediation
•
Proposals concerning other tools
VIII. Non-Formal Institutions of Cultural Mediation from Migrants Point of View
116
•
Describe the non-formal institutions and practices of cultural mediation (solidarity
groups, support from family and friends, non-formal practices from health workers etc.).
•
Do the users feel a difference between formal and non formal mediators?
•
Have cultural mediators the ability in being mediators not only from the home culture
to the host one, but also in the opposite way (i.e. Do they share with the patient some
reflections about the host culture’s ideas of illness? Would the users like it?)
Annex 6
By Nasjonal Kompetanseenhet for minoritetshelse (NAKMI),
and Folkeuniversitetet Adult Education Association
Analysis of therapeutic mediation skills the involved professionals should
have/acquire/improve from the intercultural health mediators
and the health care operators point of view
1. Field Investigation
•
•
Identify relevant health and care institutions and institutions of migration management
(included asylum centres, detention centres etc.) for the identification of types of professionals (*) working with migrants.
(*) By “professionals” we mean doctors, nurses and, in general, professionals working
with health care including mediators.
Identify types of professionals working with migrants both in primary and specialist
health services.
2. Contact and communication
•
•
Identify professionals working with migrants who can and will participate in T-SHaRE
action research, both health care operators and mediators.
Obtain contact with and informed consent from health care operators and mediators to
participate in the research.
3. Tools for collecting comparable data.
Collecting relevant data using the most appropriate methodologies / combination of methods
according to each partners’ concrete situation. Data may be obtained through combining methods
as focus groups, and / or individual interviews with professionals, both health care operators
and mediators.
For the best comparison of data we strongly recommend that each partner carry out focus
groups. Two different groups should be formed: one consisting of health care operators
(mainstream) and one of mediators (formal / informal). Each group should consist of no more
than ten participants and diversity among participants as concerns sex, age and profession /
experience / work place should be strived for.
Each group should meet once or twice, for 2 ½ - 3 hours. All themes, outlined below, should
be discussed until data saturation is obtained and all participants should be encouraged to be
active. Start by posing the main question (in italics) and supply with the sub-questions when /
if necessary. This way you will get more exploratory data.
117
The focus group should start with a brief introduction of T-SHaRE / the purpose of the group
and a brief presentation of all participants and their experiences concerning migrant patients.
If you need to supply the focus groups with individual interviews, we recommend that you pose
the same questions as in the themes for the focus groups.
4. Themes for the focus groups / interviews
What are your experiences with migrant patients?
•
•
•
•
•
How many of the patients you meet are migrants / have migrant background?
“Types” of migrant patients (age, sex, reason for migration, legal status)
Have you experienced extra challenges in your work with migrant patients?
If so, in what context / situation / health problem / type of migrant patients?
What would be of help to you (kind of tools) when experiencing challenges?
Intercultural health mediation; is there a use / need for this type of health service?
•
•
•
•
Why? How important?
In what context / situation / health problem / type of migrant patients?
Do you see any challenges in the cooperation between the health operator and the mediator?
Should mediation be supplemented with other tools, as interpreter, translated material,
training, and other?
Which skills should an intercultural health mediator have / require?
•
•
•
•
•
•
•
•
•
Personal / informal skills
Professional / formal skills
Concerning:
The health system
Diagnosis / treatment
Communication
Language
Intercultural conceptualisation / understanding of health
Relation/ communication with family /relatives
What are the training needs of intercultural health mediators?
What kind of training should they have?
Concerning:
• The health system
• Diagnosis / treatment
• Communication
• Language
118
•
•
Intercultural conceptualisation / understanding of health
Relation/ communication with family / relatives
Which skills should health operators have / require?
Concerning:
• Migrants’ rights to health care
• Migrants’ specific health situation and health needs
• Intercultural communication
• Intercultural conceptualisation / understanding of health
• Relation/ communication with family / relatives
What are your proposals concerning intercultural health mediation?
•
•
•
•
Requirements* (formal and informal) to be a mediator?
Training (both health care operators and mediators)?
Organisation of intercultural health mediation?
Other tools?
*By requirements we mean formal education, language competency, professional background,
communication skills etc.
5. Analysis of data from focus groups / interviews
•
Identify and describe mediation skills intercultural health mediators should have /require
/ improve
•
Identify and describe skills the health care operators should have / require / improve
•
Identify and describe the training needs for intercultural health mediators according to
both health care operators and mediators.
•
Identify and describe health operators’ need for additional tools (own training, interpreter,
other)
•
Identify and describe the requirements to be an intercultural health mediator.
•
Identify implications of your findings and propose possible measures for meeting the
training needs of mediators and health operators
•
If possible: disseminate your analysis and proposals back to the participants of the
research for feedback.
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120
Annex 7
By Centre médico-psycho-social Françoise MINKOWSKA
Training tested protocol
Contents of the modules were organized as follows:
Core module
Week 1:
Why train to cultural mediation? Introduction to respective roles in the healthcare relation (role
games, clinical cases and video)
History of mediation (national variations) and introduction to key concepts (empathy, neutrality,
interpreting vs. translating)
Week 2:
History of immigration and local healthcare structures. Introduction to the legal context (national
variations) and conditions to healthcare access for immigrants and refugees.
Introduction to the medical anthropology approach. The role of social determinants in the context
of immigration. Mediation within a medico-psycho-social approach (clinical cases).
Week 3:
Medical anthropology in the clinical context: Introduction to explanatory models and illness/
disease/sickness concepts. Definition of “culture” and its meaning in the healthcare context
(AMC interactive tool produced by Minkowska).
Medical pluralism and
variations in therapeutic
efficacy. The role of the
mediator in the biomedical healthcare context.
Biomedicine as a cultural
system.
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Week 4:
Brainstorming with participants. Relationship between theoretical concepts and professional
competencies. What is “cultural competence”? (clinical cases)
Round-table and evaluation of the common module.
Mental Health Module
Week 5:
Genealogy of the relationship between mental health and culture (colonialism and the emergence of ethnopsychiatry, postcolonial evolutions).
Evolution of “specialized” mental healthcare structures in local national contexts. The difficult
task of finding a balance between essentializing culture and obliterating the social determinants
of health.
Week 6:
Mediation in the context of mental health therapy: film, clinical cases, role games. Testimonies
from mental healthcare professionals and mediators.
Women’s Health Module
Week 7:
Anthropology of motherhood, parenting, birthing (videos). Confrontation to Western theories
on education, attachment and mother/infant interactions.
Mediation in the Maternal and Infant Health Context : clinical cases.
Week 8:
Mediation in the maternal and infant health context: identification of related institutions of intervention (birth clinics, schools, associations, etc.), clinical cases, videos. Testimonies from maternal and infant health professionals and mediators.
Round-table and evaluation of the specialization modules.
Themes of training
Common themes to different partners:
History and actual state in each country of:
• Migration, local health care systems, cultural mediation;
• Right and Accessibility of healthcare services for migrants and asylum seekers in each
country;
• National and local politics on social exclusion.
122
Migration, Health and Anthropology:
• The role of social determinants in migration;
• Medical Pluralism;
• Biomedicine as a cultural system;
• Definition of the concept of “culture”;
• Stereotypes, prejudices and cultural misunderstandings;
• Migration and family;
• Critical analysis of the concepts of body, identity, and gender.
Anthropology of maternity, parenthood and birth:
• Confrontation of different educational models, attachment and motherhood;
• Cultural Mediation in maternity and childhood healthcare context;
• The practice of Genital Mutilation and cultural construction of gender.
Anthropology of Mental health:
• Medical anthropology, social suffering and illness. Illness narratives;
• Relation between mental health and culture; – Cultural Mediation and Mental Health.
123
124
Annex 8
By CRIA - Centro em Rede de Investigacao em Antropologia
General Evaluation Questionnaire – T-SHaRE training pilot experience
1) From your point of you, which were the best 3 to 5 aspects of this training course?
2) In your opinion, which were the 3 to 5 least positive aspects of this training course, which
could be improved?
3) Please indicate up to 6 barriers in the access to health by immigrants and ethnic minorities
in your country?
4) Please describe 3 main ideas from the training course regarding migrant women’s and infants health which were helpful to you and state why.
5) Please describe 3 main ideas from the training course regarding cultural mediation in mental
health issues which were helpful to you and state why?
125
126
Annex 9
By Centre médico-psycho-social Françoise MINKOWSKA
Pre-training evaluation questionnaire – T-SHaRE training pilot experience
PROFESSION ___________________________________________________________________________
Previous training _______________________________________________________________________
QUESTIONS PRESERVED FOR THE HEALTHCARE PROFESSIONALS
1) Is the institution where you work addressed to a migrants population.
Yes ☐
No ☐
2) What is approximately the proportion of migrant patients that you have received in your
institution during the last year?
25% ☐
75% ☐
50% ☐
100% ☐
3) Have you already had a working experience with cultural mediators?
Never ☐
Often ☐
Always ☐
4) Do you use the patients mother tongue in the healthcare relationship?
Never ☐
Often ☐
Always ☐
QUESTIONS PRESERVED FOR CULTURAL MEDIATORS
1) In how many institutions do you work? _________
Can you specify your work context? (juridical context, social, clinical, educational etc.):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
127
2) Can you give a brief description of your work?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3) Do you use your mother tongue when you work with people who are received in the institution
where you work?
Yes ☐
Sometimes ☐
Never ☐
4) What training have you followed to be recognized as a cultural mediator?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
QUESTIONS PRESERVED FOR ALL PROFESSIONALS
1) What are the other categories of professions that are represented in your insitution?
Psychiatrist ☐
Psychologist ☐
Generalist ☐
Social worker ☐
Anthropologist ☐
Nurse ☐
Gynecologists ☐
Midwifes ☐
Educator ☐
Cultural mediator ☐
Others ☐ ____________________
2) Do you work in a team?
Yes ☐
Sometimes ☐
Never ☐
3) Do you have colleagues from different origins?
Yes ☐ (If yes can you specify their profession)
__________________________________________________________________________________
No ☐
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4) Have you read books and/or participated in conferences about migrants and cultural mediation
during the past year?
Yes ☐
No ☐
5) What is your definition for a cultural mediator?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6) What is your definition of an interpreter?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
7) How do you define the concept of culture?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8) If you aren’t a cultural mediator, what conditions do you need to work with a cultural mediator
within the healthcare context?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
9) In your opinion, could a cultural mediator work in a clinical context? If yes, which are the skills
and necessary resources in a clinical context? If no, why?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
10) Do you think that your culture can influence your professional practice?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
129
11) In what kind of situation would it be useful to work with a cultural mediator?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
12) In your opinion, which are the most important problems that migrants face in the public
healthcare services?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
13) What are your expectations regarding this training program (T- Share Project)?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Thank you for your time and contribution to our survey.
130
Post-training evaluation questionnaire – T-SHaRE training pilot experience
PROFESSION ___________________________________________________________________________
Previous training _______________________________________________________________________
1) Do you work in a team?
Yes ☐
Sometimes ☐
Never ☐
2) Have you read books and/or participated in conferences about migrants and cultural mediation
during the past year?
Yes ☐
No ☐
3) What is your definition for a cultural mediator?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
4) What is your definition of an interpreter?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5) How do you define the concept of culture?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6) If you aren’t a cultural mediator, what conditions do you need to work with a cultural mediator
within the healthcare context?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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7) In your opinion, could a cultural mediator work in a clinical context? If yes, which are the skills
and necessary resources in a clinical context? If no, why?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8) Do you think that your culture can influence your professional practice?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
9) In what kind of situation would it be useful to work with a cultural mediator?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
10) In your opinion, which are the most important problems that migrants face in the public
healthcare services?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
11) What are your expectations regarding this training program (T- Share Project)?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Thank you for your time and contribution to our survey.
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Annex 10
By Kulturno Drustvo Gmajna
Assessment of health care systems and health services for immigrants
The following questionnaire is designed to receive feedback from migrant users who have
experienced health care treatment.
METHODOLOGY
The questionnaire outlines a framework for an evaluation interview with migrant patients. A
researcher carries out evaluation interview. It is important that this researcher is not a member
of the interdisciplinary group (i.e. health care professionals, mediator, translator) that has carried
out the health care treatment of a migrant patient. A researcher introduces her or himself as an
independent researcher that wants to obtain feedback from a migrant patient regarding her or
his health care treatment in order to improve health care services for migrants. It is important
that a researcher gives an impression of a neutral researcher who cares for the benefits of
migrant patients.
This methodology encourages a personal approach that enables a short conversation with a
migrant patient about her or his feelings during health care treatment, observations, complaints,
opinions, and suggestions. The goal of the interview is a migrant’s qualitative assessment
regarding health care services and health care mediation and translation.
The researcher assures the migrant patient that the interview is anonymous and the name of
the interviewee will not be revealed to health care professionals and others responsible for
patient’s health care treatment. Therefore, the researcher never asks the migrant patient to provide
her or his name neither orally nor in writing. Researcher suggests and provides a comfortable
and safe place, where an interview may be conducted without interruptions and not visible to
the health care employees and others that may discourage the interviewee from talking.
Researcher explains to the migrant patient that the interview will be short and will respect the
time a migrant can dedicate to the interview.
Some patients may be emotionally upset after the health care treatment. In such cases, the
researcher assumes a respectful attitude to the migrant.
At the beginning of the conversation the researcher briefly explains that the participation of the
interviewee is needed in order to improve health care services for migrants.
Only after presentation the researcher may start an interview.
133
The researcher uses the questionnaire as a framework for a conversation, explaining the
questions and basic points of the interview in order to avoid double accounts on the same topic.
The questionnaire is only a tool for the interview. However, it is advisable that the researcher
covers all the important topics contained in the questionnaire.
If there is a situation, where the researcher and the interviewee do not understand and speak
the same language, the researcher should find an innovative solution for such a problem. The
researcher may use an informal translator (or mediator), for example a family member, who is
accompanying the migrant patient. However, it is important that such translator is not a member
of the interdisciplinary team (neither one form the health care staff not the mediator or translator) that treated a particular migrant.
It is advisable, where possible, to interview patients also after some time from treatment and
in a different setting (not the treatment setting) for feedback that is not emotionally engaged
in the moment of treatment, but allows for a reflection on how treatment is perceived after
some time
QUESTIONS
1. Basic personal data of the migrant patient must be collected, such as:
1. Country of origin;
2. Residential status (i.e. undocumented, asylum seeker, temporary residency, permanent
residency etc.);
3. Does the migrant have full, partial, or no health insurance?
4. How long has the migrant lived in the destination country? How good is her or his
understanding of the official language of the destination country?
2. Difficulties in accessing health care are collected in a descriptive way, covering more or less
the following points:
•
Difficulties experienced in accessing health care (from making the appointment at
health care institutions to the first reception and during the treatment itself).
• What kind of difficulties were experienced? Perceived barriers in communication, or in
cultural or bureaucratic matters lack of information etc.?
2. Who helped and what kind of help was provide?
3. Feelings and observations during the treatment (descriptive) may be dealt with as follows:
•
134
Did the physician and other health care staff really listen to you? Were they interested
in your problems and did they show empathy? Did they take enough time for you and
your treatment? What were your feelings during the treatment? Did you feel comfortable?
Were you confident with your physician and other health care staff? Did you trust her or
him? Did you have feelings of anxiety, shame, or any other negative feelings at any point
of the treatment?
•
•
•
•
Was the treatment comprehensible to you? In which language did you communicate
(your language or the official language)? Did you need a translator? Did somebody offer
you a translator? Did you suggest a translator yourself?
Did you understand all aspects of the communication? If not, was it a problem of
language or the excessive use of medical terminology?
Did you experience any other uncertainties due to non-linguistic reasons, such as gender,
religion, lifestyle, appearance, or culture?
If you were in the country you came from (country of origin), would you receive more or
less the same treatment? If not, what would be the main differences?
4. Presence of a mediator (descriptive)
•
•
•
Was there a mediator present during your treatment? If yes, who (you or health care
professionals) suggested the mediator was needed? If yes, did the mediator come with
you (i.e. informal mediator such as family member, friend, colleague) or did the medical
institution assign the mediator? If both kind of mediators (the one that came with you
and the other, assigned by the medical institution) were present, which one did in fact
provide assistance during your treatment?
Who was your mediator? Where did she or he come from (country of origin), what
language did she or he speak, what culture did she or he belong to? Mediator’s gender?
Why was the presence of the mediator necessary? Did you find the mediator supportive?
How would you describe his or her affinities: neutral, patient oriented or physician
oriented (whose side was the mediator on)? Were you satisfied with the presence and
assistance of the mediator?
What were the positive aspects of health care treatment and mediation? What were the
bad aspects? Do you have any suggestions for the improvement of health care services?
Are you familiar with any other good practices (for example from your country of origin,
from alternative medicine etc.) that could be implemented into health care services for
migrants?
5. Any other comments or remarks?
135
136
Section 4
Local Training
Protocols
137
138
Annex 11
By Nasjonal kompetanseenhet for minoritetshelse NAKMI
T-SHare Protocol Oslo (nD)
Immigration in Norway
According to the Statistics Norway (SSB)16 there are about 600.000 people living in Norway who
have either immigrated (500 000) or were born in Norway to immigrant parents (100 000). Taken
together, these groups represent 12.2 percent of the population. Approximately 287 000 people
have background from Europe, 210 000 people have background from Asia, 74 000 have a background in Africa and 19 000 have a background in South and Central America. In addition there
are 11 000 people who come from North America and Oceania.
Of the immigrants, the majority come from Poland, Sweden, Pakistan and Iraq, followed by
Somalia, Germany, Vietnam, Denmark and Iran. (NB: Swedish and Danish immigrants have a
language and culture quite similar to the Norwegian.) 34 percent of the immigrants have a
Norwegian citizenship. 40 % have lived in Norway less than 4 years. The number of foreigners
classified as undocumented is estimated to 18 000 persons.
National Laws and regulations
The Health services are regulated by several laws; among these are The Act of Patients’ Rights
and The Act of Health Personnel
The Act of Patients Rights 17
According to the Act of Patients Rights § 3-5. Information: ‘The information must be adapted
to the individual conditions, such as age, maturity, experience and cultural and language backgrounds. The information will be provided in a considerate manner. Healthcare professionals
should as far as possible ensure that the patient has understood the content and meaning of
the information. ‘
If necessary, this shall be solved by using professional interpreters. However, there are numerous
examples that family and even children are being used instead for practical or economical reasons.
Undocumented immigrants
Very recent rules (June 2011)18 state that all residents in Norway have the right to emergency care,
regardless of whether they are legal or illegal in the country. Everyone should have the same right
16
17
18
www.ssb.no
http://www.lovdata.no/cgi-wift/wiftldles?doc=/app/gratis/www/docroot/all/nl-19990702-063.html&emne=pasientrettigh*&&
www.regjeringen.no/upload/HOD/forskrift-prioriteringsforskriften.pdf
139
to an assessment from the specialist and to have the information necessary to safeguard their
right to health care. Adults who reside illegally in the country have the right to health care that
can not wait. That is, if the patient within a short time, will be in need for emergency
assistance if he or she does not get health care.
The right to health care is the same in mental health care when it comes to physical disorders. Also
persons who are mentally unstable and is believed to be dangerous, has the right to health care.
The Government is concerned that children and pregnant women as much as possible shall have
the same rights as legal residents. Women without legal residence have the right to have
performed abortions.
People without legal residence must generally still pay for the medical care received. However,
it is not entitled to demand advance payment for emergency assistance and medical care from
the specialist which can not wait.
The Act of Health Personnel 19
According to § 3 in The Act of Health Personnel, persons who shall ‘perform preventive, diagnostic, therapeutic, health-preserving or rehabilitative work’ within health have to obtain an
authorization or a license, according to § 48 and 49. (In addition comes personnel in the health
service or pharmacists, pupils and students in connection with their professional training.)
§ 4: ‘Health personnel should perform their work in accordance with the requirements of professional responsibility and caring help can be expected based on their qualifications, the nature
and situation in general.
Health professionals should abide by their professional qualifications, and obtain assistance or
refer patients to others if this is necessary and possible. If necessary to meet the patient’s needs,
the treatment shall be done by cooperation and interaction with other qualified personnel.
Interpreters
The role of the interpreter is very restricted: He/she are not allowed to add/explain or interfere
in the communication in any way. 20
19
20
140
http://www.lovdata.no/cgi-wift/wiftldles?doc=/app/gratis/www/docroot/all/nl-19990702-064.html&emne=helsepersonellov*&&
From Ethical codes for interpreters http://www.google.no/#hl=no&source=hp&q=YRKESETISKE+REGLER+FOR+TOLKER&oq=YRKESETISKE+REGLER+FOR+TOLKER&aq=f&aqi=&aql=f&gs_sm=e&gs_upl=1706l1706l0l1l1l0l0l0l0l172l172l0.1l1&bav=on.2,or.r_gc.r_pw.&fp=b53cfcd9
75a84ad1&biw=1280&bih=837
§ 3 The interpreter must be impartial and not allow their own attitudes or opinions affecting the work.
An interpreter shall not engage in favor of one or the other party in the conversation. The interpreter must take a neutral position to the case
that the interpretation is, and do not let their beliefs or opinions about the parties or what is said, appear or affect the interpretation.
The interpreter is not responsible for the content of what is to be interpreted. That responsibility belongs to the speaker. The interpreter’s task
is only to interpret what is said of the conversation the parties, without evaluating or judging the moral or truthfulness of the message.
Interpreters must not draw attention to inconsistencies or inaccuracies that are expressed, but interpret them.
§ 4 The interpreter shall interpret the contents of everything that is said, conceal nothing, without any attributes or changes.
What is said is to be translated accurately, without any changes. This means that the interpreter does not omit subject or style aspects
and does not add anything, but chooses similar information and expression as much as possible.
When there are words and phrases that are impossible or difficult to transfer, the interpreter must ask the person who uses the term rephrase
it or give a more detailed account of the content. If the interpreter later find out that something is interpreted incorrectly or omitted under the
interpretation - and this is the least important - the parties should be informed immediately.
Interprofessional work teams
Mental Health
District Mental Health services are interprofessional, but we are not yet certain to what extend
the different centers are organized as interprofessional work teams.
Women and Children Health
Women will normally go to their ordinary GP, who then may send them to specialists in Womens’
health (gynecologists). These specialists are private doctors, normally with an agreement with
the municipality that covers most of the costs. The specialists will normally not work in an
interprofessional team.
Women and Children Health
Women will normally go to their ordinary GP, who then may send them to specialists in Womens’
health (gynecologists). These specialists are private doctors, normally with an agreement with
the municipality that covers most of the costs. The specialists will normally not work in an interprofessional team.
Pregnant women may go to their GP during their whole pregnancy, or they may be referred to a
specialist as described above. During their pregnancy they also get in touch with the hospital
where the delivery is going to take to place. (An interprofessional team with obstetrics, midwifes,
nurses etc). Unless complications are expected, the contact with the birth clinic at the hospital
is rather limited until the birth is taking place.
The local Health Stations are in charge of antenatal care, health clinic 0-5 years, school health
6-20 years and youth health clinic. Projects aimed at women with minority background have
been carried out at different health stations 21
Intercultural Health Mediator
At present there is not any profession within the Norwegian Health System similar to an Intercultural Health Mediator as described in the T-share program. The closest will be the Minority
advisers in some of the districts and the Natural Helpers/Link Workers that work within different
voluntary organisations.)
Minority advisers
In Norway a few local municipalities have employed “Cultural Advisers”, working in certain schools
and neighborhoods, and some districts have also developed the concept “Minority adviser” within
social care and even at a few Health stations. These advisors are themselves immigrants and
are well established and integrated in the community. They work with individuals, providing
http://www.hiak.no/somah, http://www.google.com/#hl=en&sa=X&ei=MXQVTp7CM8nSsga8spnODw&ved=0CBQQvwUoAQ&q=stork+groruddalen&spell=1&bav=on.2,or.r_gc.r_pw.&fp=c488823cce0a6f39&biw=1680&bih=881
21
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information and guidance concerning the health and social care services. They function as coordinators for individuals and families and have a preventive and problem solving focus in their
work. They are also engaged in group activities in order to establish networks and meeting places
for promoting and facilitating community participation. The Minority advisors assist both inhabitants and health and social care workers. Since 2005, minority advisors are part of the ordinary services in the district of Alna. This is not regular jobs; the Minority Advisors are paid by
the hour. Other districts of Oslo and other municipalities have shown a lot of interest in the work
of Alna, and some have established similar services. In a report regarding the project the Minority
Advisors are described as follows.
Basic competences
• Common experience (the meeting with Norway, establishment, expectations and realities)
• Common frames of reference (the emigration society and its institutions, attitudes and
traditions, relationships between sex, parents and children, between generations, neighbors,
aesthetic and ethical ideals, art and culture, etc.)
• Other languages (forms of communication, codes, the automation in communication)
• Transnational issues (belonging, environment, network, conflicts)
• Norwegian language skills, be well oriented in the Norwegian society and about everyday
life in Norway as parents, as an employee, etc
Additional competences
• Pedagogical skills, to enjoy working with people, patience, ability to listen, seriousness,
professional attitude, resource-oriented, not judging others, politeness, respect for others
• reflection and knowledge of integration mechanisms
• personal commitment to a positive development in the local environment and in society
in general
• interested in further learning and development
• individual skills that are developed through practice, such as independence in the work
Personal competences
Natural Helpers
On voluntary basis there is a centre called Primary Medicine Workshop, in Oslo, with so called
“Natural helpers”, i.e lay people with ability and interest to collaborate with professionals to
promote health issues. They have experience in the migration process and have often already
had a special help and mediation role in their own environment.
The ‘Natural helpers’ act as contact persons and guides within their own communities environment, making it possible for professionals to develop trust in these environments act as Cultural
Mediators, as they in their own community informs about the Norwegian culture, the Norwegian
support system and Norwegian laws and regulations - and inform different professions about
the immigrants’ culture, traditions and coping and conflict resolution strategies.
On the other side are professionals who act as partners and mentors for natural helpers, collect
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and systematize relevant information which are then used to develop and refine methods and
models and provide the necessary quality of the work.
Conclusion
In spite of good experiences from districts using Minority/Cultural advisors, cultural mediation
is neither defined nor recognised as an official practice, i,e, a cultural mediator is not regarded
as a profession in itself. The reason for this is (partly) the strict regulations about who can work
as health personnel. This makes it difficult to create an “IHM”-education, unless one requirement
is that the IHM already is licensed/authorized according to the Act of Health Personnel.
In Norway we will have to build on the existing systems, where licence/authorization is required,
and focus on a protocol aimed at Health Operators, preferably working in existing interprofessional, cross cultural teams (i.e. Health workers with different cultural background working
entirely or to a large extend, with immigrant patients).
If the workplaces where the piloting is taking place also have Minority Advisers they will also be
invited to participate.
Suggested skills and profiles according to the Norwegian Context
The general characteristic concerning the Health Operator is that he/she shall
• Have a license/authorization according to the Act of Health Personnel
• Speak at least two languages fluently
• Be able to identify the various explanatory models which are at play in the clinical interaction
• Be able to cooperate well with the interpreter (and/or link-worker) if he/she do not speak
the language/dialect of the patient, and the patient do not speak Norwegian, to communicate well and to make sure that the patients problems are identified and addressed, sharing
his/her interpretation with the patient before proposing any sort of program or intervention
• Have knowledge of Human rights, Health rights of asylum seekers, refugees and undocumented foreigners
• Have knowledge about other parts of the health and social system that should be involved
besides ones own working place, and willingness to do so
Existing programmes
• There are several further education programmes at university college level within general
cross cultural competence, mainly for persons working in the public sector). One of the programs (15 credits, at the University college of Oslo) is aimed especially at those who already
have an academic education within health and care as well as two years of practice..
• We believe that the piloting should be aimed at health workers, including non-academic
health professions, (like auxiliary nurses and care workers) with some parallels to the program
from the University college of Oslo combined with the outcomes of several of the T-share
WPs. This may also make a good starting point in getting recognition of skills learnt at the
work place, for those who wants to have a formal diploma from the University College, or
from a tertiary vocational education programs for auxiliary nurses and care workers.
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•
In general it may be difficult to limit a formal program to immigrants only, as this may be
looked upon as discrimination. On the other hand a college can decide to run programs with
special entrance requirements, (for instance minority background) or to deliberately pick
students with different background (quotas.)
Training
Target groups: Health Operators and Minority Advisers
• In mental health services: psychiatrists, psychologists, nurses, social workers, educators,
occupational therapists, auxiliary nurses, others.
• In maternal and child health services: (In Norway this will be the Health Stations and /or
health center for undocumented immigrants) GPs, gynecologist, obstetrics, psychologists,
pediatricians, nurses, auxiliary nurses, social workers, minority advisors, others.
Workplaces: (Planned, will be contacted in August)
a) The health center for undocumented migrants:
Undocumented migrants - regardless of nationality, religion, ethnicity, political standpoint, sexual
orientation, gender or age - in all stages of their stay in Norway:
• former asylum seekers who have received a final rejection of their applications
• people who have received a visa or residence permit on the wrong basis
• people who have visas that do not apply anymore, people with residence permit has expired
and the people who have lost their residence permit and been expelled from Norway
• people who have come to Norway without t having to register with the authorities - such as
victims of human trafficking.
The health center’s goal is to reach particularly vulnerable persons within the group, as children
and women
b) A Mental Health District Service and District and a Health station
(in one of the districts of Oslo with a high migrant population
Participants from both workplaces will be together at the introduction module of 20 hours, then
split up, but it shall be possible to attend both the Women health and Mental Health modules
for persons from both groups
Introduction (20 hours)
(Preliminary) aims:
To promote skills for professional practice in a multicultural society and to contribute to the development of professional practitioners’ theoretical/analytical knowledge to action readiness
skills in a multicultural environment
To acquire knowledge, insight and skills in
• The responsibilities and roles as professionals in a multicultural society – key word: culture
sensitivity, self-awareness, person-centred care,
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•
•
•
•
•
•
•
•
•
•
The cross-cultural encounter – what expectations do we have for each other? Resources,
opportunities and challenges in a multicultural meeting (i.e. focus groups experiences,
participants own experiences)
Factors that affect the personal socialization process (both Health operator and patient)
Communication and relations; Communication strategies; (how) can we better make sure
that we understand each other?
How different understandings of reality are being constructed
Knowledge about different concepts of body, health, disease/illness and treatments,
explanatory models of health, disease and suffering
Life cycle and migration processes
Knowledge of Human rights, Health rights of asylum seekers, refugees and undocumented
foreigners
Increased ability to use and reflect on his/her own practice and to co-operate with
in the encounter; the patient, colleagues, interpreters, link workers
other parts of the health and social system that should be involved besides ones own working
place
Mental Health Issues (10 hours) Concentrated on ethno psychiatric and medical anthropological notions such as the problems of
aetiology, the issue of the efficacy of the acts of healing, the dimension of transference and
counter-transference, etc.). (Associazione Franz Fannon)
Mental Health (from CRIA)
• Basic Concepts on critical psychopathology
• Clinic-Etno-psychiatri: critical history of difference and medical power
• Request Analysis and interpretation of the problem.
• Mental Health service structures and problematic
To be concretized /completed
Women and children health (10 hours)
The notion of female bodies, sexuality, pregnancy, social construction of the newborn, ethnopedagogies in the first years, etc.). (Franz Fannon)
• Notions on the concepts of gender and reproductive health
• Analysis of Target Complaint and interpretation of the problem
• Maternal and Child Health service structures and problematic. (CRIA)
Suggested Methodology (Key-words, to be completed later):
Lectures,
Cases/practical examples from the participants’ own experiences,
Discussions, Role-plays and observation,
Reflection notes
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Suggested curriculum
We will build on the experiences with the existing curricula from the course at the University
College of Oslo.
Acknowledgment of skills learnt at job/recognition of prior learning
In Norway each university/university college decides if/to what extend prior learning will be
recognized. The T-share training program for health operators, combined with documentation
from the work place may
•
give the health operators in concern either a part of or full qualifications within an existing
training program, preferably the one aimed at health workers at Oslo University College
•
give access to education / training without having standard prequalification’s, (i.e. auxiliary
nurses and other health operators with a non-academic education
•
give the possibility for to enter exams directly without being present in (all) classes
This must be negotiated with the college in concern, the workplaces and the provider of the
T-share pilot program, NAKMI.
Mapping of skills
The mapping of skills must be also made in agreement between the workplace, the cooperating
university/university college(s) and the provider of the program.
The suggestion from Centre Françoise Minkowska will be our starting point in this negotiation.
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Annex 11
By Kulturno Drustvo Gmajna GMAJNA
T-SHaRE Protocol Ljubjana (SI)
INTRODUCTION
Whenever we discus construction and implementation of new services to improve social positions or enable participation of a certain segment of population, we have to be aware of the fact
that social structures are determined by various processes and relations among them. Therefore,
when we discuss migrants’ access to health care, their treatment, or establishment of Intercultural Health Mediator (IHM), we must take into account different processes taking place in the
junctions of wide social fields like migration, health and social exclusion. These junctions produce
distinctive social effects we have to consider when making proposals for new institutions, i.e.
institutions aimed at mitigating or removing obstacles that prevent individuals to fully participate in the society and at the same time preserve their subordinate social position. Namely, such
obstacles result in low quality of life of certain populations and less possibilities for development
of their potentials. Therefore, institutions are needed to effectively address real needs of people,
improve social positions of excluded populations, and rebalance existing power relations.
The question we are dealing with in the present protocol – possibilities of intercultural health
mediation, its content and integration into the health care system – requires consideration of a
specific local as well as European and global contexts of migration, migrants’ inclusion in or
exclusion from existing social institutions, especially health care system, effects these processes
have for the health of migrants, and possibilities to improve migrants’ health condition.
MIGRATIONS IN SLOVENIA AND COMPOSITION OF MIGRANTS
Migration is not a new phenomenon in Slovenia. Mechanisms for management and administration of migration from the second half of the 20th century can be divided into two historical
phases. As a member of the Yugoslav federation Slovenia experienced a number of consecutive
migration flows, but they have significantly increased from the year 1975 onward. This was the
period when we witness the decline of the “guest-worker model” in Western countries, which
were the primary destinations of migrants from Yugoslavia. Migration management at this period was modified in the direction of closing borders and stricter regulation of migrants. “With
the closure of western European labor markets the internal migration to Slovenia, which as a
more developed part of the common state replaced the closed labor markets, increases from
other republics of Yugoslavia. The first migration flow from the mid sixties is followed by the
stronger second flow from the second half of the seventies”. (Kobolt 2002: 21). The majority of
migrants in Slovenia came from Bosnia and Herzegovina. These migration flows were considered
as internal ones (within Yugoslavia), therefore the migrants themselves at that time were not
exposed to rigorous procedures of arranging residence in Slovenia.
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This practice changed dramatically in years before the collapse of Yugoslavia and in the period
of the formation of new nation states on its territory. For the past twenty years we have witnessed considerable turbulences in treatment of people (new foreigners) living on this territory.
These turbulences are the result of various processes, but we will mention only those that affected larger proportions of population.
The first process was the creation of new categories for residents (not citizens) of Slovenia that
came from other Yugoslav republics and had in 1991, after Slovenia’s independence, only temporary residency registered in Slovenia or had permanent employment without any residential
status (approximately 100,000 persons (Mekina 2007: 50)) or had registered permanent residency in Slovenia (approximately 200,000 persons). According to new after-independence laws,
those with temporary residency registered had a possibility to arranged their status in Slovenia
only as temporary residency and exclusively through employment or family reunification. Others,
who did not manage to arrange their status, faced great difficulties if they wanted to stay in
Slovenia. Those with registered permanent residency had an option to apply for Slovenian citizenship by December 1991, but those who did not apply or those, whose applications were rejected, were erased from the register of permanent residence, and by this act they lost all the
rights they accumulated in the past years of their stay in Slovenia. The erasure was declared illegal by the Slovene Constitutional Court; the rights of the erased have not been fully restored
yet. The number of erased residents according to official data is 25,671 persons.
The second process concerns the arrival of refugees from the former Yugoslav republics (Croatia
1991, Bosnia and Herzegovina 1992, and Kosovo1999) affected by war. The precise number of
refugees for many reasons is quite ungraspable. “Tens of thousands of refugees came to Slovenia. According to data provided by Immigration and Refugee Board in spring 1992 almost 45
thousand refugees were forced to migrate from Croatia and Bosnia and Herzegovina.” Immediately after the arrival some refugees migrated to countries of the European Union, Canada, the
United States and Scandinavia. The first official count was in September 1993. At that time there
were 31 thousand refugees in Slovenia (...)”. (Vre er 2007: 9). However, in fall 1992 there were
approximately 25.000 unregistered refugees who found accommodation in families in Slovenia
( onli and rnivec 2003: 16). To these numbers we have to add a few thousand of refugees
from Kosovo staying in Slovenia since 1999. They too have had obtained temporary shelter status, just like the refugees from Croatia and Bosnia and Herzegovina. Apart from these numbers
there is also a small number of individuals, asylum seekers and persons with refugee status who
got their statuses from 1992 up to today and come from many different countries.
Since 1992 there has also been migration into Slovenia of people who moved and arranged their
residential status on the basis of a new Employment and Work of Aliens Act. This means that
they had or have a work or employment permit. In this category we often find individuals who
came to Slovenia in any of the flows already mentioned above, but this legal basis (work or employment) is the corner stone of the numerous official new arrivals in Slovenia, with its peak between 2004 and 2009. The number of migrant workers has drastically fallen with the conditions
of economic crisis. According to available data there were 92.078 valid work permits in 2009, almost half of them were issued to the citizens of Bosnia and Herzegovina (Beznec 2010: 22), while
in 2011 the number of issued work permits significantly dropped.
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In addition to immigration trends in the same period we follow the trend of emigration. Alenka
Kobolt writes that the first emigration movements have been pursued already in the eighties in
response to various developments that led to the collapse of Yugoslavia. “And the result is that
the net migration since 1987 is constantly decreasing, and Slovenia is in 1991 for the first time in
35 years, confronted with negative net migration (…). The reason is emigration of predominantly
non-native population, that was employed in the Yugoslav army and administration”. (Trnovšek
1996: 14) (2002: 23). The most recent large emigration (often involuntary) was caused by the
economic crisis, since numerous migrant workers left Slovenia. The complete impact of the economic crisis on the net migration in Slovenia is not yet known as the process of emigration and
the economic crisis is still unfolding.
We can conclude that that today, the largest proportion of migrants in Slovenia are people
coming from republics of the former Yugoslavia, regardless of the year of arrival or reasons for
their migration. Yet the mechanisms to recognize their legal status on the territory vary to a
high degree. Movements of people that were considered as internal migration until 1991 became
international migration after that year. After independence Slovenia introduced a qualitatively
different way of migration management, in accordance with its changed political and economic
system. These changes were embedded into the Slovenian legislation immediately, but migration
became “an important issue only in 1999/2000, when the Slovenian legal arrangements of migration got harmonized with the European migration policies a harmonization that was integral
to the process of the Slovene accession to the EU. In practice this meant a stricter management
of asylum procedures, procedures of detention and deportation, and at the same time the first
serious regulation of economic migration “(Beznec 2010: 17). Formal treatment (management)
of migration has changed drastically, stripping migrants of opportunities to equally participate
in the society and to fully develop their potential. And yet migrants who come from countries of
former Yugoslavia are formally (in legal and administrative terms) foreigners, although often
perceive as “our” migrants since they experienced same history and their languages and cultures
are not understood as very distant from cultures of the host country.
ACCESS TO HEALTH CARE
a) Social exclusion and a problem of “access”
A need for the establishment of new services intended to ease access to various institutions
implies that certain segments of population due to various reasons face difficulties in usage of
already established structures. In the pas decades the concept of social exclusion is being
increasingly used for describing social position of these segments. This extremely wide and vague
concept may be a useful tool, since it takes into account the complexity and intertwinement of
different social fields and their effects on positions of individuals in the society.
One of the definitions coined by Graham Room states: „(Individuals)... suffer from social exclusion
where a) they suffer generalized disadvantage in terms of education, training, employment,
housing, financial resources, etc. b) their chances of gaining access to the major social institutions
which distribute these life chances are substantially less than those of the rest of population; c)
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these disadvantages persist over time“ (Abrahamson 1995: 124). The definition reveals that social
exclusion is a consequence of (mayor!) social institutions’ incapability to deal with all individuals,
although their purpose is to prevent or at least minimize the effects of their deprivation. But it
doesn’t say anything about the reasons for this condition. On the other hand Bhala and Lapeyre’s
definition of social exclusion includes the multiple dimensions of this phenomenon and in their
words it is composed of: 1) economic aspect, which refers to the exclusion from the labor market
and the distribution of resources; 2) social aspect, which is focused on the relational questions
and emphasizes the lack of participation of certain social groups in the process of decision making, the process of marginalization of deprived groups and the notion of equal opportunities; 3)
political aspect, which refers to the equality of human and political rights. This dimension, among
other things, problematizes the fact that the state as the supposed guarantee of basic rights
and liberties isn’t a neutral agent and can be also an important actor of exclusion (Zavratnik &
Zimic 2000: 834). Both definitions together reveal that social exclusion presents a long lasting
drop out of individuals or groups from one or more social networks (formal, like services and institutions, verjetno?). And that they, for various reasons, can not be satisfactory replaced by the
established (informal and formal) social mechanisms of solidarity and assistance, at least not
to the extent that is perceived as a minimum standard in a certain surrounding. The reasons for
these dropouts have to be searched for in all fields of official and unofficial organization of the
society; therefore in the objective determinants, which in combination with the subjective factors
push certain individuals on the margin. Namely, socially excluded individuals are often exposed
to different factors at once and consequently the conditions they face are the result of this
interplay.
Since social exclusion isn’t conditioned only by subjective characteristics of the deprived individuals,
we have to emphasize its structural causes. “Since we are aware that discriminations and exclusions are never contingent events but are implanted in the functioning of the authorities and
political systems, by an analysis of elements of deprivation (…) we can see a subtle functioning
of the mechanisms of power directed towards maintaining of power relations of some social
groups in relation to other. These relations are permanent, repeatable and are reproducing themselves” (Zaviršek, Škerjanc 1998: 387-388). The fact that social exclusion is caused by multiple
factors and that many of them are structural is supported also by the research on street homelessness in Slovenia. The research is focused on the population, which suffers from the most
extreme and visible form of exclusion. Dekleva and Razpotnik have identified the following aspects of street homelessness: 1) poverty, indebtedness; 2) loneliness and lack of social networks;
3) absence of statuses, lack of social power; 4) long lasting unemployment, exclusion from labor
market; 5) experiences of institutionalization; 6) abuse in the childhood, traumatic events; 7)
intergenerational persistence of exclusion and/or homelessness; 8) demoralization; 9) health
issues (chronic diseases, (handicap??), problems with mental health, addiction, double diagnosis); 10) different secondary consequences of homelessness (bad health condition, difficulties
in accessing health care and other services, victimization, criminalization, lack of starting point
to acquire a status, …) (2009: 22). Together with the acknowledgment that social exclusion is
caused by various factors we must consider also its very dynamic nature. Social exclusion is an
ever-changing process in which old mechanisms of exclusion are modified but at the same time
new forms are added.
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To conclude, when questioning the possible solutions for overcoming the social exclusion we
have to be aware of the mentioned facts. But in parallel we have to be very attentive on possible
outcomes of the solutions. The goal of ”integration” (as opposite to social exclusion) as mere
mitigation of current distress or enhancement of access to the most necessary goods, which in
no way intervenes in the established power relations and therefore maintains subordination of
certain populations, is clearly not sufficient. Similarly, an individual approach that doesn’t intend
to change systemic mechanisms of exclusion is only healing the symptoms and not the roots of
the problem.
b) Migrans’ access to health care
While discussing the treatment of migrants by the health care system we must be aware of two
interconnected levels. The first level poses a question, who has the right to use health services
and why certain categories of migrants face difficulties while accessing health care institutions.
And the second is enabling of fare and effective treatment of migrants after successful entrance
in the health care system. Besides this we have to consider also the fact that migrants are “(...)
a population suffering from more threats to health as residents of the state to which they migrated. They face more risk factors, use less health care services. Migrants are to a larger extent
socially deprived, unemployed, occupy workplaces that are harmful for their health, live in unfavorable circumstances” (Mikuš Kos 1996: 74-75). Fact that migrants are recognized as more endangered population in terms of health but they use health care services to a lesser extent leads
us to conclusion that certain objective and subjective circumstances exist, which unable effective
health care of these persons inside the established institutions. Questioning of these circumstances is therefore necessary at developing of proposals for the removal of obstacles in health
care system.
At this point we must emphasize that the accessibility of health care services depends on many
different factors. Namely it is comprised of various objective and subjective aspects. But at the
same time we also have to be aware of its dynamic nature since it is a process, realized in cooperation between singular parts of the health care system and those using its services. In that
manner the reasons for difficulties in access to health care are connected with the sole functioning of health care system (how does it function, geographic arrangement of its services, how
inclusive and flexible it is etc.) but also with the arrangements on the systemic level (who has
the right to health care, the financing of the health care etc.) and completely subjective obstacles
(lack of information, feelings of discrimination etc.). (Dekleva, Razpotnik 2009: 97) Among the
key reasons for difficulties in the relation between migrants and health care system we can list
differences in cultural background, problems with communication and lack of financial resources
but mostly the issue of the status.
Status is an essential factor regarding the access to health institutions since it defines the rights
of different categories of migrants and determines the possibilities of their participation in welfare institutions. A right to health care is closely interconnected with other migratory regulations
in particular countries. Namely, full entrance in the health care system is in different manners
denied to individuals without citizenship (and also to citizens without full health care insurance).
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Migrants are not a homogeneous legal category. We may conclude there is a correlation between
a migrant’s length of stay and the amount of rights she or he has obtained. Precarious migrant
statuses place obstacles to migrants’ effective access to health care services. In this respect,
more attention should be given to the advocacy of migrants’ rights. But when a migrant finally
acquires a more stable and long lasting legal status (for example permanent residency and
permanent work permit), more attention may be given to appropriate health care treatment in
intercultural context, which includes the question of mediation. Contemporary trends in management of migrations, i.e. the introduction of circular migrations, are designed to prevent such
process of rights accumulation. The policies of hierarchical inclusion of migrants and rejection
of migrants being unable to effectively integrate into the labor market are directed towards
accepting migrants only as workers and not as complete individuals, as patients, family members
etc. These policies are increasingly integrated on the formal level when migrant workers with
health issues don’t have the right to health insurance but also on informal level, in praxis.
T-share research and other references clearly exposed the fact that many migrants are systematically
discouraged from using urgent medical help although they have the right to it. Non-citizenship
therefore defines contours of struggle for access to health care.
Statuses are important also due to the fact that they define possibilities of mobility and therefore determine quality of life and life possibilities for particular categories of migrants. This
process also strongly influences health of migrants. Namely, circumstances which individual
migrants face because of official categorizations of persons (for example living in workers dormitory, asylum homes or precarious life of undocumented migrants) definitely have important
effect on the quality of live. At the same time they produce unofficial obstacles to the access to
health care services (lack of time or financial resources, geographical distance from the centers,
lack of information due to segregated life etc.). In situations when migrants have limited rights
to health care services a lack of financial resources presents an important obstacle. Enormous
sums of money that have to be paid in cases of non-urgent medical help function as one of the
key migrants’ arguments for not using health care services.
On the other hand, various cultural backgrounds of patients and health care staff are becoming
a common feature of today’s health care. However, this may be a problem, when for example
an individual does not use health care services because of inability to communicate (language
differences, differences in interpretative models) or fear of being discriminated. However, cultural
differences cannot be considered an obstacle to quality health care per se, but due to the ascribed
statuses of certain “cultures” in the society, which makes them a crucial systemic factor of
exclusion and maintenance of established power relations.
To conclude, Slovenia has a specific composition of migrants. The majority of migrants derive
from the newly established countries of the former Yugoslavia. In regard to this specific group,
due to the shared political past as well as cultural and linguistic similarities, the migrant’s need
of specific cultural mediation is not so explicitly in the forefront. On the other hand, migrants
from other parts of the world emphasized their difficulties with a whole set of other, mostly
statutory, systemic and bureaucratic barriers. Various legal statuses of migrants considerably
influence their access to health services and their treatment. Migrants with complete health insurance are usually satisfied with health services. Migrants (and other people) who do not have
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health insurance or have insufficient health insurance have considerable problems with access
to urgent health treatment, although they have the right to it. People without documents who
do not have sufficient financial means experience rejection in health care institutions even
though their health condition is critical.
INTERCULTURAL HEALTH CARE MEDIATION IN SLOVENIA (INFORMAL MEDIATION)
Informal mediation is already exercised in various social institutions and on various levels of
these institutions. It is not bound only to questions, regarding health and care, but it comprises
also closely related issues such as: assistance regarding status, legal framework, social care,
education, housing and employment etc.
Although the positive impact of informal mediation, as practiced in the health system and
services in Slovenia, is truly immense, it implies also some general side effects that can not be
underestimated. Confined to the informal level, to the sole responsibility of non-professional
volunteers on the one hand and informal, sporadic information exchange and advice between
health and care professionals on the other, it definitively lacks the minimum professional standards necessary for an appropriate, efficient, holistic and just treatment of a patient. Information
exchange between professionals and users, which is crucial in achieving this aim, is in most cases
partly or generally incorrect (due to language problems), imperfect (due to lack of understanding
of specific terminology) or insufficient (due to increased time-consumption). This lack is especially evident and dangerous in the field of mental health, where a professional mediator with
both language and cultural competence skills would be of highest importance, since very small
details and nuances in patient’s expression and health professionals perception and understanding of the patient’s cultural background can lead to very distinct diagnosis and consequently
very distinct drug and therapeutic treatment.
And finally, due to the fact, that informal mediation is not perceived and exercised as a systemic
basic right but is actually a kind of an individualized informal favor or sacrifice of another person,
it can produce feelings of gratitude and obligation, that in final instance can produce or reproduce
some formal or informal relations of power: between doctor and patient, husband and wife,
parents and children, citizens and migrants, associations and individuals.
Therefore, in accordance with previous experiences and opinions of migrant users of health services, an institution of cultural mediation should be recognized and formalized as an expert professional service. It should provide not only translation between languages and cultural concepts,
but – if necessary – also a kind of advocacy on behalf of a migrant. Namely, a migrant person is
often in a vulnerable position, not so much as a result of language or cultural differences, but
because of not knowing her/his rights and how to enforce them in the system. Mediation should
therefore not be understood as an passive, objective process of conflict solving between two
opposite parties, as understood and practiced in the field of juridical mediation. It should go
rather into the direction of active advocacy of the user and active information basis for the professionals. It should put a special effort in inclusion of migrants themselves, whereby respecting
individual and collective migrant subjectivities and avoiding a construction and consequent seg153
regation, victimization, alienation of specific groups (in terms of ethnicity, religion, culture,
gender, class or race).
For this reasons the migrant users would need and welcome a multi-level and multi-sided
mediation, assistance and counseling. The institution of mediation should take up a holistic approach to the field of health and care and preferably a universal character (it should provide services to migrants as well as citizens with difficulties in the access to health system services).
Migrant communities have therefore developed and articulated a proposal of a mediation between the users and the health and care professionals which would take up a form of a professional and interdisciplinary institution, comprised of medical professionals and specialists from
the field of law, social work, medicine, social science, anthropology etc.
In the opinion and experience of migrant users the medical professionals and the personnel
in health institutions in general should receive additional education in regard to most basic
information on rights of migrants, tied to their access to health services. On the basis of complaints and many different negative and positive experiences of migrants the following skills for
eventual (and already existing informal) intercultural health mediators can be extracted: the
knowledge of different languages, knowledge of medical terminology, knowledge of the basic
rules and laws regarding the rights of migrants with different statuses in health care system,
knowledge of cultural competence, sensitiveness, patience, discretion, responsiveness.
In regard to the cultural competence training the migrant users expressed their considerations
about different and sometimes even conflicting understandings of “culture”. First, there is the
danger of a stereotypical, objectified representation of different cultures. Second, a training in
“other cultures” can quickly lead to a forced construction of an “Other”, different and passive
subject, that is in need of care and assistance and incapable of taking its own decisions and
responsibilities. And third, it is obviously impossible that professionals would learn many
different languages or they would be familiar with diverse cultures.
The first and the most necessary step in cultural competence training would therefore be the
sensibility of professionals in the sense of strengthening their awareness about prevailing
stereotypes, language barriers, implicit and explicit racism, xenophobia and discrimination. A
special focus, effort and training on the phenomenon of migration, migrant rights and cultural
competence should be provided in the areas of large concentration of migrants, especially in the
health facility in Ljubljana Vi , which is in charge of health and care for asylum seekers.
ADVOCACY – MEDIATION – TRANSCULTURALITY
a) Health care advocacy
In his classic work Passing: On The social organization of dying (1967) David Sudnow explained
how presumed social value of patients affects whether the health care providers’ staff will
attempt to review them. This is how social inequality reveals itself in the functioning of the
health care system. Sudnow argued that health care staff’s decisions on how to administer care
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giving is based on the patient’s social value: patients with perceived low social worth were much
less likely to be resuscitated aggressively than patients with a perceived high social value. Since
Sudnow’s study health care field has undergone various changes. However, claims about social
inequality are still relevant in the contemporary health care contexts (Timmermans 1998). Barriers regarding access to quality health care disproportionately affect racial, ethnic, and other
minorities. Limited access to quality health care is a major barrier to successful health outcomes.
Migrants often perceive health care system as rejecting their rights and needs or even experience
health care services as oppressive. Social inequality of migrants within the health care system
cries for an institution of a migrants’ advocate representing migrants’ interests and rights in
the health care system, who is refusing migrant’s access to health care. Since there is a systemic
power unbalance between the migrant patients and the health care providers, an advocate is
supposed to help the migrant patient to enforce right to health care. The advocate’s role is to
achieve migrant’s access to health care and appropriate quality of services.
In the context of a health care system refusing to provide services to migrant patients, an intense
advocacy role in service delivery is needed. Such advocate has to be unquestionably on the side
of a migrant. Therefore, an advocate cannot be a member of some kind of inter-professional
team; the advocate cannot be a (professional) colleague of the health care providers’ staff.
However, besides problems occurring in direct encounters between migrants and health care
system, more structural determinates of migrants’ inequality exist that cannot be resolved
merely by health care advocacy or inter-cultural health care mediation. For example, undocumented and other precarious migrants do not have the right to paid sick day (paid sick leave). If
they do not work because of health issues, they risk not to get payment during their absence
from work or ultimately to loose their job. Not having the right to paid sick leave unfairly affects
their (or their ill child’s) access to health care.
b) Inter-cultural mediation
Contemporary health care values patient’s autonomy. Patient is not supposed to be an object
of health care professionals’ paternalism; health care procedures should not be imposed upon
the patient without her or his prior consent based on adequate information about the nature,
possible outcomes and other relevant aspects of particular health care procedure. Patients are
perceived as autonomous agents whose will and interests have to be respected during health
care procedures. Therefore, health care providers have to listen to patients and respect their
views, give patients information in a way they can understand them, and respect the rights of
patients to be fully involved in decision-making regarding their health care. Patient’s autonomy
is the bases for (legal) concepts such as informed consent and various ethical rules that demand
accurate information and appropriate communication between the patient and health care
providers, including language interpretation and translation of cultural explanatory models.
It is clear that language and culture do matter in providing health care. They are crucial to
diagnosis, treatment, and care. Health care system and providers need to respond to patients’
varied perspectives, values, and behaviors about health and well-being. Failure to understand
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and manage cultural differences may have significant consequences for respecting migrant
patient’s autonomy. In this respect, culturally informed strategies enable health care providers
to address challenges posed to them by the increasing complexities of globalized society.
Arguing for the implementation of inter-cultural mediation in the health care can be understood
as an attempt to introduce such culturally informed strategies into health care settings. However,
when does intercultural communication take place? Whenever the parties to a communication
act bring with them different experiential backgrounds that reflect a long-standing deposit of
group experience, knowledge and values, we are faced with intercultural communication
(Samovar 1991). Inter-cultural health mediator is perceived as an impartial third actor in the
health care context characterized by such inter-cultural communication. The cultural mediators
supposedly bridge the gap between migrant groups or migrant communities and host culture
health care organizations. Namely, they possess a set of skills and experiences to help host culture health care provider to engage effectively with the migrants. These skills and experiences
often require from an inter-cultural mediator to be more than a language interpreter, but a translator between different explanatory models.22
There are possibilities of substantial cultural diversity among doctors, nurses and other healthcare
on one side and migrant patients on the other side. The interaction between the health care
providers and the patients may therefore be frustrating for both sides due to cultural differences
(different explanatory models) and difficulties in communication and language. Inter-cultural
mediator can in such circumstances function as an inter-cultural manager for a particular health
care provider. In this respect, inter-cultural mediation can be useful as a health care system’s
tool to address cultural diversities health care systems face in today’s complex globalized
societies. Therefore, inter-cultural mediators are often employees of the host culture’s health
care provider or health care institution, intended to improve the quality of health care services
host culture provides to foreigners (Davis 2009).
Inter-cultural mediators may provide translation service, facilitate clinical encounters by overcoming
communication barriers and maintaining confidentiality, avoid misunderstandings when explaining
diagnosis and prescribed treatments, promote mutual respect and good relations between health
providers and migrants, and so forth. The role of the mediator is therefore to enable migrant
patient’s autonomy to be respected in the bilingual and multicultural health care contexts. It
addresses the question of the contemporary health care systems’ ability to provide care to patients
with culturally diverse values, beliefs, and behaviors and to meet patients’ social, cultural, and
linguistic needs. To sum up, inter-cultural health mediation is about how to increase access to
quality care, yet not about how to provide access to health care per se for socially disadvantaged
groups. The mediator’s role does not presuppose there is a clash of interests between the migrant
patient and the health care provider on a systemic level. Such approach of inter-cultural mediation
22
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Some definitions of an inter-cultural mediator: Inter-cultural mediator is considered someone with excellent bicultural skills who “affords
a bridge of understanding particularly between host culture professionals and newcomers through awareness and sensitivity to ethno-cultural
differences.”(Vargas 2000). A mediator considered a “trusted contact” (Healthlinks 2000) between their ethnic community and the service
provider. The cultural mediator is increasingly called upon whenever a host culture institution is required to have meaningful contact with a
migrant community (Richter-Malebotta 2000). They are expected to “create points of convergence between the autochthonous and the foreign
culture” (Richter-Malebotta 2000). (Davis 2009: 76).
may offer numerous benefits to the health care service providers and migrants that have no problems accessing health care services. However, for migrants that face severe difficulties in accessing
quality health care inter-cultural mediation may not produce any benefits.
The idea of inter-cultural mediation derives from the concepts of interculturality and multiculturality. These concepts understand cultures as distinguished spheres that exist together. Thus,
they seek ways in which such cultures could get on with, understand and recognize one another.
They seek opportunities for tolerance and understanding, and for avoidance or handling of conflict. However, as Welsch claims, these concepts imply and affirm traditional understanding of
cultures as autonomous spheres. If cultures were in fact still constituted in such form, then one
could neither rid oneself of, nor solve the problem of their coexistence and cooperation. However,
the description of today’s cultures as spheres is factually incorrect and normatively deceptive.
Cultural conditions today are largely characterized by mixes and permeations (Welsch 1999).
Some dilemmas that pop up in thinking about inter-cultural mediation are:
(a) Can interpretation or mediation be impartial and neutral, or does a mediator always interpret
or mediate for someone? Migrant patient may understand “impartial” cultural mediators as
agents of the health care system who resist helping them to resolve their systemic problems.
Cultural mediators may be perceived as agents of a host culture health care provider if they are
made clear that they need to avoid advocacy and remain neutral (Davis 2009).23 In the heavy
contested area of migration policy neutrality of a mediator can be understood as loyalty to the
agenda of the health care institution and to the goals of the migration policy.
(b) Who decides that a particular situation demands the involvement of an inter-cultural mediator? When does a health care context cease to be intra-cultural and start to be inter-cultural
and in need of a inter-cultural mediator? This is not an easy question. The above-described notion
of inter-cultural mediation implies that it is the health care professional who makes such decision, but of course the migrant patient or others may suggest an inter-cultural mediator to be
involved in the process.
(c) When a specific health care context is recognized as inter-cultural, should we be careful not
to become overly preoccupied with cultural difference and comparison between explanatory
models?
(d) When an inter-cultural mediator is a member of an inter-professional team, she or he is expected to be someone working as a team member with health care providers staff. While working
in a team may have many advantages, it also functions as a control mechanism preventing the
mediator to shift from a neutral role into a role of an advocate when advocacy would be necessary
and just.
23
”In their assessment of the TAMPEP project to develop cultural mediation with a sexual health service in Hamburg, Lempp and Mansbrugge
(1999) describe cultural mediators as the agents of the health services who experienced considerable angst in resolving their identities within
the service provider organization. Cultural mediators were only perceived by the report as the agents of a host-culture organization, and it was
made clear that they needed to avoid advocacy and remain neutral. However, neutrality in this instance appeared to mean loyalty to the agenda
of the employing institution and professional distance from the clients.” (Davis 2009).
157
(d) Concept of inter-cultural mediation presupposes a cultural divide between the service provider
and the migrants. However, culture is not homogenous or static. Therefore, culture cannot be
reduced to a technical skill for which mediators can be fully trained in advance and become experts. In this respect, culture must not be identified with ethnicity, nationality, and language,
since today it is hybridized and creolized.
(e) Ignoring the structural and systemic imbalance of powers in intercultural contact and communication fails to account for cultural exclusion through non-intercultural communication.
When differences in cultural power are reduced to mere semantics or cognition or individual
differences, the basic cultural inequality, domination and discrimination that lie at the heart of
contemporary intercultural (including international) communication may be smoothed over or
explained away (Shi-xu 2005). Consequently, is it adequate to argue for inter-cultural mediation
in health care without institutionalizing health care advocacy?
(e) “Intercultural” fails to resist the essentializing, “territorial view” (Streeck, 1994:286) of culture
– the notion that one can ever really be positioned between cultural systems. As such, the term
continues to persuade us that it is cultural systems not individuals which are in communication
with each other (Scollon & Wong Scollon, 1995:125).
(f) Since culture is seen as static and fixed in such a discourse, members’ capacity to create
cultural knowledge and experience through communication may be overlooked (Shi-xu 2005).24
(f) How to address the challenge that more and more individuals find themselves “outside” of
any particular culture, “outside” of its national, racial, sexual, ideological, and other limitations?
(Epstein 1999).
(g) Regarding the Explanatory Models Approach as an interview technique that tries to understand
how the social world affects and is affected by illness, Kleinman & Benson warn against misadventure when clinicians and clinical students use explanatory models. They materialize the models as
a kind of substance or measurement (like hemoglobin, blood pressure, or X rays), and use it to end
a conversation rather to start a conversation. The moment when the human experience of illness is
recast into technical disease categories something crucial to the experience is lost because it was
not validated as an appropriate clinical concern. Rather, explanatory models ought to open clinicians
to human communication and set their expert knowledge alongside (not over and above) the patient’s own explanation and viewpoint. Using this approach, clinicians can perform a “mini- ethnography,” organized into a series of six steps, developed by the authors (Kleinman, Benson 2006).
c) Transculturality
From the point of view of migrants, both may be needed: health care advocacy and inter-cultural
mediation. However, since these two roles are based on different understandings of migrants’
24
158
See for example how girls and boys who simultaneously occupy Muslim and French social identities actively (re)interprete these identities
through innovative cultural practices and innovative linguistic contexts in interaction with their peers. Both innovative and traditionalizing
patterns of cultural production are occurring simultaneously, they selectively appropriate and adapt a communicative form from their
own background and transform it into a means to express their social positioning. (Tetreault 2009).
position within the health care system, it is impossible for one person to exercise both roles.
While institutionally employed and “neutral” inter-cultural mediator may bring numerous benefits for the health care provider, efficient advocate may bring substantial benefits to migrants
who face systemic difficulties in accessing health care services.
Shi-xu notices how intercultural studies seems to circulate a general discourse that sets great
store by cross-linguistic and cross-cultural knowledge and skills and the ability to ‘translate’ linguistic and cultural differences, hence ‘intercultural competence’. Underlying this discourse is
the assumption that members of different cultures have different sets of cultural and linguistic
knowledge and skills. Consequently, this discourse is often used to explain ‘misunderstandings’
or ‘communication breakdown’. The central problem with this sort of discourse is that it obscures
the power-saturated nature of intercultural contact and communication. That is, it presumes
that different cultures are in equal relation to one another (Shi-xu 2005:). Shi-xu explains that
much of intercultural communication research and training has rested on the presumption that
the key to intercultural communication and understanding is knowledge and skills in the relevant
language and culture. He argues that what is missing from this perspective is, crucially, power
relations and (important!) the willpower to overcome them. Proceeding from this ethical and
political stance, he suggests that research, education and training take on the role of institutional
moral agents and turn their attention to critiquing power practices on the one hand and cultivating the ethical motivation to construct common goals on the other.
In this respect, the notion of transculturality seems to be more advanced and better suited to
contemporary social life than the notion of inter-culturality. Contemporary social life is not only,
intercultural, but transcultural through and through. It is a place where “culture” and its concepts
are constantly contextualized and re-conceptualized; it is postmodern, postcolonial, post-transitional, creolized world of constant becoming. In addition, cultural life is shot through with power,
hence domination, prejudice and exclusion. Therefore, it should be approached and analyzed in
terms of differential power relations and practices, where one group is dominated by another,
through differential power resources available to some groups or individuals but not to others.
However, cultural practices cannot be reduced to power relationships as such and should not be
seen as solely shaped and determined by them (Epstein 1999). Such reductionism is not correct.
Transculture is a way to transcend our “given” culture and to apply cultural transformative forces
to culture itself. Transculture is self-transformation of culture, the totality of theories and practices
that liberate culture from its own repressive mechanisms (Epstein 1999).Transculture can be defined
as an open system of symbolic alternatives to existing cultures and their established sign systems.
If we adopt the notion of constantly changing and contesting culture, the question remains: is
it possible to implement this understanding into everyday practice of health care? From this
question originates for example a concern of how to avoid cultural competency as a “trait list
approach” that understands culture as a set of already-known factors. Yet, tranculturality also
emphasizes engagement with others and with the practices that people undertake in their local
worlds. It considers issues of empowerment and transformative processes for involved actors
(in our case migrants and health care staff). Is it possible to institutionalize within health care
system a constant sensitivity to our own positionality in global as well as local powers dynamics
as an emancipatory praxis?
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SKILLS AND KNOWLEDGE OF INTERCULTURAL AND INTER-PROFESSIONAL TEAMS
From the analysis of the Slovenian context regarding migrants and health care system it is difficult to clearly identify skills inter-cultural mediators or therapeutic mediators need to acquire
or improve. In Slovenian health care system there is no official inter-cultural mediation. In addition, existing – yet extremely fragmented and arbitrary - practices of informal advocacy and mediation are not retroactively acknowledged by the health care system. Due to the composition
of migrants in Slovenia (the majority coming from the countries that used to be parts of former
Yugoslavia and speaking a language that is more or less well understood by Slovenians), the
generally very rigid official structures of health care system maintain the position that there is
no need for health care providers to familiarize themselves with the cultural backgrounds, identities and languages of migrant patients and equip themselves with cultural competence or to
implement inter-cultural mediation in health care. In general, cultural competence is not considered necessary in order to provide patients with appropriate and acceptable health care. Although nobody is explicitly rejecting it, it unfortunately still does not appear in public or
professional discourses as something that is urgent or even necessary to implement in health
care system.
However, in practice there are some fragments of informal advocacy for migrants’ access to
health care and advocacy on behalf of the patients detained in closed mental health institutions.
The latter may be important for migrants, since socio-cultural differences between migrants
and the host society as well as the lack of awareness of these differences by mental health professionals may influence rates and patterns of psychiatric hospitalization of migrants. Advocates
for migrants’ access to health care come from activists’ collectives, grassroots migrant organizations, or certain non-governmental organizations. A typical informal advocate for migrants’
access to health care is not well acquainted with medical and health care terminology. She or he
has certain experience and knowledge regarding rights to access to health care, yet has almost
none inter-cultural competence. When she or he helps to realize migrant’s access to health care
service, she or he does not usually take part in the subsequent process of providing health care
service. An advocate, therefore, does not play a role of a mediator or interpreter. Often she or
he does not even receive any further information regarding migrant’s fate within health care
system. After achieving access to health care, an informal advocate removes herself or himself
from the relationship between a migrant patient and health care personnel. She or he does not
practice advocacy regularly, but only from time to time, more or less by accident and almost exclusively in urgent cases. She or he rarely reflects her or his advocacy role.
Some informal and fragmented interpretation and even inter-cultural mediation is present in
Slovenian health care context, particularly in the field of women care. Yet, the patient’s right to
proper and professional interpretation lacks sufficient legal arrangement. At present, interpretation in health care depends upon good will and significant improvisation of certain individuals,
who act as interpreters for certain languages (for example Chinese). In other cases, rather than
professional interpreters, non-professional improvised interpreters help to improve communication between migrant patients and health care staff. There are no official guidelines for health
care staff how to act when faced with multi-lingual or multi-cultural situation. Therefore, some
suggestions are coming from the Faculty of Arts of the Ljubljana University (department for in160
terpretation) to provide for a comprehensive legal arrangement of interpretation in health care.
Similar findings apply to inter-cultural mediation in health care.
TRAINING
a) Goals
The general purpose of the training is to acquire and enhance knowledge on inter-cultural and
transcultural approaches in health and care and to outline visions, ideas and possibly a proposal
to implement official inter-cultural health mediation in Slovenia health care system.
Training will have the following purposes:
• to promote learning of knowledge useful in performing informal advocacy, interpretation
and mediation in health care;
• to promote self-organized self-learning of skills and exchange of experiences useful in
performing informal advocacy, interpretation and mediation in health care;
• to establish effective communication (creative network relationship) and support among
relevant actors (in order to each actor not only promote her or his points, but also to help
others to put across theirs).
b) Participants
Training (pilot training course) beneficiaries will include:
• informal advocates for migrants’ access to health care;
• informal interpreters and informal inter-cultural mediators;
• activists for migrant rights;
• students;
• health care professionals and health care staff.
c) Curriculum
Training will be divided in two parts. It will include lectures and – more importantly – workshops,
presentations and reflections upon concrete cases. A method of self-learning will be used, encouraging participants to share their knowledge and practical experiences.
1) General part (20 hours): social exclusion; health care system; migrations; rights of migrants in
health care; culture, inter-culture, trans-culture; cultural competence; advocacy, mediation, translation; empowerment and improving of power imbalance (practices of migrants’ self-organization
regarding health care); relationships in health care (therapeutic relationship, power imbalance).
2) Special part (20 hours) of the protocol is supposed to be divided into two areas of concern,
mental health and women health. However, in Slovenian context it is not wise to structure the
second part of the training activities in to strictly separate areas. The special part of training will
be more focused on concrete cases and practical examples, especially from mental health and
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women health. It will appear in terms of impressions, insights, feelings, observations, even new
words and concepts. This part will heavily depend upon interpersonal processes. As such it cannot
be subject to strict planning, issues will be handled as the will appear and according to its own
dynamics. It also seems wise to exchange the existing, yet rare and unstructured experiences
from women health with experiences from mental health and vice versa. In this part participants
will exchange their knowledge and experience on migrant rights in health and care system, on
notions of culture and cultural competence, as well as on good practices in overcoming difficulties
with access to health and care, with power imbalance, with the process of treatment and with
linguistic and terminological translation.
No certificate will be given to the participants. However, a final questionnaire will collect participants’ opinions about the training and their suggestions.
TESTING OF THE PROTOCOL
Health care context for the testing of the protocol requires “on the job” environment and establishment of “multidisciplinary teams”. There is no such health care context easily available for
testing the protocol in Slovenia. While we might direct our efforts at specific workplace, we
would instead like to achieve a broader impact; to promote organizational development in a
wider range of workplaces where there is almost no reflection regarding multilingual and multicultural health care situations and regarding advocacy, translation and mediation in health care.
Therefore, we will establish an autonomous space for testing of the protocol. An autonomous
space is understood as a method of engagement that will allow advocates, translators and mediators, health care professionals, social workers, lawyers, non-governmental organizations, students, researchers, activists and migrant groups and communities to effectively reach the target
group (of migrant patients) and to engage with them around a number of areas of concern, including inter-cultural mediation. This method allows for an active participatory role within multiprofessional and multidisciplinary group of actors, who shared significant experiences and
interests and who are prepared to work together with migrants on migrants’ own agenda for
action. This approach may be progressive and emancipatory, as it encourages inquiry and reflection, connects theory to practice, and creates links between informal practices and formal functioning of the health care. Simultaneously, that may result in an interdisciplinary approach.
A common social arena is an interacting system of social worlds of specific stakeholders, each
defined by discourse and with particular understandings and investments in a particular framing
of phenomena. It can function as an incubator of new meanings, representation and language
and thus the locus for the production of a particular local theory or ‘situated knowledge’ regarding
the phenomena in question. As such, it is not only in cultural multiplicity and multi-disciplinary,
but in fact transcultural and transdisciplinary.
Such autonomous space may also function as an external support structure to promote organizational changes in health care. In this way, we may make a break with the existing patterns
and develop something new and different, however using the existing practice and building from
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the past experiences. Namely, we are facing a sensitive terrain when a new concept and institution (in our case an institution of an inter-cultural mediator) is being suggested to the huge and
contested system as a health care. These issues must be further understood within trends in
contemporary migration policy and present economic crisis. Additionally, the implementation of
such institution implies also a change in mentality. We are therefore facing a complex problem
how to contribute to transforming the social situation and the related functioning of the health
care system in the field of migrant health, and in particular migrant mental health and migrant
women health.
We decided to choose a social development strategy, and not a cost-benefit argumentation to
promote the systemic changes in health care. Social development strategies distinguish themselves from orthodox economic development approaches by emphasizing the need to translate
economic processes into social goods for the socially, economically, culturally, and politically marginalized. Social development strategies try to realize gains from development – economic and
otherwise – through building capacity, agency, and participation among those at the periphery.
While it is important to bring the socially excluded into the governance process, enabling their
agency and realizing sustained civic engagement, we must be careful not to ignore the role of
public and social policies and fail to engage government officials who formulate and implement
these policies. Our assumption is that the projects contribution to transforming social situations
will depend on how well we bring different stakeholders together to learn about themselves and
each other, and identify and find ways to address the implicit barriers to the effective providing
of health care to migrants.
Although t-share distinguishes between mental health and women health, we will be using an
idea of inter-activity among areas of concern. The situation regarding advocacy and mediation
in health care in Slovenia is only starting to be discussed. Therefore, it might be inappropriate
to make a clear cut between these two fields of health care. The participants will move together
and in parallel using each other in the process of interaction and exchange despite a particular
health care field (mental or women health). However, a special attention will be given to mental
health and women health as well. The goal is to build bases for cooperation (networks) among
various fragments of advocacy and mediation in health care, rather than focus on a single workplace. The focus is therefore on the dialogically structured encounters to initiate development
activities in health care system.
Ljubljana, ___________________
Signed by:
KD Gmajna
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Annex 13
By Associazione Frantz Fanon
T-SHaRE protocol Turin (IT)
1. Operative and organizational Project proposal
1.1 Introduction
What does it mean to work with health cultural mediation? Which problems led to the use of
this strategy in the cure of immigrant people’s mental illness and with immigrant women and
their children?
Over the last few years, the ethnoclinical and linguistic cultural mediation has represented the
real challenge for all those who were interested in working with transcultural psychiatry and,
more generally, in health services for immigrant users. Both in Italy and in Europe, as well as in
the USA, in Canada or in Australia, many experiments in linguistic and cultural mediation have
been carried out within ethnopsychiatry or transcultural psychiatry services to try and respond
to health care problems of immigrant people or of members of minority groups and, more generally, to confront the issue of their accessibility to the services. Since the problems of cultural
accessibility have to be added to the economical, juridical and institutional ones , these are responsible for:
•
•
•
the decrease of the accessibility,
the creation of weaker therapeutic relationships
and the increase of the risk of drop out.
The social workers and the researcher have put forward a number of questions about these issues, which can be summarized as follows:
1.
2.
3.
4.
What happens when a foreign citizen or a migrant family meets the health services?
Are their symptoms and experiences listened to appropriately?
Can we reduce the risk of misunderstanding in the diagnostic and therapeutic process?
What kind of specific difficulties come upon in the clinical encounter with foreign
patients?
5. Which kind of “cultural competence” is required in order to properly construct an intercultural psychotherapy?
1.2. Analysis of National and Local Data
A research about the relationship between health and migration in Turin, demonstrated that
even immigrants with rights (people with documents and regularly present on the territory for
a long time) only used the health services in 50% of the cases (AA.VV, 1994) .
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Four years later (1998) another research, conducted by the Province of Turin, came to a similar
conclusion. In relation with the accessibility to the mental health services, a survey reported
Data about seven CSM (Centro di salute mentale: Mental Health Centre) in Turin, demonstrating
the really poor presence of immigrants and, on the other hand, the really high number of dropouts just after one or two consultations. On the contrary, in the Frantz Fanon Centre – Service
of counselling, psychotherapy and psychosocial support for immigrant people, refugees and victims of torture – the users were, in the same period, seven times more numerous than the total
number of users received by the aforementioned seven services together, in spite of the fact
that the Centre was only open two afternoons a week (AA.VV., 1999) .
Another research conducted some years later, once again in Turin, showed the same results
(Ponzio, 2003; Visintin, 2003) . What do all these data tell us? What do these absences mean?
And why were the Services often obstinate in denying that something had to be done to improve
the quality of care services and the satisfaction of foreign people and health workers?
The answer to the first question lies in the critical medical anthropological models and in
ethnopsychiatry.
Michele Risso and Wolfang Böker showed - in the ‘60s – the limits of Western psychiatry and
its diagnostic categories in relation with the distress and suffering of citizens who belonged
with full rights to that very same Western part of the world (the immigrants in that case were
people from Southern Italy) (Risso e Böker, 1992) .
It is clear that the presence of the Other, the foreigner, can expose the difficulties of the host
countries and reveal the contradictions and the grey areas behind many assumed truths. The
presence of the Other is a real “epistemological marker”, revealing weaknesses of various kinds
. Operators and experts often fail to respond to this situation because they are unable to recognize the weakness of their practices and interpretative models in relation with new or different
questions and conflicts.
A certain psychiatry or medicine prefers to talk about “drop out”, “low compliance” of the patient,
“poor collaboration” of the family: but all these concepts can be turned around to indicate, in
many cases, the “low quality of both the welcoming process and the relationship”, the “non sustainability of the pharmacological therapy” (economical, linked with collateral effects often not
communicated to the patient,…), the inability to manage complex relational dynamics. The meeting between alienists and foreigners has increased these problems and the abuse of similar
pseudo- concepts.
In this complex scenery we have to consider at least two factors, often linked with each other. It
is better to analyse them distinctly, keeping in mind that they are often connected:
a) The first one can be defined “the cultural matter”. The lack of knowledge about categories,
representations, and interpretative models, characteristic of a certain system of care, the weak
familiarity with other aetiological and therapeutic approaches, the lack of knowledge in relation
with different points of view about suffering and illness, are at the basis of most of the difficul166
ties normally reported. These difficulties concern both the users and the operators: both have
sometimes a limited knowledge of the healing practices in the host country and, respectively, in
the countries from which migrants come.
b) The second one concerns the “language/translation matter”. The difficulty in translating in a
proper and well-structured way their own concerns, uneasiness, fears and experiences, put the patient in an uncomfortable position, especially in those areas of diagnosis and healing where, as in
the case of mental health, a great deal of the problem lies in the “speech area”. In the same way,
the therapist’s analyses and prescriptions aren’t met with an adequate response when expressed
in a language that the patient does not master, and are devoid of all relevance if given in a language
suggesting epistemological, psychological, moral or religious assumptions which are potentially far
from (or even contradictory with) those of the patient and his family. These assumptions contribute
to the production of misunderstandings; they interfere with the process of building a successful
healing strategy and are an obstacle to the required cooperation. On the other side, the latter often
represents the most important resource when it comes to overcoming the distrust of patients and
families who perceive the care subjects and the social control actors as indistinguishable.
What are the consequences of these factors in Mental Health Services or Services for Women
Health, today? Even though the patients’ stories, their clinical biographies (anamnesis), and the
social, economic and political conditions of their countries are often unknown, a diagnosis is expressed after few meetings: a diagnosis that claims to be legitimate on the basis of a presumed
methodological objectivity. Expressions such as “reactive psychosis”, “bouffée delirante”, “religious” delirium are very recurrent and often veritable pseudo-diagnoses, that reveal the operators’ uncertainty, are coined.
Facing the unintelligibility of the Other, doubly alien (mad and foreigner), facing unknown
languages, usually people adopt two strategies: the denial of the cultural-linguistic difference,
reducing the psychic/physical suffering to the only supposed valuable model of our categories
and our strategies; or imagining that the cultural difference is the hidden code of the observed
magic. From this to a bad use of cultural mediation, the way is short.
A good part of the confusion which characterizes the existing debate on the meaning of cultural
mediation arises, furthermore, from the pretension to talk about this practice ignoring the peculiarities of its different application contexts (its role in psychotherapy, in midwifery or in schools
is very different, and the preliminary training should be different too) (de Pury Toumi, 1998) .
The wrong idea that cultural mediation is another way of obstinately taking the patient back into
the borders of his/her own cultural and ethnic world as a healing strategy has concurred to the
creation of misunderstandings. These can be particularly challenging if one considers the lack of
an appropriate training on the linguistic theories and the meaning of translation in the clinical context, which characterizes the majority of the school issuing the title of “cultural mediator”.
Both the risks mentioned above (we could call them “false positivity” and “false negativity”),
occur frequently and have already been discussed by Devereux in the ‘70s: they lead to an inef167
fective use of the linguistics-cultural difference or, on the contrary, to the impossibility to distinguish important disturbs lying under an idiom of suffering we are not familiar to. Kleinman,
more than 30 years ago, suggested the notion of “category fallacy” for this kind of problems,
underlining especially the risks coming from the pretension to adopt, without a preliminary,
proper and critical examination, diagnostic categories of Western psychiatry and medicine in
other cultural contexts.
2. General purposes
Today the activities for the Health Care are addressed mainly to the figures exposed to the risk
of marginality, rejection and psychic uneasiness due to the meeting of the risk factors.
Therefore, the training has the following purposes:
a) to support the learning of instruments meant to realize interventions of assistance and support in foreign patients;
b) to promote the establishment of multidisciplinary work groups aimed at reducing the risk of
drop out and diagnostic error, to help the patient’s therapeutic continuity, and to mediate the
conflict in the social and familiar context.
3. Description of the Pilot Service and Beneficiaries
The Mental Health Department of ASL TO1 (“Azienda sanitaria locale Torino 1” belongs to the
National Health Services) is a Public Service for the clinical treatment of mental health Disorders,
the social rehabilitation of the patients and the construction of a Network of Services around
each single patient. The territory of competence of the ASL TO1 is the South part of the City.
Inside ASL TO1, there are two S.P.D.C. (Psychiatric Services for Diagnosis and Treatment) – in
“Mauriziano Hospital” and “Martini Hospital” – for a total of 25 beds; and six C.S.M. (Mental
Health Centre) for the treatment of the patient on the territory (1. “ambulatorio” for clinical activities; 2. “Centro diurno” for rehabilitation activities; 3. “residenze”, where social workers support
people with mental health disorders living in group-apartment/”gruppi-appartamento” for their
own autonomy, self-determination and social inclusion). Since 2002, Frantz Fanon Centre (Service of counselling, psychotherapy and psychosocial support for immigrant people, refugees and
victims of torture) works inside one of the C.S.M. of ASL TO1 (Circoscrizione 3) with a team composed by psychiatrists, psychologists and cultural mediators.
In the same public context (ASL TO1), there is a Centre for Women and Child Health called Multicultural Centre (Centro multiculturale). This Public Centre offers to foreign mother a medical
support during pregnancy, birth, child’s cure in the first months of life of the babies, etc. This is
a Service particularly addressed to pregnant immigrant women in which are involved nurses,
doctor (specialized in podiatry and genecology) and cultural mediators.
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Finally, in the same ASL, there is a Centre for Women Health affected by sexually transmitted
disease (Centro MST), specially addressed to migrant women (involved in the human sexual trafficking). The team are composed by doctors specialized in sexually transmitted disease, biologists, psychologists, social workers and cultural mediators.
Training beneficiaries will be:
•
6 (six) Mental Health Operators (psychologists, psychotherapists, psychiatrists, physicians,
nurses etc. working in C.S.M., S.P.D.C., Frantz Fanon Centre of ASL TO1);
•
4 (four) Women and Children Health Operators (obstetricians, physicians, psychologists,
nurses etc. working in “Multicultural Centre”, Centre for MST );
•
10 (ten) Cultural mediators working in all Health Services of the ASL TO1 (CSM, Frantz Fanon
Centre, Multicultural Centre, etc.).
4. Methodology and specific aims
The training activities of the team selected are scheduled in a 40 hours span, 20 of which intended both to the presentation/discussion of specimen cases on which the operators and ethnoclinic team are invited to make hypothesis, explore difficulties, analyse transference and
counter-transference dynamics, and to the evaluation of the interactions with the other services
involved and the impact of the treatment on the clinical problem.
Protocols could be divided into two parts.
Part 1: A common part of 20 hours to share a common vocabulary and language with the selected
team, such as an Introduction for analyzing the notion of culture; the work of translation; the
emic representations of disease and illness, etc.;
Part 2: divided into two different levels concerning the different interventions in Mental Health
Services and Services for Women and Children Care:
Part 3 subdivided in:
Mental Health Unit (10 hours), analyzing: mental health issues (more concentrated on ethnopsychiatric and medical anthropological concepts such as the problems of aetiology, the issue of
the efficacy of the acts of healing, the dimension of transference and counter-transference, etc.).
Women Care Unit (10 hours), analyzing: women and children health, the notion of female bodies,
sexuality, pregnancy, the social construction of the newborn, ethno-pedagogies in the first years,
etc.).
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4.1 Skills of the intercultural interprofessional work team
The members of the intercultural work team should possess and develop the following skills on
different levels:
•
juridical competences: knowledge about the laws concerning migration, refugees, and asylum
seekers.
•
linguistic competences: to pay attention to their communicative style, to the way they lead
the conversation and the words they choose when facing migrants (as well as the health
professional); to consider the way their words will affect the patient, considering his/her history and background; to be aware of the different symbolic representations connected to
different languages. To be able to increase the number of dimensions involved in the interpretation of the illness. Operators have to learn to tolerate the frustration of not understanding immediately the patient’s talk, for both linguistic and semantic reasons; at the
same time, they have to learn to tolerate the presence of another health worker in the clinical
setting (this issue is particularly important in psychotherapy).
•
competences in medical anthropological issues: critical attitude towards their own theoretical
and methodological premises; knowledge about ccategories, representations and interpretative models operating in other societies and in other healing systems; knowledge of other
aetiological, diagnostic and therapeutic registers, and of other aspects of suffering and illness;
reflection on the relation of power implied in the healing practices; ability to stay and to
move inside/outside the dialectic between the concept of equality and the one of difference.
The professionals working in the field of women health have then to deepen their knowledge
around the notion of female bodies, sexuality, pregnancy, social construction of the new born,
childrearing practices etc. In mental health services they will work on the concepts of aetiology,
the issue of the efficacy of the acts of healing and more generally around ethnopsychiatry and
other medical anthropological notions.
•
•
knowledge about gender issues in different cultural contexts: to have the ability to understand other ways to be “mother”, to construct the female body, as well as different gender
expressions; in woman health services, workers will have to acquire the ability to consider
the impact gender issues have in conceiving couple and family life, body manipulation, pregnancy etc.;
teamwork competences: aptitude in working in a team and in integrating the different members’ competences to produce a complex intervention; in mental health services, the role of
the health cultural mediator is central: all the team has to recognize, to benefit and to highlight his/her competences.
Health workers will have to learn how to manage the often observed process of triangulation
that consists in a continuous involvement of the cultural mediator into the dialogue between
health workers and users; they will also have to learn to tolerate the frustration of not understanding immediately the patient’s talk;
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•
network competences: the team should cooperate with others formal and non-formal organisations working in the field (welfare work, ONG, ISI Centres, etc.); operators should be
able to orientate the users bearing in mind not only his/her clinical-therapeutic assessment
but also their social situation;
•
relational competences: the operators should be able to build up a strong therapeutic relationship with the user; the latter should feel “safe” and welcomed for sharing the reasons
for his suffering with the health operators. Each health professional has to question his/her
own personal attitude toward migrants, foreign people etc., and to reflect upon the care
process as a part of a interpersonal and on-going process, not a simple act.
4.2. Specific skills of the cultural mediator in the health’s field
The cultural mediator has to acquire:
•
a strong theoretical base in translation theory, even if his/her role will be really different
from the one of a translator;
•
how to manage the risks of “triangulation”, i.e., the ability to cope with the continuous involvement of the cultural mediator into the dialogue and the dynamic between operator and
users;
•
the ability to work on an hypothetical level and to act as a bridge between different symbolic
and semantic worlds, moving across different representations of illness and healing models
of the patients and their social and cultural context;
•
knowledge on medical jargon and categories and on psychological and psychiatric subjects.
4.3 Training proposal
The training course for health workers operating in the national health system is inspired from
the experiences we acquired during the European T-share project’s searching process.
Every module is composed of 5 hours and the complete course comprehends 40 hours. The lessons will be 8, once a week (i.e.: on Friday from 9:00 a.m. until 2:00 p.m.).
The proposed training course is divided as follow:
First part
•
Common module, 5 hours: On the Notion of Culture (identity, to be part of, ethnicity,...);
•
Common module, 5 hours: On the notion of Health, Illness/Disease/Sickness, Care (culture
as therapeutic device);
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•
Common module, 5 hours: On the notion of Immigration: the migrant as atopos or bridge
between cultures. Metaphors and linguistic games about a paradoxical existential dimension;
juridical knowledge to comprehend the status of immigrant, asylum seeker, refugee; the
permit of stay for care reasons;
•
Common module, 5 hours: On the Notion of Mediation and the Problems of Translation (the
presence of the third during the consultation, communications between physician- mediator- patient), the different levels of the cultural-linguistic mediation.
Second part
In the second part of the training 2 separated section are planed:
1) Mental Health
• Mental health module, 5 hours: History of a “disputed discipline” (ethnopsychiatry); the
North-African syndrome and the colonize dependence; “sorcery and delirium”: back to the
origins of the Italian ethnopsychiatry; the experiences of Dakar-Fann in Senegal and of
Abekeuta in Nigeria.
•
Mental health module, 5 hours: Transfer and counter transfer (Devereux) of the health operator and of the mediator; Institutionalised dehistorification (Ernesto de Martino): the problem of the therapeutic efficiency; Social and Symbolic efficacy.
2) Women’s and Children’s health
• Women’s health module, 5 hours: masculine and feminine; sexuality and gynaeco-poiesis;
conception and childbirth (representation of the childhood and ritual joined with the birth of
the child and the firsts months of life: care rituals, “manufacturing” rituals (massages and
binding); social construction of the child in migration contexts;
•
Women’s health module, 5 hours: parenthood in a migration context (to be a mother and a
father, good mothers and goods fathers, etc.); comparison between different pedagogic models and care strategies during the first childhood; Woman’s Health (i.e: MGF from anthropological and psychological perspectives).
In the second part of the course two parallel sessions will be offered: one specifically for the
health care operators and the other specifically for the health cultural mediators.
About the methodology it will be used both taught lesson, as seminars, with no more than 20
persons, of which 10 cultural mediators already working in the public health services. During the
seminar it will be developed discussions also starting from video documentaries (visual anthropology and ethnographic recorded documentation).
A final certification will be given, but only to people attending the 90% of the course. It will be
provided an attendance sheet. A questionnaire will assess the acquisition of knowledge and
skills.
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4.4 Curriculum of trainers
•
Roberto Beneduce, Psychiatrist and Anthropologist, PhD, Psychotherapist in Systemic Therapy, University of Turin, Faculty of Psychology and Department of Anthropological Sciences,
Frantz Fanon Association.
•
Simona Taliani, Psychologist and Anthropologist, PhD, Psychoanalytic Psychotherapist, University of Turin, Faculty of Psychology and Department of Anthropological Sciences, Frantz
Fanon Association.
•
Roberto Bertolino, Psychologist and Psychoanalytic Psychotherapist, Honorary Jude (at the
“Tribunale per i Minorenni” of Turin), Frantz Fanon Association.
•
Michela Borile, Psychologist and Psychoterapist, Frantz Fanon Association.
•
Lahcen Aalla, Cultural mediator, Frantz Fanon Association.
•
Gianluca Vitale, Lawyer, ASGI (Associazione Studi Giuridici sull’Immigrazione: Juridical Studies
on Migration Association).
The program of the trainers may have some changes, with the agreement of the Health Services
Chief and to the Quality standards mentioned
5. Quality standards
To assure a good level of the Training, the T-share Team provided Quality Standards, that have
to be adapted in the different Countries where the pilot course will be done. Furthermore, it’s
important to underline that the training will be provided by qualified trainers, with competences
concerning the field the T-share faces. If a single partner have not this kind of internal human
resources, it’s important to charge qualified professionals with the task.
Quality standards concerning the trainer’s curricula:
• University Degree
• Ph.D./Psychotherapist Master or Specialisation
• At least 3 years of experiences on the Field of Migration, Ethnopsychiatry and/or Medical
Anthropology and/or on Clinical activities in Services for Migrants.
Thus concluded and undersigned.
Turin, ___________________
Signed by Beneficiary
Prof. Roberto Beneduce (President - Frantz Fanon Association) - Promoter
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Annex 14
By ASL Napoli 2 Nord
T-SHaRE protocol naples (IT)
1. Introduction
1.1 The Italian context
Although Italy is a country of recent immigration, compared to other European countries,
recent years have registered a very rapid growth, bringing Italy to become one of the main
country of first entry, due to the extensive coast lines and position in the Mediterranean Sea.
In the year 2009 there is an estimated presence of 4.330.000 immigrants in the country,
lower respect to other European countries, but above European media. Main migrant
population comes from European countries: 53,6% of which more than half belongs to the
European community; 22,4% comes from the African continent, while 15,8% is of Asian origin.
The presence of female migrants is in constant growth, especially in certain communities
The last years of immigration have seen a constant growth of workers from Eastern Europe,
especially Romanian ( over 21% workers) and Ukrainian. Migrant workers represent 15,5% of
Italian labor force.
Other important factor is the growing presence of women, especially among Europeans, while
African countries continue to have a male majority among workers.
Males represent around 48% of immigrants respect to 52% of females. The presence of
children is growing: 22% of immigrant population is composed of children. Compared to
Italian pop. medium age group, migrants are “younger”, medium age is 31 yrs. compared to
43years of Italian pop. Only 2% of migrant pop. is over 65 yrs. An interesting point: 12,6%
of newly born children in Italy are born to foreign parents, in a country where the trend of
rate births is falling.
Distribution of regular migrants is different from North to South. Due to work opportunities,
62,1% of laborers are in the North, 25,1% in Centre, 12,8% in the South and the rest on the
islands. It is however estimated that the South of Italy has a larger presence of undocumented
migrants respect to all areas, being a point of first entry. It is necessary to underline the presence
in many Southern Italian Regions of a local labor market with a high unemployment rate and
the recurrence to black market work that offers employment to both undocumented migrants
and unemployed locals. Attention must be given to the condition of this labor market where
poverty and unemployment and illegal activities have become an attraction for undocumented
workers that are used as a black labor force due to a poverty condition.
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1.2 Organization of the health context in Italy
The health service is structured according to different levels of government:
•
Central-state – the Government has the responsibility to ensure the right to Health to all
citizens through a warrantee system denominated “Essential Levels of Assistance”
•
Regional-level – the Regions have the responsibility to manage the government of costs
and the accomplishment of health goals.
In Italy, the government passes major policies in the Health Service Area through the Ministry
of Health. These policies, adjusted to other areas of policy making, (such as, for example in the
case of immigrants, security measures related to the Ministry of Internal affairs, or the Ministry
of Employment and Immigration) are administered and mainstreamed through Regional Authorities. All Regions, on a local area, are organized in Local Health Authorities, called ASL, of a
strictly Public nature. All ASL have a geographical delimitation in their Region. An ASL is composed of Local Health Districts that cover often an aggregation of one or more municipalities
(according to the number of inhabitants). Small Hospitals are under the organization of the ASL
on which they are present.
Enrollment to health services is public. Health coverage is necessary in all cases and ensured to
all. A basic health role is that of the “family doctor” assigned on enrollment, who is responsible
for general practice and prescriptions for his patients.
The Local Health District administers services on a territorial basis, including specialist treatments, through medical practice, and coordinates other territorial activities, in accordance with
ASL centralized Departmental guidelines. In each district there is the organization of Maternal
and Child Health Care,(Consulting Activities), Mental Health Services, Drug and addiction services,
Rehabilitation Services and Care of the Elderly and Prevention activities. Another important territorial organization is the Integration of Social and Health Services that interface health activities
with social activities that are administered by Municipalities. This structuring permits an integrated social and health care approach to citizens, overlapping social aspects with health care.
In this area most territorial projects are coordinated on a mixed basis. Through this organization
it is possible to involve NGOs, other actors such as voluntary organizations.
1.3 Health Care and immigration policies in Italy
Current legislation on immigration, even after the latest security measures, guarantees the
human right “health for all”. This principle is adapted to the different conditions of permanence
in Italy. Parity of treatment and equality of all citizens in accessing health services, in the interest
of individuals and communities is the basic norm which understands all legislation. The effort
is on accessing larger portions of migrant users, even when in a condition of illegality. Special
measures have been foreseen for those unable to pay, or for particular situations, such as victims
of human trafficking, asylum seekers, refugees and with a particular accent on child care, according to international legislation and women’s health care.
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1.4 Context and evolution of Cultural mediation in Italy and in health services
The relationship between cultural mediation and immigration policies is first mentioned in the
national law n. 40 6/3/1998 “Discipline of immigration and norms on the condition of foreigners”,
art. 36 and 40, and the decrees D.Lgs. 286 of 25 July 1998 “Final text of dispositions concerning
immigration”, art. 38 e 42. In these dispositions the profession of cultural mediator is mentioned
as necessary in the educational field and for the integration of immigrants. In the outline of
the law 2976 C of the XV legislature “Discipline of immigration” art.1 letter o) year 2007, this
relationship is mentioned as requiring the profession of mediators, in view of the necessity to
integrate migrants especially of second generation and women.
In art. 45 regarding the educational field, the need to interchange communication between
teachers and immigrant families is dealt with also in relation to local authorities such as municipalities through the use of qualified cultural mediators. In this case particular importance is
given to language skills and knowledge of cultures of origin. Also in university curricula the
necessity to have cultural and language mediation is foreseen.
The Commission “Health and Immigration” mentions as an aim the assessment of cultural
mediation skills.
The National Health Plan 2006/2008 (point 5.7) underlines the role of cultural mediators in
removing barriers to the access and the reformulation of health services addressed to migrants.
In particular in juvenile matters where youths are subject to justice measures.(C.M. n. 6/2002
Ministry and Department of Justice, guide lines on cultural mediation in Justice Youth Services).
In these guide lines the first indications on professional requirements, contract aspects and
deontology of cultural mediators is mentioned.
On a Regional level, through local laws, deliberations protocols of activity and guide lines cultural
mediation is mentioned in specific fields such as health, schooling and justice as main areas of
intervention.
In this particular moment only certain Regions define, through deliberations, the specific
role, education and professional skills required from cultural mediators and related areas of
intervention.
The main obstacles to the use of professional mediators in Italy may be seen on various levels:
formal recognition of the professional figure is still weak. Many other new professions in Italy,
especially in the social field of human relationships, are also still seeking formal recognition.
This requires not only a clearly defined training scheme, but also a capacity of mediators to associate in professional groups that represent them on a national level. However a lot of work
has been done in very recent time, which allows mediators to be on the same level as other professions in the social field, such as educators, counselors etc.. Poor knowledge of the profession
by other health and social workers remains as an important obstacle. Confusion with voluntary
work creates impediments to a professional use of mediators.
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The Ministry of Labor is taking view of this new profession and preparing Guide Lines to outline
Cultural Mediation on a National level.
1.5 Current Training of Cultural Mediators
Many courses, mostly in the last decade, have been developed on a Regional level, with authorization
to Educational Agencies, with formal recognition by local authorities (through legislation on the
recognition of educational agencies who are authorized to give courses). Usually such courses are
funded by specific projects through partners who have an interest in developing migration policies.
1.6 Intercultural Competence and training of health workers
and inter professional teams in the Italian health context
This protocol is designed for the Regional Campania Health Service in Italy by ASL NA 2 Nord
with the aim to achieve innovative Protocols to train inter-professional and intercultural teams
in health services, based on a organization and management model of services open to immigrant users, in the key fields of mental health and women/children health.
Currently, in an infrequent manner, cultural competence has been approached as necessary to
health personnel in professional courses with credits delivered through Continuing Education in
Medicine.
These skills have been introduced as important in consideration that:
•
•
•
Immigration in Italy and in the Campania Region is constantly increasing;
Health services need to give better access, welcome and benefits to respond to the needs
of those new users,( not only on a health level but also social-cultural);
Cultural mediators, that work in the health services, do not always have sufficient competences and tools for their profession;
The T-Share project, a transnational project approved on July 2009, has worked to promote:
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Immigrants health right, with particular attention to women health, in connection to the
woman gender condition;
facilitation of intercultural communication;
innovation of the social and health migrants conditions in the public system through research
and trialing of the potentiality of an intercultural approach to health care;
development of competences for cultural mediation;
valorization of visions and therapeutic approaches of immigrants incoming cultures;
methodologies foreseen to active involvement of users and stakeholders.
1.7 Beneficiaries and training issues
Researchers have put forward a number of questions about these issues, which can be summarized as follows:
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1.
2.
3.
4.
5.
What happens when a foreign citizen or a migrant family meet the health services?
Are their symptoms and experiences listened to appropriately?
Can we reduce the risk of misunderstanding in the diagnostic and therapeutic process?
What kind of specific difficulties come upon in the clinical encounter with foreign patients?
Which kind of “cultural competence” is required in order to properly construct an intercultural
psychotherapy or appropriate care giving?
Training beneficiaries will be: mental health operators (psychologists, psychotherapists,
psychiatrists, physicians, nurses etc.), women health operators (obstetricians, physicians,
psychologists, nurses etc.), cultural mediators working in health services. (Min. 10 health care
professionals, min. 10 cultural mediators)
1.8 Methodology and specific aims
The training activities of the team are scheduled in a 40 hours, subdivided as follows:
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An introduction of 10 hours of learning dedicated to cultural mediators on specific issues of
health care;
10 hours dedicated to health workers on their inter-cultural knowledge of specific issues to
deal with immigrant users;
20 hours are dedicated to the training on the job of the inter-professional team, including
the cultural mediator.
The aim is to constitute and interact as an intercultural team working with immigrant users.
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10 hours dedicated to the intercultural team to assess the results of the intercultural team
training and the feedback of migrant users.
The general training for intercultural health mediators needs:
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Better knowledge of (legal) immigration and health legislation – influence on migrants status and access conditions to health provisions;
Knowledge of health service functioning;
Capacity to assess and to decode needs of migrants;
Linguistic capacity is defined as less important than a knowledge of cultural backgrounds
that may help staff to “understand” migrants.
It is important, for the mediator competences, to obtain a minimum level of knowledge in dealing
with the following items:
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to point out, where present, the medical culture of origin of a community.
to obtain a minimum level of knowledge in the field of Traditional Medicines such as: Traditional Chinese Medicine, Ayurvedic Medicine, African and Mediterranean Phytotherapy.
to check how much, in the experience of migration, there is still the reference to such therapeutic traditions and how:
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•
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recourse to the national health system and at the same time to the use of a dietary trend,
practices and small remedies of cure of their country of origin
exclusive recourse to their therapeutic practices and to traditional healers, in a submerged
way and out of control of the national health system.
Regarding Traditional Medicines, some hours of training are dedicated to the philosophy underlying the medical system, to criteria that guide the diagnosis, to the techniques principally used.
Given the presence of doctors and traditional healers among immigrants, their involvement at
different levels in training courses will be encouraged.
Better informative tools needs:
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Information material in other languages (booklets, workbooks, pamphlets), in particular on
certain topics such as nutrition, vaccinations, child-bearing;
Dedicated area to migrants in website resources, useful also for health workers that have
doubts on procedures.
Today the health care activities should be addressed mainly to the migrants exposed to the risk
of marginality, rejection and psychic uneasiness, due to the meeting of risk factors.
Therefore, the training has the following purposes:
a) to support the learning of instruments meant to realize interventions of assistance and support toward foreign patients;
b) to promote the establishment of multidisciplinary work groups aimed at reducing the risk of
drop out and diagnostic error, to help the patient’s therapeutic continuity, and to mediate the
conflict in the social and familiar context.
This protocol will be subscribed identifying the health services and workers involved in the training.
In the specific case of ASL Napoli 2 Nord main activities will be carry out in health services dedicated to woman and a hospital- maternity ward.
Mental Health issues will be dealt with, also through the local mental health services.
For the definition of training process and the recognition of the training on the job, the protocol
will be subscribed by a State University Faculty.
For the cultural health mediator and the recognition of their training on the job experience the
protocol will be subscribed by a recognized Regional adult education training school.
Better marketing and diffusion of results/criticisms in health assistance of migrants shall be
realized through:
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the diffusion of guidelines,
the training and upgrading of health operators to inter-cultural competence, with the system
of continuing medical education (ECM).
1.9 Organizational setting of Training
The training on the job will be conducted in the following settings:
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the Gynecological Ward of the “San Giuliano” Hospital of Giugliano;
the dedicated to migrants general practice consulting surgeries, present in Hospital and in
the Local Area Health District of Marano and Giugliano;
the Units of Women’s Health Consultation present in the Local Health Districts of Giugliano,
Lago Patria, Marano and Quarto that are coordinated by the Department of Woman and
Child Health of ASL NA2 Nord. It will be an aim of the experience on an organizational level
to enhance and improve the grade of collaboration and team work between these services
with an aim to increment access and quality of access of migrant users through simplification
of procedures, humanization of services and guaranteeing adequate on-going health care
for users.
1.10 General practice skills of health professionals in an intercultural team
Important general competence not only pertain to the intercultural field, but are related to the
care profession at large. Consequently, we can place these items of training as pertinent to the
act of “taking care of individuals and person centred approach”.
It is necessary to develop qualities such as “patience, respect, great sensibility, discreetness,
sympathy, calm, authoritativeness, capacity to welcome, listen and recognize the person in
his/her suffering, ability in giving support” (capacity to welcome, capacity to listen and recognize
the person in his/her suffering, ability in giving support with patience, respect, great sensibility,
discreetness, sympathy, calm, authoritativeness, empathy, the ability to stay and to move inside
the dialectic between the concept of equality and the one of diversity and how it influences care
practices).
The strong emphasis on these topic suggest the necessity for each professionals to question
his/her own personal attitude and to reflect upon the care as a part of a relational process rather
than a simple curing act.
The Professional Profiles involved need to acquire some knowledge on: Juridical competences
about the matter of “immigration” (specific legislation in Italy and Europe), the Services Network
in this area, fundamental anthropological concepts (culture, body, identity, illness/disease/sickness etc.).
They need to receive a high quality culturally competent practice built upon both generic and
specialist training and professional development. Awareness of the socio-historical matrix of
health and illness is considered as a core issue in regard to therapy and training. To practice cul181
tural competence in health services is a complex, multi-level process involving not only interactions within the system, but also exchanges with the community and other agencies. Within
the health care system, important areas related to cultural competence are represented by policy-making. A high qualitative standard of intervention in health and care can only be achieved
if “cultural competence” is systematically considered a “goal” for professionals, agencies and
policy makers.
1.11 General practice skills of intercultural health mediators in an intercultural team
In detail general requirements for the professional profile of mediators are:
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Capacity to interact in the doctor/patient relationship;
To make the translation of communication between the migrant and health professional,
To give explanation of medical terminology from health professionals to migrant and cultural
context from migrants to health professionals,
To establish confidence and trust in care.
Understanding of health procedures, law and rights of migrants and patients;
A knowledge and capacity to explain to health operators, from a cultural point of view,
aspects that may cause difficulty in the doctor/patient relationship;
Capacity to represent culture of origin increasing comprehension between culture of origin
and western point of view;
Possibility to take into consideration traditional know how on health care, with mutual
respect on care approach;
Facilitation of communication, not from a linguistic point of view, but in accessing family
contexts, with community of migrants.
The profile of the Cultural Health Mediator in the Italian context, needs to have the following
requirement:
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age over 18 years,
speaking and writing skills in Mother Tongue Language and other languages,
to have a good knowledge of the Italian language assessed through a test level L2,
to have personal experience in the field of migration and social matters, in order to have a
better understanding of the patient’s condition (as Gmajna has written in his final report
“the experience of travel, separation, the arrival in a foreign land helps the mediator to translate to doctors migrant’s suffering and history”),
training in medical terminology, especially a basic knowledge of western approach to health
care issues,
development of skills in reading “non verbal language” in defining the relationship already
at first contact between doctor and patient. It is not the language but the role the mediator
has in representing the patient that becomes predominant,
Communication skills not intended as simple “linguistic” capacities but as a capacity to interact in the relationship. Doctors comment that they can diagnose health problems through
a medical visit, even if there is a linguistic problem. They are however aware that this does
not produce compliance to prescriptions, if they are not sure the patient has understood or
•
if there is not a “trust” approach that allows a “cure relationship”. Health workers opt more
for a deeper understanding of western health systems (legislation, procedures...) necessary
to compliance, while mediators point to assessing needs from a cultural point of view, with
the understanding that migrants are in a “fragile/weak” condition,
Special personal characteristics to develop through experience as as capacity to listen,
sensibility, calm, ability in giving support, relationship abilities...
During the pilot services, it will be important:
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to become more competent on health matters, medical language and procedures to explain
in a simplified language doctors prescriptions or jargon (this need is expressed directly by
mediators because doctors have a medical jargon very far from patients perception),
The possibility to be a Health Educator Promoter acquiring knowledge on such themes as:
vaccinations, infectious diseases, drug addiction, women and child health,
A production of “know-how” instruments (booklets, workbooks, pamphlets, dedicated area
in website, aimed mostly to health operators to orientate them in dealing with immigrants,
Language pamphlets, aimed to migrants, to promote health.
1.12 General Principles
In this section we will insert some terms along with an integrated social-health approach: the
aim is to share this terms with T-ShaRE partners to create a common vocabulary and language.
The concept of culture:
In its broadest, anthropological sense (cultural clothing, religions, traditions, experiences)
includes language as a primary factor, which highlights in languages and meta-languages of the
body and proxemics.
The definition of Comaroff and Comaroff 1992: “Culture is a semantic space, the field of signs
and practices, in which human beings construct and represent themselves, and therefore their
society and history... Culture... is... a historically situated, historically revealed set of significantin-action, significants both material and symbolic, social and aesthetic... culture as a semantic
field that is changing, a field of symbolic production and of material practice, reinforced in complex ways... the world to understand is always fluid and ambiguous, a partially integrated mosaic
of narratives, images and significant practices”.
The concept of body :
Not just a simple bio-medical notion, the body brings a lot of meanings strongly related to the
concept of care. The bodies express more then “symptoms”, they also express meanings and
memories for the most part lost during the process of health care. They are smart bodies, who
persist on finding meanings different from those proposed by biomedicine, bodies that resemble
stories, emotional ties, constraints which on the one hand they want to forget but on the other
hand they need to remember.
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There’s a big risk - for health professionals - to consider only the “biomedical body”
To read the symptoms of these patients as something extra from the disease to diagnose, or,
rather, as something related to their culture, is to think how we can heal, adopting an interdisciplinary approach... to design the cultural aspects of suffering along with the historical and
political ones...
Critical Linguistic Mediation:
Difficulty in translating appropriately migrants interests, difficulties, uneasiness, fears and
experiences of health operators puts the migrant patient in a difficult position
Mutually, therapist’s interpretations and prescriptions aren’t met with an adequate response
when placed in a language not mastered by the patient, and are not relevant if given in a
language suggesting epistemological, psychological, moral or religious assumptions potentially
far (or even contradictory with) from those of the patient and his/her family.
Lack of familiarity with the categories, representations and interpretation modes belonging to
a specific system of healing
Little knowledge of other aethiological and therapeutic registers
No knowledge of other aspects of suffering and disease.
Demand analysis:
Methodology that considers the application for aid and care expressed by the migrant as an
“historical one”, determined also by factors that can distort, limit, coercive it, to the point of
not resolving the underlying need, reason for which applications and demands should be received
critically, and remembering that:
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the lack of information about her/his rights and/or available services of the host country
may lead the migrant woman or the psychiatric patient or their family members to ask just
what is possible, or what they think is possible to receive from that service (the supply
determines the demand),
cultural, spiritual or religious values related to the history of female oppression, to socioeconomic dependence of women, to stereotypes of masculine power and patriarchal role for
men in the countries of origin may prevent woman or man to link her/his distress/symptom
to its cause, and thereby prevent them from seeking help for their specific health problems,
or encourage them to claim for wrong or unnecessary or harmful benefits like sexual mutilations (unexpressed needs and/or constrained demand),
the health conceptualization of the origin country may devalue the importance of prophylaxis
or prevention practices, and therefore deny the application for these preventive issues.
Palliative care:
The term “palliative” means to cover the suffering, protect the patient from the discomfort and
suffering caused by illness.
Palliative care is the active and comprehensive care given to patient when the disease no longer
responds to therapies aiming at the recovery. The control of pain and other symptoms, of psychological problems, of social and spiritual needs related to suffering and death assumes primary
importance. In this field the linguistic-cultural mediation is also very useful to deal with the
emotional impact that the incoming death produces both in the physician team and in the patient / family.
Palliative care respect the life and regard dying as a natural process. Their purpose is not to accelerate or postpone death, but to respect the best possible quality of life until its end. But health
team must respect a possible different attitude from the migrant towards management of
pain and death.
Palliative care is interdisciplinary in nature and involve the migrant subject, his family and/or
the community they belong to in his organization and management.
Degree of autonomy:
Independence. Ability to manage and provide for the individual growth process, using their own
available potential and resources. Cultural mediation collaborates at the relationship between
physician team and patient, to increase mutual awareness of external and extraneous constraints on autonomy and of cultural influences on needs and healthy lifestyle choices of migrants (i.e. contraception, abortion, motherhood, female genital mutilation, female or male
adultery, impotence/frigidity, separation/divorce, etc.).
Cultural identity:
Independence. Ability to manage and provide for the individual growth process, using their own
available potential and resources.
Cultural Mediator: Roles:
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Facilitation;
“Governance”;
Changing Agent;
Cultural Mediator: intervention areas:
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Role of “bridging”: communication - information / guidance - management of the conflict
- accompany/support;
Role of “institutions supporting”: training - consulting and design – research;
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Cultural Mediator - intervention fields:
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welcome support in health facilities and eventual accompanying services (facilitation in accessibility or availability of care services and pathways);
assistance in communications (including decoding of the culturally specific meanings of illness and care and of individual diseases);
support institution/family relationship (also to facilitate the emerging of problematic attitudes and at-risk practices about genital mutilation, abortion, contraception, impotence etc);
information and sensitization to prevention;
intercultural training of health operators.
Ethno-clinic Mediation:
Mediation and ethno-clinic psychotherapy are effective where, after passing through the knowledge of traditional therapeutic techniques, the peculiarity of the suffering idioms, i.e. its representations (psychologies and epistemologies that patients, their biographies and their
vicissitudes embody), after assessing their relevance, it is possible to situate the patient conflicts
and his/her dilemmas in the horizon of his/her essential, primary links.
The emic representations of disease and illness:
To have the emic version of the meaning of migrants behaviors and beliefs about woman and
child health we should investigate how that particular woman has lived the critical steps of its
life cycle, delicate moments of personal transformation, potentially “vulnerable” for the construction and strenght of her identity and of her social role. Reach the reproductive potential,
becoming a wife, mother, lover, widow, losing the ability to reproduce for menopause, to be abandoned or repudiated: all critical steps to manage in the host country, often alone, without the
identity references and without relational and organizational support of her own family, mostly
remained in the country of origin.
We must also verify the experience about her migration project: expectations, success or failure
of this often involve in the successes or failures of the social role that she wanted and/or realized.
Health professional’s decision appropriateness:
Professionals must connect the behavior and the complained disorders with the actual conditions
and customs of everyday life. Episodes of “medical malpractice” are derived from evaluations
and medical choice correct for not “fragile” users, but turned out wrong for migrant subjects.
For example, the discharge from the hospitalization of children with respiratory viruses, to which
the prescribed drug therapy would suffice if they returned in a decent home and not in a shack
or a trailer without electricity or toilets. These living conditions were lethal for those children,
despite the drugs.
Even clinic and psychological certifications, required from woman health services, to assess the
“maturity” needed to get married among minors, or the “adequacy in parenting” on suspicion
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of neglect or ill-treatment of children, should be released with great care, comparing and
reviewing our parameters on appropriateness and maturity with those of the migrant woman
or family, with her customary and child care, as long as the fundamental rights of the weak, of
the woman, of the teenager or of the child are preserved.
1.13 Quality Standards (see the chapter: Guidelines for a transcultural model of mental health
and women health services)
1.14 Code of conduct (see the chapter: Guidelines for a transcultural model of mental health and
women health services)
2. Interventions in Health Services
2.1 Interventions in Health Services: Mental Health Care Services
Context of mental health Service Organization in Italy
Medical structures work on a principle of urgent medical treatment dealt with in a close collaboration
between a 24hrs emergency service in hospitals and local area mental health structures. In every
Local Health Company there are central functions coordinating activities mainstreamed through a
Mental Health Department. On a territorial basis, there are Local Mental Health Units, covering
more municipalities. These units are articulated in Mental Health Centers, Night and Day Hospitals,
Day Hospitals, Residential and Semi Residential Homes. People are helped to deal with pathologies
that hinder personal relationships and wellbeing also through social methodology approaches.
In these centers immediate assistance may be obtained through multi-professional teams composed of doctors, psychiatrists psychologists, sociologists, social workers, nurses and socio-educational workers.
This section contains information regarding different aspects that are related to immigrant’s
access to health services and care, focuses on dimensions such as the existence of linguistic and
procedural accessibility, and cultural obstacles that immigrants encounter in relation to health
care and treatments. It is within this context that issues regarding ‘cultural competency’ will
also emerge, drawing an image on what occurs among the different countries that are part of
the T-share project.
The Professional Profiles have to work on three levels: language level, cultural mediator, metaempirical dimension.
The fist level, the cultural mediator can give some linguistic translations.
The second level, the cultural mediation becomes a “living group”, a place in which is possible to
remember and elaborate old situations, emotions, traumatic experiences in the mother-tongue
of the patient.
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The third level is the level in which the mediation is a strategy to evoke a meta-empirical dimension: if these steps can help the patient to understand better the meaning of his illness, they
can also help us to understand better the meaning of his illness, they can also help us to understand where we can start with the care. Cultural mediators work every day in a field full of sacred,
invisible entities.
It is useful, for the mental health issues, to underline that (as Fanon said in the step 1):
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The psychotherapist (or the health worker involved) has to give up the typical quietness of
the dual relationship and the power that it normally has.
The cultural health mediator has to acquire, with therapists, a strong theoretical base in the
translation theory.
The mediator has to be supported in recognizing, exploring, and managing transfer and
counter- transfer dynamics, as well as his/her own conflicts.
The therapist has to tolerate the challenge of a “not understanding time”, when he can’t understand the conversation between patient and mediator in languages he/she doesn’t know.
He/she must became the silent witness of an interaction that he can’t understand or interpret;
nevertheless, this interaction gives him/her the possibility to think about what happens, observe emotional profiles of the communication, evaluate reactions of the patient and so on.
The professionals become the actors of the scene that involves progressively the patient
and transforms him/her in a witness, and then in an expert of different cultural worlds with
whom he/she is constantly in interaction.
The aspect that we evocated up can be defined as the dimension of a “third pole” (terzietà
in Italian).
Mediators and therapists have to construct a relationship based on trust and respect, that
will be important over all the different stages of the work.
In the training process if we acquire this methodology this will give us the possibility to pay the
right attention to the person that we are treating.
Synthetically we describe some of the key elements for a culturally competent device and quality
standards:
a) Create an interdisciplinary therapeutic team integrating their competence in a complex intervention (for mental health: psychotherapists and psychiatrists, anthropologists, cultural mediators, social workers, community and clinical psychologists; for health and family matters:
general practice medical practitioners and pediatricians, cultural mediators, psychologists, social
workers, and nurses);
b) The unit of cultural mediation is part of the therapeutic team and composed by professionals
who preferably share language and origins of the main migrant populations, providing the possibility of activating intervention “on demand” for specific needs. As a general standard, family
and friends are not used to provide interpretation services. In case of specific patients’ request
in this sense, the new guest will be considered an interlocutor in the therapeutic process and
not a surrogate of cultural mediator.
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c) The team works in a continuous relationship with the network of services available in the community, offering interventions addressing clinical and social needs. Moreover, the team should
represent a resource available to other institutions for activities of consultation on patients, supervision or institutional advisement;
d) The access to the service is guaranteed for all patients independently to their administrative
status: papers regularity will not represent a discriminating feature and in no case patients’ data
will be reported to the authorities for immigration;
e) Working and reception spaces should be accessible and comfortable, enabling the privacy of
clinical consultation and the organization of public events;
f) The team should maintain close relations with teaching and research institutions as a means
to produce and renew knowledge, stimulate further research, supervision and consultation;
g) Meetings, seminars and others open events should be organized with the aim of promoting
a debate within the community about issues of migration, health and institutions.
Cultural competence is more about changing interventions and institutions than about changing
users. A high quality culturally competent practice builds upon both generic and specialist training and professional development. Awareness of the socio-historical matrix of health and illness
is considered as a core issue in regard to therapy and training. To practice cultural competence
in health services is a complex, multi-level process involving not only interactions within the system, but also exchanges with the community and other agencies. Within the health care system,
important areas related to cultural competence are represented by policy-making. A high qualitative standard of intervention in health and care can only be achieved if “cultural competence”
is systematically considered a “goal” for professionals, agencies and policy makers.
In mental health services is important to keep in mind the importance of:
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Social field. A culturally competent health service acknowledges that users are diverse for
gender, age, ability, sexual orientation, beliefs, and that this difference is constructed in a
complex field of social forces.
Political Constrains.
Critical instrument (as questioning and interrogating diagnostic procedures and tools to explore semantic domains and linguistic uses of concepts and categories applied in the clinical
context and to rethink upon notions, interpretative and therapeutic frameworks, situating
them as products of historic, economic and political dimensions)
Clinical process. Implementing this model implies a therapeutic device that must be necessarily interdisciplinary and trans-cultural, where different actors – cultural mediators, clinical
psychologists, psychiatrists, social scientists, as well as patients, families and network of
relations – may confront and discuss about organization models, theories, interpretations,
practices and strategies of healing.
Cultural mediation. Cultural mediator, preferably a person of the same or near origin of the
patient, is neither only a translator nor a sort of (fictitious) “cultural expert”: with her or his
active and critical
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presence, cultural mediator introduces in the setting a “difference”, representing the possibility
to reformulate the meaning of stories, experiences and symptoms in a new productive form.
Identity is not a fixed and stereotyped attribute of the person, but a representation of oneself
and the other constantly enacted and reformulated according to the situation. Cultural mediation
is thus properly “productive” of a new “possible common identity”, allowing communication, mutual reformulation and efficacy. In no case this presence will be imposed in setting, but always
negotiated as a specific moment of the therapeutic process. At the same time, social and health
professionals are aware that cultural mediation is not simply a strategic tool to obtain compliance
and acquiescence, but a critical device introduced into the therapeutic system for questioning
its premises, its organization and its practice.
In the mental health services the matter of communication is more important, because, as already underlined, in the field of psychiatry the verbal communication is the protagonist. All the
meanings of words have to be well understood and, subsequently, returned to the patient.
Crucial to this exchange is the establishment of a trusting context, where the patient feels
himself/herself invited to share with the health operators the reasons for his/her suffering.
One misunderstanding could cause really serious problems for the users. For a good comprehension between the actors, it is often necessary for operators to assume an attitude open
for a cultural exchange. This implies that, he/she has to be self-critical in relation to his/her
own analysis’ models, so that, in turn, it is possible for him/her to understand what the patient
tries to convey.
The presence of the health cultural mediator is essential. Mediation must not be reduced only
to pure translation. The use of mediation only for translation needs must be discouraged in a
context such as a Mental Health Services and during a Psychiatric or Psychotherapeutic Intervention. The risk to reduce the cultural mediator intervention to a mere technicality and translation activity is high. That is a detrimental to the quality of care and it doesn’t consider all
relational dimensions, nonverbal communication included, feeling of ashamedness, confusion,
suspiciousness, trust and mistrust, etc.
During this process the therapist, on his/her side, has to learn to tolerate the frustration of not
understanding immediately the patient’s discourse/explanation, both for linguistic and semantic
reasons: during the conversation between the cultural mediator and the patient, the therapist
should keep quiet, listening and accepting to be a third party. We can say that in the consultation
room there is a real co-construction of the diagnosis in order to make it more shareable for the
patient. The aim is also to integrate into the diagnosis some important cultural aspects.
Specialized Competences
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Basic Concepts on critical psychopathology,
Request Analysis and interpretation of the problem,
Mental Health service structures and problematic.
Main diagnostic categories,
Socio-genesis,
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Psychogenesis,
Genetic/Epigenetic aspects.
2.2 Interventions in Health Services: Women and Children Care Services
Related to women’s health, our representations of sexuality, freedom, pleasure and the importance of reproduction are constantly evolving, sometimes in a pejorative way. Even those of migrant woman are changing when they arrive in a host country, their status of working women
changes together with their bargaining economic power. Health professionals must investigate
on differences in the migrant’s conceptual categories and strategies about woman and child
treatment/care/healing, about abortion, virginity, freedom and age of marriage.
The difficulty of understanding the “other’s” models, in fact, leads to alienation and hostility,
and this mutually influences the relationship established, while the skill or, at least, the attempt
to communicate creates an environment favorable for dialogue.
The very concept of “dialogue” should be part of a broader view of our concept of health, if
we believe that health is a psychological and social as well as somatic concept, and that
human systems in which the discomfort occurs are characterized by rigid and unilateral patterns of thought and behavior - rather than open to confrontation with the outside world (Bateson, 1972, 1979).
Operational methods and flexible models, including observation and comparison of migrant’s
experiences critical for the construction of social identity and individual women’s lives, such as
the birth-giving and child rearing, are desirable, in a transcultural view.
To focus on reproductive health is useful for at least two reasons: first, because, as already acknowledged by various international bodies (UN, WHO, UNFPA, PAI, etc.), this is an indicator of
population health and development. Second, it is easier, today, to organize analysis and reflections on migrant women reproductive health than on the general migrant’s health, because for
physiological reasons such as pregnancy, childbirth, childcare, etc.. women access to services
more than men, who look for services only for serious illness or as such considered.
We must also add that according to laws and rules of maternity protection, migrant women, in
the same way as Italian women, have greater guarantees of health care than men, despite some
contradictions and difficulties. Therefore, we can say that for these reasons, women are more
present, speaking and interacting with services and social/health workers, including schools that
fit for their children.
Final observation on the need that cultural mediators use migrant narratives in the therapeutic
space “to listen and care” with migrant woman and children.
“Human beings think, perceive, imagine and dream following a narrative structure. Given two or
three sensory inputs, a human being will organize them within a story, or at least within the
framework of a story “(Mancuso and Sarbin, 1983, p. 234),
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In other words, the individual gives the events an order and a plot (the plot), thus laying the
foundation for a narrative description of reality in the light of the intentions of the actor-narrator
(Bianchera and Cavicchioli, 1998; Melucci, 2001).
“The narrative terms derive [...] from individuals need to understand and internalize the
surrounding environment through an interpretive work that enables them to become part of
reality, telling it. [...] “(Groppo, Ornaghi, Grazzani and Carruba, 1999, pp. 23-24).
The structure of a story, then, is characterized by an individual component (choice of what to
tell, meanings attribution, cognitive processes: memory, emotions, planning) and a culture component (choice of how to tell, meanings sharing, historical and social processes). Individuality
and “culturality” meet and the product of this meeting is the narration of a personal event.
The professionals working in the field of women’s health have then to deepen their knowledge
around the notion of female bodies, sexuality, pregnancy, social construction of the new born, etc.
As far as women health services, explanatory clarity is a priority both in the diagnostic and prescriptive phase. Operators should be able to clearly describe what is happening (i.e. the causes
of an infection) and what the patient has to do in order to remove her symptoms, making sure
she has well understood, repeating and dwelling on details if necessary. From a linguistic point
of view, the terms used will move on different levels and registers, according to the patient’s
peculiarities, always keeping in mind that each person gives different meanings to the same
word. A good mutual comprehension also increases the patient’s adhesion to the proposed treatment. All the operators involved (physicians, midwives, cultural mediators) have to consider the
way their words – i.e. during the communication of a diagnosis of sexually transmitted disease
to a woman victim of trafficking – will impact on the patient, considering her history and background. In the interaction between operators and users what takes place is not only a mere information exchange, but a construction of the diagnosis: the woman will leave the consulting
room with a new label that will have a great impact on her representations and well-being.
In some Women Health Services the absence of the Cultural mediators forces many professionals
to ‘use’ some member of the family or kinship for translation and/or for communication of the
diagnosis, the prognosis and the treatment. It’s not unfamiliar to ‘involve’ also the child of the
patient into this process of
communication (this is why in the literature some authors talk about the “exposure of theso
called “second generation children”: children who must take into account the experience of knowing something that the parent would to take in secret or in a private sphere).
All these kind of interventions had to be clearly discouraged through the presence of a Professional Team.
Even when the Cultural mediator is at work, in some cases this will not guarantee the success
of the process of communication. I.e. the case of trafficking victim women and their relationship
with Cultural mediators coming from the same Country: feeling of ashamedness or external con192
dition of social exclusion may introduce in the communication implicit level of mistrust and suspiciousness. In this case, the Cultural mediator has to posses specific communicative skills, that
take into account the implicit level of migration condition. The cultural mediators interviewed
underlined, then, their need to increase their competences and their knowledge around medical
categories and medical jargon “in order to be able not just to translate but also to explain” according to WP5 Final Report (to be seen also WP5 reports from Shen/ASL Napoli 2 Nord and
Minkowska Team): they ask for a specific training claiming that sometimes they are asked to
explain some scientific topics that require a specific knowledge and so they contribute to generate misunderstandings.
•
•
•
•
•
•
Basic concepts in maternal and child health and education,
Notions on the concepts of gender and reproductive health,
Basic notions on health and evolutionary age,
Analysis of Target Complaint and interpretation of the problem,
Maternal and Child Health service structures and problematic.
Variations in understandings of female bodies, sexuality, pregnancy, social constructions of
the new born, childrearing practices, etc.
Our Proposal is to adapt “mediation” to the context, but acknowledging the mediator as an
active agent and a key part in the process, being his physical placing in the group a reflection of
this aspect. This is based on the idea that “it is important to make interpreters feel at ease and
ensure that they have the best opportunity to use their linguistic skills and cultural understandings in the service of the client (Tribe, 2005). This needs to be addressed in a way that ensures
that one has clinical responsibility in the decisions regarding the client’s care, but simultaneously
be open to other inputs. A warm and supportive atmosphere between clinician and mediator is
likely to facilitate the therapeutic relationship for the good of the client and their work together”.
Service providers should have written guidelines and a contract that mediators are asked to adhere
to and ideally sign – covering aspects such as confidentiality, roles, responsibilities, and ethics.
For the process of “Training and learning on the Job” space will be given for assessment. After consultation, practitioners will schedule a few minutes with the mediator after the session to review
how they worked together and any other issues relevant to the session. This time can be used to:
•
•
•
Allow time to ask the mediator his/her perceptions of the meeting and to inform practitioner
of any cultural factors that may be relevant and that may have been missed. This also allows
health workers to check with intercultural health mediators about anything that may have
been noticed, for example from non-verbal communication or expressions;
Allow the questioning of issues that are unclear through the patient/user account and knowledge from home country or region, that enable clarification;
Ask the mediator how it was working with the practitioner and vice-versa and whether one
could usefully change anything in the way of working (e.g. pace of speaking, length of speaking, clarity and so on).
193
Below the legislation about the cultural mediation practices in Italy:
GUIDELINES FOR THE RECOGNITION OF PROFESSIONAL FIGURE
OF THE INTERCULTURAL MEDIATOR
Of the Institutional Working Group for the Promotion of Intercultural Mediation by the Ministry
of the Interior Department for Civil Liberties and Immigration Policies Central Direction for the
Immigration and Asylum Policies and the European Union, European Fund for the Citizens’
Integration of Third Country of the Immigration and Asylum 2007 - 2013
Riconoscimento di alcune qualifiche professionali regionali tra cui il Mediatore Culturale
Regione Campania, DGR 8 ottobre 2003 n. 2843; (Allegato A) “Approvazione delle figure professionali sociali della Regione Campania”; DGR 3 dicembre 2004 n. 2209 (Allegato B) “Certificazione
dei percorsi formativi e delle competenze professionali”
Figura del Mediatore Culturale e relativo Percorso Formativo
Regione Abruzzo, DGR 29 novembre 2006, n. 1386/P; (Allegato A) “Mediatore Culturale. Approvazione della qualifica professionale e dei relativi percorsi formativi”
Regione Lazio, DGR 24 aprile 2008, n. 321; (Allegato 1) “Approvazione del profilo professionale e
formativo del Mediatore Interculturale. Istituzione della Commissione per la definizione dei criteri
per il riconoscimento dei crediti formativi”
Regione Liguria, DGR 4 agosto 2006 n. 874 “Definizione della figura professionale di “Mediatore
Interculturale” e approvazione degli indirizzi per i contenuti minimi dei percorsi formativi di 1°
livello (qualifica) e di 2° livello (specializzazione)”; DGR 6 ottobre 2006 n. 1027 “Inserimento nel
repertorio degli attestati di qualifica o specializzazione, di cui alla D.G.R. n. 2409 del 27/06/1997,
della qualifica di “Mediatore Interculturale”; DGR 22 dicembre 2006 1517/2006 “Definizione delle
modalità di riconoscimento di crediti formativi per la figura professionale di “Mediatore Interculturale”, ai sensi della D.G.R. n. 874 del 04/08/2006”
Regione Friuli Venezia Giulia, DPR 22 dicembre 2006 n. 0412/Pres. “Regolamento per la tenuta
e la revisione dell’Elenco regionale dei mediatori culturali previsto dall’art. 25, commi 6 e 7, e dell’articolo 30 delle legge regionale 4 marzo 2005, n. 5 (Norme per l’accoglienza e l’integrazione
sociale delle cittadini e dei cittadini stranieri immigrati)”
Regione Valle d’Aosta, Delibera n. 483 del 18 febbraio 2002 “Approvazione dell’accordo di collaborazione sottoscritto tra enti diversi per la realizzazione del progetto “Cavanh – fase 2” e del
trasferimento di fondi all’I.R.R.E. – VDA quale soggetto coordinatore. Finanziamento di spesa”;
Direttiva n. 2671 del 22 luglio 2002 “Approvazione della Direttiva regionale sulle attività di mediazione interculturale previste dall’accordo di collaborazione sottoscritto tra enti diversi per la realizzazione del progetto “Cavanh – fase 2”, di cui alla D.G.R. n. 483/2002”; DGR del 1 settembre
2006 n. 2531; (Allegato) “Nuove disposizioni regionali in materia di attività di mediazione inter194
culturale ai sensi della legge regionale 20 giungo 2006, n. 13”
Percorso Formativo per Mediatore Culturale
Provincia Autonoma di Bolzano, DGP 26 novembre 2001 n. 4266 “Approvazione del programma
del corso annuale a tempo pieno per la qualifica di Mediatore/trice Intercultuale (art. 5, comma
2 della LP 12.11.1992, n. 40 Ordinamento della formazione professionale)”
Regione Emilia Romagna, DGR 14 febbraio 2005 n. 265 177/2003 “Approvazione degli standard
e dell’offerta formativa a qualifica e revisione di alcune tipologie di azione di cui alla delibera di
G.R. n. 177/2003”; DGR 10 novembre 2004 n. 2212, (Allegato A e B) “Approvazione delle qualifiche
professionale in attuazione dell’art. 32 comma 1, lett. C della L.R. 12/2003 – primo provvedimento”; DGR 30 luglio 2004 n. 1576 “Prime disposizioni inerenti la figura professionale del Mediatore Interculturale”; GPG/2009/171 “Approvazione di nuove qualifiche professionali, ai sensi
della Del. G.R. n. 2166/2005 e modifiche agli standard professionali e formativi per la qualifica
per Mediatore Interculturale, di cui alle Del. G.R. 2212/2004 e 265/2005”; (Allegato B)
Regione Piemonte, Determinazione n. 399 del 19 maggio 2000 “Nuove denominazioni standard”
della Direzione regionale Formazione professionale lavoro,
Settore Standard formativi Regione Toscana, DGR 12 settembre 2005 n. 903 (Allegato) “Approvazione del disciplinare per la gestione del repertorio regionale dei profili professionali”; DGR
30 giugno 1997 n. 754 “Approvazione del nuovo repertorio dei profili professionali regionali finalizzato alla progettazione didattica delle attività formative”.
Pozzuoli, 14/07/2011
Signed by Promoter
Health Director - p.t- ASL NA 2
Dr. Carlo Bruno
Beneficiaries
U.O.C. Maternal & Child Health Care Director – ASL NA 2 Nord
Dr.ssa M.Teresa Pini
U.O.C. Obstetrics and Gynecology Director – ASL NA 2 Nord
Dr. Salvatore Sciorio
Social Coop DEDALUS – President
Dr.ssa Elena De Filippo
Università Orientale - Center Life Long Learning, President
Prof.ssa Luigia Melillo
Dipartimento Director of Mental Health - ASL NA 2 Nord
Dott. Gennaro Perrino
195
196
Annex 15
By Centre Médico-psycho-social Françoise MINKOWSKA
T-SHaRE Protocol Paris (fR)
Cultural Mediation in the French Context
There is no single definition of cultural mediation in France, although there seems to be a consensus around the two central roles of the cultural mediator:
(1) The interpreter function (language translation)
(2) The “bridging” function (building bridges between two worlds, between differing cultural
representations)
In the present institutional landscape, mediators are engaged by the public health, education
and judicial systems, among others. The 1996 charter of social and cultural mediation (FIA-ISM)
states that cultural mediation is a response to:
(1) an economic and ideological crisis in France
(2) the evolution of the migratory flow from West Africa to France
(3) social exclusion and the rupture of family ties among migrants.
In addition to local and state government reliance on mediators, mediation is a primary service
provided by the proliferation of associations generated in accordance with the laws of 1901 and
1981, which produced the mouvement associatif. A 2002 Guide to Intercultural Mediation lists
more than 150 resources categorized by type of activity and mission.
Therefore, there is no one legal chart framing the practice of cultural mediation in France, but
some associations have elaborated their own (see, for example: http://fia-ism.fr/Page-88La_Charte_de_FIA_ISM.html).
1) Context and evolutions
Cultural mediation in France emerged with family reunification policies in the 1980s. These policies triggered social, economic and legal issues that had been less prevalent in the era of male
migrant workers in residence without families. These included problems with housing, documentation, employment, childrearing, the educational system and marital disputes. Many of
these dilemmas came to the attention of the social workers (travailleurs sociaux) associated
with numerous state institutions—schools, hospitals, local government, criminal justice system
and so forth. In response to this onslaught of problems perceived as cultural in origin, the public
health system, in particular, turned to interpreters and subsequently to ‘‘cultural mediators’’ in
an effort to effectively communicate with non-French-speaking migrants. Initially, these efforts
were directed especially at women, who were in frequent contact with state institutions in the
197
context of maternal and child health concerns. Cultural mediation as a formal profession emerged
from this post-1976 phase of exploratory approaches to public health interventions with West
African migrants. Anthropologists, sociologists and psychologists helped to shape the concept
of ‘‘mediator,’’ as distinct from that of ‘‘interpreter’’. By the mid-1980s, cultural mediators, principally women originally from the migrant societies of origin, were solicited by maternity hospitals, child health clinics and similar institutions.
The mediator’s function was literally to translate, on the one hand, but also (and perhaps more
significantly) to bridge social worlds. Thus her role was to translate conceptually the discourse
of state institutions to migrants while conveying to biomedical and social work personnel the
local meanings and practices of migrant clients. Mediators are intended to sustain client autonomy but assist social workers and other practitioners in carrying out public health, educational
and other institutional objectives.
2) Training
Since there is no overarching framework for cultural mediation in France, various institutions
propose cultural mediation training programs, each program varying with the institution’s specific professional approach. In other words, some programs will offer training in the healthcare
context (http://www.ipaos-culture-et-sante.com/les-formations/medecine/), or in the school
context (http://fia-ism.fr/Page-855-Formation_specifique__Mediation_Scolaire_.html).
3) Current programs for cultural mediation in health care services
Cultural mediation is external to health care services (and initiatives are independent from the
Ministry of Health), with the exception of “specialized” mental healthcare institutions in France,
which inherently integrate cultural mediation approaches into their respective health services,
and which also offer cultural mediation training to external institutions/professional in the
context of university programs. For example, the Minkowska Center, offers a clinical medical
anthropology approach to cultural mediation (university program:
http://www.minkowska.com/rubrique.php3?id_rubrique=159, and independent training sessions:
http://www.minkowska.com/article.php3?id_article=3047), the Avicenne hospital (university
program: http://www-smbh.univ-paris13.fr/smbh/enseig/enseig_diu_du/dupsytranscult_.html)
offers a transcultural psychiatry approach to cultural mediation, and the George Devereux
Center offers an ethnopsychiatry approach to cultural mediation (university program:
http://www.ethnopsychiatrie.net/activit/DESU.htm).
Outside of university training programs offered via these healthcare institutions, a myriad
of independent training programs exists, with approaches to cultural mediation in the healthcare
context. Among them, we can only name a few, such as IPAOS (http://www.ipaosculture-et-sante.com/les-formations/medecine/) , or URACA (http://www.uraca.org/actionfrance/index.htm). These are based in Paris, but there are many other associations in other
regions which offer training programs locally.
198
The myriad of programs entails that there is no homeogeneity or standards as to the definition
and practice of cultural mediation in the healthcare context.
Standards for practice in France
(adapted from the European model report compiled by AFF)
As it was recurrently pointed out in the T-Share reports and as most training programs in cultural
mediation underline, professionals engaging in cultural mediation activities must possess relational competencies: the ability to be supportive and sensitive while ensuring the necessary authoritativeness and calm necessary in clinical interactions; the ability to show empathy and to
listen in order to establish “a relationship based on trust and confidence” (Cria: WP5 Report).
1) Knowledge skills
Knowledge of core anthropological concepts (culture, body, identity, illness/disease/sickness,
explanatory models of health, disease, and suffering) (see AFF’s report for detailed definition
in WP7 –Step 1). As indicated in WP7 Step 2 report, “professionals working in the field of women
health have then to deepen their knowledge around the notion of female bodies, sexuality, pregnancy, social construction of the new born, etc. In mental health services they will work on the
concepts of aetiology, the issue of the efficacy of the acts of healing and more generally around
ethnopsychiatric and medical anthropological notions”.
Knowledge of the service network and its functioning: ability to identify local institutions providing social services and social assistance to immigrants and refugees. This includes immigrant
associations who perform as links or bridges between local institutions, the individual and his/her
community (beyond social services, this includes socialization activities).
Knowledge of the legislation on immigration: knowledge of the legislation on immigration in
France, particularly as it pertains to healthcare issues (ie. visa for medical reasons, conditions of
access to State Medical Assistance) as well as ability to map local institutions providing legal
aid to immigrants and refugees.
2) Clinical competences
Decentering, or the ability to see the confrontation of explanatory models at play: With a background training in the clinical medical anthropology approach, the healthcare professional should
learn to identify the various explanatory models which are at play in the clinical interaction (the
clinician’s, the patients’, and the system’s – disease, illness, and sickness) and which are necessary to grasp in order to enhance mutual comprehension and respect on the one hand, and enable
to construction of a reliable diagnosis on the other.
Triangulating: Beyond the basic relational skills mentioned earlier in the introduction to this section, the ability to position oneself as the third person in the interaction, and maintain the dia199
logue between the clinician and the patient. This may require to prepare the interaction prior to
the clinical
interview, especially if the clinician or the patient have never worked with a mediator: the role
of the mediator has to be explained, as well as the dynamics of mediation (this includes, as underlined in AFF’s WP7-step 2 report, a preparation for the clinician “to tolerate the frustration
of not understanding immediately the patient’s talk, both for linguistic and semantic reasons”).
Interpreting: As indicated earlier, cultural mediators are not mere translators. Their role is to
bridge between explanatory models. That requires an ability to move from one symbolic and
semantic system to another (as underlined in the “decentering” definition) but also to manage
non-verbal interactions which, without good mediation skills, could quickly generate misunderstandings. Non-verbal elements may be linked to the flow of the clinical exchange, but also to
the social positioning of its participants (especially with regards to gender and age).
Neutrality and confidentiality
3) Special competences
Mental Health
•
•
•
•
Sociogenesis
Psychogenesis
Maternal and Child Health: Variations in understandings of female bodies, sexuality, pregnancy,
social constructions of the new born, childrearing practices, etc.
Methodology for recognition of prior learning
Considering the evolution of cultural mediation practices in the French context, as of today, many
indivudals consider themselves – and practice as – cultural mediators in the healthcare context.
If our goal is to homegenize practices at the national level – on the basis of the transcultural
model provided by the T-Share project – and to make cultural mediation standards uniform, we
need to assess standards for cultural mediation skills which some professionals may already
have acquired along their career. In order to do so, we must 1) identify theformal institutional
process providing ackwoledgment for “experience learning”, and 2) indentify the particular skills
expected to be assessed in the prior learning certification process for cultural mediation professional credits, and for specialization credits in mental health and women’s health.
1) National laws related to the acknowledgment of skills learnt on the job
In France, a national process exists which enables one to get all or a part of a certification
(diploma, certificate with a professional end or professional qualification certificate) based on
200
his/her professional experience, i.e. a certification of the skills he/she acquired through experience. This process is called VAE, the French acronym for the Validation of Learning from Experience (Validation des Acquis de l’Expérience).
Are considered as experience any activity which is salaried or non-salaried (shopkeeper, shopkeeper’s collaborator, self-employed activity, farmer, craftsman…) or voluntary (within a union
or an association). Any individual, disregarding his/her age, nationality, status and education
level who can attest of at least three years of salaried, non-salaried or voluntary experience.
The objective in obtaining VAE is to acquire the equivalent of school credits necessary to access
a university-level training program. If we anticipate the creation of an “intercultural clinical mediator” state diploma/certification in France, we would imagine for it to be managed by the Ministry of Health and Social Affairs, and more specifically the DRASS (Regional Direction of Health
and Social Affairs). The “intercultural clinical mediator” certification should then be registered
on the National Repertory of Vocational Certifications (in French RNCP: Répertoire National des
Certifications Professionnelles, which lists all certifications available through VAE).
2) National mapping of skills related to each typology of practitioner foreseen in the interprofessional, intercultural work teams in the field of mental health
Knowledge
Skills
(ex : regroupement familial,
travail, études, asile, raisons
médicales)
situation and its impact
on mental health
(ex: Cimade, MSF)
(ex: Comede, Primo Lévi)
support for immigrants and
refugees specifically
concepts
(culture, body, identity) and of the
medical anthropology framework
201
Knowledge
Skills
3. Mental health aetiology
Sociogenesis
Psychogenesis
Explanatory clarity
jargon”
skills
3) National mapping of skills related to each typology of practitioner foreseen in the interprofessional, intercultural work teams in the field of women’s health
Knowledge
Skills
(ex : regroupement familial,
travail, études, asile, raisons
médicales)
mental health
(ex: Cimade, MSF)
(ex: Comede, Primo Lévi)
support for maternal and infant
health
(ex: network of local PMIs)
202
concepts
(culture, body, identity) and of the
medical anthropology framework
3. Women’s health concepts
pregnancy, social constructions
of the new born, childrearing
practices, etc.
skills
Establish respect and trus
registers, attitudes, especially
as they relate to gender positions
Explanatory clarity
jargon”
4) National methodology for assessment of skills learnt on the job
On the basis of a standard framework identified at the European level by T-Share partners, and
on the basis of its national/regional variations in terms of institutional applicability, we identify
the following institutions as competent in assessing skills for intercultual clinical mediators. We
suggest theses institutions involve a formal collaboration between universities and health
infrastructures:
Centre Françoise Minkowska and Université Paris Descartes, Paris
Graduate Diploma “Santé, maladie, soins et cultures”
Consultation Transculturelle Avicenne and Université Paris 13
Graduate Diploma “Psychiatrie transculturelle”
Centre George Devereux and Université Paris8
Graduate Diploma “Pratiques cliniques avec les familles migrantes,
Intervention et Prévention”
There also exist graduate program which are strictly university-based:
Université Bordeaux 2
Master professionnel « Anthropologie spécialité Santé, migration, médiation »
Université Lyon 2
Master 2 Interculturel « Psychologie des pratiques et des relations interculturelles »
Université Paris 7
Graduate Diploma “Pratiques professionelles en situations interculturelles”
Finally, Inter Service Migrants, a NGO which was created in 1970 and operates a the only professional interpreter services today, should be indentified as a partner in the assessment of skills.
Their training sessions take an approach to intercultural mediation, and a great number of their
professionals also work as intercultural mediators.
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204
Annex 16
By Centro em Rede de Investigacao em Antropologia CRIA
T-SHaRE Protocol Lisbon (PT)
1.1. Introduction
T-Share is a pilot project aimed at promoting Cultural Mediation in Health Services (namely in
Mental Health and Women Health Units). The project is implemented by an international
network made up by public and private bodies operating in five countries (Italy, France, Portugal,
Slovenia and Norway) in the field of the health of migrant people. Objectives of the Project are
to improve health care systems in order to make them accessible and reliable for immigrants,
to train health operators in order to cooperate with new professional profiles – namely health
mediators – and to work in an interdisciplinary perspective, to give value to different visions,
approaches, knowledge, competences to health and care.
Through the elaboration of original protocols of training and intervention and through the
accompaniment of selected groups of professionals in their practice, the project aims at
addressing the specific health needs of migrant patients as well the training needs of health
professionals in the fields of Mental Health and Women’s Health.
The project is framed in the “Lifelong learning programme” funded by the European Commission.
1.2. Immigration in Portugal
Portugal is a country with a little more than 10 million inhabitants and with a percentage of
documented migrants around 4,3% and an estimated significant number of undocumented
persons. While immigration history was marked from the 70’s, since the late 1990s Portugal
witnessed a sudden 200% rise in the immigrant population (Machado, Pereira & Machaqueiro,
2010). According to International Immigration Outlook 2011 (OECD)25, the recent trends registered
in 2009 in Portugal for immigrants are: 457,000: 4, 3% of the total population. The most represented immigrants are: Brazilians (26%); Ukrainians (12%) and Capeverdians (11%).
According to the Portuguese National Statistic Institute (INE) the major nationalities represented
are Brazil, Romania, Moldavia, Guinea-Bissau, followed by Angola, Cape-Verde and Ukraine. The
number of foreigners classified as undocumented 2009 was estimated to be 6,1% (numerically
this corresponds to 3.309 from a total population of 54.227). The Chinese immigrants represent
6,3%.26 Nevertheless, the national census conducted during this year and that will be available
in September (2011) shall enable a better assessment of the Portuguese reality in these terms.
25
26
http://www.oecd.org/document/40/0,3343,en_2649_37415_48303528_1_1_1_37415,00.html
IN: http://sefstat.sef.pt/Docs/Rifa_2009.pdf
205
The number of asylum seekers decreased from 161 in 2008 to 139 in 2009. These figures place
Portugal as one of the countries with less asylum seekers in Europe.
1.3. Health and migration profiles
In terms of health, the central government is responsible for developing health policy and managing its implementation through a National Health Service. The regional health administrations
(RHAs), depending on the Ministry of Health, are responsible for the implementation of the
health policy at the regional level. In Portugal, there are three coexisting systems of health care
coverage: the National Health Service (NHS), special social health insurance schemes for certain
professions (health subsystems) and voluntary private health insurance.
In regards to migrant health care, since 2002, the Office of High Commissioner for Immigration
and Ethnic Minorities (now called High Commissioner for Immigration and Intercultural Dialog ACIDI) developed a migrant integration program that included several areas for action, including
work and professional training, housing, education and health. In 2007, the Plan for Migrant
Integration (Plano para Integração dos Imigrantes: Resolução do Conselho de Ministros n.º 63A/2007, Law of 3rd of May) establishes the guidelines and practices to be adopted nationwide.
However, most migrants are located in Lisbon, Amadora, Cascais, Setúbal, Faro and Oporto, and
practices vary between places and health services.
Research data about the relationship between health and migration in Portugal has been summarized recently in a local report (Portugal) of the MIGHEALTHNET- Information Network on
Good practice in Health Care for Migrants and Minorities in Europe (Fonseca et al., 2009). This
report acknowledged that very few (if any) health services or institutions collect data on migrants
and health in a systematic manner. However, many research studies have been conducted in
recent years in areas of access of primary care, maternal health, HIV/AIDS treatment, reproductive and sexual health, and mental health; in special populations such as children and adolescents, undocumented migrants, refugees and asylum seekers; and in special issues such as social
representations of health and health problems with higher prevalence among immigrants such
as diabetes, vascular and heart problems, oral hygiene, and mental health problems.
Regarding maternal health, based on the work of Machado et al (2006), the report demonstrated
that immigrant descendants have higher foetal and neonatal mortality rates, and women have
more problems during pregnancy, including infectious diseases. Migrant women and families
seek more help from hospitals than community health centres, given that they seldom have an
attributed family doctor. As far as mental health issues, reported data estimate that 1/4 to 1/3
of migrants may show signs of psychological distress (Godinho et al, 2008).
1.4. Mediation in heath services
In Portugal, mediation is usually conducted by a Portuguese citizen with linguistic skills, who
does not necessarily possess specific training or formal qualification. “Mediator” may be an interpreter designated by the immigrant community, without specific training or formal qualification; a health service professional (physician, nurse, etc.) with linguistic skills; people who
undergo brief training in an association, or a patient’s family member. The regime in which me206
diators operate in Portugal varies between a member of staff, an external individual consultant
or a volunteer from associations that enhances immigrant causes.
Nevertheless, efforts in Portugal have been made concerning mediation practices. Indeed the
High Commission for Intercultural Dialogue in Portugal has promoted and implemented since
2009 mediation courses, in which the majority of individuals attending are from immigrant backgrounds or immigrants themselves. The course is composed by two years attendance, the first
year, being theoretical, addressing matters related to the structure of the health system and
other matters such as cultural and social aspects involved in health. The second year has a practical (in the field) component, supervised by a sociologist. The requirements to attend oblige individuals to possess a graduate degree (in any area).
ACIDI’s project is aimed at providing cultural mediators to health services, in order to support
immigrant and foreign patients. This plan has been put into practice in some specific cases
(Amadora and Setúbal, namely, “Associação de Jovens Promotores da Amadora Saudável” and
the National Centre of Support to the Immigrant - CNAI).
The legislation that attempts to establish a legal status of the “cultural mediator” is the Law
n.º 105/2001, which refers that mediation may be conducted in schools and other public places
such as health settings, through the development of protocols, individual work contracts or consultation contracts, following general work law regarding public jobs/employment. It indicates
that people from the ethnic groups of origin of the communities should be preferred and that
they should have specific training (while not specified in detail). Legislator highlights that the
cultural mediator has the function of collaborating in the integration of immigrants and ethnic
minorities, from the perspective of promoting intercultural dialogue and social cohesion.
The same law states however that the profession still does not have specific legislation in terms
of status, profession and training. The lack of specific framework is, in our opinion, one of the
causes motivating instability regarding work/professional-identity and a lack of investment in
training, aspects that have been mentioned to be insufficient in assuring changes at practice
levels (Machado, Pereira & Machaqueiro, 2010).
The field of activity is difficult to define since there is still no coherent definition of the role of the
mediator in terms of areas of intervention, training, required education or work status. A “multifaceted” mediator is most common in practice, to whom a variety of possible tasks are attributed.
2. GENERAL PURPOSES FOR A PILOT TRAINING PROGRAM
Having T-Share purposes27 as the background of this work, we consider that the implementation
of cultural mediation training must be adapted to the social, political contexts and needs of each
country and based on the research results gathered during the first part of T-Share project.
27
To train health operators in order to cooperate with new professional profiles – namely health mediators-, to acquire cultural skills
and to become able to work in an interdisciplinary perspective.
207
For what concerns Portugal, a training course on cultural mediation should be an opportunity to
re-think practices and representations as well as interpretations, in order to promote a better
system of care of immigrant patients by:
1) improving the quality of communication between health workers and foreign patients as
well as therapeutic efficacy;
2) reducing the risk of dropout;
3) increasing visibility of Services and their accessibility.
Furthermore, we previously set ourselves four general goals: one is to identify socio-cultural
barriers to care for various racial/ethnic groups, through focusing on specific social and cultural
factors that form the basis for individual health beliefs, behaviours, values, and preferences and
how they potentially mitigate a patient’s ability to obtain quality care. The second goal is to
explore at what level these barriers occur (organization level, clinical encounter level, and so on).
The third goal is to identify cultural competence interventions that address these specifically
identified socio-cultural barriers. The fourth and final goal is to link these interventions to a
framework that can be applied in the elimination of racial/ethnic disparities in health and health
care.
3. DESCRIPTION OF THE PILOT SERVICE AND BENEFICIARIES
In a first moment we insist on creating a general/formal/common background in our target
groups, as the basis to implement a training program adapted to our/theirs needs and professional, legal and human realities. This procedure intents to bridge Portugal’s lack of legal and
professional framework regarding “cultural mediation” and “cultural competences” in Health
Care, mentioned before: a fact that impose some specific needs/limits to the implementation
and development of this training, which should be considered and analyzed.
This is a process that is being built through meetings with the institutions before the protocol
signature (which is planned to be done in September).
Being CRIA the promoter, we expect that the training protocol will be sign by two different Public
Services:
•
•
Maternidade Dr. Alfredo da Costa, the public hospital specialized in obstetric and focused on
children and mother care;
ACIDI, a public institution that has the mission to cooperate in the conception, execution
and assessment of public and transversal political measures addressed to immigrants and
ethnical minorities, and that has developed a project on Cultural Mediation in the Public
Health Services.
These Institutional Beneficiaries were selected among the Services contacted for the research
activities.
208
Training beneficiaries will be:
•
•
•
Mental Health Operators (psychologists, psychotherapists, psychiatrists, physicians, nurses
etc.);
Women Health Operators (obstetricians, physicians, psychologists, nurses);
Cultural mediators working in Health Services.
We are expecting to gather a minimum of 10 health care professionals and a minimum of 10
cultural mediators.
4. METHODOLOGY AND SPECIFIC AIMS
4.1. General framework
A “culturally competent” health care system has been defined as one that acknowledges and
incorporates – at all levels – the importance of culture, assessing cross-cultural relations, reflecting upon the dynamics that result from cultural and social differences, and preparing to
meet culturally unique needs. A culturally competent system is also built on an awareness that
acknowledges the integration and interaction of health beliefs and behaviors, disease prevalence
and incidence, and treatment outcomes for different patient populations. Furthermore, the field
of cultural competence has recognized the inherent challenges in attempting to disentangle “social” factors (e.g., socioeconomic status, supports/stressors, and environmental hazards) from
“cultural” factors vis-à-vis their influence on the individual patient. As a result, understanding
and addressing the “social context” has emerged as a critical component of cultural competence
we will therefore refer to socio-cultural barriers throughout to emphasize this connection, and
will integrate this idea into our working definition of cultural competence.
Given all the aspects and dimensions previously mentioned, we set ourselves to set four goals:
one is to identify socio-cultural barriers to access care for various; racial/ethnic groups, through
focusing on specific social and cultural factors that form the basis for individual health beliefs,
behaviors, values, and preferences and how they potentially mitigate a patient’s ability to obtain
quality care. The second goal is to explore at what level in the process of obtaining care these
barriers occurred (health systems level, clinical encounter level, and so on). The third goal is to
identify cultural competence interventions that address these specifically identified socio-cultural barriers. The fourth and final goal is to link these interventions to a framework that can be
applied as to eliminate racial/ethnic disparities in health and health care.
4.2. Skills of an intercultural-interprofessional work team
The practice of an interdisciplinary and inter-professional team that works with immigrants or
citizens with different linguistic, religious or cultural characteristics, is based on the acquirement
of 1) general competences (organizational and relational skills, theoretical tools to understand
migratory processes, critical notions of the common-use concepts); 2) specialized competences,
according to the characteristics of the health service concerned.
209
General Competences
Organization of public services
Right to Health and Basic community health concepts
Communication and relation
The construction of the clinical relationship
Critical approach to common-use concepts: culture, ethnicity, ethnic identity
Basic notions of medical anthropology (body, health, illness as social signifiers)
Migration Dynamics, Human Rights and Citizenship
Mental Health:
Basic Concepts on critical psychopathology
Request Analysis and interpretation of the problem
Mental Health service structures and problematic
Clinical Ethno-Psychiatry
Maternal and Child Health:
• Basic concepts in maternal and child health and education
• Notions on the concepts of gender and reproductive health
• Basic notions on health and evolutionary age
• Analysis of Target Complaint and interpretation of the problem
• Maternal and Child Health service structures and problematic.
Possible Profiles involved:
• In mental health services: psychiatrists, psychologists, nurses, social workers, educators, occupational therapists and others;
• In maternal and child health services: gynecologist, obstetrics, psychologists, pediatricians,
nurses, social workers and others.
• Mediators with experience in the field and specific training.
4.3. Specific skills of the cultural mediator in the health’s field
The general characteristic concerning the ‘cultural mediator’ is that s/he should speak the client’s
first language, and when necessary also speak the same dialect as the client (as a means to be
able to refer and be aware of ethnic and country related issues). Nevertheless, it is not certain
that a mediator from the same country/ethnic group may be the best choice. In some cases a
match in gender, age and religion among mediators and users can be considered useful (Nijad,
2003), especially in specific cases (domestic violence, discussion of taboo areas, etc.). However,
it is important to assess the individual requirements, through the capacity of using the user/patient/clients maternal language.
Cultural mediators is required to be fluent in two languages and have an understanding of the
different cultural and symbolic contexts, which means, being aware of the diverse linguistic representations and capable of promoting interplay between them.28 S/he should manage the flow
28
210
Guide to languages by country : http://www.ethnologue.com/country_index.asp
of communication in order to preserve accuracy and completeness, and in order to build a good
relationship between provider and patient. Furthermore, a specific task is related to ensure that
concerns raised during or after an interview are addressed and referred to the appropriate
resources.
4.4. Training proposal
The training course for health professionals and cultural mediators is inspired by the results of
the previous steps (research) of the T-Share project. The course will be addressed to professionals
of different background operating in a mental health and in a mother and child health unit, as
well as to cultural mediators interacting with them in a functional structure. The number o beneficiaries will not exceed 20.
The training activities are scheduled in 40 hours, subdivided as follows:
•
•
a 10 hours “general competence” module dedicated separately to cultural mediators and
health professionals (20 hours total);
20 hours of “specific competences” acquisition, trained on-the-job for the inter-professional
team, cultural mediators.
The aim is to constitute and interact as an intercultural and interdisciplinary team working with
immigrant users.
Teaching methodology will include interactive lessons/seminars, case studies, training and supervision “on-the-job”.
A questionnaire will assess the acquisition of knowledge and skills.
A final certification will be given to people attending 80% of the course.
4.5 Curriculum of trainers
Chiara Pussetti (Ph.D. Cultural Anthropology, University of Torino, 2003) is presently senior associate researcher of the Center of Research in Anthropology (CRIA/ISCTE/IUL) and Associate
Professor in Medical Anthropology at University of Lisbon. She has conducted ethnographic fieldwork on the island of Bubaque, Arquipelago of Bijagós, Guinea Bissau, since 1993, focussing on
the local discourses on emotion and affliction. Since 2003 she conducted research on the emotional experience of displacement and the strategies of suffering and cure of African immigrants
in Portugal. Her publications include several books and articles published in Italy, Portugal and
Brazil.
Francesco Vacchiano is Clinical Psychologist and PhD in Cultural Anthropology. He is presently
fellow researcher at the CRIA/ISCTE-IUL and member of the Frantz Fanon Centre of Turin (Italy)
for the Mental Health of Migrating People. He joins clinical and research experiences on migration
and health, refugees, institutional encounters and borders. He works as trainers of health and
211
social workers in Portugal, Spain, Italy, Switzerland and Morocco. He published several articles
on migration, subjectivity, institutions and a book on the etnhopsychology of migration.
Carla Moleiro is Assistant Professor at the Social and Organizational Psychology Department
(DEPSO) at ISCTE-IUL and a researcher of CIS. She obtained her PhD in Clinical Psychology at
the University of California, Santa Barbara, USA, 2003. She specialized in Clinical Psychology at
the University of Lisbon, and as a psychotherapist at the Portuguese Association for Behavioral
and Cognitive Therapies (APTCC). She has developed clinical work on complex disorders, dual diagnoses and personality disorders. She is currently working on mental health and migration, and
with clients from ethnic and sexual minorities (i.e. LGBT).
Elizabeth Challinor is senior associate researcher at the Centre for Research in Anthropology –
UM Portugal. Her research areas include medical anthropology and the anthropology of development (participation, gender, state-civil society relations). She has carried out fieldwork in Cape
Verde (1996-7, 2005, and 2007) and is currently working in Porto amidst the Cape Verdean Diaspora (2008-2010) addressing issues of identity and power in Cape Verdean migrant experiences
of birth, parenthood and citizenship.
Maria Cristina Santinho possesses a Master in Anthropology (1985-1989), with specialization in
Cultures and Ideologies at the Escuela Nacional de Antropologia e História (National School of
Anthropology and History) of Mexico City. She obtained her PhD in Medical Anthropology with a
dissertation on Asylum Seekers and Refugees in Portugal. She attended a Post-Graduate Course
Refugee Trauma: Global Mental Health at the University of Harvard (2008/2009). She is currently
a researcher at CRIA (“Centro em Rede de Investigação em Antropologia and CEA (Africa Study
Centre) – ISCTE University – Lisbon, Portugal, and also teaches anthropology at the Department
of Psychology - Lusófona University. She is also President of the NGO “GIS - Group Migration
and Health”.
Silvia Olivença is PhD student at the Anthropology Department of ISCTE-Lisbon University Institute, Clinical Psychologist (ISPA – Lisbon). She is trainned in Transcultural Psychiatry at the
Université Paris 13 and in Mediation in Transcultural Settings at the Hôpital Cochin of Paris. She
is member of the International Association of Ethnopsychoanalysis.
Joana Santos has a graduate degree in Sociology from the Minho University; an M.A in Anthropology obtained at ISCTE/IUL and is currently undertaking a PhD in Anthropology at the Institute
for Social Sciences from the University of Lisbon. She has participated in various research projects
since 2008 and collaborated with two different Research Centers in Portugal: CIES-ISCTE/IUL
and CRIA- ISCTE/IUL. Through conducting research and pursuing studies she has developed research on issues relating to gender, religion, migration, health, infancy.
5. QUALITY STANDARDS
To assure a good level of the Training, the T-share Team provided Quality Standards, that have
to be adapted in the different Countries where the pilot course will be done. Furthermore, it’s
212
important to underline that the training will be provided by qualified trainers, with competences
concerning the field the T-share faces. If a single partner have not this kind of internal human
resources, it’s important to charge qualified professionals with the task.
Quality standards for trainers:
• University Degree
• Ph.D., Master or Specialisation
• At least 3 years of experiences on the Field of Migration, Ethnopsychiatry and/or Medical
Anthropology and/or on Clinical activities in Services for Migrants.
Quality standards for the Services:
• To develop a shared ethical code of conduct.
• To train services professionals to the “cultural competence” framework and cultural mediation in the context of healthcare.
• To favour multilingual, multidisciplinary teams. Such teams would allow patients (adults,
children and families) to access consultations, if necessary, in their language of origin, with
consideration for their cultural representations of health-care, of the body, and of suffering.
It is up to the professionals to answer to the specific care-seeking: diagnostic and therapeutic
view, mediation, collaboration with other teams (particularly in the perspective of joint therapies), raising awareness in the approach of concerned populations.
• To favor multidisciplinarity by including different actors implied in the health seeking itinerary
of the patient.
• To coordinate interventions with referring and partner institutions (health or non-health
related).
• To focus on health promotion/disease prevention (intercultural tools for health education).
• To share opinions and suggestions with users and communities.
• To produce documents and information tailored to patients’ literacy, language, metaphors,
idioms of distress.
• To make data on performance available to users and stakeholders.
• To foster ongoing training of staff.
• To partner with communities in order to facilitate circulation of information and materials.
• To assessing the impacts produced after a year of implementation of field training, both in
health services (health workers, socio-cultural mediators), and users (immigrants), in order
to identify possible deviations and corrections.
• To promote the creation of a virtual platform for sharing experiences and reflections.
• To promote among the institutions (Ministry of Health, Ministry of Employment, Ministry
of Social Security) the creation of a legal framework for the profession of socio-cultural health
mediator.
6. CODE OF CONDUCT
To acquire and strengthen these skills, the involved operators should recognize and respect some
fundamental principles, a code of conduct that will act as a professional regulation.
213
6.1 General principles
Ethical Awareness - Formal codes of ethics and other practice guidelines are helpful, but not
sufficient to ensure that professionals are sensitive to diversity issues in their practice and research. Professional ethical awareness is a continuous, active process that involves constant
questioning and personal responsibility.
Respect for People’s Rights and Dignity - Different cultures, ethnicities, religions, languages,
ages, genders, sexual orientations, and other such characteristics are integral to one’s identity
and give meaning to one’s lives. Genuine respect among social and health professionals and
those with whom they interact is key to ethical relationships and to the respect of people’s autonomy and dignity.
Beneficence - The role of social and health professionals is the promotion of health and wellbeing, as a facilitator in clarifying, understanding, encouraging, and helping others gain more
power and satisfaction in their lives.
Nonmaleficence – Social and health professionals should not allow their professional relationships with clients to be prejudiced by any personal views they may hold about lifestyle, gender,
age, disability, race, sexual orientation, beliefs or culture. As such, they are responsible for not
bringing or promoting harm to their clients.
Responsibility – Social and health professionals uphold elevated professional standards of conduct, clarify their professional roles and obligations, and accept appropriate responsibility for
their professional behavior. Furthermore, they are aware of their professional and scientific responsibilities to society and to the specific communities in which they work.
Justice – Justice refers to the recognition that fairness entitles all persons to access to and benefit
from the contributions of one’s work and to equal quality in the processes, procedures, and services being conducted by social and health professionals. Thus, social and health professionals
actively seek to understand the diverse cultural background of the clients with whom they work,
and do not condone or engage in discrimination based on age, culture, ethnicity, disability, gender,
religion, sexual orientation, marital, or socio-economic status.
Competence - Competency consists of attitude (awareness), knowledge (what), skills (how),
judgment (when), and diligence (commitment) in serving the well-being of diverse others, within
the realm of a specific scientific domain in which one has training. Continuous updating of the
evolving research and theory in the scientific and professional literature is an important aspect
of ethical competence.
Context–centered practices - In context–centered practices, social and health professionals recognize that all individuals (including themselves) are influenced by different backgrounds, ap-
29
214
With the necessary cautions, as recently outlined by 1) Arthur Kleinman and Peter Benson in “Anthropology in the Clinic: The Problem of Cultural
Competency and How to Fix It.” PLoS Med. 2006 October; 3(10): e294. Published online 2006 October 24. doi: 10.1371/journal.pmed.0030294
and 2) Elizabeth Carpenter-Song et al. in “Cultural Competence Reexamined: Critique and Directions for the Future.” Psychiatr Services,
58:1362-1365, October 2007. doi: 10.1176/appi.ps.58.10.1362.
preciating the variety of human experiences and belongings. As such, they strive to understand
and respect the diversity of their clients, including differences related to age, ethnicity, culture,
gender, disability, religion, sexual orientation and socioeconomic status, while also taking account
of individual, family, group and community differences.
Consciousness of the complex dimensions of difference – Social and health professionals are
aware that “difference” is not a natural attribute of individuals or groups, but a specific social
and political construction. In their approach they recognize their responsibility in influencing the
common representations of these differences and the consequences over their practice.
6.2 Specific guidelines for social and health professionals
Self-Awareness: Social and health professionals are encouraged to recognize that, as cultural
beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions
of and interactions with individuals who are different from themselves in terms of age, ethnicity,
culture, religion, gender, sexual orientation, disability, and socioeconomic status.
Cultural Sensitivity to the Other: Social and health professionals are encouraged to recognize
the importance of cultural sensitivity and responsiveness, knowledge, and understanding about
all individuals as they work with their users.
Self-Knowledge: Culturally competent social and health professionals have specific knowledge
about their own background and how it personally and professionally affects their definitions
and biases of normality-abnormality and the process of healing.
Knowledge: Culturally competent social and health professionals possess knowledge and understanding about how immigration issues, poverty, oppression, powerlessness, racism, sexism,
discrimination, and stereotyping influenced and influence the lives of the people with whom
they work with.
Knowledge of the other socio-cultural contexts: Culturally competent social and health
professionals possess specific knowledge and information about the particular group(s) that
they are working with. They are aware of the specific life experiences, cultural heritage, and
historical background of their clients, and how these affect the manifestation of psychological
distress, help-seeking behavior, and the appropriateness or inappropriateness of intervention
approaches.
Helping Relationship: Social and health professionals address the ‘comfort needs’ of the patient
in relation to the interpreter with regard to factors such as age, gender, ethnic background, and
other potential areas of discomfort. When the issue arises, these potential areas of discomfort
for the patient are discussed with the patient and addressed appropriately.
Confidentiality: Social and health professionals explain the boundaries and the meaning of
confidentiality, its implications and consequences to their patients, and respect their physical
and personal/emotional privacy, as necessary.
215
Informed Consent: Social and health professionals respect the patient’s autonomy and, as such,
provide information to each person regarding his/her condition or situation and treatment (as well
as family members and/or legal representatives, as appropriate) to obtain informed consent.
Visions of Health/Illness: Culturally competent social and health professionals respect clients’
religious and/ or spiritual beliefs and values about physical and mental functioning. Hence, they
respect local helping practices and community intrinsic help-giving networks.
Mediation: Culturally competent social and health professionals are able to collaborate with cultural mediators, and to seek consultancy of other healers and practitioners as well as religious
and spiritual leaders in the treatment of patients when appropriate.
Language: Culturally competent social and health professionals value multilingualism and do
not view another language as an impediment to the intervention. They take responsibility for
interacting in the language requested by the client and, thus, may need to (a) seek an interpreter
with cultural knowledge and appropriate professional background or (b) refer to a knowledgeable
and competent bilingual professional.
Limits of Competence: Culturally competent social and health professionals seek out educational,
consultative, and training experiences to improve their knowledge and the effectiveness of their
practice in working with different social groups. Being able to recognize the limits of their competencies, they (a) seek consultancy, (b) seek further training or education, (c) refer out to more
qualified individuals or resources, or (d) engage in a combination of these.
Supervision: Culturally-sensitive supervision is sought as an indispensable tool to develop an
on-going process of self-questioning and self-awareness, as well as a relational awareness in
working with the Other.
Organization: Social and health professionals are encouraged to support culturally-informed
policies and practices.
Education: As educators, social and health professionals are encouraged to employ the constructs
elaborated in critical field and up-to-date researches approaching difference in education and
training of other social and health professionals.
Research: Culturally sensitive researchers are encouraged to recognize the importance of conducting context–centered and ethical research, concerned with the environments where persons,
and their relations, are (trans)formed, namely by cultural, social, political and other factors.
Lisbon, ___________________
Signed by
- Beneficiary
- Promoter
216

transcultural skills for health and care - T

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