Healthcare for migrants, participatory health research and implementation science—better health policy and practice through inclusion. The RESTORE project

Abstract

Background: This is a time of unprecedented mobility across the globe. Healthcare systems need to adapt to ensure that primary care is culturally and linguistically appropriate for migrants. Evidence-based guidelines and training interventions for cultural competence and the use of professional interpreters are available across European healthcare settings. However, in real-world practice migrants and their healthcare providers ‘get by’ with a range of informal and inadequate strategies. RESTORE is an EU FP7 funded project, which is designed to address this translational gap.

Objectives: The objective of RESTORE is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultations in selected European primary care settings.

Design: RESTORE is a qualitative, participatory health project running from 2011–2015. It uses a novel combination of normalization process theory and participatory learning and action research to follow and shape the implementation journeys of relevant guidelines and training initiatives. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork, with a complementary health policy analysis led by Scotland. In each setting, key stakeholders, including migrants, are involved in participatory data generation and analysis.

Expected results: RESTORE will provide knowledge about the levers and barriers to the implementation of guidelines and training initiatives in European healthcare settings and about successful, transferrable strategies to overcome identified barriers. RESTORE will elucidate the role of policy in shaping these implementation journeys; generate recommendations for European policy driving the development of culturally and linguistically appropriate healthcare systems.

Keywords::

• migrant healthcare
• linguistic and cultural competency
• translational gaps
• normalization process theory
• participatory learning and action research

KEY MESSAGE:

• Migration across Europe is increasing—it is important to adapt healthcare services so that they are culturally and linguistically appropriate.

• European collaborations are necessary to enhance knowledge about implementation of interpreted consultations in diverse settings.

• The involvement of migrants and other key stakeholders enhances the veracity and relevance of research and policy.

INTRODUCTION

This is a time of unprecedented mobility across the globe with the number of international migrants estimated to be 214 million (1). In 2010, there were over 32 million migrants living in the then 27 member countries of the EU (2). From a human rights perspective (3,4), healthcare systems must adapt to ensure that care is delivered effectively to migrants so that they receive culturally appropriate and high quality care for their complex health and social care needs.

Adapting healthcare systems so that they are culturally and linguistically appropriate is a major priority and challenge (5). The routine use of interpreters is a particularly important adaptation, which can support communication between migrants and service providers who do not have a shared language or cultural background (6). Guidelines and training initiatives relating to the use of professional interpreters and cultural competence are available in many national contexts. However, there is ample international evidence to show that, in daily practice, healthcare providers ‘get by’ without training and by using a range of informal strategies to support communication in consultations with migrants (7,8). These informal strategies include the use of friends and family members, including children, as interpreters, body language and gesturing, or the use of online translating technologies (9). This leads to a problem in that migrants’ access to healthcare is compromised as they may lack trust and faith in their primary care consultations and their doctor–patient relationships (10–12); the resultant issues relating to risk and patient safety are significant. This situation is worsening because of current economic austerity (13).

THE RESTORE PROJECT

The knowledge base on the translational gap between policy, evidence and daily health care practice is limited. We know very little about why GPs and other health professionals do not accept or implement the available guidelines and interventions, or under what circumstances they would do so. RESTORE (Box 1) is addressing this gap and augmenting the evidence base about implementation of initiatives to support cross-cultural communication in primary care settings. Our full study protocol is published (14); here we summarize key aspects of the study and reflect on our working together as a consortium.

Box 1. The RESTORE project.

RESTORE—REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings.

A research project focused on optimizing medical and psychosocial primary care for migrants in Europe. By using innovative scientific methods such as Participatory Learning and Action (PLA) and the Normalization Process Theory (NPT), RESTORE will explore how cultural differences and language barriers can be overcome by general practitioners and primary care staff in cross-cultural consultations and, at the same time, how available resources can be used efficiently in health systems across Europe. The RESTORE project (2011–2015) is funded through the EU FP7 programme health theme with a budget of €2.9 million.

Collaboration:

Ireland (Co-ordinator): Anne MacFarlane^a , Project coordinator, Marianne Tormey; University of Limerick; Ciaran Clissmann, Pintail Ltd, Dublin, Ireland

Mary O’Reilly-de Brún Senior researcher, Tomas de Brún Senior researcher; National University of Ireland, Galway

Scotland: Frances Mair^a, Catherine O’Donnell^a, Nicola Burns; University of Glasgow.

England: Christopher Dowrick^a, Katja, Gravenhorst; University of Liverpool.

The Netherlands: Maria van den Muijsenbergh^a, Evelyn van Weel-Baumgarten^a, Erik Teunissen; Francine van den Driessen Mareeuw; Radboud University Nijmegen Medical Centre.

Austria: Wolfgang Spiegel^a, Christine Princz; Medical University of Vienna

Greece: Christos Lionis^a, Aristoula Saridaki, Maria Papadakaki, Maria Vlahadi; University of Crete.

International Advisory Board: Santino Severoni (Italy), Piroska Östlin (Denmark), Roumyana Petrova-Benedict (Belgium), Nigel Mathers (England), Alexander Bischoff (Switzerland), Carl May (England)

^aPartner country leads.

RESTORE focuses on the implementation of evidence-based health guidance, e.g. guidelines to enhance communication in cross-cultural consultations and interventions, e.g. training initiatives on interculturalism and the use of professional interpreters. We are currently exploring how these are applied, or not, into routine practice in selected European primary care settings. We are investigating, and shaping, the requisite implementation processes using a unique combination of contemporary social theory, the normalization process theory and a participatory research methodology, participatory learning and action research.

Normalization process theory (NPT) is a sociological theory, which is used as a conceptual framework to ‘alert’ researchers to factors that can influence implementation (15). The conceptual framework uses four constructs—coherence, cognitive participation, collective action and reflexive monitoring. Participatory learning and action (PLA) research is developed from the Global South—the developing nations of Africa, Asia and Latin America (16), and has been applied in a range of settings including healthcare (17). Its main goal is to ensure that stakeholders who are typically marginalized from research and development projects are meaningfully involved and ‘have a voice’ in project development alongside other, usually more powerful, stakeholders. While NPT and PLA have previously been applied separately in implementation studies, this is the first time they have been combined (14). The combined application of NPT and PLA provides a novel example of how theory can be translated into primary care research with potential practical implications.

OBJECTIVES

Our five major study objectives are to determine:

• What guidelines and training initiatives are available in our partner countries to support communication in cross-cultural primary care consultations?

• How are these guidelines and training initiatives applied by primary care staff? What are the processes of implementation, ‘on the ground’ in routine practice?

• What is the capacity of primary care settings, in different organizational and healthcare contexts, to incorporate implementation processes within their current organizational arrangement?

• Is the implementation of guidelines and training initiatives sustainable—leading to normalized use of these guidelines and training initiatives in routine practice?

• What are the benefits of using NPT and PLA to investigate and support implementation processes?

METHODOLOGY

RESTORE is a qualitative, participatory health project running from 2011–2015. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork within that period. This enables cross-country discussions about the fieldwork design and engagement in comparative analysis of the influence of healthcare contexts on these implementation journeys.

We have used purposive and maximum variation sampling approaches to identify and recruit ‘information rich’ stakeholders—migrant service users, general practitioners, primary care nurses, practice managers and administrators, interpreters, cultural mediators, service planners and policy makers. We have conducted a mapping exercise to identify relevant guidelines and training initiatives. We have initiated a PLA-brokered dialogue with stakeholders structured around NPT's four constructs. We are encouraging stakeholders to share knowledge with each other about a range of guidelines and initiatives and help them to consider which ones:

• Make sense to them—coherence

• They wish to ‘buy into’ and drive forward as an implementation project—cognitive participation

• Are workable in their local contexts—collective action

• Impact positively on their work—reflexive monitoring

From this process, stakeholders in each of the five national fieldwork settings have democratically selected a single guideline or training initiative for implementation in their local setting. We are now in the process of investigating and supporting the implementation journeys for these selected interventions.

Throughout the fieldwork, we are generating and analysing qualitative data in an iterative manner following the principles of thematic analysis, combined with participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings (18).

The fieldwork component is complemented by a comprehensive health policy analysis, which also uses NPT and is led by our research team in Scotland. This analysis will explore to what extent the policy arena supports, or otherwise, guideline or training implementation. All members of the consortium have received training in NPT and PLA so that we have a consistent and rigorous approach to their application in fieldwork and health policy analysis across settings.

EXPECTED RESULTS

RESTORE will provide empirical data about

• Levers and barriers to the implementation of guidelines and training initiatives in our European settings

• Successful strategies to overcome identified barriers

• The transferability of strategies to overcome barriers across national and healthcare system boundaries

• The role of policy in shaping the implementation journeys leading to recommendations for European policy on culturally and linguistically appropriate healthcare systems

Implications for practice

Results will be based on real-world experiences of implementation, from the perspectives of all stakeholders including migrants and primary care personnel. Results can inform policy and practical guidance on delivering healthcare for migrants that is linguistically and culturally appropriate. This is important to optimise healthcare effectiveness and avoid adverse outcomes.

Implications for science

The results of our innovative combined use of NPT and PLA will be relevant to the broader field of implementation science. Both NPT and PLA are increasingly popular in diverse fields; our process-focused research combining NPT and PLA will be relevant across a range of health domains.

PROPOSING AND DELIVERING THE FP7 RESTORE PROJECT

Topic selection

The Call for proposals (Health.2010.3.1–1) was for research about translational gaps. The topic of migrant health was a shared concern and area of expertise across our initial group of consortium members. The decision to use migrant health as our case study for translational research meant that we were consolidating interests in migrant health issues but also extending our research endeavours beyond descriptive studies or intervention studies to engage in innovative translational research. This combination of track record and state-of-the art innovation enhanced our critical thinking about the topic, aims and objectives of RESTORE. It also allowed us to propose an innovative approach to an exciting research topic that crosses disciplines while remaining firmly in the scope of the call.

Creating the collaborative consortium

Our consortium grew organically from existing networks. There was an inter-agency network of social scientists in Ireland, an academic collaboration between clinical and non-clinical colleagues in Ireland and the UK and professional and academic cooperation between GP colleagues in England, the Netherlands, Austria and Greece. The value of bringing these networks together was that the consortium was founded on strong, existing working relationships and, with that, good interpersonal dynamics and confidence that we could work together effectively. However, we also enjoyed some ‘freshness’ as everyone had the opportunity to meet new colleagues from new countries and disciplines. This was strengthened further as new researchers were recruited in each country once the grant was awarded; this has resulted in a consortium of eighteen early, mid and late career primary care academics representing sociology, anthropology, general practice and primary care.

Writing the RESTORE proposal

We established a small, core-writing group to draft initial ideas and circulate them for comment and development before making final decisions. This balance between directive and consultative approach to the development of the proposal was effective because it was inclusive and also efficient.

We were joined, as a project partner, by an EU project manager with extensive expertise of FP7 and other programmes. The benefits were immediate in terms of having guidance on the budget, management and administration, EU technologies and processes, project negotiation, etc. This expertise was complemented by regular contact with the FP7 National Contact Point for Health. This expert input about EU and FP7 funding has provided security that management and administration are well monitored and allows those of us in research roles to devote our energies and time to the scientific elements of the project.

WHY WAS THIS INITIATIVE SUCCESSFUL IN ATTRACTING SUPPORT?

The scientific research had a strong ‘fit’ with the call for funding—this was the key to its success. If there is no ‘fit,’ there will be no funding. The methodological design was strong because it resonated with recommendations about the design of implementation research. Specifically, following Greenhalgh et al. (19), the research is:

• Process-oriented so that attention is focused on the features that underpin success or failure of implementation rather than on, for example, the content of the guideline being implemented

• Examining implementation processes in a consistent fashion across different international contexts

• Meticulously detailed to allow comparisons across international contexts

• Participatory, engaging ‘on the ground’ practitioners as partners in the research process.

Furthermore, the combination of partners’ expertise in the funding application was appropriate to the study objectives and thus to our proposed plan of work. Within the consortium, there is a balance of expertise in general practice and primary care, NPT, PLA, migrant health, medical education, health policy and qualitative research. We brought these distinct areas together, creating a multi-disciplinary synergy. The involvement of international collaborators on our International Advisory Board has given an external, but expert, perspective on our work.

Finally, the work of RESTORE is focused on a community of service users that are a priority for the EU (4). RESTORE benefits from a very international perspective; the resultant recommendations for EU-level policy will be strengthened by empirical findings from across member States.

WHAT COULD OTHER RESEARCHERS LEARN FROM THIS PROJECT?

After learning that our funding initiative was successful, our attention turned to creating a successful project in terms of process as well as scientific outcomes. In terms of process, at the outset we clarified leadership roles and divisions of labour. We invested considerable time and energy in communication, using e-mail, teleconferences, video conferences and Skype, to complement six-monthly face-to-face meetings. We have also benefited from additional face-to-face time together to discuss RESTORE and build relationships during our NPT and PLA training programme. Spending time learning together has helped to build strong team bonds, to the benefit of every aspect of the project.

Furthermore, we invested time in establishing a shared ethos and supportive environment for working together. This was founded on principles of respectful communication and genuine partnership. We agreed that the consortium would be a ‘safe space’ for questions, reflections and queries about our work and progress. We used participatory strategies as icebreakers, which allowed us to engage and connect with new consortium members in a relaxed and fun manner. We established an authorship policy group at the outset to create clear guidance and a discussion forum for an issue that is known to cause tensions in research groups. When difficulties or challenges arise, we have a valuable point of reference (our ethos of respectful communication) to moderate our dealing with them. Taken together, these actions have fostered a positive environment in which we work and learn together, which we believe greatly benefits our research endeavour.

ACKNOWLEDGEMENTS

The authors thank Dr Ciaran Duffy, Enterprise Ireland and Dr Martina Prendergast, National University of Ireland Galway for their support in the development of RESTORE.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.