2.2.2. Study Design

Empirical quantitative studies and qualitative studies, case reports, mixed-method studies, reports and opinion articles were included in the review.

Studies designed to improve, assess or report on communication in the primary healthcare consultation setting were included. The definition of the "primary healthcare provider team" is diverse; hence this review was limited to the literature involving the following clinical healthcare providers (HCP): general practitioners (GPs), nurses and midwives. The literature including mental health professionals was also excluded as this clinical area has specific characteristics that shape the communication context.

Studies were excluded if the setting was not within a healthcare encounter or if it was related to accessing healthcare.

#### *2.3. Data Extraction and Quality Assessment*

Study characteristics were extracted by one author using a data extraction proforma. Characteristics included country of origin, aims, participants, setting, study design, methodology, results and recommendations/applications.

The quality of the included literature was assessed using the respective Joanna Briggs Institute critical appraisal checklists for qualitative research (10-item checklist), text and opinion papers (6-item checklist), studies reporting prevalence data (9-item checklist) and case reports (8-item checklist) [22].

#### *2.4. Data Analysis and Synthesis*

Qualitative and quantitative methodologies are varied in nature; therefore, a narrative synthesis of the literature was undertaken and involved using inductive thematic analysis in which dominant and recurrent themes were identified. The narrative synthesis described by Popay et al. [19] was used in guiding the process. The analysis involved generating codes from the literature to identify key ideas and then identifying the themes by grouping the codes with similar ideas together. The relevant codes which aligned with the initial research question were all incorporated into themes. We also used grouping and tabulation methods for preliminary synthesis of the study characteristics.

#### **3. Results**

The systematic database searches identified 4692 articles. Twelve further articles were identified through hand-searching of reference lists and citations. After the removal of duplicates, 2676 articles remained. A further 2588 articles were removed after screening of the title and abstracts. Full texts of the remaining 88 articles were obtained and assessed against inclusion criteria. Full texts could not be obtained for five of the articles. After reviewing the 83 available full texts articles, 21 articles were included in the narrative synthesis (Figure 1). This included sixteen qualitative studies, two opinion articles, two quantitative studies and one case report.

**Figure 1.** PRISMA flow diagram: The PRISMA diagram details the search strategy and selection process.

The included articles were conducted in nine countries; six articles were from Australia, four from the Netherlands, three from the United States, two from Ireland, two from Scotland and one each from Norway, Denmark, Sweden, and Canada. All articles were published between 1999 and 2018 (Table 1).

The studies represented the experiences of a total of 357 patient participants and 231 healthcare providers. Of the eighteen qualitative and quantitative studies, nine looked at patient experiences of communication in healthcare setting, six looked at HCP experiences and three looked at HCP and patient perspectives. Both the quantitative studies looked at the HCP experiences. Patient participants were described as "refugees" in seventeen articles, "asylum seekers" in two articles and "refugees and asylum seekers" in two articles.

The Joanna Briggs Institute critical appraisal checklists scores for qualitative studies ranged from 6 to 9 (out of 10), the case report was 5 (out of 8), the studies reporting prevalence data ranged from 7 to 8 (out of 9) and the opinion articles were 6 (out of 6). All of the studies were deemed to be of high quality, so were all included in the literature review (Table 1). Table 2 identifies the study aims, objectives and outcome measures of included studies.

*Int. J. Environ. Res. Public Health* **2021**, *18*, 1469


*Int. J. Environ. Res. Public Health* **2021**, *18*, 1469


Abbreviation: n/a, not applicable. b Abbreviation: GP, general practitioner. C Abbreviation: HCP, Healthcare provider.







*Int. J. Environ. Res. Public Health* **2021**, *18*, 1469


Three themes were identified from the included literature from both the patient and healthcare provider perspectives: (a) linguistic barriers, (b) clinician cues and (c) cultural understanding. The included quantitative studies focused only on linguistic barriers whilst the other study types had elements of all three themes.

#### *3.1. Linguistic Barriers*

Linguistic barriers were identified through the qualitative and quantitative studies, opinion articles and the case report. This theme emphasized the challenges stemming from the discordance of language between the patient and HCP as well as the difficulties of organizing and using both professional and informal (family and friends) interpreters.

### 3.1.1. Qualitative Studies

Across studies, accessing appropriate interpreters in a timely manner was one of the prominent challenges highlighted by HCPs. In particular, those with limited experience working with migrants were not always aware of available interpreting services (e.g., telephone services) and the time required to organize an interpreter before the consultation with the patient [32,34,35,40].

*"The times that I have needed it they have been–appointments have been booked well in advance. How do you book an interpreter when someone rings up at lunchtime and sees you two hours later for something that is minor or insignificant?"* —HCP [34]

Generally HCPs felt that professional interpreters were more experienced with medical terminology and, therefore, provided better outcomes [23,32,33,41]. In the absence of professional interpreters, they used family or friends as interpreters for clinical consultations but expressed their concerns about safety, confidentiality and accuracy of translation [23,25,32,33,36].

*"Sometimes it is okay, but in the majority of the cases it is better with the authorized interpreters since they are more familiar with the medical terminology. So it is always a poorer consultation. It is typically the family being used and I feel they shouldn't be there at all"* —HCP [33]

Patients often reported that they were not confident using interpreters due to fear that their problems would not remain confidential and would become gossip. This caused them to be less open with their HCP [31,35]. HCPs also reported that often patients would choose to have a consultation without an interpreter due to the interpreter being known in the community [38].

*"Sometimes you will see a client who does not want to work with an interpreter, especially in small communities there are limited numbers of interpreters from that community. The client may know the interpreter or know people who know the interpreter and they will worry about confidentiality. That causes a lot of embarrassment for women* . . . *"* —HCP [38]

Miscommunication with both professional and informal interpreters (e.g., family and friends) was also seen as an issue by patients in several studies as they sometimes felt that the translations were not correct or the language the interpreter was using was slightly different to their own. HCP experiences in some studies also showed that they were apprehensive about the translation as patients often spoke for an extended period but the responses received through the interpreter were relatively short [24,25,31].

*"When you get a translator and the translator doesn't really get you the translation in details. Some of them just talk and talk and then when it comes to the translator, he can't put the words the [right] way..." —patient* [24]

In the absence of interpreters and with limited language skills, patients expressed that they sometimes did not understand the information and explanations that the HCP had given. However, they did not often express this and hence left with unresolved questions and, in some instances, incorrect diagnoses [31,35].

*"Inevitably there were misunderstandings during her GP consultations and, on one occasion, her son who had diarrhoea was prescribed medication for constipation..." patient* [35]

#### 3.1.2. Quantitative Studies

A survey of 38 HCPs in the United States showed that HCP's overestimated how often they themselves used informal interpreters and underestimated the patient's satisfaction with the interpreter quality [23].

According to telephone interviews with general practitioners in Ireland, 77% responded saying language assistance was required during consultation with refugees and asylum seekers [36]. However, the results from the study show that only 7% of HCPs could name a professional interpreting service and only 5% could name one which they had used. In consultations where an interpreter was required but they managed without, the HCP either used sign language and diagrams, the patient spoke some English or the GP themselves had some knowledge of the patient's language [36]. There was also a greater preference for informal interpreters and the main reason reported was accessibility. However, concerns about confidentiality with informal interpreters was reported by 43% compared to 11% with professional interpreters.

#### *3.2. Clinician Cues*

Across a number of included studies, patients consistently emphasized the importance of non-verbal cues and compassion from the HCPs, such as smiling, nodding, kindness and showing patience. They were all seen to be factors in helping to alleviate stress and improving trust as they allowed the patients to feel welcome and valued, and reportedly affected perceived levels of engagement [24,26–29,37,39].

*"When you sit with a doctor and you hear kind words, that has an influence on your nerves, on your body. You start feeling better, healthier, than when the doctor is angry." —patient* [27]

*"We don't have anybody here. It is very important that the doctor is friendly." patient* [28]

On the other hand, lack of interest from the HCP and not being taken seriously about their health concerns led patients to be less open in their communication [24,26,28,29,42]. Patients reported that they were not likely to trust and communicate with an HCP who was not willing to consider their individual characteristics and needs [26–28,42].

*"I did not give him the medical file, because he was not interested. My expectation was somebody who will be open to me, like doctors in Africa." —patient* [26]

*"That generalizing attitude is what still makes me angry." —patient* [26]

In contrast, HCP's willingness to listen to the patient's personal story and non-medical information was seen as a way to encourage trust and improve the relationship. The HCP's openness, understanding and attentiveness towards the patient's needs, alongside willingness to take detailed medical history, helped to build trust and allowed the patient to open up to them [24,26–29,37].

*"To show that you are interested in the person, not only in the disease; to show that you want to know something about the context. Sometimes it is difficult to find time for it in a busy practice, but I see it is a worthwhile investment* . . . *"* —HCP [27]

#### *3.3. Cultural Understanding*

Cultural considerations play a key role in open communication and understanding of medical context between patients and HCPs.

When organizing professional interpreters, it was important to some patients that same gender interpreters were organized to allow them to be open with the HCP. When they had interpreters of the opposite gender, they expressed that they felt it was inappropriate and that they felt embarrassed [23,24,28,31,38]. Patients reported that having interpreters and HCPs of the same gender allowed for them to form a connection and speak more freely about their health concerns [24,37].

*"Give her a woman translator, so that she can be open to tell all the problems" patient* [24]

*"Religion sometimes says it is good for you to have [a] female doctor if you are female" —patient* [24]

HCPs expressed that often a challenge for them was causing patients to understand and explain their symptoms due to cultural differences [23,25,27,30,33,34]. They reported that there were cultural differences in the way some patients interpreted health and illness, as well as challenges in addressing long-standing cultural beliefs which impacted the medical care they gave. Patients also expressed not wanting to contradict the HCPs who were seen as authority figures and felt that any self-advocacy from them would not be accepted, which highlighted the notion of hierarchy within the interaction [31]

*"They have a different culture, so their cultural perception of symptoms and what they mean... trying to interpret the difference between a bloated abdomen and a painful abdomen, just becomes an impossible task..."* —*HCP* [25]

#### **4. Discussion**

This review found that refugees and asylum seekers experience a range of communication challenges and obstacles in primary care consultations. These relate to the availability and access to appropriate interpreters, HCP demeanor and cultural considerations. The highlighted themes: linguistic barriers, clinician cues and cultural understanding, are all interrelated and emphasize the preferences for considerate and appropriate care.

While previous research looking at the use of interpreters in healthcare services has shown the benefits of professional interpreters in communication, clinical outcomes, utilization and satisfaction, [43,44] the findings from this review highlight the practical and relational challenges of organizing and using interpreters in consultations with refugees and asylum seekers. Patient preferences for same-sex interpreters further complicated these challenges. Although quantitative studies included in this review indicate the challenge of being able to access professional interpreters, who were more proficient in medical terminology, the qualitative evidence demonstrates that the alternative (i.e., to use informal interpreters) can produce poor quality translation and confidentiality concerns. Importantly, studies included in the review also report concerns about accuracy and confidentiality when using professional interpreters, illustrating that the clinical encounter is complex and that both professional and informal interpreters provide benefits and challenges. Challenges with language and the use of interpreters, for example, transcend clinical context and are a pervasive system challenge [45].

Issues around cultural considerations and understanding were identified as potential challenges in the healthcare encounter. Our review indicates that HCPs often play a role in helping bridge the gap in different cultural understandings but perceive this to be an ongoing challenge in their practice. Other studies in this review focused on cultural issues of gender concordance, and existence of a clinician–patient power dynamic in primary consultations which limited communication. While these cultural issues are undeniably important, previous research highlights that there are many other cultural differences and beliefs which influence health and healing practices [46]. Different cultures have different understandings of illness and disease and many have traditional healing practices [46]. The fact that these issues are absent from the studies included in this review suggest that the research in primary care communication may have only looked at this aspect of communication and the HCP's role superficially with this population group. To address this research gap, further work should be done to understand the role of cultural factors in developing a shared understanding of health in primary care.

As well as identifying challenges, this review also uniquely summated the literature about factors which facilitate primary care consultations with refugees and asylum seekers. Non-verbal and compassionate care aspects of communication, for example, emerged as an important factor in helping improve comfort and trust between the HCP and patient. The patients preferred to see HCPs who were welcoming, kind and patient, and those who were willing to take time to listen to non-medically relevant information and took an interest in them as a person. These findings align with the previous literature which identifies such non-verbal cues as a method to help alleviate anxiety and improve trust in patient-centered communication. [47–49] Non-verbal cues and compassionate care by HCPs play a key role in assisting to build the HCP–patient relationship, and additionally, identify an opportunity for a positive healthcare encounter when there are linguistic and cultural barriers present with patients from refugee and asylum seeker backgrounds.

The refugee and asylum seeker experiences identified in our review are similar to those found in other migrant groups, including language barriers, interaction with HCPs and cultural differences in healthcare [50,51]. Experiences of non-migrant and non-refugee populations also highlight similar desires for the traits which they consider important in their HCP, in terms of clinician demeanor and competence [24,52]. The model of humanistic medicine provides a framework for understanding these similarities as it illustrates that the experiences and preferences of patients are generalizable to the patient experience as a whole. With an emphasis on HCPs being compassionate and empathetic towards their individual patients and being aware of their emotions, concerns and suffering [53], humanistic medicine is seen as the basis of medicine [54]. However, there are challenges with applying humanistic care in practice as HCPs find bureaucratic barriers and challenges with time given the business-like climate of certain areas of medicine [55]. In addition to the linguistic and cultural barriers, HCPs treating refugee and asylum seekers have to navigate social factors and experiences of trauma [5,6]. Nevertheless, applying this framework of humanistic care has benefits to both the patients and the HCPs [55], suggesting organizational support should be given in this area. Greater effort should be undertaken to provide humanistic and compassionate care when encountering refugees and asylum seekers and healthcare systems need to provide support to HCPs to facilitate this approach.

There are strengths and limitations of this review. A strength was that systematic searches were conducted using seven relevant databases with additional reference and citation searches. In addition, full texts which were in languages other than English were also reviewed, further strengthening the search strategy. It is therefore unlikely that published studies have been missed. However, due to the defined inclusion criteria, some literature may have been excluded if it used the broad term of migrants rather than specifying the subpopulation group.

Another strength of this review is that the included literature covers various ethnic groups in various western resettlement countries. However, the number of participants combined from all the studies is still relatively limited which may not allow for any conclusions concerning the communication experiences of a broad group of refugees and asylum seekers in different countries. Furthermore, interpretations based off participant demographics, such as sex difference, age difference or the educational difference in refugee and asylum seeker populations are not possible as they are not reported in many of the included studies. Another limitation is at the search strategy only identified the scientific literature and failed to capture grey literature, such as non-government organization reports which often report on patient and HCP experiences.

#### **5. Conclusions**

Primary care HCPs need additional support to allocate time and provide compassionate and humanistic care desired by refugees and asylum seekers. Ongoing issues with organizing and routinely utilizing professional interpreters suggest infrastructure should be in place to allow HCPs to be trained on the accessibility of accessing professional interpreters, with systems that allow for timely scheduling. Beyond issues of language, refugees

and asylum seekers may also to be sensitized to non-verbal cues and compassionate care from the HCP. This is an area that should be further investigated, particularly in light of the current shift to virtual consultation for some healthcare encounters.

**Author Contributions:** L.T., P.P. and S.B. conceived of this study and its design. P.P. conducted the data collection. P.P. and H.D. performed the screening process. P.P. performed the content analysis and coding. L.T., P.P., S.B. and D.M.M. were involved in interpreting the results. All authors have read and agreed to the published version of the manuscript.

**Funding:** Financial support for this study was provided by Australian National Health and Medical Research Council (NHMRC)/Centres of Research Excellence project: Testing, Translation and Uptake of Evidence in General Practice: A systems approach to rapid translation. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare that they have no competing interests.

**Declarations:** Ethics approval and consent to participate, Not applicable.

**Consent for Publication:** Not applicable.

**Availability of Data and Materials:** Data for this systematic review were derived from published articles which are available in the public domain and may be subject to copyright. Relevant data supporting the conclusions of this systematic review are included within the article and supporting files.

#### **Abbreviations**

HCP—Healthcare provider; WEOG—Western European and Other States Group; Clinicians—general practitioners, nurses and midwives.

### **Appendix A. Search Terms Used For Database Searches**

1. Pop

Refugee\$


(Primary healthcare)


Communicat\$

