Moving towards culturally competent health systems for migrants? Applying systems thinking in a qualitative study in Malaysia and Thailand

Angkurawaranon, Chaisiri and Pocock, Nicola Suyin and Chan, Zhie and Loganathan, Tharani and Suphanchaimat, Rapeepong and Kosiyaporn, Hathairat and Allotey, Pascale and Chan, Wei-Kay and Tan, David (2020) Moving towards culturally competent health systems for migrants? Applying systems thinking in a qualitative study in Malaysia and Thailand. PLoS ONE, 15 (4). e0231154. ISSN 1932-6203, DOI

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Background Cultural competency describes interventions that aim to improve accessibility and effectiveness of health services for people from ethnic minority backgrounds. Interventions include interpreter services, migrant peer educators and health worker training to provide culturally competent care. Very few studies have focussed on cultural competency for migrant service use in Low- and Middle-Income Countries (LMIC). Migrants and refugees in Thailand and Malaysia report difficulties in accessing health systems and discrimination by service providers. In this paper we describe stakeholder perceptions of migrants' and health workers' language and cultural competency, and how this affects migrant workers' health, especially in Malaysia where an interpreter system has not yet been formalised. Method We conducted in-depth interviews with stakeholders in Malaysia (N = 44) and Thailand (N = 50), alongside policy document review in both countries. Data were analysed thematically. Results informed development of Systems Thinking diagrams hypothesizing potential intervention points to improve cultural competency, namely via addressing language barriers. Results Language ability was a core tenet of cultural competency as described by participants in both countries. Malay was perceived to be an easy language that migrants could learn quickly, with perceived proficiency differing by source country and length of stay in Malaysia. Language barriers were a source of frustration for both migrants and health workers, which compounded communication of complex conditions including mental health as well as obtaining informed consent from migrant patients. Health workers in Malaysia used strategies including google translate and hand gestures to communicate, while migrant patients were encouraged to bring friends to act as informal interpreters during consultations. Current health services are not migrant friendly, which deters use. Concerns around overuse of services by non-citizens among the domestic population may partly explain the lack of policy support for cultural competency in Malaysia. Service provision for migrants in Thailand was more culturally sensitive as formal interpreters, known as Migrant Health Workers (MHW), could be hired in public facilities, as well as Migrant Health Volunteers (MHV) who provide basic health education in communities. Conclusion Perceptions of overuse by migrants in a health system acts as a barrier against system or institutional level improvements for cultural competency, in an already stretched health system. At the micro-level, language interventions with migrant workers appear to be the most feasible leverage point but raises the question of who should bear responsibility for cost and provision-employers, the government, or migrants themselves. © 2020 Pocock et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Item Type: Article
Funders: Asia Pacific Observatory on Health Systems and Policies (APO) [grant no. N/A], China Medical Board's Equity Initiative [IF055-2018]
Uncontrolled Keywords: Undocumented Immigrants; Immigration Policy; Patient Protection and Affordable Care Act
Subjects: R Medicine
Divisions: Faculty of Medicine
Depositing User: Ms. Juhaida Abd Rahim
Date Deposited: 17 Aug 2020 06:53
Last Modified: 17 Aug 2020 06:53

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